Every finding on record at Crossings at East Lake of Journey LLC, The

Based on observations, staff and resident interviews, record reviews, and review of facility policies titled, Infection Prevention and Control Program, Infection Preventionist, and Enhanced Barrier Precautions, the facility failed to maintain an effective infection prevention and control program. Specifically, the facility failed to ensure staff consistently used the required Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP) protocols, failed to conduct required infection surveillance audits, and failed to demonstrate staff competency through completed infection control competency checkoffs. The deficient practices created the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors.Findings Include:Review of the facility policy titled Infection Prevention and Control Program revised 3/20/2025, revealed under Policy Explanation and Compliance Guidelines: . 3. a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services. b. The Infection Preventionist serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance Committee. 16. a. All staff shall receive training . regarding the facility's infection prevention and control program, including policies and procedures. b. All staff shall demonstrate competence in relevant infection control practices. c. Direct care staff shall demonstrate competence in resident care procedures established by our facility.Review of the facility policy titled Infection Preventionist revised 2/1/2024 revealed under Policy Explanation and Compliance Guidelines: . 12. a. Develop and implement an ongoing infection prevention and control program to prevent, recognize and control the onset and spread of infections in order to provide a safe, sanitary and comfortable environment. e. Oversight of resident care activities.Review of the facility policy titled Enhanced Barrier Precautions revised January 2026 revealed under Policy Explanation and Guidelines: . 1. a. All staff receive training on enhanced barrier precautions . and are expected to comply with all designated precautions. b. All staff receive training on high-risk activities and common organisms that require enhanced barrier precautions. 2. b. An order for enhanced barrier precautions will be obtained for residents with any of the following: . i. Wounds and/or indwelling medical devices (e.g. feeding tubes .) .3. a. Make gowns and gloves available immediately outside the resident's room. d. The infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. 4. High-contact resident care activities include: . d. Providing hygiene. f. Changing briefs or assisting with toileting.Observation on 1/13/2026 at 3:19 pm revealed Certified Nursing Assistant (CNA) GG provided hygiene care including a brief change to R2 without adhering to required EBP protocols. Despite signage posted on the resident's door indicating required precautions and the availability of PPE outside the room, the CNA entered the resident's room without donning (putting on) a gown while providing direct care to a resident with multiple wounds and receiving tube feeding.Interview on 1/13/2026 at 3: 32 pm with CNA GG confirmed that she did not wear the required gown while providing care to R2. CNA GG stated that she believed the resident did not have a condition that required EBP precautions.Interview and record review conducted on 1/12/2026 at 11:17 am with the Infection Preventionist (IP) revealed the facility failed to maintain documentation of required infection control surveillance and staff competency validation. Specifically, the IP was unable to provide evidence of ongoing audits for critical infection prevention practices, including but not limited to hand hygiene compliance, proper use of PPE, and equipment cleaning and disinfection. The IP produced a total of nine Peri Care/Hand Washing Audit Tool forms completed during a single month of October 2025 for the previous 12 months and stated that no additional infection control audits had been conducted. The IP further stated that she had not been auditing staff and was not aware that routine surveillance auditing was required, questioning whether this was a new expectation. In addition, upon request, the IP was unable to produce any staff infection control competency checkoffs for the previous 12 months. No competency validation documentation related to hand hygiene, PPE use, or other infection prevention practices was provided by the Director of Nursing (DON).Interview on 1/14/2026 at 10:20 am with IP revealed that she expected staff to wear PPE when providing direct contact with a resident who was on EBP.Interview on 1/14/2026 at 10:44 am with the DON revealed that his expectation was for staff to follow established protocols for direct resident care and to use PPE as required. The DON stated that staff were expected to follow their training. The DON further stated that leadership conducted walk-throughs; however, no formal infection control audits were conducted, and no written audit documentation was maintained. The DON stated that CNA competencies were completed during orientation; however, when asked to produce documentation of CNA infection control competency checkoffs, the DON was unable to provide any records.

Based on observations, resident and staff interviews, record review, and review of the facility's policies titled, Baseline Care Plan and Comprehensive Care Plans, the facility failed to ensure that one of 16 residents (R) (R39) using a specialized mattress had a properly functioning air mattress. The deficient practice had the potential to decrease R39's functional ability and healing progress made while in the facility placing her at increased risk for pressure ulcers/ injuries.Findings include:During a review of the facility's policy titled Baseline Care Plan revised 12/23/2023 revealed under Policy: The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. Under Policy Explanation and Guidelines: .2. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable. b. Interventions shall be initiated that address the resident's current needs including: i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk. ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living. iii. Any special needs such As for IV therapy, dialysis, or wound care. c. Once established, goals and interventions shall be documented in the designated format.During a review of the facility's policy title, Comprehensive Care Plans revised 3/20/2025 revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a residence medical, nursing, and mental and psychosocial needs and all services that are identified in the residence comprehensive assessment and meet professional standards of quality. Under Policy Explanation and Guidelines:1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. All services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet professional standards of quality, and incorporate culturally competent and trauma informed care as indicated. 3. Comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the residence highest practicable physical, mental, and psychosocial well-being.During a review of R39's facility's admission records revealed diagnoses that include but not limited to schizoaffective disorder, bipolar type acute and chronic respiratory failure with hypoxia, morbid (severe) obesity with alveolar hypoventilation, obstructive sleep apnea, chronic pain syndrome, shortness of breath, dependence on supplemental oxygen, depression, unspecified, insomnia, unspecified, posttraumatic stress disorder, chronic.During a review of R39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. Section GG (Functional Abilities and Goals) revealed the need for maximum assistance with all Activities of Daily Living (ADLs) care needs. Section M (Skin Conditions) revealed the risk of developing pressure ulcers/ injuries.During a review of R39 care plan revealed, Requires assistance (assist) with ADL's related to (r/t) weakness, decreased mobility, pain. She requires the assist of one with ADLs. She is able to participate in her care. The amount of assist may vary from day to day. Staff will adjust and assist. Pressure reducing cushion to wheelchair. Refer to therapy as needed. Weekly skin assessment by licensed nurses.During a review of the facility's Service Task Detail document revealed that the service order for R39's air mattress was not placed until 1/12/2026 at 3:05 pm, and that the second order for a replacement mattress was placed on 1/13/2026 at 6:06 pm.A review of the facility's Active Rentals list revealed that R39 was originally ordered and was in use of a [NAME] 1B 42 air mattress and that the facility ordered her a Air Force 1000 Plus 42 air mattress on 1/13/2026.The initial observation/ interview on 1/11/2026 at 1:23 pm with R39 revealed her stating that her air mattress had been broken since 1/9/2026 and they can't fix it. She stated that she is in a lot of pain due to mattress being deflated and was currently resting on the metal base of the bed. R39 stated that the staff was aware as she informed the staff immediately. She stated that the recreation staff had attempted to fix the issue without success and was told that there was no one to look at it till Monday. R39 denied being offered another bed until her bed was fixed.Observation/ interview on 1/12/2026 at 2:07 pm revealed R39s air mattress deflated with her still in bed lying on the it without any barrier between her mattress and the metal frame. She stated that she was told that a part needed to be ordered for the mattress and it would arrive tomorrow, 1/13/2026. She denied being offered another mattress for the time being.Observation/ interview on 1/13/2026 at 12:00 pm revealed that R39 was in bed with the deflated air mattress still in place. She again denied being offered a change of mattress or temporary mattress until the part came in. She stated that she was having a lot of back pain due to the mattress and asked if the nurse could be called to administer pain medication.During an interview on 1/13/2026 at 12:17 pm with the Activities Director revealed that she was made aware of the deflated air mattress by R39 on 1/9/2026 and immediately informed the nursing staff after attempting to fix it without success. She stated that she again attempted to fix the mattress on 1/12/2026 without success and that R39 was complaining of pain in her back. She stated that she again informed the nurse and was told that administration was aware and already addressing it.An observation/interview on 1/13/2026 12:23 pm with the Director of Nursing (DON) revealed that he was made aware of the bed being broken on 1/11/2026 and had been in communication with the rental company. He stated that he was informed by the rental company that the part to fix the bed had to be ordered and was expected to be delivered on 1/12/2026 but never arrived. He denied being aware of R39 being offered another mattress or change in bed until the part arrived. He admitted that R39 should have been offered another mattress and stated that he would follow up with the company on the delivery.An interview on 1/14/2026 at 12:11 pm with the Administrator and the DON revealed that the part for R39's mattress did not arrive and that the company was contacted. The Administrator stated that the company informed him that they did not have the same mattress available but had something similar for the time being. The DON stated that they convinced R39 to use the rental until her regular air mattress became available.

Based on record review, staff interviews and review of the facility policy titled, Resident Assessment - Coordination with PASARR Program Date Reviewed/ Revised:12/24/2023 the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level two was submitted for two of 21 residents (R) (R3 and R69) reviewed for PASARR II. This deficient practice had the potential to place R3 and R69 at increased risk of not receiving required behavioral health support to meet their daily needs.Findings include:Review of the facility policy titled Resident Assessment - Coordination with PASARR Program, dated 12/24/2023 revealed under Policy: This facility coordinates assessments with the Preadmission Screening and Resident Review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or related condition receive care and services in the most integrated setting appropriate to their needs. Under Policy Explanation and Compliance Guidelines: All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid screening rules. a. PASARR Level I is the initial pre-screening completed prior to admission. i. A negative Level I screen permits admission to proceed and ends the PASARR process unless a possible serious mental disorder or intellectual disability arises later. ii. A positive Level I screen requires a PASARR Level II evaluation prior to admission. 5. b. PASARR Level II is a comprehensive evaluation completed by the appropriate state designated authority (not by the facility). It determines whether the individual has a mental disorder, intellectual disability, or related condition, identifies the appropriate setting for the individual, and recommends any specialized or rehabilitative services needed. If a resident was not screened due to an approved exception and remains in the facility longer than 30 days: b. The Level II resident review must be completed within 40 calendar days of admission.1. Review of the electronic medical record (EMR) revealed that R3 was admitted with pertinent diagnoses including, but not limited to, post traumatic stress disorder, depression (unspecified), persistent mood (affective) disorder (unspecified), suicidal ideations, and generalized anxiety disorder. Review of R3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating R3 was cognitively intact. Section I (Active Diagnoses) revealed anxiety disorder, malnutrition, post traumatic stress disorder (PTSD).Review of R3's care plan dated 7/31/2025 indicated a problem that R3 exhibits behaviors related to suicidal ideations. He is in a depressed mood and is sad about being away from family and his recent admission to the nursing facility. He stated that he does not have a plan but thinks about it. Goals included that R3 will have fewer episodes of behavior by the review date. Interventions included administering medications as ordered and monitoring for side effects and effectiveness, assisting the resident in developing more appropriate coping methods, and encouraging the resident to express feelings appropriately. Caregivers are to provide opportunities for positive interaction and attention, stopping to talk with him when passing by. Behavioral services are to be consulted as needed. Focus: R3 uses psychotropic medications related to psychiatric conditions, mood, depression, and suicidal ideations. Goal: The resident will remain free of psychotropic drug related complications, including movement disorders, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through the review date. Interventions: Administer psychotropic medications as ordered by the physician. Consult with pharmacy and the physician to consider dosage reduction when clinically appropriate, at least quarterly. Discuss with the physician and family the ongoing need for the medication. Review behaviors, interventions, and alternate therapies attempted and their effectiveness per facility policy. Educate the resident, family, and caregivers about risks, benefits, and potential side effects or toxic symptoms. Monitor and record occurrences of target behavior symptoms and document per facility protocol. Review of the Physician's Orders for R3 included but was not limited to: Order dated 1/10/2026: Mirtazapine Tablet 15 mg. Give 1 tablet by mouth once daily for generalized anxiety and insomnia. Order dated 11/20/2025: Hydroxyzine HCl Oral Tablet 25 mg. Give 1 tablet by mouth twice daily for anxiety. Order Note dated 1/12/2026: The order for Mirtazapine Tablet 15 mg, 1 tablet by mouth once daily for generalized anxiety and insomnia, triggered drug protocol alerts/warnings for a drug to drug interaction.During an interview on 1/12/2026 at 2:13 pm with Social Services (SS), she stated she was not certain whether R3 had a PASARR Level II and confirmed that R3's name was not on the PASARR list.During a follow up interview on 1/13/2026 at 10:20 am, Social Services confirmed that after reviewing R3's medical records, R3 did have diagnoses that qualified for a PASARR Level II, but it had not been submitted.During an interview on 1/14/2026 at 11:12 am with the Director of Nursing, it was clarified that the PASARR Level II assessment was used to determine a resident's mental status. This responsibility typically falls under Social Services. 2. Review of the EMR revealed R69 was admitted with pertinent diagnoses including, but not limited to, post traumatic stress disorder (unspecified) and major depressive disorder.Review of R69's quarterly MDS assessment dated [DATE] revealed BIMS score of 15, indicating R69 was cognitively intact. Section D (Mood) revealed little interest or pleasure in doing things; feeling down, depressed, or hopeless; trouble falling or staying asleep or sleeping too much; and feeling tired or having little energy. Section E (Behavior) indicated no behaviors exhibited. Section N (Medications) indicated antidepressant medication use. Section I (Active Diagnoses) also revealed depression and post traumatic stress disorder (PTSD).Review of R69's care plan dated 4/30/2025 indicated a problem that R69 is under the age of 55 and at risk for social isolation. The goal was for the resident to make a positive adjustment with peers through the next review. Interventions included encouraging family visits, encouraging the resident to engage in activities of interest, and providing emotional support and supportive counseling as needed.Review of the Physician's Orders for R69 included but was not limited to: Order dated 1/8/2026: Trazodone HCl Tablet 50 mg. Give 1 tablet by mouth once daily for insomnia/depression. Order dated 1/7/2026: Escitalopram Oxalate Tablet 5 mg. Give 1 tablet by mouth once daily for depression.During an interview on 1/12/2026 at 2:13 pm, Social Services revealed that there was no PASARR Level II for R69, as she was not aware of his diagnosis of PTSD.During a follow up interview on 1/13/2026 at 10:20 am, Social Services confirmed that after reviewing R69's medical records, R69 did have the diagnosis to qualify for a PASARR Level II, but it had not been submitted.During an interview on 1/14/2026 at 10:32 am, R69 stated he would benefit from additional services.

Based on observations, resident and staff interviews, record review, and a review of the facility's policy titled, Activities of Daily Living (ADLs), the facility failed to ensure one of 42 sampled residents (R) (R13) who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and good hygiene. This failure had the potential to decrease R13 self-esteem and contribute to psychosocial distress.Findings include:During a review of the facility's policy titled Activities of Daily Living (ADLs) revised 3/20/2025 revealed under Policy: The facility will, based on resident's comprehensive assessment and consistent with the resident's needs and choices, ensure our residents abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. Under Policy Explanation and Compliance Guidelines: . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility's admission records for R13 revealed diagnoses that included but not limited to peripheral vascular disease, longstanding persistent atrial fibrillation, chronic kidney disease, stage 3, type 2 diabetes mellitus without complications, heart failure, acquired absence of left leg below knee, chronic obstructive pulmonary disease, cognitive communication deficit, depression and need for assistance with personal care.Review of R13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive decline. R13 requires maximal assistance with all ADL care needs.Review of the care plan for R13 revealed a focus area of ADLs: Requires assistance (assist) with Activities of Daily Living debility, decreased mobility, pain, self-care deficit, weakness. He requires the assist of one for ADLs. He is able to participate in his care. Resident will have care needs met daily with assistance of staff as needed. Bed Mobility - staff assistance as needed. Assist as needed with shower twice weekly or per resident preference. Assist resident as needed with proper body alignment while in bed as needed. Continence - assist with incontinent care. Eating: Staff assistance as needed. Encourage resident to participate to the fullest extent possible with each interaction; praise resident for effects and success. Encourage choices with care. Monitor and report changes in physical functioning ability and in ROM ability. Nail care PRN (as needed). Personal Hygiene - Staff assistance as needed. Staff to assist with completion of ADL's on a daily basis. Therapy to eval and treat as indicated. Toilet use: Staff assistance as needed. Use Mechanical Sit to Stand Lift x2 staff assistance for transfer. During an initial observation and interview on 1/11/2026 at 12:17 pm revealed R13 fingernails with a buildup of black/ dark brown substance under the nails and each nail was long and unkempt. R13 stated it's been over a month since they were cleaned or cut, and it needs cutting.Observation on 1/12/2026 at 9:09 am revealed R13's fingernails had not been addressed. Nails remained long and unkempt with black/ dark brown substances packed underneath each nail on both hands. Observation completed on 1/13/2026 at 1:29 pm accompanied by the Director of Nursing (DON) revealed R13's fingernails remained dirty with black/ dark brown substance underneath each nail, all nails long and uneven. The DON confirmed the findings and stated that there is no reason for it to be like this, I will take care of it immediately. He revealed that it was the Certified Nursing Assistant's (CNA) job to ensure resident's grooming was completed with ADL care.An interview on 1/14/2026 at 9:48 am with CNA AA revealed that R13 had on occasion requested to have his nails cleaned and cut. She revealed that she had cleaned and cut his nails in the past but not recently. She stated that sometimes due to R13 being in pain or having swelling in his hands, she did not do nail care often. She denied reporting this to the nurse.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Accidents and Supervision, the facility failed to ensure the environment remained free of accident hazards. Specifically, the facility allowed an electrical appliance capable of producing heat (a clothes iron) to be present and accessible in one resident's (R) (R85) room on a unit that housed residents with wandering behaviors. This deficient practice had the potential to cause burns and fire-related injury.Findings include:Review of the facility policy titled Accidents and Supervision revised 2/1/2024 revealed under Policy: The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes: 1. Identifying hazard(s) and risk(s). 2. Evaluating and analyzing hazard(s) and risk(s). 3. Implementing interventions to reduce hazard(s) and risk(s). Under Identification of Hazards and Risks: The process through which the facility becomes aware of potential hazards in the resident environment and the risk of a resident having an avoidable accident. a. All staff . are to be involved in observing and identifying potential hazards in the environment . b. The facility should make a reasonable effort to identify the hazards and risk factors for each resident.Review of the electronic medical record (EMR) revealed R85 was admitted to the with diagnoses including but not limited to right-sided hemiplegia and hemiparesis following a cerebral infarction, epilepsy, unspecified convulsions, aphasia and fluency disorder following cerebral infarction, generalized muscle weakness, and major depressive disorder.Review of R85's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated R85 was cognitively intact. Section GG, functional status, revealed R85 was impaired to one side requiring supervision or touching assistance with Activities of Daily Living (ADLs).Review of R85 care plan dated 1/11/2026 indicated a problem of risk for injury due to decreased mobility, need for staff assistance with ADLs, seizure disorder, communication impairment, fall risk, and smoking-related hazards. Goals included but not limited to remaining free from injury, maintaining safe transfers and bed mobility, being able to communicate basic needs, and avoiding burns or fire-related injuries. Interventions included but not limited to assisting with ADLs as needed, observing the resident while shaving, providing staff supervision during transfers and bed mobility, implementing seizure precautions, ensuring a safe environment with call light in reach and bed in lowest position, monitoring for signs of burns or unsafe smoking practices, and documenting changes in physical functioning.Review of the Physician Orders for R85 included but was not limited to:Order dated 6/20/2025 for behavior monitoring: monitor and document behaviors, number of episodes, interventions, outcomes, and side effects every shift due to verbal aggression, anxiety, depression, agitation, and other behavioral concerns. Interventions include redirection, environment changes, diversion, toileting, and setting limits. Order dated 11/10/2025 for behavioral intervention: resident frequently displays verbal aggression; interventions include moving to a calmer environment and verbal redirection. Document any acute changes or difficulty with redirection. Order dated 11/12/2025 for Topiramate 50 mg BID (twice a day): administer as prescribed for seizure management, observe for seizure activity, implement seizure precautions.Order dated 11/12/2025 for Lexapro (escitalopram) 20 mg daily: monitor mood and behavior, administer as prescribed.Order dated 12/10/2025 for Buspirone 5 mg BID (twice a day): monitor anxiety and behavioral symptoms, administer as prescribed.Order dated 12/20/2025 for Trazodone 100 mg nightly: administer as prescribed for mood support, monitor for sedation or behavioral side effects.Observation on 1/11/2026 at 1:50 pm with R85 in his room revealed a clothes iron, plugged in, positioned on the windowsill next to his bed.Observation on 1/12/2026 at 12:12 pm of R85's room confirmed that the clothes iron remained on the windowsill beside his bed. Observation and interview on 1/12/2026 at 1:50 pm with R85, in the presence of Licensed Practical Nurse (LPN) II, verified the presence of a clothes iron on the windowsill. R85 stated that the iron was functional and that he used it to iron clothes on top of his bed. He also stated that staff were aware of the iron.Review of R85's progress notes dated 1/12/2026 revealed a care plan meeting conducted with R85 and his sister regarding acceptable equipment for resident use, safe practices, and inventory of personal belongings.Interview on 1/12/2026 at 1:54 pm with LPN II revealed that she denied being aware that resident had a clothes iron and did not notice it positioned on the windowsill.Interview on 1/12/2026 at 2:15 pm with the Director of Nursing (DON) revealed that he was not aware that R85 had a clothes iron in his room. Follow-up interview at 3:17 pm confirmed that the clothes iron was removed from R85's room and placed in the DON's office. The DON reported that staff had been in-serviced regarding hazardous items, a facility-wide audit of resident rooms is being conducted, and a list of residents who wander is being compiled. The DON also confirmed that R85's family did not provide the iron.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to implement the Care Plan related to a mechanical lift transfer for one of three residents (Resident (R)7) reviewed for mechanical lift transfers in a total sample of 14 residents. The deficient practice placed the residents at risk of harm due to the inappropriate transfers.Findings include:Review of the facility policy titled, Comprehensive Care Plans, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.Review of the 4/30/2025 Activities of Daily Living Care Plan located in the Care Plan tab of the EMR revealed, Use Mechanical Lift for transfers x2 staff assistance.Review of the facility investigation dated 6/17/2025 revealed, CNA [certified nurse aide] stated that during transfer from wheelchair to bed, the resident slid to the floor. R7 stated, It was because I had on these socks. R7 denied hitting his head and denied any pain. Resident stated, while laughing, I slid off the bed when she was trying to put me in bed because of the socks on me.I'm okay, I slid down on my butt.During an interview on 8/18/2025 at 3:12 pm, the Director of Nursing (DON) was asked if CNA4 transferred R7 without the mechanical lift and another staff person. The DON stated, Yes, but I think this was updated after the fall. The DON was told that the mechanical lift intervention with two staff was on the care plan at the time of admission. The DON stated, Ok.

Based on observations, staff interviews, and record review, the facility failed to follow nutrition orders for one of three residents (Resident (R)5) reviewed who received nutrition via a feeding tube. This failure placed R5 at risk for health complications and weight loss.Findings include:Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was readmitted to the facility with a diagnosis of spastic quadriplegia cerebral palsy (a severe form of cerebral palsy that affects all four limbs and the trunk).Review of the revised 9/4/2023 Feeding Tube Care Plan located in the Care Plan tab of the EMR revealed, R5 is receiving fluids and nutrients via a tube secondary to Dysphagia Swallowing [difficulty swallowing] problem.Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 6/17/2025 revealed that R5 had a both a gastrostomy tube (feeding tube in the stomach) and a jejunostomy tube (feeding tube in the jejunum which is part of the small intestine) for nutrition. She was assessed as being severely cognitively impaired.Review of an Order Summary dated 7/10/2025 located in the EMR under the Orders tab by the Registered Dietician (RD) revealed, Every 24 hours for nutrition Osmolyte 1.5 Continuous: Give formula at 32ml/hour (milliliters per hour) via j-tube [jejunostomy]. In addition, R5 was to have a one hour stop time for staff to check for residual [to see if there was formula that had not been digested].During an observation on 8/18/2025 at 2:15 PM, R5's tube feeding pump was turned off and the feeding tube was disconnected from the pump however, the container of Osmolyte 1.5 was still hanging on the pole. Licensed Practical Nurse (LPN)3 entered the room with a new container of Osmolyte 1.5 and began to hang the container on the pole. LPN3 was asked how long was R5 to have her feeding tube pump off during the day. LPN3 stated, It's off from 10:00 AM to 2:00 PM each day.During an interview on 8/20/2025 at 2:15 PM, the [NAME] President (VP) for Nutrition was asked if R5 was to have her tube feedings held from 10:00 AM to 2:00 PM per the nurse's statement. The VP stated, The only order I have is for her to have the tube feedings held for one hour and then check for residuals. The VP further stated, I think she (RD) mentioned at one point there was a 10-2PM hold on the tube feedings, when she returned from the hospital however, we did not have Osmolyte 1.2 and only had Osmolyte 1.5, so she converted the Osmolyte 1.5 to meet the same nutrition values as the Osmolyte 1.2. The RD wanted it to be run continuously at 32ml/hour as R5 experiences vomiting.During an interview on 8/20/2025 at 2:25 PM, LPN4 stated, I wrote the order (for the tube feedings) when she came back from the hospital. She had an order for Osmolyte 1.2, but we only had Osmolyte 1.5 so, the RD came in and wrote a new order for Osmolyte 1.5 at 32ml/hour continuously.Review of the Discontinued Orders located in the Order Summary tab of the EMR revealed, Jevity 1.5 at 55ml/hr. for 20 hours a day. On at 2PM and off at 10AM. Start date: 10/16/2024 and discontinued on 7/1/2025.During an interview on 8/20/2025 at 2:36 PM, the Director of Nursing (DON) was asked what his expectation was regarding following the RD's nutrition orders. The DON stated, My expectation is that the orders are to be followed.

Based on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP) for two of 14 sampled residents (Residents (R) 5 and R9). The facility failed to utilize EBP for R5 and R9, who shared a room and had both gastric and jejunostomy feeding tubes for nutrition. This failure placed the residents at risk of increased transmission of infection.Findings include:1. Review of the admission Record located in the Profile tab of the electronic medical record (EMR) revealed R5 was admitted to the facility with a diagnosis of spastic quadriplegic cerebral palsy (a severe form of cerebral palsy).Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 6/17/2025 revealed R5 was assessed by staff to be severely impaired in cognition and had a feeding tube for nutrition.Review of the Feeding Tube Care Plan revised 9/4/2023 located in the Care Plan tab of the EMR revealed, R5 is receiving fluids and nutrients via a tube secondary to dysphagia, swallowing problem. An 11/3/2024 Intervention included, Enhanced Barrier Precautions.During an observation and interview on 8/19/2025 at 2:38 PM, Registered Nurse (RN)1 entered R5's room and provided oral care. RN1 did not wear a gown when providing resident care. RN1 confirmed she did not utilize EBP.2. Review of the admission Record located in Profile tab of the EMR revealed R9 was admitted to the facility with a diagnosis of cerebral palsy.Review of the annual MDS located in the MDS tab of the EMR with an ARD of 6/5/2025 revealed R9 was assessed by staff to be severely impaired in cognition and was provided nutrition through a feeding tube.Review of the Feeding Tube Care Plan revised 9/26/2023, located in the Care Plan tab of the EMR revealed, R9 is receiving all fluids and/or nutrients via a tube secondary to dysphagia, DZ [disease] process. An 11/3/2024 intervention included Enhanced Barrier Precautions.During an observation and interview on 8/19/2025 at 2:43 PM, CNA7, after finishing washing R5's face, obtained a new washcloth and provided care to R9. CNA7 stated, I was not made aware of the need for EBP when caring for R5 or R9.During an interview on 8/19/2025 at 4:30 PM, the Director of Nursing (DON) stated, There should have been a sign on the door and staff should have utilized the PPE [personal protective equipment.]

Based on observations, staff and resident interviews, and the review of the facility policy titled, Pest Control Program, the facility failed to maintain an effective pest control program in five of eight resident rooms (Rm102,103,403,407,506). Findings include: Review of the facility policy titled, Pest Control Program revised date 2/16/2024, under Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Under Policy Explanation and Compliance Guidelines: number 4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal regulations. An interview on 3/7/2025 at 12:13 pm with Resident (R) R2 confirmed she sees roaches every day and she tries to kill them, but they are faster than her. R2 revealed that she must shake her clothes when she removes them from the dresser drawers. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed R2 had a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident had little to no cognitive impairment. Review of a undated Quality Assurance and Performance Improvement (QAPI) meeting notes, revealed under the Agenda Items section Grievance: Resident Council Minutes revealed no trend identified for pest control- (Company Name). Review of the facility's Pest Sighting Logs dated from 8/2021 to 3/2025 revealed a report of 207 pest sightings of ants, gnats, roaches, and spiders. Specifically, there were five reported ants and roaches sighting from 3/1/2025-3/6/2025. Review of the Community Weekly Operational Report dated 1/10/2025 to 3/6/2025 for Physical Plant/Environment revealed for the weeks of 1/10/2025 and 1/15/2025, under Compass Care Highlights for pest control issues in rooms (101, 403, 405, 504) Expressed to (exterminating company). However, no other address for Physical Plant/Environment pest control was mentioned for the weeks following. Review of Pest Control Technician Service Inspection report# 1122099 dated 12/18/2024 and #1129073 dated 1/8/2025, revealed in tech comments: There are multiple places that could benefit from sanitation, like nurses' desk, dresser inside patient rooms, and patient restroom. There are multiple rooms that need cleaning in order to help get the roach activity under control. Review of Pest Control Technician Service Inspection report# 1136037 dated 2/5/2025, revealed in tech comments that 103,403 has major issues inside dressers and sink area. The unit also has sanitation issues. Observations on 3/7/2025 at 11:37 am revealed in room [ROOM NUMBER] several small and medium-sized roaches crawling on the floor, climbing on the wall, and the sink counter. Observation walking rounds were conducted on 3/7/2025 starting at 2:00 pm to 2:21 pm in Rm102,103,403,407, and 506 with the Housekeeper Director, Administrator, and the [NAME] President (VP) of Clinical Service for the environmental, sanitation, and pest control sightings. It was confirmed that in all five (5) of the rooms, there were sightings of live and dead small to medium-sized brownish/black roaches in resident dresser drawers, cabinets, sink counters, floors, and on the walls. An additional observation with the Administrator confirmation revealed in room [ROOM NUMBER] a spider in the resident cabinet near the sink counter. Interview on 3/7/2025 at 11:47 am Housekeeper AA revealed she was informed twice this week by a couple of residents of a sighting of roaches in their rooms. Housekeeper AA shared that when she is informed of a pest sighting, she enters the room number and concern in the pest book at the nurse station. Interview on 3/7/2025 at 4:15 pm with the Administrator (the Regional [NAME] President present for support) revealed he is aware of the infestation issue. So, to address concerns, the facility completes daily rounds that are conducted with the charge nurse, and when pest technicians come to provide treatment, he is accommodated. The administrator shared that the Community Weekly Operational report is not all-encompassing to address each room, but the report does address direct concerns. Interview on 3/7/2025 at 4:52 pm with the Pest Control Technician CC revealed the facility does have a roach issue, and it is due to the sanitation of the facility. The Technician explained that when conducting treatments, he observed food at the nurses' station and inside the resident's dresser drawer. The Technician confirmed, based on his observation, that the dresser drawer has never been cleaned; he sprayed the treatment, but the roaches came back due to the dresser drawer not being cleaned or moved. Technician CC shared that the treatment is effective for 90 days leaving a residue, however the issue will not go away until the sanitation is fully addressed.

Based on observations, record review, and staff and resident interviews, the facility failed to ensure two of 45 sampled residents (R) (R51 and R38) call lights were accessible and placed within their reach while in bed. This deficient practice had the potential to cause delayed assistance, medical attention and worsening of the residents' medical conditions. Findings include: 1. Review of the Electronic Medical Record (EMR) for R51 revealed diagnoses that included but not limited to aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting the left non dominant side, muscle weakness, difficulty walking and need for assistance. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns), a Brief Interview of Mental Status (BIMS) revealed, R51 had a memory problem; Section GG (Functional Abilities and Goals) revealed, R51 required substantial /maximum assistance for toileting hygiene, bath, upper body dressing, personal hygiene and dependent on staff for lower body dressing and transfers. Observation on 1/6/2025 at 10:54 am revealed, R51 lying in bed with the call light observed on the floor beside bed. Observation on 1/6/2025 at 12:00 pm revealed, R51 lying in bed with the call light observed on the floor beside bed. Observation on 1/6/2025 at 3:00 pm revealed, R51 lying in bed with the call light observed on the floor beside bed. Interview on 1/6/2025 at 3:13 pm with Registered Nurse (RN) JJ confirmed the call light was on the floor beside R51's bed. She revealed, the call light should not be on the floor and should be on R51's bed and accessible to him. She further stated she should have clamped the call light on R51's pillow or his bedsheets beside him so that he could have access to the call light. Interview on 1/6/2025 at 3:17 pm with Certified Nursing Assistant (CNA) KK confirmed the call light was on the floor beside R51's bed. She revealed, she attended to R51, and did not see the call light on the floor. She stated it should not be on the floor, and it should have been clamped on R51's pillow or bedsheet so that he could have access to it. Interview on 1/7/2025 at 1:31 pm with the Unit Manager (UM) MM revealed, the call lights should be in place for the residents to use. She stated her expectations were for the CNAs and the nurses to ensure the call lights were in place and accessible to the residents. She stated the CNAs do rounds every two hours and the nurses do rounds continually on the floor. She stated the call lights should be clipped on to the residents' pillows or their bedsheets as close to the residents as possible for them to access it. She further stated the outcome if the call lights were not in place could possibly cause harm to the residents if they did not have access to the call lights and needed help. Interview on 1/7/2025 at 1:39 pm with Director of Nursing (DON) revealed, his expectations were for the call lights to always be accessible to the residents. He stated anyone who goes into the residents' rooms should ensure the call lights were accessible to the residents. The DON further stated that primarily the nurses and CNAs were the ones who should ensure the call lights were always accessible to the residents. He stated the outcome if the call lights were not accessible to the residents would be a delay in care and it may also lead to grievances from the residents or family members. He stated it could also increase the level of dissatisfaction with the level of care provided by the facility. 50170 2. Review of the EMR for R38 revealed diagnoses that included but not limited to Parkinson's disease, dysphagia, contracture of muscle to the left upper arm and contracture of muscle to the right upper arm. Review of the Quarterly MDS dated [DATE] for Section C (Cognitive Patterns) revealed, a BIMS of 10 which indicated the resident was moderately impaired; Section GG (Functional Abilities and Goals) revealed, R38 required substantial /maximum assistance for toileting hygiene, bath, upper body dressing, personal hygiene and dependent on staff for lower body dressing and transfers. Observation on 1/8/2025 at 1:25 pm revealed, there were no staff members present in the hallway or the residents' rooms in the locked dementia unit. Upon entering R38's room, the resident was lying in bed with a substance, appearing to be food, coming from his mouth and onto his clothes and shoulder. The resident began to cry when approached. When asked what was wrong, the resident continued to cry. His call light was lying on the side of his bed near his head, but due to his contracted condition, he was unable to reach it. Observation and interview on 1/8/2025 at 1:30 pm revealed, R38 lying in bed with vomit on his mouth and clothing. When R38 was questioned, if he was, okay? he mumbled a response. R38 was asked if he could press his call light, and he mumbled, Yes. When prompted to demonstrate, the resident was unable to push the call light due to his contracted condition. Interview on 1/8/2025 at 1:43 pm with CNA CC and CNA DD about R38's ability to call for assistance. CC stated that although R38 is contracted, You may not believe me, but this man can use his arm. CNA CC attempted to demonstrate this by pulling the covers down, but the resident did not move his arm. When asked how R38 typically calls for help, CNA CC responded that he would usually yell for assistance. CNA CC admitted that the call light was not in the proper position for the resident to use it and expressed uncertainty as to why it had been placed in a higher position. CNA DD explained that she was usually stationed near R38's room to monitor him for help as needed. However, when asked why no staff were present in the hallway or rooms at the time of the observation, CNA DD stated that she had been assisting another resident. CNA DD confirmed that R38 does not use the call light but instead typically says hey to get the staff's attention. Further interview, with CNA CC when asked again to demonstrate how R38 could call for help, CNA CC became defensive, stating, I don't know, this isn't usually my patient, but since y'all think I'm lying, I'm just going to leave. CNA DD then reiterated that R38 does not press the call light button and instead uses his voice to alert staff. During an interview on 1/8/2025 at 4:07 pm with the Director of Nursing (DON) revealed, that that R38 was able to press his call light when it was placed on his shirt, but not very often. DON revealed that he had personally answered R38's call light a couple of times. During an interview on 1/9/2025 at 10:32 am with the Restorative Aide, EE regarding R38's call light usage, she mentioned that while he initially did not use the call light, he has adapted to using a flat call device operated with his chin. She expressed confidence that the flat call device currently in place adequately meets his needs. Restorative Aide, EE believes that while R38 has pressed the call light using his contracted hand in the past, it may have been accidental, as he typically yells for assistance when needed. A policy was requested however, the facility's personnel stated there was no policy on call lights.

Based on observations, resident and staff interviews, record review, and review of the facility-provided document titled Your Rights and Protections as a Nursing Home Resident, the facility failed to honor the resident's right to make a choice for one of 45 sampled residents (R) (R8) related to returning to bed for a nap. The deficient practice had the potential to place R8 at risk for unmet care needs and a diminished quality of life. Findings include: A review of the undated facility-provided document titled Your Rights and Protections as a Nursing Home Resident revealed the What are my rights in a nursing home? section included Be Treated with Respect: . You have the right to decide when you go to bed, rise in the morning, and eat your meals. A review of R8's electronic medical record (EMR) revealed diagnoses included a cerebrovascular accident (CVA) with right-sided hemiparesis, hypertension, type 2 diabetes mellitus, depression, anxiety, dementia, insomnia, and muscle weakness. A review of R8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section GG (Physical Abilities and Goals) documented the resident was dependent for transfers. A review of R8's Annual MDS assessment dated [DATE] revealed Section F (Preferences for Customary Routine and Activities) documented it was very important for the resident to make his own choices. A review of R8's Physician's Orders revealed no order or intervention for the resident to sit up in a wheelchair for eight hours a day. A review of R8's care plan dated 5/22/2019 revealed a Focus on activities of daily living (ADL) function, including The amount of care may vary from day to day. Interventions included allowing the resident to make choices and offer positive reinforcements when indicated. Observation on 1/6/2025 at 9:27 am revealed that R8 was asleep and leaning forward in a wheelchair in his room. Observation and interview on 1/6/2025 at 10:04 am revealed that R8 was sitting in his chair in his room. He stated he was ready to be put back to bed and pushed his call light for assistance. Observation on 1/6/2025 at 10:10 am revealed Certified Nursing Assistant (CNA) II entered the R8 room and closed the door. Observation on 1/6/2025 at 11:00 am revealed R8 was sitting in his wheelchair in his room. In an interview with R8 on 1/6/2025 at 11:58 a.m., he stated that the facility staff would not assist him back to bed until after lunch. He stated he desired to take a catnap before getting back up for lunch. He further stated that he did not always want to take a nap before lunch, but he would like to from time to time. In an interview on 1/7/2025 at 4:17 pm, CNA II stated she recalled R8 did ask to be put back to bed on 1/6/2025, and later that day, he asked again. She stated she preferred he wait until after he ate his lunch to be put back to bed so she didn't have to keep getting him up and putting him back. She stated she understood his rights. In an interview on 1/8/2025 at 3:13 pm, Registered Nursing (RN) GG stated that if a resident requested to lie down, it was their right to do so. RN GG further stated she did not know why CNA II would refuse to put R8 to bed as much as he would like. In an interview on 1/9/2025 at 4:22 pm, the Director of Nursing (DON) stated that if a resident wanted to lie down, they should be allowed to do so.

Based on staff interview and record review, the facility failed to accurately code a fall with major injury on the Minimum Data Set (MDS) for one of three residents (R) R14 reviewed for accidents. This failure had the potential to place R14 at risk for additional falls and an adverse effect on her quality of life and quality of care. Findings include: Review of R14's Admission Record revealed, diagnoses that included but were not limited to other fracture of upper end of left tibia, subsequent encounter for closed fracture with routine healing and other fracture of upper and lower end of left fibula, subsequent encounter for closed fracture with routine healing, dated 8/21/2024. Review of the Electronic Medical Record (EMR) revealed, R14 sustained a fall on 8/13/2024 when she attempted to get out of bed without calling for assistance. The x-rays revealed, a proximal fracture to the left tibia. R14 was hospitalized and treated without surgical intervention. R14 returned back to the facility on [DATE]. Review of the quarterly MDS assessments, dated 8/19/2024, 10/23/2024, and 11/25/2024 for Section J (Health Conditions) revealed, the omission of the fall sustained on 8/13/2024. Interview on 1/9/2025 at 3:33 pm with the MDS Coordinator confirmed the fall was not captured during those assessments and should have been. She stated, she would make the corrections immediately.

Based on observations, staff interviews, record review, and review of the facility's policy titled Restorative Nursing Programs, the facility failed to revise the care plan that addressed the refusals of restorative nursing services for one of 45 sampled residents (R) R8. Specifically, the facility failed to revise the care plan that included alternative interventions for splint usage and Range of Motion (ROM) exercises. Findings include: Review of the facility's policy titled Restorative Nursing Programs, dated 2/1/2024 revealed, 10. A resident's Restorative Nursing plan will include: (a.) The problem, need, or strength the restorative tasks are to address. (b.) The type of activities to be performed. (c.) Frequency of activities. (d.) Duration of activities. (e.) Measurable goal and target date. Review of R8's clinical records revealed diagnoses that included cerebrovascular accident (CVA) with right-sided weakness and contractures of the right upper and lower extremities. Review of R8's physician orders dated 9/4/2019 revealed, Resident presents with right knee contracture, and would benefit from a right knee contracture splint to increase ROM and prevent/correct contractures, and deformities of the right knee; Resident presents with right wrist/hand contracture and would benefit from a contracture splint to increase ROM and prevent/correct contractures and deformities of the right wrist/hand. Review of R8's care plan with revision date of 9/26/2023 revealed, ADL function: [Resident Name] is at risk for Alteration in ADL (Activities of Daily Living) care r/t (related to) his h/o (history of) CVA with right sided weakness and vision deficit to right eye. He has contracture to RUE (right upper extremity) and RLE (right lower extremity). He is able to participate in his care minimally. Staff will adjust and assist. Often refuses ADL care and shower even though he is encouraged. Interventions included but not limited to Range of motion as ordered by PMD (date initiated 9/26/2023) and splints as ordered to right hand/right knee (date initiated 9/26/2023 with revision date of 11/3/2024). However, the care plan did not address R8's refusals of restorative care, including splint use, nor did it document any alternative interventions or strategies to encourage participation. Observation on 1/6/2025 at 9:28 am revealed, R8 was observed in his room in a wheelchair, sleeping and not wearing a splint to his right hand/wrist or right knee. Observation on 1/7/2025 at 4:17 pm revealed, R8 was observed in the dining room not wearing a splint to his right hand/wrist or right knee. Observation on 1/8/2025 at 10:35 am, revealed, R8 was observed in the dining room not wearing a splint to his right hand/wrist or right knee. Interview with Registered Nurse (RN) GG on 1/9/2025 at 3:13 pm revealed, she had been at the facility since March 2024 and did not recall R8 having a splint or restorative services documented in his care plan prior to the survey. She later identified a note, revised on 1/9/2025, indicating refusals for splint use. Interview with Restorative Aide FF on 1/9/2025 at 3:15 pm revealed, she did not provide services for R8 unless explicitly documented in the care plan. She revealed, R8 often refused restorative care, which led to the service not being provided consistently. She confirmed that there was no prior documentation of refusals or interventions for refusal of restorative services in R8's records. During an interview on 1/9/2025 at 3:35 pm with the Minimum Data Set (MDS) Coordinator when asked about R8's care plan, regarding the use of a splints for his contractures and any documentation related to his refusals and interventions, the MDS Coordinator confirmed that splint use and resistance had been recently updated in the care plan as of 1/9/2025. The MDS Coordinator also confirmed that when R8's refuses the splint, staff were instructed to encourage him and document his refusals. The MDS Coordinator revealed, alternative interventions such as adjusting the splint or providing additional support, were not previously mentioned in the care plan however, the updated plan included specific language regarding his refusals and strategies for encouraging compliance. The MDS Coordinator emphasized that these updates were made to ensure accurate documentation and alignment with R8's current needs and behaviors. Cross Reference F688, F842

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Activities of Daily Living, the facility failed to provide activities of daily living (ADL) care for three of 45 sampled residents (R) (R8, R38, and R16) according to the resident's care needs. Specifically, the facility failed to ensure R8 and R38 received nail care and failed to ensure R16 received a bath or shower. This deficient practice had the potential to place R8, R38, and R16 at risk for unmet needs and a diminished quality of life. Findings Include: A review of the facility's policy titled Activities of Daily Living, dated 2/1/2022, revealed the Policy section included . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care. The Policy Explanation and Compliance Guidelines section included . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. A review of R8's Electronic Medical Record (EMR) revealed diagnoses included a cerebrovascular accident (CVA) with right-sided hemiparesis, type 2 diabetes mellitus with diabetic cataracts, legal blindness, and muscle weakness. A review of R8's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 14 (indicating little to no cognitive impairment). Section GG (Physical Abilities and Goals) documented upper and lower extremity impairment on one side and required substantial/maximal assistance for personal hygiene. A review of the care plan revealed a Focus area initiated on 5/22/2019 and revised on 9/26/2023 of ADL function, indicating the resident was at risk for alteration in ADL care due to CVA and vision deficit. Interventions/Tasks included communication to all staff regarding resident special care needs and goals. Observation on 1/6/2025 at 10:04 am revealed that R8 was sitting in his chair with his right hand contracted and his fingernails dirty and long and digging into the skin. Observation on 1/7/2025 at 4:11 pm revealed R8 was in the dining room, and his fingernails remained long and dirty. In an interview on 1/7/2025 at 4:17 pm, Certified Nursing Assistant (CNA) II confirmed R8's fingernails were long and dirty. She stated she had not noticed his nails being long and dirty. She further stated since R8 was diabetic, she would notify the nurse. Registered Nursing (RN) GG stated she could attempt to cut R8 nails, but due to their thickness, she would need to consult the podiatrist. RN GG confirmed that it was not a good idea to leave R8's nails so thick and long. RN GG asked R8 if he would be okay with getting his nails clipped, and R8 responded, Yes, it's hurting me really bad. In an interview on 1/8/2025 at 12:38 pm, the Director of Nursing (DON) revealed he expected resident shower days to include observations of nails to ensure residents were groomed appropriately. The DON stated if the shower was refused, observation of nails and hair should be documented on the shower sheet. He further stated nails should not grow to the length that they curl unless the resident wants them to, and the outcome included overgrown nails, which can be unsightly, and a buildup of dirt, which could be a health risk. 50170 2. A review of R38's EMR revealed diagnoses included Parkinson's disease, osteoarthritis, diabetes mellitus, muscle weakness, and contracture of muscle right and left upper arm. Review of R38's Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS of 10 (indicating moderate cognitive impairment). Section GG (Functional Abilities) documented R38 was dependent for ADL care, including personal hygiene. Review of the care plan dated 12/9/2024 revealed a Focus area of the resident was dependent with ADLs and care. Interventions/Tasks included ensuring the resident is groomed daily. Observation on 1/8/2025 at 1:33 pm revealed R38's nails appeared long, unclipped, and with dirt and debris built up on the thumb, and his hand was contracted. Observation on 1/8/2025 at 4:06 pm revealed R38's nails appeared to have been cleaned but were still long and unclipped. In an interview on 1/8/2025 at 1:43 pm, CNA DD confirmed they did need to do something about his nails. In an interview on 1/8/2025 at 4:07 pm, the DON acknowledged the resident's nails needed care due to them being unkept. In an interview on 1/9/2025 at 2:49 pm, CNA DD and Licensed Practical Nurse (LPN) NN revealed they provided nail care on R38's shower days on Tuesdays, Thursdays, and Saturdays. They stated R38 refuses to have his nails clipped. They further stated that hospice was responsible for bathing the resident and providing nail care, and it was also the facility's responsibility to provide nail care. LPN NN asked R38 if he would like his nails clipped and if his nails bothered him, and R38 replied, Yes. LPN NN declined to acknowledge the length of R38's nails and stated that they monitor him to ensure his nails aren't digging into his skin. In an interview on 1/9/2025 at 3:07 pm, the DON confirmed R38's nails had dirt and debris on them and declined to confirm how long R38's nails were. 38154 3. Review of R16's EMR revealed diagnoses to include hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, dementia, hypertensive retinopathy, seborrheic dermatitis, and psoriasis vulgaris. Review of R16's Quarterly MDS assessment dated [DATE] revealed Section C (Cognitive Patterns) documented a BIMS score of 11 (indicating mild cognitive impairment). Section E (Behavior) documented no behaviors. Section GG (Functional Abilities and Goals) documented R16 required partial to moderate assistance for oral hygiene and substantial to maximal assistance for toileting hygiene, shower/bathe self, lower body dressing, footwear, personal hygiene, and shower/tub transfer. Review of the care plan revealed a Focus area revised on 9/2/2021 of the resident was at risk for alteration in care related to impaired mobility and cognitive deficit. Staff will provide and adjust care as needed. The Goal was for R16 to appear clean, well-groomed, and dressed as per preferences. Interventions/Tasks included communication to all staff regarding the resident's special care needs and goals, encouraging the resident to participate to the fullest extent possible with each interaction, and establishing customary routine for ADLs that is agreeable to the resident. In an observation and interview with R16 on 1/6/2025 at 12:06 pm in his room, he was alert, oriented, and pleasant. Observation revealed the skin on his right arm was dry and scaly, his face was ashen, and debris was noted on his pillow and bedsheets. When asked if he received regular showers, he stated he did not. He stated his shower schedule was Tuesday, Thursday, and Saturday and that he did not get his shower last Saturday (1/4/2025). In an observation and interview with R16 in his room on 1/7/2025 at 11:42 am, he was alert, oriented, and pleasant. Observation revealed his skin was dry and ashen. He stated he did not have a shower today, but he could not recall if he had one yesterday. Review of the CNA Bath and Skin Audit Tool dated October 2024 to date revealed R16 received four showers in October 2024 (10/10, 10/14, 10/22, 10/24), one shower in November 2024 (11/7), seven showers in December 2024 (12/2, 12/4, 12/13, 12/18, 12/20, 12/25, 12/31), and two showers in January 2025 (1/2 and 1/6). In an interview with LPN LL on 1/7/2025 at 11:00 am, she stated the shower schedule was posted at each nurse's station and staff should report any missed or refused showers to the nurse. She stated the nurse would then visit with the resident to confirm the refusal, find out the reason, and try to determine a more suitable time for the resident to shower. She further stated the nurse should notify the charge nurse, the DON, and the Responsible Party (RP). She stated the shower should include shampoo, shave, and nail care. Finally, she stated the nurse had to sign off on all shower sheets. In an interview with CNA FF on 1/07/2025 at 11:15 am, she stated resident showers were scheduled twice a week and always included shampoo, shave, and nail care. She stated she would report missed showers or refusals to the nurse. In an interview with CNA II on 1/07/2025 at 11:30 am, she stated the CNAs offered showers twice weekly and as needed and included shampoo, shave, and nail care. She stated refusals or missed showers should be reported to the attending nurse. In an interview with LPN HH on 1/9/2025 at 1:19 pm, she stated without shower sheets, there was no way to confirm if a resident received his/her shower. She stated the number of documented shower sheets for R16 revealed he did not receive his showers as scheduled. She further stated that R16 had a history of refusing care, which should be documented on the shower sheets. In an interview with RN GG on 1/9/2025 at 1:46 pm, she stated she expected the nursing staff to perform all scheduled showers and report refusals or missed showers to the attending nurse, who will sign off on all shower sheets, speak with the resident about the reason for the refusal, and notify the Unit Manager, Physician, DON, and the RP.

Based on observation, staff and resident interviews, record review and review of the facility's policy titled Restorative Nursing Programs, the facility failed to provide evidence that restorative services for splinting and range of motion (ROM) were consistently provided for one of four residents (R) (R8) reviewed for rehab and restorative nursing services. Findings include: Review of the facility's policy titled Restorative Nursing Programs, dated 2/1/2024 revealed, 6. Residents, as identified during the comprehensive assessment process, will receive services from restorative aides when they are assessed to have a need for restorative nursing services. These services may include passive or active range of motion, splint or brace assistance, bed mobility training and skill practice, and training and skill practice in transfers or walking. Review of R8's Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognition) revealed, a Brief Interview of Mental Status (BIMS) of 5, which indicated moderate cognitive impairment, Section GG (Functional Abilities) revealed, R8 required substantial /maximum assistance for toileting hygiene, bath, upper body dressing, personal hygiene and dependent on staff for lower body dressing and transfers; and Section O (Special Treatments and Programs) revealed, no restorative services documented. Review of R8's physician orders dated 9/4/2019 revealed, orders for a right knee contracture splint to increase ROM and prevent/correct contractures and a contracture splint to increase ROM and prevent/correct contractures and deformities of the right wrist/hand. Record review of R8's Physical Therapy (PT) discharge summary revealed, that R8 received PT from 1/10/2024 to 3/8/2024; Discharge Recommendations: Restorative Program Established/Trained= Restorative Splint and Brace Program. Passive Range of Motion (PROM) right hand wrist all joints 10x2 reps. Right-hand splint application for four to six hours daily and monitor for pressure areas. Further review of R8's medical records revealed, no documentation that R8 received restorative services. Observation on 1/6/2025 at 9:28 am revealed, R8 was observed in his room in a wheelchair, sleeping and not wearing a splint. Observation on 1/7/2025 at 4:17 pm revealed, R8 was observed in the dining room not wearing a splint. Observation on 1/8/2025 at 10:35 am, revealed, R8 was observed in the dining room not wearing a splint. Interview on 1/6/2025 at 10:40 am with R8 stated he would feel more comfortable if they could put something in his hands, and maybe it wouldn't hurt him so much. Interview on 1/9/2025 at 3:08 pm with R8 revealed, he doesn't recall ever wearing a splint, and he believe if he did, it wouldn't be so bad now. He said he never refused to get any help for his hand, and if possible, he would love to get some help now. Interview on 1/9/2025 at 3:13 pm with Registered Nurse (RN) GG revealed, she had been at the facility since March of last year, and she didn't ever recall R8 having a splint. She was not sure about restorative care if he refused or whether the care plan was being updated, but she would check the electronic medical records (EMR) in the Plan of Care (POC) section. She said that if any restoratives were needed, they would be in the EMR under POC. RN GG stated she was able to find a note that R8 refused splints, saying the word splints with s meant for his lower leg and right hand. RN GG was asked to provide the date. She stated it was revised today, 1/9/2025. Interview on 1/9/2025 at 3:15 pm with Restorative Aide (RA) FF revealed, when asked if she could locate the notes for restorative services for R8, she stated if it's not in the POC, she didn't provide services, and he must have refused. Interview on 1/8/2025 at 4:07 pm with the Director of Nursing (DON) revealed, that R8 was supposed to receive restorative nursing services. He revealed that he was unable to provide any documentation of restorative nursing care, even for the past six months, due to the system acquisition issues. A request was made upon the facility for additional documentation of the restorative nursing program for R8 but was not provided prior to the survey exit. Cross Reference F842, F657

Based on observations, staff interviews, record review, and review of the facility's policies titled, Medication Storage and Storage of Medications, the facility failed to lock two of four (100-Hall and 200-Hall) medication carts when not in use and failed to remove expired medications from two of four (100-Hall and 500-Hall) medication carts. Findings include: Review of facility's policy titled Medication storage dated 2/14/2024 revealed, Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (ie. Medication carts .). Review of facility's policy titled Storage of Medications dated 8/2024 revealed, 1. General Guidelines: 8. Outdated .medications . are immediately removed from inventory, disposed of according to procedure for medication disposal . 1. Observation on 1/7/2024 at 9:32 am revealed, the medication cart on the 100-Hall was left open and unattended during medication administration after Registered Nurse (RN) JJ removed medications from the medication cart and went into a resident's room without locking the medication cart. Observation on 1/7/2024 at 10:20 am revealed the medication cart on the 200-Hall was left open and unattended during medication administration after RN JJ removed medications from the medication cart and went into a resident's room without locking the medication cart. Interview on 1/7/2025 at 10:52 am with RN JJ revealed, the medication cart was not locked and was left unattended on the 100 and 200 halls. She stated she should not have left the medication cart open and unattended because someone could go in the cart. She stated, if a resident opened the cart, they would have access to the medications, and it could lead to a bad outcome for the resident. Interview on 1/8/2025 at 9:10 am with Director of Nursing (DON) revealed, his expectations was for the medication carts to be locked at all times when not in use. He stated the outcome would be the medication in the medication cart would be accessible to any unauthorized person such as visitors, unlicensed staff or residents. He stated if residents accessed the medications in the medication cart, they could experience adverse medical events. Interview on 1/8/2025 at 11:52 am with Unit Manager (UM) MM revealed, the medication cart should not be left open, and it should be locked by the nurse when not in use. She stated the outcome would be someone could possibly get in the medication cart when it was left open. She stated if a resident takes the medication from the cart because it was left open, the resident could get sick and need to be hospitalized . 2. Observation on 1/8/2025 at 10:50 am revealed, the 100 Hall cart had four bottles of expired medications. There were two bottles of iron tables which expired on 12/2024, one bottle of aspirin which expired on 12/2024 and one bottle of ferrous sulfate tables which expired on 12/2024. Observation on 1/8/2025 at 12:33 pm revealed, the 500 Hall cart had two bottles of expired medications. There was one bottle of iron tables which expired on 12/2024 and one bottle of pro-stat which expired on 9/2023. Interview on 1/8/2025 at 11:00 am with RN JJ confirmed the expired medications were in the medication cart. She stated that expired medications should not be in the medication cart. She further stated if the residents were administered the expired medications, they could possibly get sick. Interview on 1/8/2025 at 12:35 pm with Licensed Practical Nurse (LPN) LL confirmed the expired medications were in the medication cart. She stated that expired medications should not be in the medication cart. She further stated it was a medication error to administer expired medications to residents and it could cause complications if the residents were administered the expired medications. She also stated there could be adverse reactions to the residents if the residents received the expired medications. Interview on 1/8/2025 at 12:48 pm with UM HH for the 500-Hall revealed, medications should be checked by day and night shift nurses and the expired medications should be removed from the medication cart so that they would not administer them to the residents. She further stated if the residents received expired medication the outcome would be the medications would not work effectively, and the residents could get sick or have adverse effects of the expired medications. Interview on 1/8/2025 at 4:25 pm with UM MM for the 100 and 200 halls revealed, the day and night shifts nurses should check the medications daily and if the medications were expired, they should be disposed of. She further stated there would be no known outcome to the residents if they were given the expired medications. Interview on 1/9 2025 at 2:20 pm with the DON revealed, his expectations were for the expired medications to be promptly removed by the licensed nurses. He stated he was unsure of the outcome if residents received expired medications because he did not have much experience about expired medication and how it would affect the residents if they received it.

Based on staff interviews, record review, and review of the facility's policy titled Restorative Nursing Programs, the facility failed to complete, maintain, and make readily accessible accurate documentation of medical records for one of four residents (R) (R8) reviewed for rehab and restorative nursing services. Findings include: A review of the facility's policy titled, Restorative Nursing Programs, dated 2/1/2024 revealed, 12. Restorative aides will implement the plan for a designated length of time, performing the activities, and documenting on the Restorative Aide Documentation Form. 13. The Restorative Nurse or designated licensed nurse will provide oversight of the restorative aide activities, review the documentation at least weekly, and evaluate the effectiveness of the plan monthly. Review of R8's medical records revealed diagnoses including a cerebrovascular accident (CVA) with right-sided weakness and contractures of the right upper and lower extremities. Review of R8's physician orders dated 9/4/2019 revealed, restorative services, including passive ROM for the right wrist and hand and the application of a splint for 4-6 hours daily to prevent contractures and maintain mobility. Review of R8's physical therapy discharge summary dated 3/8/2024 revealed, recommendations for the restorative program with right hand splint application for 4-6 hours daily and passive ROM (Range of Motions) exercises for the right wrist and hand. Review of R8's Quarterly Minimum Data Set (MDS) dated [DATE] for Section GG (Functional Abilities) revealed, R8 required substantial /maximum assistance for toileting hygiene, bath, upper body dressing, personal hygiene and dependent on staff for lower body dressing and transfers; and Section O (Special Treatments and Programs) revealed, no restorative services documented. Further review of R8's medical records revealed, there was no documentation of restorative nursing services being provided as ordered. Interview on 1/8/2025 at 4:07 pm with the Director of Nursing (DON) revealed, that R8 was supposed to receive restorative nursing services. He revealed that he was unable to provide any documentation of restorative nursing care, even for the past six months, due to the system acquisition issues. Interview on 1/9/2025 at 3:15 pm with Restorative Aide (RA) FF revealed, when asked if she could locate the notes for restorative services for R8, she stated if it's not in the POC. Interview on 1/9/2025 at 4:45 pm, the Administrator acknowledged the facility's challenges in providing complete and accurate documentation of restorative nursing services for R8. He stated that, as of today, the facility had been working diligently to address the gaps identified during the investigation. The Administrator confirmed that restorative services, including splint application and ROM exercises, should have been documented in R8's medical records per the facility's policy. The Administrator noted that the facility had faced significant challenges related to the system transition from the previous ownership. This transition had caused delays in retrieving historical medical records and other pertinent documentation. He expressed frustration with the slow progress in obtaining necessary access to the electronic medical record (EMR) system and legal documentation, stating that the facility ' s legal team was working with the previous owners to resolve the issue. Cross Reference F688, F657

Based on observations, staff interviews, record review, and review of the facility's policy titled Hand Hygiene, the facility failed to maintain infection control protocol by not practicing hand hygiene during wound care for one of three residents (R) R64 receiving wound care. The deficient practice had the potential to increase the risk of infection due to cross-contamination and the potential to increase the risk of spread of infection to R64 and other residents. Findings include: Review of the facility's policy titled Hand Hygiene dated 2/1/2024 revealed, Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors . Policy Explanation and Compliance Guidance: 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Review of R64's Annual Minimum Data Set (MDS) dated [DATE] revealed, Section C (Cognitive Pattern), a Brief Interview of Mental Status (BIMS) of 15 which indicated R64 had intact cognition and Section M (Skin conditions) revealed, R64 had a stage 4 pressure ulcer. Review of R64's physician's orders dated 12/10/2024 revealed orders that included but not limited to, 1. Wound care: Cleanse area to sacrum with Dakin's. Apply Dakin's wet to moist dressing. Cover with protective dressing every day shift for skin integrity AND as needed for skin integrity; 2. Collagenase Ointment 250 UNIT/gram (GM), Apply to sacrum topically every day shift for wound healing; 3. Renew Wound Consult: Follow and treat until wound is healed. Observation on 1/8/2025 at 11:27 am revealed, Wound Care Nurse (WCN) HH performing wound care on R64's stage four sacral wound. During observation WCN HH removed her gloves and put on a clean pair of gloves without sanitizing her hands. Interview on 1/8/2025 at11:40 am with WCN HH confirmed she did not sanitize her hands after she removed the used gloves and before putting on a new pair of gloves. She stated she should have sanitized her hands in between glove change to prevent the spread of germs to R64. She stated the resident could get an infection if she did not sanitize her hands after removing her gloves and before putting on a new pair of gloves. Interview on 1/8/2025 at 11:50 am with Unit Manager (UM) MM revealed, that staff should wash their hands or hand sanitize before going into the residents' rooms, rendering care to the residents, after removing gloves and before putting on a new pair of gloves. She stated if hand hygiene was not performed the outcome would be the residents could get infections. Interview on 1/9/2025 at 2:16 pm with Director of Nursing (DON) revealed, his expectations were for hand hygiene to be performed during wound care. He stated the nurse should adhere to the standard precautions and precautions related to the wound. He stated it was a clean technique, and the nurse needs to adhere to it. The DON further revealed that hand hygiene should be performed before donning gloves, after removing gloves and before putting on new gloves. He stated if hand hygiene was not performed the outcome could cause delayed healing for the resident.

Based on observations, record review, interviews, and policy review titled Comprehensive Care Plans, the facility failed to develop and implement person-centered comprehensive care plans for three of 34 sampled residents (R). Specifically, facility failed to maintain emergency trach supplies in the facility and at the bedside for R69; failed to develop a care plan for the use of Continuous Positive Airway Pressure (CPAP) and failed to indicate the accurate code status for Advanced Directive (AD) for R19. On September 29, 2023, a determination was made that a situation in which 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. The facility's Administrator, Director of Nursing (DON), Regional Nurse Consultant (RNC), and Assistant Regional Nurse Consultant (ARNC) were informed of the Immediate Jeopardy (IJ) on September 29, 2023, at 9:32 am The noncompliance related to the Immediate Jeopardy was identified to have existed on August 5, 2023, when R69 tracheostomy tube attempted to become dislodged and the nurse held the tube in place until emergency medical services arrived, due to facility not having emergency tracheostomy supplies at bedside or in the facility. An Acceptable Removal Plan was received on October 3, 2023. The removal plan included reassessing R69, placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies on the crash cart, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for tracheostomy care. Through interviews with facility staff, observation of tracheostomy supplies, observations of R69, clinical record review of revised care plan, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on October 1, 2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of the policy titled Comprehensive Care Plans dated 2/1/2022, indicated the policy is to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights with measurable objects and timeframes to meet a residents medical, nursing, and mental and psychosocial needs identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: Number 3: revealed the care plan will describe: a. services to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial wellbeing. c. specialized services. d. goals for admission, desired outcomes, and preferences for future discharge. Number 5: the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment. Number 8: qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions initially and when changes are made. 1. Review of the clinical record for R69 revealed he was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy status (surgical procedure to open a direct airway through an incision in the trachea [windpipe]), acute respiratory failure, and dysphasia (language disorder which affect the ability to produce and understand spoken language). Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not recorded with documentation that resident is rarely/never understood. Section O revealed the resident received oxygen therapy and had a tracheostomy. Review of the care plan revised on 6/23/2023 revealed the focus of tracheostomy related to impaired breathing with respiratory failure-requires continuous oxygen. Interventions to care include observe/document for restlessness, agitation, confusion, increased heart rate, and bradycardia, observe/document respiratory rate, depth, and quality every shift and document, provide good oral care daily and as needed, suction as necessary, use universal precautions, and assist with coughing as needed. Additional intervention Tube Out Procedure keep extra trach tube and obturator at bedside, if tube is coughed out, open stoma with hemostat, if tube cannot be reinserted, monitor/document for signs of respiratory distress. If unable to breathe spontaneously elevate the head of bed 45 degrees and stay with resident. Obtain medical help immediately. Interview on 10/3/2023 at 9:00 am Certified Nursing Assistant (CNA) CCC stated the resident care plan identifies the tasks for the staff to take care of the residents. She stated if residents have problems with respiratory status, she notifies the nurse immediately. Interview on 10/3/2023 at 9:05 am Licensed Practical Nurse (LPN) UU stated the care plan drives the nursing process. She stated the nurse should consult the care plan as it relates to the care needed for all residents. Interview on 10/3/2023 at 9:25 am LPN YY stated the care plan is important in directing the care of each resident. She stated the care plan will trigger assessments the nurse must complete on the medication administration record (MAR) and task for personal care and restorative care for the CNAs to complete. She stated it is the nurse's responsibility to become familiar with the care plan of each resident they are caring for. Interview on 10/3/2023 at 12:13 pm Director of Nursing (DON) and Regional Nurse Consultant (RNC) revealed care plans are updated by the MDS coordinator when assessments are completed. The MDS coordinator attends clinical meetings and when information is shared related to a change in condition or concerns that should be added to the care plan, the MDS coordinator will update the care plan focus, goal, or interventions as needed. The DON stated the MDS coordinator is the person who initiates and updates the comprehensive care plans. During further interview, the DON stated when the MDS Coordinator is not available to update the care plans, he can update the care plans. He stated his expectation is that the care plan be developed within seven days after the comprehensive assessment is completed and after each quarterly MDS assessment is completed. He stated he expected the care plan to be updated in real time as changes are identified and as needed to meet the residents' needs. The MDS Coordinator was not available for interview. 2. Review of the clinical record for R19 revealed she was admitted to the facility on [DATE] with multiple diagnoses including schizoaffective disorder, chronic respiratory failure, cerebral infarction, bipolar disorder, and hyperlipidemia. Review of the quarterly MDS dated [DATE], revealed BIMS was coded as 13, indicating no cognitive impairment. Section O revealed the resident used a C-PAP machine. Review of the care plan revised 8/3/2023 revealed resident is at risk for altered respiratory status related to diagnoses of pneumonia and acute/chronic respiratory failure. Interventions to care include nebulizer treatments and oxygen therapy as ordered. There was no evidence of a focus area for diagnosis of sleep apnea with the use of CPAP machine nightly. During further review of the care plan revealed Advanced Directive was indicated as a Full code. Interventions to care include complete necessary paperwork and document in medical record. Review of Order Summary Report dated 9/27/2023, revealed an order to apply C-PAP machine on night shift - resident will keep on throughout the night every night related to sleep apnea. The order date is 6/22/2023. Further review revealed an order for 'Do Not Resuscitate (DNR)' dated 3/24/2023. Review of Physician Orders for Life Sustaining Treatment (POLST) revealed the document was signed by resident and physician on 3/20/2023. The POLST indicated resident's wishes to allow natural death - Do Not Attempt Resuscitation. The POLST contained a concurring physician signature dated 3/22/2023. Interview on 9/27/2023 at 1:57 pm MDS Care Plan Coordinator confirmed that R19 care plan did not indicate the use of a C-PAP and stated it should have been updated for the use of C-PAP with her last quarterly assessment. During further interview she verified the care plan revealed residents' Advanced Directive indicated 'Full Code' with Physician Order for DNR. She did not have an explanation why the care plan for Advance Directive did not match the Physician Order. Interview on 9/29/2023 at 1:03 pm DON revealed that during the daily clinical meeting, all new orders, and residents with changes in care are discussed. The DON further stated that the MDS /Care Plan Coordinator attends the meeting each day and gathers information needed for MDS assessments and care plan updates/revisions. 47947 48397

Based on observations, record review, staff interviews, and review of the policy titled Tracheostomy Care, the facility failed to ensure staff were trained for emergency care of tracheostomies (trachs) and provide emergency tracheostomy kits for one resident (R) R69 reviewed for tracheostomy care. The facility's failure to train staff and provide emergency tracheostomy kits in the event that the resident's airway was compromised, resulted in R69 trach tube becoming dislodged and an emergency room visit to have tube re-inserted. In addition, the facility failed to properly store resident respiratory care equipment when not in use for R19's Continuous Positive Airway Pressure (C-PAP) mask and for R70's nebulizer mask. There were 18 residents receiving respiratory services. On September 29, 2023, a determination was made that a situation in which 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. The facility's Administrator, Director of Nursing (DON), Regional Nurse Consultant (RNC), and Assistant Regional Nurse Consultant (ARNC) were informed of the Immediate Jeopardy (IJ) on September 29, 2023, at 9:32 am The noncompliance related to the Immediate Jeopardy was identified to have existed on August 5, 2023, when R69 tracheostomy tube attempted to become dislodged and the nurse held the tube in place until emergency medical services arrived, due to facility not having emergency tracheostomy supplies at bedside or in the facility. An Acceptable Removal Plan was received on October 3, 2023. The removal plan included reassessing R69, placing tracheostomy supplies at the bedside in the resident's room and extra tracheostomy supplies on the crash cart, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revision, re-education of administration staff, and review/revision of policies and procedures for tracheostomy care. Through interviews with facility staff, observation of tracheostomy supplies, observations of R69, clinical record review of revised care plan, and review of staff in-services, the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on October 1, 2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: Review of the policy titled Tracheostomy Care dated 2/22/2022 revealed Compliance Guidelines: Number 3. Tracheostomy care will be provided according to the physician orders, comprehensive assessment, and individualized care plan such as monitoring for resident specific risks for possible complications, psychosocial needs as well as suctioning as appropriate. General considerations include: b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an Ambu bag easily accessible for immediate emergency care. Review of documents titled Licensed Nurse Competency, provided by the DON, revealed three licensed nurses had completed competency checklist for Basic Nursing Skills tracheostomy care. The checklist did not reveal competency training for emergency trach management. The DON stated that he could not locate any additional education related to tracheostomy care. 1. Review of the clinical record for R69 revealed he was admitted to the facility on [DATE] with multiple diagnoses including tracheostomy status (surgical procedure to open a direct airway through an incision in the trachea [windpipe]), acute respiratory failure, and dysphasia (language disorder which affect the ability to produce and understand spoken language). Review of the quarterly MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not recorded with documentation that resident is rarely/never understood. Section O revealed the resident received oxygen therapy and had a tracheostomy. Review of the care plan revised on 6/23/2023 revealed a focus for tracheostomy related to impaired breathing with respiratory failure-requires continuous oxygen. Interventions to care include observe/document for restlessness, agitation, confusion, increased heart rate, and bradycardia, observe/document respiratory rate, depth, and quality every shift and document, provide good oral care daily and as needed, suction as necessary, use universal precautions, and assist with coughing as needed. Additional intervention Tube Out Procedure keep extra trach tube and obturator at bedside, if tube is coughed out, open stoma with hemostat, if tube cannot be reinserted, monitor/document for signs of respiratory distress. If unable to breathe spontaneously elevate the head of bed 45 degrees and stay with resident. Obtain medical help immediately. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was not scored and documented resident is rarely/never understood. Section G revealed the resident was totally dependent on staff for bed mobility, locomotion on and off unit, dressing, eating, toilet use, bathing and personal hygiene and required two-person physical assistance. Section O revealed the resident required tracheostomy care. Review of R69 September 2023 Order Summary Report revealed an order dated 8/17/2023 for trach care daily and as needed, without orders for trach tube type, size, or whether the trach is to be cuffed or uncuffed, or emergency management if the trach should become dislodged. Further review revealed continuous oxygen at two liters per minute (lpm) via nasal cannula dated 3/32/2023. Review of Progress Note dated 8/5/2023 at 11:11 am revealed Licensed Practical Nurse (LPN) AA documented residents' trach attempted to become dislodged. The writer held trach in place and applied oxygen and suction . until emergency medical services (EMS) personnel arrived. Review of document titled After Visit Summary from [name] Healthcare, dated 8/5/2023, indicated reason for the visit was tracheostomy tube change with diagnosis of unspecified tracheostomy complication. Notated on the document is a handwritten note that reads: Trach size is not here, called they were unable to tell writer size. Observation on 9/26/2023 at 10:15 am R69 was observed lying in bed alert but nonverbal. He had a tracheostomy with oxygen at four liters per minute (LPM) via tracheostomy. Observation of a plastic bag hanging on a pole with contents including a Shiley #5 inner canula and a manual resuscitator bag. Sitting on the bedside table was a suction machine and canister with a suction catheter attached. There were no other trach supplies located in the room. Interview on 9/26/2023 at 4:44 pm with Registered Nurse (RN) BB revealed she works at the facility through a staffing agency since early 2022. She stated she provides basic trach care for R69, including suctioning and changing the tracheostomy ties. RN BB stated she had not received any training from the facility related to emergency care for trach decannulation. During further interview, she stated if the trach came out, she would put something over the stoma, attempt to put it back in, make sure resident was oxygenated, and call the DON for assistance. Interview on 9/26/2023 at 4:55 pm with RNC CC stated emergency items to be kept at bedside for tracheostomy residents include a manual resuscitator bag, replacement trach tubes, an obturator, and a suction machine and cannister. She verified the only supplies in R69's room were a Shiley #5 inner cannula and a manual resuscitator bag. Sitting on the bedside table was a suction machine and canister with a suction catheter attached. She searched the room for supplies and was unable to locate an obturator or extra trach tubes. She stated if decannulation should occur, she hoped the nursing staff has been trained in providing emergency care for decannulation. Interview 9/26/2023 at 5:13 pm with RNC DD verified R69's Oxygen flow rate was set at four LPM with the current Physician Orders were for oxygen at two LPM via nasal cannula. She verified there was no evidence in Physician Orders to indicate the type and size of the trach tube R69 was using, or any emergency care orders for accidental dislodgment of the trach. During further interview, she stated that in an emergency, the nurses would have to look through the progress notes to locate the size of the trach tube resident had in place. Interview 9/26/2023 at 5:27 pm the DON stated the only competency/skills checklist he could locate were for three nurses. He stated the competency/skills checklist for tracheostomy care did not indicate procedures for emergency care for dislodged trach cannulas, or information for emergency trach kits. He stated he was not sure whether the facility had a policy for emergency care for trach dislodgement or a policy for trach kits. During further interview he stated that if resident's trach came out, he would expect the nurse to put an inner cannula in the stoma, make sure resident can still breath and to try to re-insert the trach at the facility if possible. The DON confirmed R69 should have an emergency tracheostomy kit at his bedside and visible to the staff in the event of an emergency. Interview on 9/26/2023 at 5:42 pm with RN PP revealed she has worked at the facility since March 2023 and stated she has provided care for R69. She stated she had basic training for general trach care but indicated she had not been provided training related to replacing the trach or emergency decannulations. Interview on 9/27/2023 at 9:53 am with LPN KK revealed she had not received any training on the facility protocol or what to do in an emergency situation if R69's trach came out. LPN KK further stated she would look for a smaller size trach to put back in if the trach came out. but if one was not available, she would call for help. She stated she was not familiar with the facility's policy on trachs. Interview on 9/27/2023 at 1:17 pm LPN AA revealed that on 8/5/2023 she noticed R69's trach was coming out. She stated she attempted to tighten the trach ties and push the trach back in, but it would not go in. She stated she did not see another trach tube at resident's bedside, so she yelled out for someone to call 911. During further interview, she stated she held the trach in place until emergency medical services (EMS) arrived so he would not cough it completely out. She stated that she called the hospital and was informed that the trach was out and had to be replaced. Interview on 9/29/2023 at 2:47 pm with RNC DD revealed R69 now had a #6 Shiley trach at bedside with an obturator. She stated she entered the Physician Order for the Shiley #6 XLT trach after searching through the electronic record for the information for the trach size and RNC DD looked at the trach and revealed the resident had a Shiley #5 trach in place. During further interview, she stated the orders she had obtained and entered into the electronic record were not correct. Interview on 10/2/2023 at 11:12 am LPN UU revealed that she works at the facility through a staffing agency. She stated that she had not had any training from the facility on what to do in an emergency situation with the trach. During further interview, LPN UU revealed that supplies at the facility for trach residents are a hit and miss. She stated there was an issue with needed supplies in the facility to care for R69's trach. Interview on 10/2/2023 at 1:20 pm with Nurse Practitioner (NP) TT revealed that she works in the facility Monday through Friday. NP TT stated it is her expectation that the nurses are trained on how to care for tracheostomies in emergency situations and how to reinsert the trach tube at the bedside if a decannulation occurs. Telephone interview on 10/2/2023 at 6:36 pm with Medical Doctor (MD) DDD revealed the staff should have been educated/trained to care for R69 prior to resident being admitted to the facility. MD DDD further stated the staff should be skilled enough to replace the trach in the event of decannulation and the facility should always have trach supplies readily available to care for the needs of the residents with tracheostomies. 2. Review of the clinical record for R19 revealed she was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure unspecified whether with hypoxia or hypercapnia, pneumonia, and sleep apnea. Review of the care plan revised 8/3/2023 indicated R19 has a potential risk for altered respiratory status related to pneumonia, chronic respiratory failure. Interventions to care include administering medications as ordered, head of bed elevated or out of bed during episodes of difficulty breathing, monitor for signs and symptoms of acute respiratory insufficiency or distress. There is no evidence that resident is care planned to use C-PAP machine at night. Review of the quarterly MDS dated [DATE], revealed BIMS was coded as 13, indicating no cognitive impairment. Section O revealed the resident used a C-PAP machine. Review of R19's September 2023 Order Summary Report revealed an order dated 6/22/2023 to apply (C-PAP) Continuous Positive Airway Pressure machine on night shift indicating resident will keep on throughout the night. Review of Electronic Medication Administration Records (E-MAR) dated April 2023 through September 2023, indicated the C-PAP machine was documented as being used nightly. Review of Progress Note dated 4/14/2023 revealed R19 resident used the C-PAP intermittently while napping during the day. Observation on 9/26/2023 at 11:27 am revealed resident lying in bed with eyes closed. The C-PAP mask was lying on the floor on the left side of the residents' bed. Observation on 9/27/2023 at 9:45 am revealed the C-PAP mask was placed on the dresser un-bagged. Interview on 9/27/2023 at 9:45 am with R19 confirmed she uses the C-PAP mask at night. Resident nodded her head no when asked if the mask is usually stored in a bag when not in use. Interview and observation on 9/27/2023 at 12:21 pm LPN KK verified the C-PAP mask was on the dresser and not properly stored. She stated that the mask should be stored in a bag when not in use. During further interview, she stated R19 removes the C-PAP herself, but stated the staff is responsible for cleaning and storing the C-PAP mask in a bag. Interview on 9/27/2023 at 12:38 pm the DON stated that all respiratory masks are supposed to be stored in a plastic bag and placed in the drawer of the dresser when not in use. 3. Review of the clinical record for R70 revealed he was admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (COPD). Review of the quarterly MDS dated [DATE] revealed a BIMS of 15, which indicated the resident was cognitively intact. Section J indicated health conditions listed as shortness of breath (SOB) with exertion, sitting, and lying flat. Section O revealed the resident used Oxygen. Review of the care plan revised 8/2/2023 indicated R70 has a potential risk for altered respiratory status related to COPD. Interventions to care include give nebulizer treatments and oxygen therapy as order, monitor/document/report to physician as needed any signs/symptoms of respiratory infection, acute respiratory insufficiency, respiratory distress, implement treatment as ordered by physician, and observe/document breathing patterns, pace/schedule activities providing adequate rest periods. Review of the September 2023 Clinical Physician's Order revealed orders for Advair, tiotropium bromide (Spiriva Respimat), albuterol sulfate inhalation aerosol powder, and oxygen two LPM via nasal cannula (NC). Observation on 9/26/2023 at 10:47 am and 5:30 pm in R70's room revealed on the nightstand on the right side of the bed, nebulizer mask lying beside the machine on the table. The nebulizer mask was not bagged or covered, and the tubing was not dated. Observation on 9/27/2023 at 9:50 am revealed the nebulizer mask continued to be lying on the nightstand beside the nebulizer machine uncovered and the tubing was not dated. Interview on 9/26/2023 at 10:47 am R70 stated when his breathing treatment is finished, he lays the mask on his bedside table. He stated the staff do not offer a bag or cover the mask when not in use. Interview on 9/27/2023 at 1045 am LPN YY confirmed R70's nebulizer mask was lying on the nightstand un-bagged. She confirmed the tubing was not dated. Interview on 9/27/2023 at 11:02 am the DON revealed his expectation was that the nebulizer mask be stored in a clear bag and the date clearly marked on the tubing as well as the bag. He stated the tubing and mask are changed weekly on Sunday nights. 47146 48397

Based on observations, record review, interviews, review of the facility assessment, and review of job descriptions for the Administrator and the Director of Nursing (DON), the facility administration failed to provide oversight and monitoring to ensure that competent nursing staff are available and trained to care for residents admitted with special care needs (such as care for a tracheostomy- a surgical procedure to open a direct airway through an incision in the trachea/windpipe). In addition, administration failed to ensure open communication between nursing staff to facilitate ordering of supplies needed to care for a resident with a tracheostomy and ensure there were emergency tracheostomy supplies available at bedside and crash cart for one resident (R) R69 sampled for tracheostomy care. On September 29, 2023, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to a resident. The facility's Administrator, Director of Nursing (DON), Regional Nurse Consultant (RNC), and Assistant Regional Nurse Consultant (ARNC) were informed of the Immediate Jeopardy (IJ) on September 29, 2023, at 9:32 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on August 5, 2023, when R69's tracheostomy tube attempted to become dislodged and the nurse held the tube in place until emergency medical services arrived, due to facility not having emergency tracheostomy supplies at bedside or in the facility. An acceptable Removal Plan was received on October 3, 2023. The Removal Plan included purchasing and placing tracheostomy supplies at the bedside in the residents' room, extra tracheostomy supplies in the crash cart, in-servicing nursing staff on location of tracheostomy supplies and tracheostomy care, care plan revisions, and education of all licensed staff on emergency care for trach tube dislodgement. Through observations, record review, and interviews the survey team verified all elements of the facility's IJ Removal Plan, and the immediacy of the deficient practice was removed on October 1, 2023. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing the provision of care for residents with tracheostomies. Findings include: 1. Administration failed to ensure that nursing staff are trained and competent to care for residents admitted with special needs such as emergency care for tracheostomy tube dislodgement. 2. Facility administration failed to maintain emergency tracheostomy supplies in the event of accidental dislodgement of trach tube. Cross Refer F695 3. Facility Administrator and Director of Nursing failed to perform duties of their job descriptions that facilitated medical care to the residents of the facility. 4. Facility Administration failed to implement care plan interventions that addressed emergency care and supplies at bedside for R69 admitted with a tracheostomy. Cross Refer F656 Review of the Facility Assessment Tool reviewed 5/25/2023 revealed every patient considered for admission is reviewed by the Director of Nursing or designee to assure clinical needs can be met. Regarding care areas, diagnosis or conditions not previously supported, appropriate education and competency assessment will be completed prior to admission. Needed medical supplies or resources not maintained in the facility will be acquired from contracted suppliers, local vendors, or other healthcare facilities. Review of the undated document titled Job Description and Performance Standards for the Administrator revealed the purpose of this position was to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet the needs of residents in compliance with federal, state, and local requirements. The primary functions and responsibilities include: 2. Establish written policies regarding responsibilities and activities of individuals employed. 3. Establish systems to enforce the facility policies and procedures. 8. Supervise all department supervisors and administrative staff. 10. Assume responsibility with department supervisors to implement effective policies to ensure adequate staffing to meet facility needs. 14. Ensure that all necessary supplies are purchased and available. 26. Establish systems to ensure compliance with all federal, state, and local regulations. Review of the undated document titled Job Description and Performance Standards for the DON revealed the purpose of the position was to provide nursing management, set resident care standards for all direct care providers, and provide complete supervision and management for the nursing department. The primary functions and responsibilities include: 1. Assume responsibility for the development of nursing service objectives and performance standards of nursing practice for nursing personnel. 2. Assume Accountability for the development, organization and implementation of approved policies and procedures. 3. Supervise and evaluate all direct resident care and initiate corrective action as necessary. 4. Assess resident care needs and assist in the development of individualized plans of care. 5. Assess resident pre-admission and/or admission information and determine appropriate level of care. 17. Direct and implement nursing service educational programs including, but not limited to orientation and in-services for licensed nursing personnel. 19. Demonstrate consistent management of nursing service problems, emergency situations, and initiated life-saving measures. 20. Assume responsibility for nursing service compliance with federal, state, and local regulations. 21. Ensure availability of equipment for nursing personnel. 22. Assess equipment and supply needs. Review of the clinical record revealed R69 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure with tracheostomy (a surgical procedure to open a direct airway through an incision in the trachea/windpipe), hypertension, and dysphagia following cerebrovascular disease. Review of R69 September 2023 Physician Orders revealed an order dated 8/16/2023 for pulmonology consult per family request related to decannulation, continuous oxygen at two liters per minute (lpm) via nasal cannula dated 3/21/2023, and trach care daily and as needed dated 8/17/2022. There was no indication what type or size of trach tube used, or emergency care for dislodged tube. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not scored and documented resident is rarely/never understood. Section G revealed the resident was totally dependent on staff for bed mobility, locomotion on and off unit, dressing, eating, toilet use, bathing and personal hygiene and required two-person physical assistance. Section O revealed the resident required tracheostomy care. Review of Nurses Note dated 8/5/2023 at 11:11 am revealed Licensed Practical Nurse (LPN) AA documented residents' trach attempted to become dislodged. The writer held trach in place and applied oxygen and suction . until Emergency Medical Services (EMS) personnel arrived. Observation on 9/26/2023 at 10:15 am of R69's room revealed resident had tracheostomy and oxygen in use at four liters per minute via tracheostomy. Observation of a plastic bag hanging on a pole with contents including a Shiley #5 inner canula and a manual resuscitator bag. Sitting on the bedside table was a suction machine and canister with a suction catheter attached. Observation on 9/26/2023 at 5:25 pm of the emergency crash cart revealed there were not any emergency trach supplies available on the cart. Observation on 9/29/2023 at 8:09 am in R69's room revealed there were no emergency trach supplies or obturator found at bedside or in chest of drawers. Interview on 9/26/2023 at 4:55 pm in R69's room with Registered Nurse (RN) CC and the Director of Nursing (DON) stated emergency items to be kept at bedside for tracheostomy residents include a manual resuscitator bag, replacement trach tubes, an obturator, and a suction machine and cannister. RN CC stated if decannulation should occur, she hoped the nursing staff had been trained in providing emergency care for decannulation. The DON verified the only supplies in R69's room in the bedside chest were three suction catheters, Ipratropium Bromide and Albuterol sulfate nebulizer meds, and an unbagged nebulizer mask. One trach mask is not in a bag. Interview on 9/26/2023 at 5:13 pm with RN CC stated the oxygen flow rate ordered for R69 is continuous oxygen at two liters (L) via nasal cannula/trach. During further interview, she stated the staff would have to look through the progress notes to determine the size for the trach tube. Interview on 9/26/2023 at 5:18 pm with RN DD confirmed there were no orders for the trach size for R69, or specific orders for emergency care for dislodgement. Interview on 9/26/2023 at 5:27 pm DON revealed there are suction catheter kits in the facility but stated there were no trach obturators in the facility. He revealed he doesn't know if R69's trach is a Shiley five or six. He stated he uses the Order Wizard to keep information on what trach supplies have been ordered. During further interview, the DON stated there are no obturators, emergency trach tubes, ties, or cleaning kits in the facility. He stated I am almost sure that R69 is the only trach resident the facility had, beside the resident in 4/2022. Interview on 9/26/2023 at 5:42 pm with RN PP revealed she had training on trach suctioning, cleaning, changing out the inner cannula. She indicated she had not had any training on what to do if decannulation happened, but stated if the tube comes out, she will give oxygen with mask over the trach. During further interview, she stated if resident had another tube, she would put it back in. Interview on 9/27/2023 at 9:53 am Licensed Practical Nurse (LPN) KK stated she had not received any formal training on the facility protocol or what to do in an emergency if the trach tube came out. The LPN stated some facilities allow nurses to replace trach tubes so she would look for a smaller size tube to put back in but if there are not any in the facility, she would call for help. During further interview, she stated she is not familiar with the facility's policy on tracheostomies. Interview on 9/27/2023 at 1:17 p.m. with LPN AA stated on 8/5/2023 she noticed R69's trach was coming out. She revealed that the trach ties were intact, so she attempted to push the trach back in, but it would not go in. LPN AA stated when this event happened, she did not see a replacement trach tube or any other emergency supplies at the bedside, so she yelled out for someone to call 911. During further interview, she stated that she held the trach in place until EMS arrived. Interview on 10/2/2023 at 11:12 am with LPN UU indicated she completed a skills checklist prior to working at the facility. She revealed she had training related to providing trach care at another facility but stated she had not had any training from the facility. During further interviews, she stated that she had not had any training in what to do in an emergency with tracheostomies if the tube became dislodged. LPN UU further stated that supplies at the facility for the trach resident are a hit and miss and that there are issues with needed supplies in the facility to care for R69. Interview on 10/22/2023 at 1:20 pm with Nurse Practitioner (NP) GG revealed it is her expectation that the nurses in the facility are trained in basic care and cleaning of the tracheostomy. Continued interview revealed NP GG stated the nurses should be trained on how to use the emergency equipment and how to reinsert the trach at the bedside in an emergency, if the trach tube comes out. 48397

Based on observation, record review, and staff interview, the facility failed to provide sufficient nursing staff to assure the needs of 19 of 22 residents, (R) (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#15, R#16, R#17, R#18, R#19, R#20, R#21, and R#22) were met for residents to achieve the highest practicable level of well-being. Specifically, residents were not tested and/or monitored for COVID-19 and 14 of 40 nursing staff working [DATE] through [DATE] were not tested in a manner consistent with current standards of practice for conducting COVID-19 testing, due to insufficient staff. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:30 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: According to a COVID-19 Infection Control Line Listing for the facility, two staff members tested positive for COVID-19: one on [DATE] and another on [DATE]. Two residents also tested positive for COVID-19 on [DATE]. There is no evidence that the facility conducted outbreak testing for 13 of 22 residents reviewed. There is no evidence that 14 of 40 nursing staff working [DATE] through [DATE] were tested weekly according to outbreak testing status and/or based on county positivity rate, with no evidence that 11 of those 14 nursing staff were tested at all. R#10, who tested positive on [DATE], was transferred to hospital on [DATE] with worsening COVID symptoms and expired on [DATE]. Outbreak testing was initiated on [DATE] during the survey. R#11 tested positive for COVID-19 and expired at the facility on [DATE]. R#21 and R#22 tested positive and were placed on the 200 Hall (later designated as a COVID-19 unit and Observation unit). Three staff members also tested positive. The facility did not have separate COVID and Observation units and did not have dedicated staff. The facility had discarded barriers needed for the COVID unit and had to reorder. The facility had not contacted the local Department of Public Health (DPH) for guidance after continued outbreaks in the facility. The facility had no evidence of routine monitoring of residents for signs and symptoms of COVID-19 for 19 of 22 residents reviewed. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.35(a)(1)(2) Sufficient Nursing Staff, F725; 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; 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; and 42 CFR 483.80 (h)(1)-(6) Covid-19 Testing-Residents & Staff, F886. F725, F835, F837, F867, F880, and F886 were at a Scope and Severity (S/S) of a L. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of [DATE] Nurses Open Shifts posted at the time clock revealed open shifts with no coverage as follows: [DATE]-one first shift, one second shift and one third shift [DATE]-one second shift and two third shifts [DATE]-one first shift, two second shifts, and one third shift [DATE]-two third shifts [DATE]-two second shifts [DATE]-one second shift [DATE]- two second shifts and three third shifts [DATE]-three second shifts and two third shifts [DATE]-three second shifts and two third shifts [DATE] two third shifts, with one being filled Review of residents Medication Administration Records (MAR) revealed the DON worked medication carts on [DATE], [DATE], [DATE], [DATE], and [DATE]. Observation on [DATE] at 11:06 a.m. revealed the 200 Hall, which houses COVID-19 positive residents and Observation residents, had no dedicated coverage and the duties of administering medications was being split between Licensed Practical Nurse (LPN) AA and LPN QQ who were also administering medications on other units. Observation on [DATE] at 9:15 a.m. revealed the DON was administering medications to residents on the 500 Hall. Observation on [DATE] at 11:30 a.m. and [DATE] at 9:00 a.m. revealed the 200 Hall, which houses COVID-19 positive residents and Observation residents, had no dedicated coverage and the duties of administering medications was being split between LPN AA and LPN KK who were also administering medications on other units. Observation on [DATE] at 9:15 a.m. revealed the DON was administering medications to residents on the 400 Hall. Observation on [DATE] at 9:10 a.m. revealed Registered Nurse (RN) RR was administering medications from two medication carts, one for the 100 Hall and one for the 300 Hall. Observation on [DATE] at 10:10 a.m. revealed RN VV working with two medication carts, 400 Hall and 500 Hall. Observation on [DATE] at 9:20 a.m. revealed the 200 Hall, which houses COVID-19 positive residents and Observation residents, had no dedicated coverage and the duties of administering medications was being split between LPN AA and LPN WW who were also administering medications on other units. Observation and interview on [DATE] at 9:20 a.m. with LPN GG revealed there was no nurse assigned to work the 500 Hall cart at this time. She stated that an RN from another facility is supposed to come administer the medications. Observation on [DATE] at 11:03 a.m. revealed the Administrator was administering resident's medications on the 500 Hall. (He is a nurse) Observation on [DATE] at 2:25 p.m. revealed the Minimum Data Set (MDS) nurse was administering medications on the 300 Hall. Interview on [DATE] at 1:00 p.m. with ADON revealed she has been employed at the facility for two months. She stated that she helped the DON with the COVID-19 testing for staff and residents. The ADON resigned on [DATE] during the survey. In accordance with the Center for Medicare and Medicaid Services (CMS) memo QSO-,d+[DATE]-NH, dated [DATE], the facility was required to conduct twice weekly testing of staff from [DATE] to [DATE]. Weekly testing of staff was required from [DATE] through [DATE]. Outbreaks occurred on [DATE], [DATE], [DATE], and [DATE] which required residents and staff be tested every three to seven days until no new positives. Review of the actual nurse staffing hours for facility nursing staff revealed that from [DATE] through [DATE], Registered Nurse (RN) NN, RN UU, Licensed Practical Nurse (LPN) FF, LPN CCC, LPN DDD, LPN EEE, Certified Nursing Assistant (CNA) FFF, CNA GGG, CNA HHH, CNA III, and CNA JJJ worked during this time period. There is no evidence that the above staff were tested for COVID-19 during that time period. According to facility testing documents for staff, the DON was tested on [DATE] and [DATE] only, the Assistant Director of Nursing (ADON) was tested on [DATE] only, and Agency LPN AA was tested on [DATE] only. Review of the clinical record revealed the following COVID-19 testing information for previously negative residents for [DATE] through [DATE]: R#1, R#4, R#11, and R#22 were not tested . R#9 and R#10 were tested on [DATE] only. R#2, R#3, R#5, R#7, R#8, and R#22 were tested on [DATE] only. R#6 was tested on [DATE] only. In addition, review of the clinical records revealed no evidence that R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#15, R#16, R#17, R#18, R#19, R#20, R#21, and R#22 were routinely monitored for signs/symptoms of COVID-19 until [DATE]. Review of Department of Public (DPH) recommendations dated [DATE] revealed staffing support was needed, for COVID Unit and as unit managers for directing/managing staff to get tested each week. During an interview on [DATE] at 11:37 a.m., CNA BB stated that her regular shift is the 11:00 p.m. to 7:00 a.m., but she works two to three double shifts per week, because there is not enough staff working to care for the residents. Interview on [DATE] at 1:11 p.m. with DON revealed that there is no specific day that the COVID testing is done, but usually done on Tuesday's and Friday's. She stated that if staff do not come to the COVID clinic, she contacts the department heads and informs them staff need to be tested . She stated she is unable to follow up to see if the staff that missed testing were actually tested later. Further interview on [DATE] at 3:34 p.m. with DON revealed she has been employed at the facility for eight months but has been in the DON role for three months. She stated that it is hard to get staff to come to work when they are scheduled. She stated the facility has a lot of open vacancies for Nurses and CNA's, so ninety to ninety five percent of the staff are agency. She further stated that she must substitute for the lack of charge nurses by administering medications to residents three to four times per week and she is responsible for duties of the Infection Control Preventionist (ICP) Nurse, Staffing Coordinator and COVID-19 testing. Interview on [DATE] at 9:20 a.m. with LPN AA revealed she has worked at the facility through the staffing agency since [DATE]. LPN AA revealed the facility does not have enough nurses to work, so she usually must split working the 200 Hall with the nurse working the 300 Hall. Further interview on [DATE] at 2:04 p.m. with DON revealed that there was no-one in the role of ICP when she was hired, but the previous DON was supposed to be collecting the surveillance data. She stated she has been inconsistent with the data collection and surveillance tracking because she has had to work on the medication cart three to four days per week, and she just did not have time to do it. Interview on [DATE] at 11:20 a.m. with LPN FF revealed that the facility does not have enough staff. She stated that she and another nurse often have to share the assignment of a third nurse, because there is no third nurse that day. LPN FF revealed nurses just do not come to work at this facility. Interview on [DATE] at 9:05 a.m. with CNA XX revealed that she gets pulled from Restorative to work on the floor often, and when that happens, the CNA's are supposed to continue the Restorative Program for their assigned residents. She stated that she does not have time to provide care to her assigned residents and provide Restorative Care for all the residents in the Program. During an interview on [DATE] at 4:00 p.m., CNA ZZ stated that she works 16 hour shifts most of the time, 3:00 p.m. to 7:00 a.m., due to open shifts. Cross refer to F886.

Based on observation, interviews, record review, review of the job descriptions for the Administrator and Director of Nursing (DON), the facility administration failed to provide oversight and monitoring of the Infection Control Program by not implementing the Center for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) recommended practices for COVID-19; and failed to ensure facility had adequate staff to provide for the needs of the residents. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:30 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: According to a COVID-19 Infection Control Line Listing for the facility, two staff members tested positive for COVID-19: one on [DATE] and another on [DATE]. Two residents also tested positive for COVID-19 on [DATE]. There is no evidence that the facility conducted outbreak testing for 13 of 22 residents reviewed. There is no evidence that 14 of 40 nursing staff working [DATE] through [DATE] were tested weekly according to outbreak testing status and/or based on county positivity rate, with no evidence that 11 of those 14 nursing staff were tested at all. R#10, who tested positive on [DATE], was transferred to hospital on [DATE] with worsening COVID symptoms and expired on [DATE]. Outbreak testing was initiated on [DATE] during the survey. R#11 tested positive for COVID-19 and expired at the facility on [DATE]. R#21 and R#22 tested positive and were placed on the 200 Hall (later designated as a COVID-19 unit and Observation unit). Three staff members also tested positive. The facility did not have separate COVID and observation units and did not have dedicated staff. The facility had discarded barriers needed for the COVID unit and had to reorder. The facility had not contacted the local Department of Public Health (DPH) for guidance after continued outbreaks in the facility. The facility had no evidence of routine monitoring of residents for signs and symptoms of COVID-19 for 19 of 22 residents reviewed. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.35(a)(1)(2) Sufficient Nursing Staff, F725; 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; 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; and 42 CFR 483.80 (h)(1)-(6) Covid-19 Testing-Residents & Staff, F886. F725, F835, F837, F867, F880, and F886 were at a Scope and Severity (S/S) of a L. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of Job Description and Performance Standards for the Administrator, dated [DATE], revealed the purpose of this position is to establish and maintain systems that are effective and efficient to operate the facility in a manner to safely meet residents' needs in compliance with federal, state, and local requirements. To establish and maintain systems that are effective and efficient to operate the facility in a financially sound manner. Authority is delegated to the individual in this position to develop, maintain and implement operational policies and procedures to meet residents' needs in compliance with federal, state, and local requirements; determine the personnel requirements of the facility and hire or arrange for sufficient staff to implement the facility policies and procedures; develop a monitoring system to assure compliance with federal, state and local requirements. Review of Job Description and Performance Standards for the DON, dated [DATE], revealed the purpose of this position is to provide nursing management, set resident care standards for all direct care providers and provide complete supervision and management for the nursing department. Authority is delegated in this position to assess resident needs and interview, hire and terminate adequate nursing personnel; set resident care standards in accordance with accepted current standards of care to provide high quality care to residents; develop and implement policies and procedures for nursing care of residents; supervise and manage all aspects of the nursing department; assess, direct and supervise residents' care needs; cooperate with administration to assure efficient, cost effective operation of the facility. The facility had a change in Administrator and DON on [DATE]. The facility failed to provide effective oversight and monitoring of their infection control and prevention program. 1. Administration failed to provide sufficient nursing staff to assure the needs of 19 of 22 residents, (R) (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#15, R#16, R#17, R#18, R#19, R#20, R#21, and R#22) were met for residents to achieve the highest practicable level of well-being. Specifically, residents were not tested and/or monitored for COVID-19 and 14 of 40 nursing staff working [DATE] through [DATE] were not tested in a manner consistent with current standards of practice for conducting COVID-19 testing, due to insufficient staff. Cross refer to F725. 2. Administration failed to ensure monitoring systems were provided with feedback for data collection related to Infection Control, including COVID-19 outbreak testing logs, and failed to identify issues with outbreak and routine testing for staff and outbreak testing for residents. Cross refer to F867. 3. Administration failed to ensure residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #15, #16, #17, #18, #19, #20, #21, and #22) were routinely monitored for signs/symptoms of COVID-19, failed to maintain communication with local health department during continued outbreaks, and failed to have a dedicated COVID-19 unit. Cross refer to F880. 4. Administration failed to ensure routine and outbreak testing for COVID-19 was conducted in a manner consistent with current standards of practice for 13 residents, (R) (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#21, and R#22) of 22 residents reviewed for COVID-19 testing. Additionally, Administration failed to ensure testing was completed and results documented for 14 of 40 nursing staff working [DATE] through [DATE]. Cross refer to F886. The facility was required to conduct twice weekly COVID testing of staff from [DATE] to [DATE], weekly testing of staff from [DATE] through [DATE]; with outbreaks occurring on [DATE], [DATE], [DATE], and [DATE]. Review of e-mail correspondence between Administrator and the Department of Public Health Epidemiology from [DATE] through [DATE] revealed submission of line listing with no request for assistance during an on-going outbreak of COVID-19. Review of the actual nurse staffing hours for facility nursing staff revealed that from [DATE] through [DATE], Registered Nurse (RN) NN, RN UU, Licensed Practical Nurse (LPN) FF, LPN CCC, LPN DDD, LPN EEE, Certified Nursing Assistant (CNA) FFF, CNA GGG, CNA HHH, CNA III, and CNA JJJ worked during this time period. There is no evidence that the above staff were tested for COVID-19 during that time period. According to facility testing documents for staff, the Director of Nursing (DON) was tested on [DATE] and [DATE] only, the Assistant ADON was tested on [DATE] only, and Agency LPN AA was tested on [DATE] only. During initial tour on [DATE] at 10:30 a.m. with the DON revealed there was no dedicated COVID-19 unit, although it was reported the facility was currently COVID free, with six residents in Observation on the 200 Hall, due to new admission status. Observation on [DATE] at 11:45 a.m. of the 200 Hall revealed three newly tested positive residents (R#11, R#21, and R#22) were being housed in the rooms on the right side of the 200 Hall (Observation Unit), without dedicated staff to attend to them. Observation on [DATE] at 9:15 a.m. revealed the DON was administering medications on the 500 Hall. Observation on [DATE] at 9:15 a.m. revealed the DON was administering medications on the 400 Hall. Observation on [DATE] at 11:03 revealed the Administrator was administering medications on the 500 Hall. Interview on [DATE] at 1:11 p.m. with DON revealed that there is no specific day that the COVID testing is done, but usually done on Tuesday's and Friday's. She stated that she splits the testing with the Assistant Director of Nursing (ADON). She stated that she makes an announcement on the paging system for staff to come get COVID tested , and that staff sign in when they come to the clinic. During further interview, she stated that if staff do not come to the COVID clinic, she contacts the department heads and informs them staff need to be tested . She stated she does not follow up to see if the staff that missed testing were actually tested later. During further interview on [DATE] at 3:34 p.m., the DON stated that she has been employed at the facility for eight months and has been in the role of DON for three months. She stated that the facility hires staff, but they do not show up and the facility is using approximately ninety percent agency staff, but she still has to work the medication cart three to four days per week. Interview on [DATE] at 1:00 p.m. with ADON revealed she has been employed at the facility for two months. She stated that she helped the DON with the COVID testing for staff and residents. She stated that she does not know how the tracking for the staff testing was being done. The Assistant DON resigned on [DATE] during the survey. During an interview on [DATE] at 10:30 a.m., the Administrator stated that he has been at this facility since [DATE]. He stated that the COVID unit was taken down, because they did not have any COVID positive residents at that time, but stated the last two rooms on the 200 Hall are COVID rooms if they should need them. He stated that the decision to take the unit down was a joint decision with DON and Regional Administrator and was taken down sometime in [DATE]. During further interview, he stated he is not sure what happened to the barrier walls for the COVID unit, but stated they were probably in storage somewhere onsite. When questioned if he contacted the Department of Public Health Epidemiology for assistance during an ongoing outbreak of COVID-19, he replied yes, I contacted them about a week before you came and they did a zoom visit on [DATE] and an onsite visit on [DATE]. He stated they made some recommendations, and they are working on those recommendations now. Phone interview on [DATE] at 11:46 a.m. with the Medical Director (MD) revealed he has weekly conversations with the Administrator, either in person or via phone. He stated that they do not have specific things they talk about but discuss what is happening in the facility. He stated that there was nothing mentioned to him about COVID outbreaks or any indications regarding staffing concerns. Interview on [DATE] at 11:19 a.m. with Administrator, revealed that he is aware that the DON is working the medication cart, when staff call out. During further interview, he stated that he has also worked the medication cart when staff do not show up or call out. (He is an RN)

Based on review of Facility Assessment, interviews and review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program the facility's Governing Body failed to ensure the QAPI program was effective in identifying, developing and implementing corrective actions to address concerns with the facilities Infection Control policies and procedures regarding COVID-19 testing; and failed to oversee facility staffing to ensure adequate staff to provide care and services to residents. The census was 85. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:30 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: According to a COVID-19 Infection Control Line Listing for the facility, two staff members tested positive for COVID-19: one on [DATE] and another on [DATE]. Two residents also tested positive for COVID-19 on [DATE]. There is no evidence that the facility conducted outbreak testing for 13 of 22 residents reviewed. There is no evidence that 14 of 40 nursing staff working [DATE] through [DATE] were tested weekly according to outbreak testing status and/or based on county positivity rate, with no evidence that 11 of those 14 nursing staff were tested at all. R#10, who tested positive on [DATE], was transferred to hospital on [DATE] with worsening COVID symptoms and expired on [DATE]. Outbreak testing was initiated on [DATE] during the survey. R#11 tested positive for COVID-19 and expired at the facility on [DATE]. R#21 and R#22 tested positive and were placed on the 200 Hall (later designated as a COVID-19 unit and Observation unit). Three staff members also tested positive. The facility did not have separate COVID and observation units and did not have dedicated staff. The facility had discarded barriers needed for the COVID unit and had to reorder. The facility had not contacted the local Department of Public Health (DPH) for guidance after continued outbreaks in the facility. The facility had no evidence of routine monitoring of residents for signs and symptoms of COVID-19 for 19 of 22 residents reviewed. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.35(a)(1)(2) Sufficient Nursing Staff, F725; 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; 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; and 42 CFR 483.80 (h)(1)-(6) Covid-19 Testing-Residents & Staff, F886. F725, F835, F837, F867, F880, and F886 were at a Scope and Severity (S/S) of a L. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: A review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised [DATE], policy statement is the facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Policy Interpretation: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Five Strategic Elements 2. Governance and leadership: c. Members of the facility leadership are accountable for the QAPI efforts. e. Staff are encouraged to identify and report quality concerns as well as opportunities for improvement. The facility had a Facility Assessment Tool dated [DATE]. The Facility Assessment Tool documented that the assessment tool was completed by the Administrator that is no longer at the facility, the Director of Nursing (DON) marked through of previous DON and current DON had written, the Governing Body Rep (Representative) and the Medical Director (MD). The Facility Assessment Tool documented the facility Infection Preventionist monitors infections daily thru a process of review of documentation, orders and resident/patient assessments. Daily data collection and surveillance occurs to ensure infection criteria, process and standards are followed. Education is provided to staff, residents and family members as needed. The infection control program is evaluated monthly during the QAPI meeting and as needed. Review of undated document titled East Lake Arbor Governing Body revealed the Governing Body consists of Regional Executive Director Consultant, Regional Nurse Consultant and Executive Director/Administrator. Interview on [DATE] at 11:11 a.m. with Administrator revealed that he has invited the Regional Executive Director to attend QAPI meetings, but he has not attended yet. Phone interview on [DATE] at 11:33 a.m. with Regional Executive Director KKK stated that he was part of the governing body providing oversight to the facility. He stated facility Administrator is responsible for management of the facility and reports directly to him. He stated he is not sure how often the Governing Body meets, but he visits the facility one day per week. During further interview, he stated that he was notified about COVID outbreak in the facility but cannot recall when he was notified. He stated he believes the facility was testing for COVID as they were supposed to be doing, but not able to state how long COVID outbreak has been. He stated the facility is having success using staffing agencies. He stated that he was not sure what role the Governing Body plays in QAPI, he stated he does not attend the meetings. Phone interview on [DATE] at 3:38 p.m. with Regional Executive Director LLL stated he provides oversight between the Governing Body and the Administrator for facility management and operations. He stated he also provides support to the Regional Executive Director KKK. He stated that he visits the facility every two to three weeks. He stated that the Governing Body has zoom meetings weekly, and stated the last meeting was two weeks ago. He stated he gets updates about COVID positive cases all the time but cannot recall when the last update was. He stated he was not aware of any concerns with lack of testing residents or staff members. He stated he was aware of the facilities use of agency nurses but was not aware that the DON was being utilized as Charge Nurse working on the medication cart. During further interview, he stated that he has from time to time attended QAPI meetings, but not regularly. Interview on [DATE] at 10:10 a.m. with Administrator revealed that the facility did not have a policy for Governing Body. Cross Refer F725, F880, F886.

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 COVID-19 screening/testing and staffing. The census was 85. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:30 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: According to a COVID-19 Infection Control Line Listing for the facility, two staff members tested positive for COVID-19: one on [DATE] and another on [DATE]. Two residents also tested positive for COVID-19 on [DATE]. There is no evidence that the facility conducted outbreak testing for 13 of 22 residents reviewed. There is no evidence that 14 of 40 nursing staff working [DATE] through [DATE] were tested weekly according to outbreak testing status and/or based on county positivity rate, with no evidence that 11 of those 14 nursing staff were tested at all. R#10, who tested positive on [DATE], was transferred to hospital on [DATE] with worsening COVID symptoms and expired on [DATE]. Outbreak testing was initiated on [DATE] during the survey. R#11 tested positive for COVID-19 and expired at the facility on [DATE]. R#21 and R#22 tested positive and were placed on the 200 Hall (later designated as a COVID-19 unit and Observation unit). Three staff members also tested positive. The facility did not have separate COVID and observation units and did not have dedicated staff. The facility had discarded barriers needed for the COVID unit and had to reorder. The facility had not contacted the local Department of Public Health (DPH) for guidance after continued outbreaks in the facility. The facility had no evidence of routine monitoring of residents for signs and symptoms of COVID-19 for 19 of 22 residents reviewed. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.35(a)(1)(2) Sufficient Nursing Staff, F725; 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; 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; and 42 CFR 483.80 (h)(1)-(6) Covid-19 Testing-Residents & Staff, F886. F725, F835, F837, F867, F880, and F886 were at a Scope and Severity (S/S) of a L. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) Program revised [DATE], revealed: policy statement: the facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals. Policy Interpretation: The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents. Five Strategic Elements include: design and scope; governance and leadership; feedback, data systems and monitoring; performance improvement projects; and systematic analysis and systematic action. Action Step: 13. Gathering and using QAPI data in an organized and meaningful way. Areas that may be appropriate to monitor and evaluate include: a. Clinical outcomes; pressure ulcers, infections, medication use, pain, falls, etc. 16. Recognizing patterns in system of care that can be associated with quality problems. 18. Planning, conducting and documenting PIP's (Performance Improvement Plans). 19. Conducting Root Cause Analysis to identify the underlying issues that contribute to recognized problems. A review of the Quality Assurance Performance Improvement (QAPI) meeting sign in sheets revealed that the members of the committee included but were not limited to the Administrator, Director of Nursing, Medical Director, Infection Control and Preventionist, Assistant Director of Nursing, Social Services Director, Wound Nurse, Minimum Data Set (MDS) Nurse, Activity Director, Dietary Manager, Human Resources, Admissions Director, Environmental Services, Staffing Coordinator, Consultant Pharmacist, and Nurse Practioner. During months of [DATE] through [DATE], there have been 11 committee members present, without a set agenda. Review of [DATE] QAPI meeting minutes revealed the Staffing Coordinator voiced concerns related to staffing and Administrator agreed to work with her to try and increase staff in the facility. Review of [DATE] QAPI meeting minutes revealed the Staffing Coordinator states we have less than 20 full-time employees and we need to increase the wages and get more staff into the facility. The Administrator instructed her to run some new ads on indeed and to contact additional agencies until we could hire our own staff. An ad was placed for a full-time Wound Nurse and she was hired but never showed up for orientation. Review of [DATE] QAPI meeting minutes revealed the Administrator signed a contract with a new staffing agency. The staffing PAR was increased to 3.1. This was the approved new budget status although the minimum is 2.5. Due to shortage of wound care nurse, the Director of Nursing, the Assistant Director of Nursing, Charge Nurses and the Administrator will assist with wound care. Review of a QAPI Plan dated [DATE] provided by the Regional Nurse Consultant with identified problem statement as: Insufficient routine screening and/or monitoring of residents for signs and/or symptoms of Covid-19. Lack of Covid-19 testing based on the county's positivity rate for all dedicated and/or contracted staff members. Goals: Licensed staff will routinely screen and monitor for signs and/or symptoms of Covid-19 at the beginning of the shift and prn (as needed). Plan: New tracking methods to be utilized for screening and testing. Facility leadership staff will monitor compliance of the screening and testing. Root Cause(s) include staff education on the requirements of the screening and testing process, tracking of screening/testing, and testing station location. Barriers include current tracking tools, lack of follow-up and lack of licensed staff education. Interview on [DATE] at 3:29 p.m. with the Regional Nurse Consultant revealed that she held an Ad Hoc QAPI meeting today and provided one on one education with the Director of Nursing about the new process and forms for tracking. She stated that there had not been any concerns with COVID-19 testing or outbreak status presented in any prior QAPI meetings. During an interview on [DATE] at 1:05 p.m., the Administrator stated that QAPI meets monthly, and each department will have opportunity to discuss concerns within their department. He stated that he was not aware of issues with the Infection Prevention Program. Cross Refer to F880, F886

Based on observations, record review, interviews, and review of facility policy titled Visitation and Infection Control Policy the facility failed to implement an effective Infection Control Program to prevent the spread of infections, including COVID-19. Specifically, the facility failed to have a dedicated COVID-19 positive unit with dedicated staff, failed to routinely monitor 19 of 22 residents (R) (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #15, #16, #17, #18, #19, #20, #21, and #22) for signs/symptoms of COVID-19, and failed to don/doff appropriate Personal Protective Equipment (PPE). In addition, the facility failed to maintain communication with local health department during continued COVID-19 outbreaks, failed to store resident personal care items appropriately, failed to conduct non-COVID-19 infection surveillance from [DATE] through [DATE] and failed to ensure PPE was stocked. The facility census was 85. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:30 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: According to a COVID-19 Infection Control Line Listing for the facility, two staff members tested positive for COVID-19: one on [DATE] and another on [DATE]. Two residents also tested positive for COVID-19 on [DATE]. There is no evidence that the facility conducted outbreak testing for 12 of 22 residents reviewed. There is no evidence that 14 of 40 nursing staff working [DATE] through [DATE] were tested weekly according to outbreak testing status and/or based on county positivity rate, with no evidence that 11 of those 14 nursing staff were tested at all. R#10, who tested positive on [DATE], was transferred to hospital on [DATE] with worsening COVID symptoms and expired on [DATE]. Outbreak testing was initiated on [DATE] during the survey. R#11 tested positive for COVID-19 and expired at the facility on [DATE]. R#21 and R#22 tested positive and were placed on the 200 Hall (later designated as a COVID-19 and Observation unit). Three staff members also tested positive. The facility did not have separate COVID and observation units and did not have dedicated staff. The facility had discarded barriers needed for the COVID unit and had to reorder. The facility had not contacted the local Department of Public Health (DPH) for guidance after continued outbreaks in the facility. The facility had no evidence of routine monitoring residents for signs and symptoms of COVID-19 for 19 of 22 residents reviewed. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.35(a)(1)(2) Sufficient Nursing Staff, F725; 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; 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; and 42 CFR 483.80 (h)(1)-(6) Covid-19 Testing-Residents & Staff, F886. F725, F835, F837, F867, F880, and F886 were at a Scope and Severity (S/S) of a L. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of the facility policy titled Visitation and Infection Control Policy updated to address the Coronavirus Disease 2019 (COVID-19), revised [DATE] revealed policy interpretation and implementation: 1. The facility, consistent with federal regulations, implements universal, standard infection control practices, including a. Standard Precautions b. Hand hygiene c. Respiratory hygiene d. Vaccinations e. Signs and symptoms of common communicable diseases. 2.c. Residents may be screened up to three (3) times per day; number 2f. Residents with confirmed COVID-19 who have not met criteria for discontinuing transmission-based precautions should be placed in an isolation unit. New admissions and re-admissions whose COVID status is unknown or not fully vaccinated should be placed on the observation unit; make PPE, including facemask, eye protection, gowns, gloves, and shields/goggles available immediately outside of the resident's room when it's determined PPE is needed for the resident; 2n. If necessary, the facility will identify dedicated employees to care for COVID-19 patients and provide infection control training. 1. Observation on [DATE] at 10:30 a.m. during initial tour with the DON revealed the 200 Hall was identified as the Observation unit. At the end of the 200 Hall were two rooms (206 and 208) that were for COVID positive residents if they needed them. There was no type of protective barrier to separate rooms [ROOM NUMBERS] from the Observation rooms. Interview on [DATE] at 11:00 a.m. with the DON, Infection Control Preventionist (ICP), revealed she has had the role of DON and ICP for three months. She stated there are six residents on the Observation unit. Observation on [DATE] at 11:45 a.m. of the 200 Hall revealed three newly tested positive residents (R#11, R#21 and R#22) were being housed in the rooms on the right side of the 200 Hall (Observation Unit), without dedicated staff to attend to them. Observation on [DATE] at 11:06 a.m. revealed the 200 Hall, which houses COVID-19 positive residents and Observation residents, had no dedicated coverage and the duties of administering medications was being split between Licensed Practical Nurse (LPN) AA and LPN QQ who were also administering medications on other units. Observation on [DATE] at 9:30 a.m. revealed there are six residents on the Observation unit and three residents in COVID isolation rooms. There is no barrier to separate the Observation unit from the COVID unit. Observation on [DATE] at 11:30 a.m. and [DATE] at 9:00 a.m. revealed the 200 Hall, which houses COVID-19 positive residents and Observation residents, had no dedicated coverage and the duties of administering medications was being split between LPN AA and LPN KK who were also administering medications on other units. Observation on [DATE] at 9:10 a.m. of the 200 Hall revealed that on the COVID rooms, 206 and 208, plastic barriers for the doorways were lying on the floor, at the entrance of the room. Interview on [DATE] at 9:10 a.m. with CNA BB, revealed the plastic barriers on the doorways on the 200 Hall are always falling down, because the tape is not holding the plastic on the doorway. Interview on [DATE] at 2:05 p.m. with Maintenance Supervisor revealed he took the COVID barrier down back in [DATE] as he was directed to do by the Administrator. He stated that he cleaned the poles and stored them in the Maintenance office. He stated that when the last couple of residents tested positive for COVID, he cut the plastic to fit over individual room doors on the Observation unit, to have extra protection from the newly diagnosed COVID residents. During further interview, he stated that he ordered a new COVID barrier kit, and it is due to be delivered on [DATE]. Observation on [DATE] at 9:20 a.m. revealed the 200 Hall, which houses COVID-19 positive residents and Observation residents, had no dedicated coverage and the duties of administering medications was being split between LPN AA and LPN WW who were also administering medications on other units. Observation on [DATE] at 3:45 p.m. revealed the 200 Hall, which houses COVID-19 positive residents and Observation residents, had no dedicated coverage and the nursing aide duties were being shared by Certified Nursing Assistant (CNA) JJ and CNA BBB who were also working on other units. Observation on [DATE] at 4:30 p.m. revealed a COVID plastic barrier wall assembled on the 200 Hall, separating rooms [ROOM NUMBERS] from the Observation unit. Observation on [DATE] at 11:12 a.m. revealed the plastic barrier wall was not sealed around the barrier poles on the 200 hall COVID unit, not creating a closed unit. During an interview on [DATE] at 11:30 a.m., the Maintenance Assistant stated that the double-sided tape on the barrier plastic is not sticking due to unzipping the plastic, causing it to pull from the poles. Observation on [DATE] at 10:50 a.m. revealed the COVID barrier wall on the 200 Hall had been taken down. There were no COVID-19 positive residents at this time. 2. Review of the clinical record for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#15, R#16, R#17, R#18, R#19, R#20, R#21 and R#22 revealed no evidence that residents were being routinely monitored for signs and symptoms of the COVID-19 virus, until the evening shift of [DATE] after surveyor made inquiries. Interview on [DATE] at 3:34 p.m. with DON revealed that Charge Nurses should be routinely assessing residents for signs and symptoms of COVID-19 each shift and documenting in the electronic medical record (EMR) MAR. She verified residents were not being monitored for signs and symptoms of COVID-19. 3. Observation on [DATE] at 2:20 p.m. revealed the Assistant Director of Nursing (ADON) was walking the all units, including the COVID-19 unit, without wearing a face shield (eye protection), as recommended by Department of Public Health (DPH) meeting on [DATE]. Observation on [DATE] at 5:20 p.m. revealed RN UU exited a resident room on the 300 Hall, wearing gloves and pushing the meal cart down the hall. Interview on [DATE] at 5:20 p.m. with RN UU, revealed that she did not touch any residents, so she thought it was ok to throw the gloves away in the trash can in the dining room. Observation on [DATE] at 10:55 a.m. revealed an isolation gown observed hanging on Point of Care (POC) monitor in the hallway on the Observation unit. Observation on [DATE] at 12:45 p.m. revealed housekeeping staff MMM was cleaning room [ROOM NUMBER] (COVID positive room) and exited the isolation room wearing gloves and gown and doffed at her cart. Observation on [DATE] at 11:59 a.m. revealed an isolation gown was hanging on a POC monitor on the 200 COVID/Observation Hall. 4. Interview on [DATE] at 10:30 a.m. with Administrator revealed that he has been at this facility since [DATE]. He stated that the COVID unit was taken down sometime in [DATE] because they did not have any COVID positive residents ([DATE] was last COVID positive resident in [DATE]). However, the last two rooms on the 200 Hall are COVID rooms if they should need them. He stated that the decision to take the unit down was a joint decision with DON and Regional Administrator. During further interview, he stated he is not sure what happened to the barrier walls, but stated they were probably in storage somewhere onsite. When questioned if he contacted the DPH Epidemiology for assistance during an ongoing outbreak of COVID-19, he replied yes, I contacted them about a week before you came and they did a zoom visit on [DATE] and an onsite visit on [DATE]. He stated they made some recommendations, and they are working on those recommendations now. Review of DPH Epidemiology Infection Control Assessment and Response Tool (ICAR) dated [DATE], [DATE] (onsite) and [DATE] (onsite) revealed areas of concern with staffing support needed for COVID unit and also to ensure testing each week, recommend increasing staff to assist DON, recommend fingernail education as nail extenders noted on staff, limited supply of Alcohol Based Hand Rub (ABHR) in four room suites, recommendation for all staff to wear eye protection, PPE education on when/where to don/doff, post CDC PPE donning/doffing signage on resident doors, recommend isolation carts outside each residents room with assigned personal to keep stocked, environmental staff cleaning without wearing gloves and need for Observation unit and COVID unit to be kept separate. Review of the facility's COVID-19 weekly line list of staff and residents, received from the facility, revealed that from the week of [DATE] through the week of [DATE] the facility had four new COVID positive Residents and six new positive staff. There was evidence to support resident and staff weekly testing related to the outbreaks in [DATE]. However, review of email correspondence from DPH to the surveyor dated [DATE] revealed that the last ICAR, prior to [DATE], during the survey, was conducted with the facility on [DATE]. Review of e-mail correspondence between Administrator and the DPH Epidemiology from [DATE] through [DATE] revealed submission of line listings with no request for assistance during an on-going outbreak of COVID-19. 5. Observation on [DATE] at 9:25 a.m. in room [ROOM NUMBER] revealed un-bagged and un-labeled bath basin sitting on sink counter in a semi-private room. Observation on [DATE] at 10:10 a.m. in room [ROOM NUMBER], revealed two un-bagged and un-labeled bath basins on the floor under the sink, in a semi-private room. Observation on [DATE] at 10:13 a.m. in room [ROOM NUMBER], revealed an un-bagged and un-labeled bath basin on the floor under the sink. Observation on [DATE] at 10:20 a.m. in room [ROOM NUMBER], revealed three un-bagged and un-labeled bath basins on top of a closet, in a semi-private room. Observation on [DATE] at 10:22 a.m. in room [ROOM NUMBER], revealed an un-bagged and un-labeled urine measuring bowl in the bathroom, on the floor. Observation on [DATE] at 3:30 p.m. in room [ROOM NUMBER] revealed an un-bagged and unlabeled bath basin on the counter and an un-bagged and un-labeled urinal hanging on the grab bar in the bathroom. Observation on [DATE] at 1:45 p.m., in room [ROOM NUMBER], revealed a bath basin on the floor under the sink, not bagged. 6. Review of Infection Control Surveillance data for the past 12 months revealed there was no Infection Control or Antibiotic Stewardship data collected for the months of [DATE] through [DATE]. Inconsistent COVID-19 data was the only data collected. Interview on [DATE] at 2:04 p.m. with DON/ICP revealed that there was no one in the role of ICP when she was hired, but the previous DON was supposed to be collecting the surveillance data. She stated she has been inconsistent with the data collection and surveillance tracking because she has had to work on the medication cart three to four days per week, and she just did not have time to do it. 7. Observation on [DATE] at 10:55 a.m. revealed the PPE cart outside room [ROOM NUMBER], observation room, was not stocked with gloves or gowns. Observation on [DATE] at 11:40 a.m. revealed the PPE cart outside room [ROOM NUMBER], observation room, was not stocked with gowns or masks.

Based on record review and staff, Medical Director, and Regional Nurse Consultant interviews, the facility failed to conduct routine and outbreak testing for COVID-19 in a manner consistent with current standards of practice for 13 residents, (R) (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, R#11, R#21, and R#22) of 22 residents reviewed for COVID-19 testing. Additionally, the facility failed to ensure testing was completed and results documented for 14 of 40 nursing staff working [DATE] through [DATE]. On [DATE] a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy (IJ) on [DATE] at 10:30 a.m. The noncompliance related to the IJ was identified to have existed on [DATE]. The IJ is outlined as follows: According to a COVID-19 Infection Control Line Listing for the facility, two staff members tested positive for COVID-19: one on [DATE] and another on [DATE]. Two residents also tested positive for COVID-19 on [DATE]. There is no evidence that the facility conducted outbreak testing for 13 of 22 residents reviewed. There is no evidence that 14 of 40 nursing staff working [DATE] through [DATE] were tested weekly according to outbreak testing status and/or based on county positivity rate, with no evidence that 11 of those 14 nursing staff were tested at all. R#10, who tested positive on [DATE], was transferred to hospital on [DATE] with worsening COVID symptoms and expired on [DATE]. Outbreak testing was initiated on [DATE] during the survey. R#11 tested positive for COVID-19 and expired at the facility on [DATE]. R#21 and R#22 tested positive and were placed on the 200 Hall (later designated as a COVID-19 unit and Observation unit). Three staff members also tested positive. The facility did not have separate COVID and observation units and did not have dedicated staff. The facility had discarded barriers needed for the COVID unit and had to reorder. The facility had not contacted the local Department of Public Health (DPH) for guidance after continued outbreaks in the facility. The facility had no evidence of routine monitoring of residents for signs and symptoms of COVID-19 for 19 of 22 residents reviewed. The IJ was related to the facility's noncompliance with the program requirements at 42 CFR 483.35(a)(1)(2) Sufficient Nursing Staff, F725; 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; 42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control, F880; and 42 CFR 483.80 (h)(1)-(6) Covid-19 Testing-Residents & Staff, F886. F725, F835, F837, F867, F880, and F886 were at a Scope and Severity (S/S) of a L. At the time of the exit on [DATE], the IJ remained ongoing. Findings include: Review of the Georgia Department of Public Health COVID-19 PCR Test Positivity Rates and Classification, Georgia, revealed positivity rate for [NAME] County was as follows: [DATE]=11.6% [DATE]=10.1% [DATE]=8.4% [DATE]=7.3% [DATE]=6.5% [DATE]=5% [DATE]=4.3% [DATE]=4.2% [DATE]=4.5% [DATE]=4.5% The Test Positivity Classification for these time periods was red which is greater than 10% for weeks of [DATE] and [DATE]; yellow which is ,d+[DATE]% for [DATE], [DATE], [DATE] and [DATE]; and green which is less than 5% for [DATE] through [DATE]. Based on the county infection rates noted above, the Center for Medicare and Medicaid Services (CMS) identified in memo QSO-,d+[DATE]-NH, dated [DATE], the requirement that a facility test all staff, contracted staff working in the building, and consultants, twice a week when the county COVID-19 positivity rate for the county is greater than 10%. When the county COVID-19 positivity rate is ,d+[DATE]% staff testing is to be conducted once per week; and for county COVID-19 positivity rate less than 5% staff testing should be conducted once per month. In addition, CMS identified in QSO-,d+[DATE]-NH, dated [DATE], the requirement for outbreak testing, all staff and residents should be tested , and all staff and residents that tested negative should be retested every three to seven 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. Review of the COVID-19 Staff Line Listing revealed staff tested positive for COVID-19 on [DATE], [DATE], and [DATE]. Review of the COVID-19 Resident Line Listing revealed a resident tested positive for COVID-19 on [DATE]. The facility began outbreak testing for residents and staff on [DATE] during survey where additional residents and staff members tested positive for COVID-19 on [DATE], [DATE], [DATE], and [DATE]. Review of the actual nurse staffing hours for facility nursing staff revealed that from [DATE] through [DATE], Registered Nurse (RN) NN, RN UU, Licensed Practical Nurse (LPN) FF, LPN CCC, LPN DDD, LPN EEE, Certified Nursing Assistant (CNA) FFF, CNA GGG, CNA HHH, CNA III, and CNA JJJ worked during this time period. There is no evidence that the above staff were tested for COVID-19 during that time period. According to facility testing documents for staff, the Director of Nursing (DON) was tested on [DATE] and [DATE] only, the Assistant ADON was tested on [DATE] only, and Agency LPN AA was tested on [DATE] only. Review of the clinical record revealed the following COVID-19 testing information for previously negative residents for [DATE](when an outbreak occurred) through [DATE]: 1. R#1 was admitted to the facility on [DATE] and was last tested on [DATE]. There is no evidence that COVID testing was performed after [DATE] through [DATE]. 2. R#2 was admitted to the facility on [DATE] and was last tested on [DATE] and [DATE]. There is no evidence of any other COVID testing from [DATE] through [DATE]. 3. R#3 was admitted to the facility on [DATE] and was last tested on [DATE] and [DATE]. There is no evidence of any other COVID testing through [DATE]. 4. R#4 was admitted on [DATE], transferred to the hospital on [DATE] and was readmitted on [DATE]. There was no evidence of COVID testing through [DATE]. 5. R#5 was admitted to the facility on [DATE] and was last tested on [DATE]. There is no evidence of any other COVID testing from [DATE] through [DATE]. 6. R#6 was admitted to the facility on [DATE] and was last tested on [DATE] and [DATE]. There is no evidence of any other COVID testing from [DATE] through [DATE]. 7. R#7 was admitted to the facility on [DATE] and was last tested on [DATE] and [DATE]. There is no evidence of any other COVID testing through [DATE]. 8. R#8 was admitted to the facility on [DATE] and was last tested on [DATE] and [DATE]. There is no evidence of any other COVID testing through [DATE]. 9. R#9 was admitted to the facility on [DATE] and tested positive for COVID-19 on [DATE]. There is no evidence that COVID testing was done prior to [DATE]. 10. R#10 was admitted to the facility on [DATE]. The resident tested positive for COVID-19 on [DATE]. There is no evidence that COVID testing was performed prior to [DATE]. Further review of the clinical record revealed R#10 was transferred to hospital on [DATE] with worsening COVID symptoms and expired on [DATE]. 11. R#11 was admitted to facility on [DATE]. R#11 tested positive on [DATE]. There is no evidence that COVID testing was performed prior to [DATE]. Further review of the clinical record revealed R#11 expired on [DATE] at the facility. 12. R#21 was admitted to the facility on [DATE] and was not tested until [DATE] and tested positive. 13. R#22 was admitted to the facility on [DATE]. The resident was tested for COVID-19 on [DATE] and [DATE]. Resident tested positive on [DATE]. There is no evidence that the resident was tested prior to [DATE]. There were no documented refusals of testing for residents or staff. Review of Quality Assessment and Performance Improvement Plan dated [DATE] provided to surveyor by Regional Nurse Consultant with identified problem statement as: Lack of Covid-19 testing based on the county's positivity rate for all dedicated and/or contracted staff members. Plan: New tracking methods to be utilized for screening and testing. Facility leadership staff will monitor compliance of the screening and testing. Root Cause(s) include staff education on the requirements of the screening and testing process, tracking of screening/testing, testing station location. Barriers include current tracking tools, lack of follow up and lack of licensed staff education. Interview on [DATE] at 11:00 a.m. with DON revealed she has been employed at the facility for eight months but has had the role of DON and Infection Control Preventionist (ICP) for three months. She stated that the County Positivity Rate was 4.2 and the facility is currently testing residents and staff once monthly. During further interview, she stated this morning she had two dietary staff members to test positive for COVID. Interview on [DATE] at 1:11 p.m. with DON revealed that there is no specific day that the COVID testing is done, but usually done on Tuesday's and Friday's. She stated that she splits the testing with the Assistant Director of Nursing (ADON). She stated that she makes an announcement on the paging system for staff to come get COVID tested and that staff sign in when they come to the clinic. During further interview, she stated that if staff do not come to the COVID clinic, she contacts the department heads and informs them staff need to be tested . She stated she is unable to follow up to see if the staff that missed testing were actually tested later. She stated that staff know COVID testing is not optional and if staff do not come to get tested , they will be removed from the schedule. She further stated that the ADON will come in early to do testing of the night shift staff. During an interview on [DATE] at 3:29 p.m., the Regional Nurse Consultant stated that she held an Ad Hoc QAPI meeting today and provided one on one education with the DON about the new process and forms for tracking. She stated that there had not been any concerns with COVID-19 testing or outbreak status presented in any prior QAPI meetings. Interview on [DATE] at 12:20 p.m. with Housekeeping Supervisor revealed that she has been tested weekly on Wednesdays. She stated that if her staff are off on the Wednesday test day, then they are tested on their first day back to work. The DON confirmed during interview on [DATE] at 12:10 p.m. that the tracking logs for resident and staff testing she provided to the surveyor was all that she could find. Interview on [DATE] at 1:00 p.m. with ADON revealed she has been employed at the facility for two months. She stated that she helped the DON with the COVID testing for staff and residents. She stated that she would use a daily census sheet when testing residents and that is how they tracked testing. She stated that she did not do any type of documentation that residents had been tested , unless they tested positive. She further stated that she does not know how the tracking for the staff testing was being done. Phone interview on [DATE] at 11:46 a.m. with the Medical Director revealed he has weekly conversations with the Administrator, either in person or via phone. He stated that there was nothing mentioned to him about COVID outbreaks in the facility.

Based on facility policy review, record review, observations, interviews, and review of the Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure professional standards of care were met regarding the cleaning of glucometers for seven out of 23 residents (R) receiving blood glucose checks in the facility, (R#2, R#4, R#15, R#25, R#35, R#71, and R#285). Specifically, nursing staff were not following the standard of care related to cleaning and sanitizing glucometers prior and after each resident's use to avoid cross contamination. The facility's failure to ensure professional standards of care were followed related to sanitizing the resident's glucometers to prevent the cross contamination of blood borne illnesses was determined to be likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was determined to exist on 9/18/18, when the surveyor observed R#25 's blood glucose level being checked with a glucometer that had not been appropriately sanitized prior to use. The immediate jeopardy was related to the facility's noncompliance with the program requirements at CFR 483.21(b)(3)(i) Professional Standards (F658 Scope/Severity: K); CFR 483.35(a)(3)-(4),(C), Nursing Services (F726, Scope/Severity: K); CFR 483.70 Administration (F835, Scope/Severity: K); CFR 483.75(g)(2), Quality Assessment and Assurance (F867, Scope/Severity: K); CFR 483.80 (a)(1)(2)(i)(ii)(iii) (4) Infection Control Program (F880 Scope/Severity: K). The facility's Administrator, Regional Director of Operations, and Regional Nurse Consultant were informed of the Immediate Jeopardy on 9/20/18 at 5:18 p.m. The noncompliance related to the immediate jeopardy was identified to have existed as of 9/18/18 during the observation of medication administration nursing staff failed to properly sanitize the glucometers before and after use for R#2, R#4, R#15, R#25, R#35, R#71, and R#285. On 9/23/18 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 9/22/18. Based on validation of the A[NAME] the State Survey Agency (SSA) conducted observations, record reviews, interviews and review of the facility's policies as outlined in the A[NAME], the State Survey Agency (SSA) determined the immediate Jeopardy was removed on 9/23/18. The Scope and Severity were lowered to E while the facility continued management level oversight of licensed nursing staff and develops and implements a plan of correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The findings include: Review of the Georgia Practical Nurses Practice Act with a copyright date of 2013 documents the following: The practice of licensed practical nursing (LPN) 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 maintenance of health and prevention of illness through acts authorized by the board, which shall include, but not be limited to, the following: A. Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations . B. Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes D. Administering treatments and medications ; Review of the Manufacturer's Guidelines for the use of the Assure Platinum Blood Glucose Monitor read, in pertinent part, Cleaning and Disinfecting Guidelines: Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed using a commercially available EPA (Environmental Protection Agency)-registered disinfectant detergent or germicide wipe, To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter, many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use on wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint -free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70 - 80%), To disinfect the meter, dilute 1 ml (milliliter) of household bleach (5 - 6% sodium [MEDICATION NAME] solution) in 9 ml of water to achieve a 1:10 dilution (final concentration of 0.5 - 0.6% sodium [MEDICATION NAME]). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers. Take extreme care not to get liquid in the test strip and key code ports of the meter. With all recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. Review of the Manufacturer's Guidelines for use of Super Sani-Cloth Germicidal Disposable Wipes read, in pertinent part, Kills HIV-1 (AIDS Virus), [MEDICAL CONDITION] Virus (HBV) and [MEDICAL CONDITION] Virus (HCV) on the pre-cleaned environmental surfaces/objects in two minutes at room temperature (68-77 Degrees F) in health care setting in which there is an expected likelihood of soiling of surfaces/objects with blood or body fluids, and in which the surfaces/objects likely to be soiled with blood or body fluids can be associated with the potential for transmission of Human Immunodeficiency Virus ,[MEDICAL CONDITION]. Type 1 (HIV-1) (associated with AIDS, [MEDICAL CONDITION] Virus (HBV) and [MEDICAL CONDITION] (HCV). Observations during Medication Administration on 9/18/18 and 9/19/18 revealed the following: 1. Licensed Practical Nurse (LPN) DD was observed performing R#25's blood glucose check on the 200 Unit on 9/18/18 at 11:29 a.m. LPN DD cleaned the glucometer with an alcohol prep pad for approximately 15 seconds prior to using the monitor to obtain R#25's blood glucose level. 2. LPN DD was observed performing R#4's blood glucose checks on the 200 Unit on 9/18/18 at 11:33 a.m. LPN DD cleaned the glucometer with an alcohol prep pad for approximately 10 seconds prior to using the monitor to obtain R#4's blood glucose level. 3. LPN DD was observed performing R#285's blood glucose checks on the 200 Unit on 9/18/18 at 11:38 a.m. (immediately after performing R#4's blood glucose check). LPN DD cleaned the glucometer with an alcohol prep pad for approximately 10 seconds prior to using the glucometer to obtain R#285's blood glucose level. During an interview with LPN DD on the 200 Nursing unit on 9/18/18 at 11:45 a.m., he stated, I usually use an alcohol swab to clean the meter. I think I might have had one in-service, when I started working here in (MONTH) (regarding proper sanitization of a glucose monitor). The LPN additionally stated, I think had one in-service when I started working here in March. LPN DD couldn't recall if he'd been trained, or not on the use of glucometer). I don't know what kill time is. 4. Observation on the 100 Unit on 9/18/18 at 4:54 p.m. revealed LPN FF performing R#15's blood glucose check. LPN FF made no attempt to clean the glucometer prior to obtaining R#15's blood glucose level. 5. LPN FF was observed performing R#2's blood glucose check on the 100 Unit on 9/18/18 at 5:15 p.m. (immediately after obtaining R#15's blood glucose). LPN FF did not clean the glucometer prior to obtaining R#2's blood glucose level. 6. LPN FF was observed obtaining R#71's blood glucose checks on the 100 Unit on 9/18/18 at 5:25 p.m. (immediately after obtaining R#2's blood glucose). LPN FF did not clean the glucometer prior to obtaining R#71's blood glucose level. During an interview conducted with LPN FF on the 100 Nursing unit on 9/18/18 at 5:30 p.m., she stated, We clean the glucometers with soap and water every week. I use an alcohol pad sometimes between residents to wipe glucometer off. I do that randomly. We have Clorox Disinfecting wipes on the cart. LPN FF showed the surveyor a container of Clorox Disinfecting Wipes on the medication cart. She stated, I don't use these, though. LPN FF only had one glucometer on this medication cart, which she used for monitoring blood glucose for all residents on the unit. Additionally, LPN FF stated she did not remember receiving training on how to properly clean a glucometer. 7. Observation on the 200 Unit on 9/20/18 at 8:58 a.m. revealed LPN AA performing R#35's blood glucose check. LPN AA cleaned the glucose monitor with an alcohol prep pad for approximately 20 seconds prior to obtaining R#35's blood glucose level. During an interview with LPN AA on the 200 Nursing unit on 9/20/18 at 9:11 a.m., the LPN stated, I have to sanitize the glucometer with an alcohol pad before I use it. Additionally, LPN AA stated, he did not remember receiving training on how to sanitize the glucometer. During an interview with LPN EE on the 100 Nursing unit on 9/18/18 at 11:51 a.m., she stated, I clean the glucometer with alcohol before and after each use. I haven't received any training on how to clean the glucometer. During an interview with LPN GG on the 100 Nursing unit on 9/19/18 at 5:35 p.m., she stated, The glucometer are cleaned with alcohol and the Clorox wipe. I use a Clorox wipe and then alcohol. During an interview with Unit Manager (UM) BB on the 100 Nursing unit on 9/20/18 at 8:54 a.m., she stated, The process for cleaning the glucometer is to use the wipes kept in the bottom drawer of the medication cart to clean the meter and then let it dry. During an interview with the Regional Clinical Director in the conference room on 9/20/18 at 9:20 a.m., she stated, The Glucometers should be cleaned before and after use. The staff have a Clorox based cleaner on the medication carts for cleaning the glucometer. I think it's a Purple Top Sani-Wipe. She indicated on glucometer was kept in each medication cart, and the same glucometer was used for all residents receiving medication from that cart. During an additional interview with the Regional Clinical Director in the conference room on 9/20/18 at 12:09 p.m., The policies aren't being followed. We have been unable to find training documentation for any of the nurses. We are doing competencies right now with all of the nurse. During an interview with the Medical Director in the conference room, via phone, on 9/20/18 at 2:23 p.m., he stated, I would expect, minimally, for the policy to be followed. During an interview with the Administrator in the conference room on 9/21/18 at 11:10 a.m., he stated the Assistant Director of Nursing (ADON) was responsible for the Infection Control program in the facility, however she was no longer working in the facility as of 9/7/18. The facility implemented the following actions to remove the immediate Jeopardy: I. Record review revealed the RNC provided training to the RN supervisor and the ADON on the professional standards of care as it relates to the staff cleaning the glucometers properly with the correct disinfectant and avoid using the same glucose meters on residents with infectious [DIAGNOSES REDACTED]. All trainig records to be maintained in the Administrators office. II. Record review and interviews revealed the RNC,ADON and RN Supervisor have completed 100% staff training on meeting the professional standards of care as it relates to the proper cleaning of the glucose meter. III. Interview with the ADON that she responsible for Staff development and she plant to incorporate the training of glucose meters for al new hires, annually and needed.(sic) IV. Record review and interview with the RNC revealed she has redesigned the daily audit sheets to focus on the professional standards of licensed staff must exhibit performing finger sticks correctly according to the training received and suing (sic) the glucometers. If during the daily audit a deficient practice is identified the observer will intervene and remove the nurse prior to contact with the resident. The audit sheet will reflect the necessary retraining for the employee (sic). The daily audit sheet will be reviewed and by the RNC. ADON, and Administrator. The audit sheets will be maintained in the Administrator's office. V. The RNC and ADON will be responsible for gathering for presenting the result of the dialy audits and trainig to the QAPI committee for monitoring for adherence to the A[NAME]. VI. The DON/ADON will provide education regarding professional Standards upon hire and annually for all licensed nurses. Documentation of the education and competency will be located in the Administrators office. VII. The ADON/Unit Manager will perform Glucose cleaning audits to assure that the level and type of care meets the professional standards for Licensed nursed, daily, each shift,7 days per week. the audits will be documented and maintained in the Administrators office. VII. Results will be presented to the QAPI committee, by the Administrator and/or the DON, to allow the QAPI committee to monitor completion of licensed nurse competencies r/t cleaning and decontamination of the Glucometer, to ensue compliance. The State Survey Agency (SAA) validated the facility Credible Allegation of Immediate Jeopardy Removal as follows: Review of the facility's Allegation of Compliance (A[NAME]) Manual revealed the facility Regional Nurse Consultant (RNC) reviewed and revised the facility's policy for sanitizing the glucometers for residents requiring finger sticks to monitor blood glucose on 9/20/18. Revision of the policy also included the storage of separate glucometers for those residents identified with an infectious disease. Review of the facility in-service records dated 9/20/18 to 9/22/18 revealed the RNC, Assistant Director of Nursing (ADON) and the Unit Manager (UM) BB provided training to facility licensed staff on the revised policy titled Policy in Cleaning and Disinfecting the Glucose Monitor. Review of the facility training records revealed the training provided by the RNC, ADON, and the UM BB also included a skills competency checklist for each licensed staff member. Review of the facility 's A[NAME] records also included audit forms developed by the RNC. The audits were to be completed daily on different shifts to monitor the licensed staff compliance with decontamination/sanitation and storage process of the glucometers. The RNC/ADON/designee will be responsible for completing the audits and the audit forms will be turned over to the Administrator. The audit form does reflect what interventions or actions (i.e. remedial training, etc.) will be taken if a deficient practice is identified. Observation of the medication cart for 300 Hall with LPN OO on 9/22/18 at 2:15 p.m. revealed LPN OO demonstrated the procedure for cleaning the glucometers as follows: Before using the meter on a resident staff clean/sanitize the meter using Santi Cloth Bleach wipes cleaning both sides two minutes then let it air dry for one minute and repeated the procedure after obtaining the resident's finger stick blood sugar. LPN OO stated if a resident has an infectious disease [DIAGNOSES REDACTED]. The same cleaning procedure will be used, and their glucometers will be stored in a plastic bag with the resident's name. Observation of the 400 Hall medication cart with LPN DD on 9/22/18 at 2:30 p.m. revealed the medication cart contained two glucometers for two residents with infectious diseases. The LPN created a clean field, set-up cleaning supplies (disinfectant wipes) and plastic cup. LPN DD performed hand hygiene and donned gloves; then inspected glucometer for traces of dried blood then obtained one Santi Cloth Bleach towel wiping the entire machine; then obtained a second wipe and continued to sanitize the machine for two minutes (checking his watch) and then placed the machine in the plastic cup to let it air dry for one minute. LPN DD stated the glucometers for these two residents are not be shared with other diabetic residents on the unit to avoid cross contamination. And the glucometer in the Styrofoam cup was to be used on the other diabetic residents on the 400 Hall. Observation of the 500 Hall medication cart with LPN AA on 9/22/18 at 2:45 p.m. revealed two glucometers in separate plastic bags for two residents with infectious disease diagnosis. LPN AA used hand sanitizer to clean her hands and then laid down two paper towels for clean field, set-up supplies to obtained blood sugar. LPN AA then used hand sanitizer again and donned gloves removed glucometer from the plastic bag and wiped glucometer with Sani wipe according to new policy for two minutes. LPN AA timed himself by watching the wall clock then placed the glucometer in a plastic cup to air dry for one minute. After demonstrating the decontaminating procedure for the glucometer, LPN AA stated it is now the facility policy to use separate glucometers for residents to avoid cross contamination Observation on 200 Hall with LPN FF 9/22/18 at 4:20 p. m. LPN FF used hand sanitizer and then set-up a clean field with paper towels then donned gloves and used Santi Cloth to sanitize glucometer for two minutes. LPN FF timed herself by watching the clock on the wall and then placed the glucometer in a clean cup to air dry for a minute. Then preceded to perform resident's finger stick (followed procedure for blood testing) LPN FF returned to medication cart and performed sanitizing procedure on the glucometer without any problems. Observation on 9/22/18 at 5:30 p.m. on the 300 Hall revealed LPN EE preparing to demonstrate hand sanitizing process for the glucometers. LPN EE used hand sanitizer and created clean field. Wiped the glucometer for 30 sec with Santi cloth and obtained a clean Santi cloth and wrapped the glucometer in the same cloth and placed in clean plastic cloth. Asked LPN EE if this was how she was trained? LPN stated she works at another LTC facility and that's they do it. LPN EE was asked to sanitize the glucometer the way she was trained. LPN EE repeated the procedure this time setup another clean field, used hand sanitizer and donned gloves, then wiped the meter front and back, sides, insertion site, then pulled another Santi cloth and continued with the sanitizing method for the two minutes and then placed in clean cup to air dry for one minute. Observation on 9/23/18 at 5:57 a.m. on the 500 Hall revealed LPN QQ started to sanitize the glucometer when she realized that she had not established a clean field, had not used hand hygiene and was not wearing gloves. LPN identified these areas herself and requested to start over again. LPN QQ used the hand sanitizer, created a clean field, and donned gloves then used two Santi-Cloth Bleach wipes to clean meter for two minutes and then placed the monitor in a clean plastic cup to air dry for one minute. LPN QQ explained those residents with a [DIAGNOSES REDACTED]. Observation on 9/23/18 at 6:25 a.m. on the 200 Hall with LPN RR had an instruction sheet on the medication cart for guidance in performing the procedure. LPN performed the sanitizing procedure without any difficulty. Interview with the RNC on 9/23/18 at 10:10 a.m. in the conference room revealed that she and the ADON will be responsible for monitoring the licensed staff for compliance. Audits will be conducted daily on the different shifts to identify any deficient practice. RNC stated if a deficient practice is identified, then that employee will be removed from resident care and receive remedial training immediately. The RNC also stated the audits and training records will be presented in the scheduled QAPI meetings to review staff compliance. An interview with the ADON on 9/23/18 at 10:30 a.m. in the conference room revealed that she is also responsible for staff education. The ADON stated that she has included sanitation and storage training of the glucometers in the new employees' orientation schedule. The ADON further stated all licensed staff will receive competency training on the glucometers annually and as needed.

Based on facility policy review, record review, observations, and interviews, it was determined the facility failed to ensure nursing staff was appropriately trained to provide clinical services, specifically the sanitizing and/or decontaminating the glucometers for of seven out of 23 residents (R) (R#2, R#4, R#15, R#25, R#35, R#71, and R#285) receiving blood glucose checks. Specifically, the facility was unable to provide documentation of the licensed staff receiving training on how to properly sanitize the residents' glucometer before and after each resident use to prevent cross contamination. The facility's failure to ensure licensed staff were appropriately trained to sanitize the glucometers to avoid cross contamination was determined to be likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was determined to exist on 9/18/18, when the surveyor observed R#25 's blood glucose level being checked with a glucometer that had not been appropriately sanitized prior to use. The immediate jeopardy was related to the facility's noncompliance with the program requirements at CFR 483.21(b)(3)(i) Professional Standards (F658 Scope/Severity: K); CFR 483.35(a)(3)-(4),(C), Nursing Services (F726, Scope/Severity: K); CFR 483.70 Administration (F835, Scope/Severity: K); CFR 483.75(g)(2), Quality Assessment and Assurance (F867, Scope/Severity: K); CFR 483.80 (a)(1)(2)(i)(ii)(iii) (4) Infection Control Program (F880 Scope/Severity: K). The facility's Administrator, Regional Director of Operations, and Regional Nurse Consultant were informed of the Immediate Jeopardy on 9/20/18 at 5:18 p.m. The noncompliance related to the immediate jeopardy was identified to have existed as of 9/18/18 during the observation of medication administration nursing staff failed to properly sanitize the glucometers before and after use for R#2, R#4, R#15, R#25, R#35, R#71, and R#285. On 9/23/18 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 9/22/18. Based on validation of the A[NAME] the State Survey Agency (SSA) conducted observations, record reviews, interviews and review of the facility's policies as outlined in the A[NAME], the State Survey Agency (SSA) determined the immediate Jeopardy was removed on 9/23/18. The Scope and Severity were lowered to E while the facility continued management level oversight of licensed nursing staff and develops and implements a plan of correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy titled Infection Control: Cleaning and Disinfecting Blood Glucose Meters Policy, dated 5/10 documented It is the policy of this facility to clean and disinfect blood glucose meters in a manner consistent with manufacturer's recommendations and in accordance with current CDC (Centers for Disease Control) guidelines for prevention of infection. Review of the facility's document titled the Infection Control: Cleaning and Disinfecting Blood Glucose Meters Training, undated, read, in pertinent part, Learning Objectives: At the conclusion of this program, the participant will be able to 1. State the reason for cleaning and disinfecting the glucose meters, 2. Discuss materials for cleaning and disinfecting glucose meters, 3. State the appropriate times and frequency for cleaning ad disinfecting glucose meters, 4. Demonstrate cleaning and disinfecting glucose meters, and 5. To use the purple top disinfectant with at least 2-minute kill time. Review of the facility's document titled The Glucometer Competency Checklist, dated 12/16, documented, Disinfection process for the glucometer with Super Sani-wipes prior to use: 3. Open and unfold 1st wipe to clean any blood and/or bodily fluids from the glucometer, 4. Unfold a second wipe to disinfect by wiping down all surfaces of the glucometer, 5. Allow the treated surface to remain wet for a full two (2) minutes, 6. Place the glucometer on a clean barrier surface and allow to air dry. 1. Licensed Practical Nurse (LPN) DD was observed preparing to perform R#25's blood glucose check on 9/18/18 at 11:29 a.m. on 200 Hall. LPN DD cleaned the glucometer with an alcohol prep pad for approximately 15 seconds prior to using the glucometer to obtain R#25's blood glucose level. 2. LPN DD was observed preparing to perform R#4's blood glucose check on 9/18/18 at 11:33 a.m. on 200 Hall. LPN DD cleaned the glucometer with an alcohol prep pad for approximately 10 seconds prior to using the monitor to obtain R#4's blood glucose level. LPN DD had previously used this same glucometer to check the blood glucose on R#25. 3. LPN was observed preparing to check R#285's blood glucose on 9/18/18 at 11:38 a.m. on the 200 Hall. LPN DD cleaned the glucometer with an alcohol prep pad for approximately 10 seconds prior to using the glucometer to obtain R#285's blood glucose level. LPN DD used this same glucometer on R#4 a few minutes earlier. Record review revealed R#285 had an infectious disease diagnosis. 4. LPN FF was observed preparing to perform R#15's blood glucose check on 9/18/18 at 4:54 p.m. on the 100 Hall. LPN FF did not clean the glucometer prior to obtaining R#15's blood glucose level. 5. LPN FF was observed preparing to perform R#2's blood glucose check on 9/18/18 at 5:15 p.m. on the 100 Hall. LPN FF did not clean the glucometer prior to obtaining R#2's blood glucose level. LPN FF had just finished using the same glucometer on R#15 a few minutes earlier. 6. LPN FF was observed preparing to perform R#71's blood glucose check on 9/18/18 at 5:25 p.m. on the 100 Hall. LPN FF did not sanitize the glucometer prior to obtaining R#71's blood glucose level. This was the same glucometer that LPN FF use to obtain R#2's blood glucose a few minutes earlier 7. LPN AA was observed preparing to check R#35's blood glucose on 9/20/18 at 8:58 a.m. on the 100 Hall. LPN AA cleaned the glucometer with an alcohol prep pad for approximately 20 seconds prior to obtaining R#35's blood glucose level. During an interview with LPN DD on the 100 Hall on 9/18/18 at 11:45 a.m., he stated, I usually use an alcohol swab to clean the glucometer. From training, from all that I've got, that's what we do. I think I had one in-service when I started working here in March. LPN DD couldn't recall if he'd been trained, or not on the use of glucometer. I don't know what kill time is. During an interview with LPN EE on the 100 Hall on 9/18/18 at 11:51 a.m., she stated, I clean the glucometer with alcohol before and after each use. I haven't had any training on how to clean the glucometer. I don't know what kill time is. During an interview with LPN FF on the 100 Hall on 9/19/18 at 5:30 p.m., she stated, she did not remember being trained on how to properly clean a glucometer. During an interview with LPN GG on the 100 Hall on 9/19/18 at 5:35 p.m., she stated, I've had no training here on the cleaning the glucometer that I recall. During an interview with Unit Manager (UM) BB in the 100 Hall nurse's station on 9/20/18 at 8:54 a.m., she indicated the correct product for cleaning the glucometer was the purple top Sani-wipes, but stated she did not know what the kill time was for the product. During an interview with LPN AA on the 100 Hall on 9/20/18 at 9:11 a.m., he indicated he did not remember receiving training on how to sanitize the glucometers. During an interview with the Regional Clinical Director in the conference room on 9/20/18 at 1:14 p.m., she stated, No staff training records were found for any of the licensed nursing staff members. I looked through the records, and nothing could be found. We are doing training and competencies right now. The facility failed to provide the staff with training on the manufacturer's recommendations on the cleaning procedure of the glucometers for residents requiring finger sticks for blood sugar monitoring. Cross Reference to F880 The facility implemented the following actions to remove the immediate Jeopardy: I. On (MONTH) 20, (YEAR), the Regional Nurse Consultant provided training to the ADON, Unit Manager, and Nurse Supervisor on Infection control as it relates to cleaning and decontaminating of the blood glucose meters. II. On (MONTH) 20, (YEAR), The Unit Manager/ADON provided education to 2 RN's and 10 LPN's, in Person, with competency and return demonstration of cleaning and decontaminating of the Glucometer. The training included; infection control, cleaning and disinfecting the blood glucose meter and the Observation of the License Nurse Demonstrating competency in cleaning and decontaminating the glucose meter, using the Approved Germicidal Disposable wipes. The documentation of this training and competency will be maintained in the Administrator's office III. On (MONTH) 21, (YEAR), The Unit Manager/ ADON provided education to 1 RN and 3 LPN' s, in Person, with competency and return demonstration of cleaning and decontaminating of the Glucometer. The training included; infection control, cleaning and disinfecting the blood glucose meter and the Observation of the License Nurse Demonstrating competency in cleaning and decontaminating the glucose meter, using the Approved Germicidal Disposable wipes. The documentation of this training and competency will be maintained in the Administrator's office. IV. On (MONTH) 21, (YEAR), The Unit Manager/ADON provided education to 1 RN and 5 LPN's, By Telephone. The training included; infection control, cleaning and disinfecting the blood glucose meter using the Approved Sani Cloth Germicidal Disposable wipes. The documentation of this training will be maintained in the Administrator's office. V. As of (MONTH) 21, (YEAR), the facility completed education in regard to meeting the professional standard of care to 4 RN' s and 18 LPN' s for a total of twenty-two (22) of the twenty-four (24) Licensed nurses or 92 % of the Licensed nursing staff. The remaining 2 licensed nurses, who were unavailable for training due to being off duty, or on leave, are to receive this in-service training upon their return to work, prior to direct patient care. VI. The DON/ ADON will provide Glucose cleaning/decontamination training and competency to nurses, upon hire and annually for all licensed nurses. Documentation of the education and competency will be maintained in the DON's office. VII. The ADON/Unit Manager will perform Glucose cleaning audits, for License nurses daily, each shift, 7 days per week. The audits will be documented and maintained in the Administrator's office. VIII. If deficient practice is observed during the audit, the observer will immediately intervene, prior to resident contact. The Nurse will be retrained, and the observation will continue. If the nurse is unable to maintain compliance, the nurse will be removed from resident care and provided remedial training until they are able to perform the proper process for cleaning and decontaminating the Glucose meter or they are removed from duty. IX. Results of the training and audits will be presented to the QAPI committee, by The Administrator and/or the DON, to allow the QAPI committee to monitor completion of licensed nurse competencies r/t cleaning and decontaminating of the Glucometer, to ensure compliance. The State Survey Agency (SAA) validated the facility Credible Allegation of Immediate Jeopardy Removal as follows: Review of the facility's policy titled Infection Control: Cleaning and Disinfecting Blood Glucose Meters updated 9/21/18 revealed the procedure as follows: a) before each use of the blood glucose meter machine mist be inspected for debris. The machine may be cleaned with a lint free dampened cloth with soapy water. b) the machine should be wiped down for two minutes both front and back with Santi-Cloth Bleach wipes to disinfect the machine. The machine should air dry for one minute before it is used. c) Do not clean inside the battery compartment or test strip port. Allow the machine to air dry as you prepare to perform the blood glucose testing. d) When glucose testing of an individual resident is completed the machine should be cleaned and disinfected by wiping it down front and back, with Santi Cloth Bleach wipes. e) the machine should air dry for one minute before the next use. f) Residents with [DIAGNOSES REDACTED]. It will be cleaned/decontaminated, labeled, and stored in a plastic bag in the Med Cart. Review of the facility's training records revealed the Regional Nurse Consultant (RNC) provided Glucomer cleaning training to Assistant Director of Nursing (ADON) and the Unit Manager (UM BB) on 9/20/18. Review of the facility's Allegation of Compliance (A[NAME]) documents revealed the facility conducted in-services on (MONTH) 20, and 21, (YEAR). The facility's licensed nurses had received training on the facility's revised policy for cleaning blood glucose meters. In addition to training on the cleaning process the licensed staff received training on the storage of the of the glucometers for those residents with an infectious disease diagnosis. It was a requirement for the staff to complete a competency checklist during the training. The in-service was provided by the Regional Nurse Consultant, (RNC), the Assistant Director of Nursing (ADON), and the Unit Manager (UM BB). The facility had completed training on 100% of its licensed staff which includes 18 of 18 Licensed Practical Nurses and four of four Registered Nurses. Review of the facility's document titled Glucometer Competency Checklist (undated) revealed the facility had completed skill competency checklists for 18 of 18 Licensed Practical Nurses and four of four Registered Nurses which is100% of the licensed staff. Review of the facility's document titled Nursing Blood Glucose Monitoring System (undated) revealed the RNC and ADON were utilizing this document to monitor the staff's compliance with disinfecting and storage of the residents' glucose meters. The document was revised to reflect if any problems are identified with compliance additional intervention or action will be taken to prevent reoccurrence. Interview with the RNC on 9/23/18 at 10:10 a.m. conference room revealed that when the problem with sanitizing the glucose meters was identified, she reviewed and revised the facility's policy for cleaning and storage of the glucometers. RNC also stated that she immediately trained the ADON and UM BB on the correct procedure, so that they could assist with the training and monitoring the entire licensed staff. The RNC also stated the monitoring for compliance would be done daily on various shifts. If a compliance problem was identified in the audits, that employee would receive remedial training until they are able to perform the proper process for cleaning and decontaminating the glucometer or the employee is removed from duty. The RNC further stated the audits will be maintained in the Administrator's office. Also, that she and the ADON will be responsible for presenting the results of the training and monitoring audits to the Quality Assurance Performance Improvement Committee (QAPI) meetings.

Based on interview and review of facility policy and contracts, it was determined that the facility Administrator was unaware that licensed nursing staff were using glucometers between residents without properly sanitizing the instrument per manufacture recommendations for 23 residents requiring glucose monitoring. The facility's failure to identify nursing staff's noncompliance with sanitizing the glucometers between residents use has caused, or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was determined to exist on 9/18/18. The immediate jeopardy was related to the facility's noncompliance with the program requirements at: CFR 483.21(b)(3)(i) Professional Standards (F658 Scope/Severity: K); CFR 483.35(a)(3)-(4),(C), Nursing Services (F726, Scope/Severity: K); CFR 483.70 Administration (F835, Scope/Severity: K); CFR 483.75(g)(2), Quality Assessment and Assurance (F867, Scope/Severity: K); CFR 483.80 (a)(1)(2)(i)(ii)(iii) (4) Infection Control Program (F880 Scope/Severity: K). The facility's Administrator, Regional Director of Operations, and Regional Nurse Consultant were informed of the Immediate Jeopardy on 9/20/18 at 5:18 p.m. The noncompliance related to the immediate jeopardy was identified to have existed as of 9/18/18 during the observation of medication administration nursing staff failed to properly sanitize the glucometers before and after use for R#2, R#4, R#15, R#25, R#35, R#71, and R#285 On 9/23/18 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 9/22/18. Based on validation of the A[NAME] the State Survey Agency (SSA) conducted observations, record reviews, interviews and review of the facility's policies as outlined in the A[NAME], the State Survey Agency (SSA) determined the immediate Jeopardy was removed on 9/23/18. The Scope and Severity were lowered to E while the facility continued management level oversight of licensed nursing staff and develops and implements a plan of correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The findings include: An interview was conducted on 9/21/18 at 10:52 a.m. in the facility's conference room with the Administrator. Per the Administrator, the Director of Nursing (DON) never made him aware that the licensed staff were not routinely cleaning glucometers per manufacturer recommendations. The DON was expected to monitor for the proper sanitizing of glucometers by nursing staff as her role of facility Infection Preventionist. The Administrator also reported the DON was responsible for the training of nursing staff of the proper cleaning technique of glucometers. The Administrator reported there was no documentation available to demonstrate nursing staff ever received glucometer cleaning training per manufacturer's recommendations. The Administrator also reported during the interview, the facility also conducted surveillance of medication administration by facility nursing staff through a contractual agreement with an outside pharmacy service. The contracted pharmacy service provides a nurse consultant who conducts monthly onsite visits. The onsite visits consist of the nurse consultant making direct observations of facility nursing staff during their routine medication administration times. Regular reports are submitted to the facility by the nurse the consultant for review. The reports are intended to identify any irregularities that need to be addressed by facility administration and management. Neither the facility's DON, nor the contracted Pharmacy Nurse Consultant had made the Administrator aware of any problems regarding the proper cleaning of glucometers by the facility's licensed staff. Review of the facility document titled Daily Census Report' dated 9/20/18 revealed the following 23 residents were identified as receiving finger sticks for blood glucose monitoring: R#2, R#4, R#5, R#15 , R#23 , R#25, R#26, R#29, R#30 , R#42, R#45, R#49, R#52, R#67, R#69, R#75, R#71, R#79, R#80, R#183, R#187, R#234, and R#285. Review of the facility's Pharmacy Consultant Agreement dated 7/01/14 indicated The Consultant shall, upon request of the facility, provide consultation on the functional quality of provider pharmacy services, and facility compliance with various qualified indicators. Opportunities for improvement identified during the performance of that advanced services will be reported to the facility along with recommendations that if action upon, will insure facility compliance. These services shall include: Evaluation of facility medication administration error rate with follow up one-to-one training of facility nursing staff to provide an environment where maximum accuracy (<5% error rate with no significant errors), and appropriate technique are assured. Telephone interview conducted on 9/21/18 at 3:12 p.m. with the Pharmacy Nurse Consultant. The Pharmacy Nurse Consultant reported she began conducting monthly onsite visits at the facility starting approximately four years ago. Onsite responsibilities included direct observation of facility nursing staff administering medications. Direct staff observations of facility staff were primarily limited to pills or tablets being administered by oral route to residents. The Pharmacy Nurse Consultant reported rarely observing facility staff checking resident's blood glucose levels using a glucometer due to her standard arrival time to the facility of 9:00 a.m. on the day of her visits. Facility practice was to have resident's ordered morning blood glucose checks completed by 6:30 a.m. The Pharmacy Nurse Consultant reported she was under no direction, and had not received any request from facility management or administration officials to observe varying routes of mediation administration. Whatever medication administration procedures facility nursing staff were performing upon her arrival is what she observed. The Pharmacy Nurse Consultant reported if she would have observed facility nursing improperly cleaning glucometers outside of manufacturer's recommendations, she would have included those observations in her monthly reports to the facility. The facility implemented the following actions to remove the Immediate Jeopardy: I. On (MONTH) 20, (YEAR), the Administrator was educated, by the Regional Director of Operations, on Infection Control as it relates to the requirements for cleaning and decontaminating of Glucose meters. The documentation of the education will be maintained in his personnel file in the Administrator's office. II. On (MONTH) 20, (YEAR), the Administrator was educated, by the Regional Director of Operations on the facility QAPI policy. III. On (MONTH) 20, (YEAR), the Administrator was educated, by the Regional Director of Operations on the A[NAME] drafted for the cited deficiency F880 as it relates to cleaning and decontaminating blood glucose meters. The Administrator's responsibility for oversight will specifically include: a. Assuring that the policy for cleaning and decontaminating the Blood Glucose meter is trained and implemented for all licensed staff prior to working another shift. b. Validating the audit of 100% of resident's diagnosis, MD orders, and Medication administration records, that were reviewed by the Regional Nurse Consultant, to determine who and how often they received finger stick blood sugar checks, the MD was notified of the results of this review. c. Validating The audit of 100% of MD orders, to determined who receives finger stick blood sugar checks. 23 residents were identified to receive finger stick blood sugar checks, according to the MD orders. d. Ongoing communication with the Medical Director regarding these 23 residents, and their potential exposure to an infectious disease. e. Assuring that education is provided to all licensed nurses prior to their working another shift in the facility. f. Validating the Documentation of the education and competencies to be maintained in the DON's office. g. Assure that Nurses that are unable to successfully clean and decontaminate the Blood Glucose meter are removed from duty. h. Maintaining the glucose audits that the ADON/Unit Manager will perform for License nurses daily, 1.:ad1 shift, 7 days pt:r wt:t:k, in tht: Administrator's office. i. Assuring that Results are presented to the QAPI committee, by The Administrator and/or the DON, to allow the QAPI committee to monitor staff compliance with cleaning and decontaminating of the Glucometer, to ensure that this procedure is in compliance IV. The Regional Director of Operations / Regional Nurse Consultant will, daily review, 7 days per week, the Administrators management of the A[NAME] to include; a. Education has been completed and documented b. Competency has been completed successfully c. Audits have been completed and documented d. Any Non-compliant area receives retraining and competency demonstrated e. New hires trained on cleaning/decontaminating of the Glucometer f. · Validate that Documentation is stored per the A[NAME] V. On (MONTH) 21, (YEAR), The Regional Director of Operations/ Regional Nurse consultant reviewed the Ad-Hoc QAPI minutes to assure that the Administrator is reporting on the A[NAME] plan as it relates to cleaning and decontaminating of the Glucose meters. The State Survey Agency (SAA) validated the facility Credible Allegation of Immediate Jeopardy Removal as follows: Review of the facility's training records dated 9/20/18 revealed the facility Administrator training from the Regional Director of the Operations on the Infection Control related to the requirements for cleaning and sanitizing the glucometers. The Administrator's training included a review of the facility's revised policy on the Cleaning and Disinfecting of the Glucose Meters. The training also included the Administrator's responsibility oversight which included validating the audits of the physicians' orders for residents receiving fingerstick for glucose monitoring. Ongoing communicating with the Medical Director regarding the 23 residents receiving finger sticks and their potential exposure to an infectious disease. Validating the documentation and education and competencies to be maintained in the Director of Nursing's office. Monitoring the training, competency skill checklist and audits for 100% compliance. And assuring the results are present to the QAPI committee to ensure staff compliance. Additional review of the facility training records revealed the Administrator received additional training on the facility's Quality Assurance Performance Improvement (QAPI) Policy on 9/21/18 provided by the Regional Director of Operations. This training included a review of the summary report of a QAPI meeting which identified the policy statement and the primary goals of the QAPI committee. The Administrator training record also included an allegation of compliance sheet signed by the Administrator and the Regional Director of Operations verifying the Administrator's training. Review of the facility's training records dated 9/21/18 revealed the Regional Director of Operations and the Regional Nurse Consultant reviewed Ad-Hoc QAPI minutes to ensure the Administrator was reporting on the Allegation of Compliance (A[NAME]) plan related to decontamination and storage of the glucose meters. Review of the attendance sheet revealed the Ad-Hoc meeting was attended by all QAPI Committee members including the Medical Director. Interview with the Administrator and the Regional Director of Operations was conducted on 9/23/18 at 3:33 p.m. in the conference room revealed the DON at the time was also the Infection Control Nurse for facility was responsible for identifying any problems related to possible transmission of the infectious diseases. Both stated when the problem was identified thru the survey process they first became aware the DON was not performing Infection Control Nurse responsibilities and that the staff had not received any training on the sanitation of the glucometers according to manufacturer's recommendations. During the interview the Regional Director of Operations stated he was surprised the Pharmacy Nurse Consultant had not identified this problem earlier for the survey. This was part of the Pharmacy Nurse Consultant's responsibilities. The Regional Director of Operations also stated that he planned to schedule training for the Pharmacy Consultant Nurse on the facility revised policy for sanitation and storage of the residents' glucometers. Interview with the Administrator on 9/23/18 at 4:10 p.m. in the conference room the Administrator reiterated the training he had from the Regional Director Operations as to his role in the QAPI Committee and the his role in the oversight monitoring of the facility compliance to the A[NAME]. The Administrator also stated that he had received training on how to clean and decontaminated the glucometers. and since he now knows the process he could conduct his own spot check of the nurses to ensure compliance.

Based on interview and review of facility policy and procedure, it was determined that the facility failed to have a functioning Quality Assessment and Performance Improvement (QAPI) Committee to oversee the implantation of the facility's QAPI Program. The QAPI did not lend itself to identify deficient practice related to infection control, specifically proper sanitizing glucometers before and after use. The licensed nursing staff were using glucometers between residents without sanitizing the instrument per manufacture recommendations for 23 residents requiring the use of the glucometers. The QAPI Committee failed to monitor infection control practices of facility nursing staff was determined to had caused, or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified was determined to exist on 9/18/18. The immediate jeopardy was related to the facility's noncompliance with the program requirements at: CFR 483.21(b)(3)(i) Professional Standards (F658 Scope/Severity: K); CFR 483.35(a)(3)-(4),(C), Nursing Services (F726, Scope/Severity: K); CFR 483.70 Administration (F835, Scope/Severity: K); CFR 483.75(g)(2), Quality Assessment and Assurance (F867, Scope/Severity: K); CFR 483.80 (a)(1)(2)(i)(ii)(iii) (4) Infection Control Program (F880 Scope/Severity: K The facility's Administrator, Regional Director of Operations, and Regional Nurse Consultant (RNC) were informed of the Immediate Jeopardy on 9/20/18 at 5:18 p.m. The noncompliance related to the immediate jeopardy was identified to have existed as of 9/18/18 during the observation of medication administration nursing staff failed to properly sanitize the glucometers before and after use for R#2, R#4, R#15, R#25, R#35, R#71, and R#285 On 9/23/18 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 9/22/18. Based on validation of the A[NAME] the State Survey Agency (SSA) conducted observations, record reviews, interviews and review of the facility's policies as outlined in the A[NAME], the State Survey Agency (SSA) determined the immediate Jeopardy was removed on 9/23/18. The Scope and Severity were lowered to E while the facility continued management level oversight of licensed nursing staff and develops and implements a plan of correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) Plan, dated 2001, revised (MONTH) 2014: The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state and local regulatory agency requirements. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. The QAPI Committee shall help various departments/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. The plans and approaches should include specific time frames for implementation and follow-up. The committee shall track the progress of any active plans of correction. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented. Interview conducted on 9/21/18 at 10:52 a.m. in the facility's conference room with the Administrator. Per the Administrator, the Director of Nursing (DON) was responsible as the facility's Infection Preventionist and QAPI committee member to train, monitor and report any irregularities to him and the QAPI committee through verbal and written reports. At no time did the DON make him or the QAPI committee aware that facility nurses were not cleaning glucometers between resident uses, per manufacturer's recommendations. The Administrator also reported during the interview on 9/21/18 at 11:00 a.m. in the conference room, the facility also conducted surveillance of medication administration by facility nursing staff through a contractual agreement with an outside pharmacy service. The contracted pharmacy service provides a nurse consultant who conducts monthly onsite visits. The onsite visits consist of the nurse consultant making direct observations of facility nursing staff during their routine medication administration times. Regular reports are submitted to the facility by the nurse the consultant for review. The reports are intended to identify any irregularities that need to be addressed by facility administration and management. Review of Consultant Activity Reports dated 7/06/18 and 8/14/18 revealed neither report addressed observing staff use and cleaning of glucometers between resident use. Neither the facility's DON, nor the contracted pharmacy nurse consultant had made the Administrator aware of any problems he needed to be made aware of regarding the proper cleaning of glucometers by facility staff. Cross Reference to F880 The facility implemented the following actions to remove the Immediate Jeopardy: I. On (MONTH) 20, (YEAR), The Regional Director of Operations educated the Administrator on the facility QAPI policy / process. a. Review of Operations b. Identify opportunities for improvement c. Determine the root cause d. Implement the performance improvement e. Evaluate II. On (MONTH) 20, (YEAR), the Regional Nurse Consultant reviewed the existing QAPI action plans and performance improvement. III. On (MONTH) 20, (YEAR), The Regional Nurse Consultant developed an action plan for Cleaning and decontaminating the glucose meters. IV. On (MONTH) 21, (YEAR), The Regional Nurse Consultant educated the QAPI committee on the facility QAPI policy / process. Committee members include; The Administrator, DON/ ADON, Medical Director, SSD a. Review of Operations b. Identify opportunities for improvement c. Determine the root cause d. Implement the performance improvement e. Evaluate V. On (MONTH) 21, (YEAR), the facility QAPI committee convened an Ad-Hoc QAPI meeting. VI. On (MONTH) 21, (YEAR), The Regional Director of Operation and the Regional Nurse Consultant attended and monitored the Ad-hoc QAPI meeting to assure that the process is facilitated per policy and training. The State Survey Agency (SAA) validated the facility Credible Allegation of Immediate Jeopardy Removal as follows: Review of the facility Allegation of Compliance (A[NAME]) documents revealed on 9/20/18 the Regional Director of Operations provided education to the Administrator on the facility's Quality Assurance Performance Improvement policy and process. The process included a review of the facility operations; identify opportunities for improvement; determine any root causes of a deficient practice; implement performance improvement and evaluate the outcome. Additional review of the facility's A[NAME] dated 9/23/18 revealed the facility's QAPI committed convened an Ad Hoc QAPI meeting. The Regional Director of Operations and the Regional Nurse Consultant were in attendance to ensure the process was facilitated according to facility policy and training. During an interview with the Regional Director of Operations and the Administrator on 9/23/18 at 3:55 p.m. in the conference room the facility's A[NAME] was reviewed with both parties and discussed the QAPI components. The Regional Director of Operations stated the Regional Nurse Consultant had the reviewed the existing QAPI action plans and performance improvement. In addition to developing an action plan for decontaminating the residents' glucometers. The Regional Director of Operations also stated the RNC provided additional training to all the QAPI Committee members including the Administrator and the Medical Director. The Director of the Regional Operations conducted individual training for Administrator related to his responsibilities for QAPI and provided training to the Medical Director on his responsibilities as medical portion of the program. The Regional Director also stated that he planned to provide training to the Medical Director and the Pharmacy Nurse Consultant on the policy of the glucometer sanitation. An additional interview with the Administrator and the Regional Director on 9/23/18 at 5:10 p.m. in the conference room revealed the administrative team were planning to schedule a QAPI meeting within the next five to seven days to discuss the outcome the Immediate Jeopardy survey and review the facility 's corrective action plan. The administrative team plan to review the licensed staff completed competency skills checklist and audits conducted since 9/21/18.

Based on facility policy review, clinical record review, observations, and staff interviews, the facility failed to ensure appropriate infection control measures were taken to prevent potential transmission of highly infectious diseases, such as [MEDICAL CONDITION] and human immunodeficiency virus ,[MEDICAL CONDITION]. for a total of 23 out of 23 residents receiving blood glucose checks in the facility. Seven residents (R), #2, R#4, R#15, R#25, R#35, R#71, and R#285) were observed receiving blood glucose checks during the survey. Of those seven residents observed, one resident (R#285) was diagnosed with [REDACTED]. Specifically, blood glucose meters were not appropriately sanitized between use for any of the above referenced residents. The facility's failure to ensure infection control measures were taken to prevent residents from potentially contracting infectious diseases it was determined to be likely to cause serious injury, harm, impairment, or death to residents. Immediate Jeopardy was determined to exist on 9/18/18, when the surveyor observed R#25 's blood glucose level being checked with a glucometer that had not been appropriately sanitized prior to use. The immediate jeopardy was related to the facility's noncompliance with the program requirements at: CFR 483.21(b)(3)(i) Professional Standards (F658 Scope/Severity: K); CFR 483.35(a)(3)-(4),(C), Nursing Services (F726, Scope/Severity: K); CFR 483.70 Administration (F835, Scope/Severity: K); CFR 483.75(g)(2), Quality Assessment and Assurance (F867, Scope/Severity: K); CFR 483.80 (a)(1)(2)(i)(ii)(iii) (4) Infection Control Program (F880 Scope/Severity: K). The facility's Administrator, Regional Director of Operations, and Regional Nurse Consultant were informed of the Immediate Jeopardy on 9/20/18 at 5:18 p.m. The noncompliance related to the immediate jeopardy was identified to have existed as of 9/18/18 during the observation of medication administration nursing staff failed to properly sanitize the glucometers before and after use for R#2, R#4, R#15, R#25, R#35, R#71, and R#285 On 9/23/18 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 9/22/18. Based on validation of the A[NAME] the State Survey Agency (SSA) conducted observations, record reviews, interviews and review of the facility's policies as outlined in the A[NAME], the State Survey Agency (SSA) determined the immediate Jeopardy was removed on 9/23/18. The Scope and Severity were lowered to E while the facility continued management level oversight of licensed nursing staff and develops and implements a plan of correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. The findings include: Review of the facility's policy titled Infection Control: Cleaning and Disinfecting Blood Glucose Meters Policy, dated 5/2010 read, in pertinent part, It is the policy of this facility to clean and disinfect blood glucose meters in a manner consistent with manufacturer's recommendations and in accordance with current CDC (Centers for Disease Control) guidelines for the prevention of infection; and Equipment: Blood glucose meter, Commercially prepared pads moistened with 5 - 6 % sodium hypochlorite solution such as Sani-Cloth Bleach Wipes;, and Procedure: 1. Before each use of the blood glucose meter, the machine should be inspected for debris and cleaned, 2. The machine should be wiped down, both front and back, with Sani-Cloth Bleach Wipes to clean and disinfect the machine. The machine should air dry for one (1) minute before it is used, 3. Do not clean the battery compartment, code chip port or test strip port. Allow the machine to air dry as you prepare to perform the blood glucose testing, 4. When blood glucose testing of an individual resident is completed the machine should be cleaned and disinfected by wiping it down, both front and back, with Sani-Cloth Bleach Wipes, 5. The machine should air dry for one (1) minute before the next use. Review of the Manufacturer's Guidelines for the use of the Assure Platinum Blood Glucose Monitor read, in pertinent part, Cleaning and Disinfecting Guidelines: Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed using a commercially available EPA (Environmental Protection Agency)-registered disinfectant detergent or germicide wipe, To use a wipe, remove from container and follow product label instructions to disinfect the meter. Take extreme care not to get liquid in the test strip and key code ports of the meter, Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used; use on wipe to clean and a second wipe to disinfect. Option 2: To clean the outside of the blood glucose meter, use a lint -free cloth dampened with soapy water or [MEDICATION NAME] alcohol (70 - 80%), To disinfect the meter, dilute 1 ml (milliliter) of household bleach (5 - 6% sodium hypochlorite solution) in 9 ml of water to achieve a 1:10 dilution (final concentration of 0.5 - 0.6% sodium hypochlorite). The solution can then be used to dampen a paper towel (do not saturate the towel). Then use the dampened paper towel to thoroughly wipe down the meter. Please note that there are commercially available 1:10 bleach wipes from a variety of manufacturers. Take extreme care not to get liquid in the test strip and key code ports of the meter. With all recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level. Please follow the disinfectant product label instructions to ensure proper drying time. Review of the Manufacturer's Guidelines for use of Super Sani-Cloth Germicidal Disposable Wipes indicated, Kills HIV-1 (AIDS Virus), [MEDICAL CONDITION] Virus (HBV) and [MEDICAL CONDITION] Virus (HCV) on the pre-cleaned environmental surfaces/objects in two (2) minutes at room temperature (68-77 Degrees F) in health care setting in which there is an expected likelihood of soiling of surfaces/objects with blood or body fluids, and in which the surfaces/objects likely to be soiled with blood or body fluids can be associated with the potential for transmission of Human Immunodeficiency Virus ,[MEDICAL CONDITION]. Type 1 (HIV-1) (associated with AIDS, [MEDICAL CONDITION] Virus (HBV) and [MEDICAL CONDITION] (HCV). The following concerns were identified during observations of medication administration on 9/18/18 and 9/19/18: 1. Licensed Practical Nurse (LPN) DD was observed performing R#25's blood glucose check on the 200 Unit on 9/18/18 at 11:29 a.m. LPN DD cleaned the blood glucometer with an alcohol prep pad for approximately 15 seconds prior to using the monitor to obtain R#25's blood glucose level. 2. LPN DD was observed performing R#4's blood glucose checks on the 200 Unit on 9/18/18 at 11:33 a.m. (immediately after obtaining R#25's blood glucose check). LPN DD cleaned the glucometer with an alcohol prep pad for approximately 10 seconds prior to using the glucometer to obtain R#4's blood glucose level 3. LPN DD was observed performing R#285's blood glucose check on the 200 Unit on 9/18/18 at 11:38 a.m. (immediately after performing R#4's blood glucose check). LPN DD cleaned the glucometer with an alcohol prep pad for approximately 10 seconds prior to using the glucometer to obtain R#285's blood glucose level. During an interview with LPN DD on the 200 nursing unit on 9/18/18 at 11:45 a.m., he stated, I usually use an alcohol swab to clean the meter. I think I might have had one in-service, when I started working here in (MONTH) regarding proper sanitization of a glucometer. This is the type of wipe we have (showed surveyor an orange top Sani-Wipe container). I don't use these, to be honest. LPN DD only had one glucometer on his medication cart, which he used for monitoring blood glucose for all residents on the unit. 4. Observation on the 100 Unit on 9/18/18 at 4:54 p.m. revealed LPN FF was observed performing R#15's blood glucose check. LPN FF did not clean the blood glucometer before obtaining R#15's blood glucose level. 5. LPN FF was observed performing R#2's blood glucose check on the 100 Unit on 9/18/18 at 5:15 p.m. (immediately after obtaining R#15's blood glucose). LPN FF did not clean the glucometer before obtaining R#2's blood glucose level. 6. LPN FF was observed performing R#71's blood glucose check on the 100 Unit on 9/18/18 at 5:25 p.m. (immediately after obtaining R#2's blood glucose). LPN FF did not clean the glucometer before obtaining R#71's blood glucose level. During an interview conducted with LPN FF on the 100 nursing unit on 9/18/18 at 5:30 p.m., she stated, We clean the blood glucometers with soap and water every week. I use an alcohol pad sometimes between residents to wipe the glucometer off. I do that randomly. We have Clorox Disinfecting wipes on the cart. LPN FF showed the surveyor a container of Clorox Disinfecting Wipes on the medication cart. She stated, I don't use these, though. LPN FF only had one glucometer on this medication cart, which she used for monitoring blood glucose for all residents on the unit. 7. Observation on the 200 Unit on 9/20/18 at 8:58 a.m. revealed LPN AA performing R#35's blood glucose check. LPN AA cleaned the glucometer with an alcohol prep pad for approximately 20 seconds prior to obtaining R#35's blood glucose level. Review of a facility document titled Order Report by Category document, dated 9/20/18 indicated there were a total of 23 residents (including the seven sampled residents) receiving regular blood glucose monitoring currently residing in the facility. A review of a facility document titled [DIAGNOSES REDACTED].#285 had an infectious disease [DIAGNOSES REDACTED]. During an interview with LPN AA on the 200 nursing unit on 9/20/18 at 9:11 a.m., he stated, I have to sanitize the glucometer with an alcohol pad before use. LPN AA only had one glucometer on his medication cart, which he used for monitoring blood glucose for all residents on the 200 unit. During an interview with LPN EE on the 100 Hall on 9/18/18 at 11:51 a.m., she stated, I clean the glucometer with alcohol before and after each use. During an interview with LPN GG on the 100 Hall on 9/19/18 at 5:35 p.m., she stated, The glucometer gets cleaned with alcohol and the Clorox wipe. I use a Clorox wipe and then alcohol. I use the Clorox wipe, let dry, then I use alcohol. During an interview with Unit Manager (UM) BB on the 100 nursing unit on 9/20/18 at 8:54 a.m., she stated, The process for cleaning the glucometers is to use the wipes kept in the bottom drawer of the medication cart to clean and then let it dry. This is to be done before and after each resident's blood sugar is taken. During an interview with the Regional Clinical Director in the conference room on 9/20/18 at 9:20 a.m., she stated, The glucometers should be cleaned before and after each resident's use. The staff have a product on their medication carts. It's a Clorox based cleaner for cleaning the glucometer. I think it's a Purple Top Sani-Wipe. She indicated a glucometer was kept on each medication cart, and the same glucometer was used for all residents receiving medication from that cart. During an interview with the Regional Clinical Director in the conference room on 9/20/18 at 12:09 p.m., she provided the facility policy for cleaning and disinfecting of the glucometers and stated, They (the policies) aren't being followed. We are doing competencies right now with all of the nurse. During an interview with the Medical Director in the conference room, via phone, on 9/20/18 at 2:23 p.m., he stated, I would expect, minimally, for the policy to be followed. My expectation is to follow the policy. Period. During an interview with the Administrator in the conference room on 9/21/18 at 11:10 a.m., he stated the Assistant Director of Nursing (ADON) was responsible for the Infection Control Program in the facility, however she was no longer working in the facility as of 9/7/18. He stated a new Infection Control Nurse/ADON had been offered the position on 9/17/18 (the first day of the survey), but had not begun working in the position yet. During an interview with the Pharmacy Nurse Consultant via phone on 9/21/18 at 3:05 p.m., she stated she visited the facility monthly to do observations of medication pass. She stated she usually came to the building for the 9:00 a.m., medication pass, and so she did not often see blood sugar monitoring due to the fact that it was administered at 6:30 a.m. She stated, I do know that they are supposed to be cleaning their glucometers. She stated, On a rare occasion I will watch insulin and blood sugars, but I usually watch oral meds. She indicated she thought she had seen a blood glucose checked in (MONTH) of (YEAR). She stated, They are supposed to be using .not the bleach .not the alcohol .I can't think of the name (of the cleaning product to be used). They are supposed to clean it and let it sit for two minutes or so. I'm blank right now, but it comes in a little individual package. I don't document what they clean with. She stated, I don't look closely at what the staff is cleaning the glucose monitor with, I just know they pull out a packet and clean it. I do not pay attention to the specifics of what the name of what they are using to clean with. The facility implemented the following actions to remove the Immediate Jeopardy: I. On (MONTH) 20, (YEAR), the facility Policy on Cleaning and disinfecting the Blood Glucose meter was reviewed, by The Regional Nurse Consultant. The policy was updated to include: Residents with a [DIAGNOSES REDACTED]. This Glucose meter will be maintained in a plastic bag, labeled with their name, in the Med Cart. The product to be utilized for cleaning the Glucometers is the Sani Cloth Disposable Germicidal Wipe. II. On (MONTH) 20, (YEAR), 86 of 86 resident's; diagnosis, MD orders, and Medication administration records were reviewed by the Regional Nurse Consultant, to determine who and how often they received finger stick blood sugar checks, the MD was notified of the results of this review. III. On (MONTH) 20, (YEAR), The Regional Nurse reviewed 100% of MD orders, to determine who receives finger stick blood sugar checks. 23 residents were identified to receive finger stick blood sugar checks, according to the MD orders. The facility consulted with the Medical Director regarding these 23 residents, and their potential exposure to an infectious disease. The Medical Director recommended monitoring for signs and symptoms of infection by the licensed nurse, with documentation, for 14 days starting 9/21/18. If symptoms occur, diagnostic testing will be facilitated. Residents or responsible parties were notified on 9-21-18, by the Regional Nurse. Notification is documented in each resident's medical record. Voice mail Messages were left for 2 of the 23 contacted. One return call was received on 9-21-18, and notification was completed. Daily calls, with documentation in the medical record, will continue to the last responsible party until notification is complete. IV. On (MONTH) 20, (YEAR), The Regional Nurse Consultant identified that 7 residents have a [DIAGNOSES REDACTED]. 4 of these seven, are included in the 23 residents receiving finger stick blood sugar checks, who require the use of the glucose meter. The Regional Nurse Consultant provided these 4 residents with an individual Glucose meter for their use. They were placed in individual, labeled, plastic bags and stored back in the Med carts, by The Regional Nurse. V. On (MONTH) 20, (YEAR), The Regional Nurse Consultant immediately removed the remaining Glucometers from the medication carts. They were cleaned/decontaminated with the approved Sani Cloth Germicidal Disposable wipes for 2 minutes and allowed to dry. They were stored back in the Med carts, by The Regional Nurse. VI. On (MONTH) 20, (YEAR), The Unit Manager/ADON provided education to 2 RN's and 10 LPN's, in Person, with competency and return demonstration of cleaning and decontaminating of the Glucometer. The training included; infection control, cleaning and disinfecting the blood glucose meter and the Observation of the License Nurse Demonstrating competency in cleaning and decontaminating the glucose meter, using the Approved Sani Cloth Germicidal Disposable wipes. The documentation of this training and competency will be maintained in the Administrator's office. VII. On (MONTH) 21, (YEAR), The Unit Manager/ADON provided education to 1 RN and 3 LPN's, in Person, with competency and return demonstration of cleaning and decontaminating of the Glucometer. The training included; infection control, cleaning and disinfecting the blood glucose meter and the Observation of the License Nurse Demonstrating competency in cleaning and decontaminating the glucose meter, using the Approved Sani Cloth Germicidal Disposable wipes. The documentation of this training and competency will be maintained in the Administrator's office. VIII. On (MONTH) 21, (YEAR), The Unit Manager/ADON provided education to 1 RN and 5 LPN's, By Telephone. The training included; infection control, cleaning and disinfecting the blood glucose meter using the Approved Sani Cloth Germicidal Disposable wipes. The documentation of this training will be maintained in the Administrator's office. IX. As of (MONTH) 21, (YEAR), the facility completed education in regard to meeting the professional standard of care to 4 RN's and 18 LPN's for a total of twenty-two (22) of the twenty-four (24) Licensed nurses or 92 % of the Licensed nursing staff. The remaining 2 licensed nurses, who were unavailable for training due to being off duty, or on leave, are to receive this in-service training upon their return to work, prior to direct patient care. X. The ADON/Unit Manager will perform Glucose cleaning audits, for License nurses daily, each shift, 7 days per week. The audits will be documented and maintained in the Administrator's office. XI. If deficient practice is observed during the audit, the observer will immediately intervene, prior to resident contact. The Nurse will be retrained, and the observation will continue. If the nurse is unable to maintain compliance, the nurse will be removed from resident care and provided remedial training until they are able to perform the proper process for cleaning and decontaminating the Glucose meter or removed from duty. XII. The DON/ADON will provide Glucose cleaning/decontamination training and competency to nurses, upon hire, annually, and as needed for all licensed nurses. Documentation of the education and competency will be maintained in the DON's office. XIII. Results will be presented to the QAPI committee, by The Administrator and/or the DON, to allow the QAPI committee to monitor staff compliance with cleaning and decontaminating of the Glucometer, to ensure that this procedure is in compliance. QAPI members to include The Administrator, DON/ADON, Medical Director, and Social Service Director. XIV. The Director of Nursing for the facility has been on PTO (Paid Time Off) from Wednesday, (MONTH) 19, (YEAR) to current and will be exited from employment on Monday, (MONTH) 23, (YEAR). The Regional Nurse Consultant will remain as Acting Director of Nursing until a replacement is identified. The State Survey Agency (SAA) validated the facility Credible Allegation of Immediate Jeopardy Removal as follows: Review of the facility's training records revealed the RNC, ADON, and Unit Manager (UM BB) started staff training on the sanitizing and storage of the resident's glucometers on 9/20/18. Review on 9/23/18 confirmed that 100% of the facility's licensed staff had been trained on the facility's revised policy for sanitizing the glucometers. Review of the facility's A[NAME] document titled Facility Activity Reports dated 9/22/18 revealed the licensed staff daily documentation monitoring the 23 residents for signs and symptoms cross contamination. As of 9/23/18 none of the 23 residents have exhibited any signs or symptoms of an infectious process. Review of the facility policy titled Policy on Cleaning and Disinfecting the Blood Glucose Meter revealed the policy was reviewed and revised by the facility's Regional Nurse Consultant on 9/20/18. The policy was updated to include the following: Residents with [DIAGNOSES REDACTED]. The glucose meter will be maintained in a plastic bag, labeled with their name in the medication cart. The product to be utilized for cleaning the glucometers is the Sani Cloth Disposal Germicidal Wipe. Review of the facility document titled Daily Census Report dated 9/20/18 revealed the Regional Nurse Consultant (RNC) had identified those residents with physician's orders that required finger sticks for glucose monitoring and the frequency. The RNC identified 23 residents that required finger sticks for blood glucose. The RNC also identified seven residents with infectious disease diagnoses. Of those seven residents with an infectious disease diagnosis, four residents required the use of a glucometer. Observation of the medication cart on the 100 Hall on 9/22/18 at 2:00 p.m. revealed four glucometers machines. Two glucometers in the styrofoam cups and two meters in plastic bags. The two glucometers belonged to R#2 and R#15. Both residents were identified as diabetics but infectious disease diagnosis. Interview with the Licensed Practical Nurse (LPN) TT during the observation revealed the residents were to have their glucometers maintained in a separate plastic bag. LPN TT also stated the cleaning procedure for meters staff should wash their hands first create clean field set-up equipment then use Sani Cloth Bleach wipes to clean the entire machine for two minutes and let it air dry for one minute before using on the resident. LPN TT further stated after use, the staff should again disinfect the glucometer using the Santi Cloth Beach wipes cleaning front and back of machine for two minutes and let it air dry for one minute. While explaining the procedure the nurse removed a container Santi Cloth Bleach wipes from the medication cart with the directions on the container. Observation of the 400 Hall medication cart with LPN DD (LPN DD was identified in the Immediate Jeopardy survey) (LPN was employed six months ago to work the 7-3 shift on 400 hall) on 9/22/18 at 2:30 p.m. revealed the medication cart contained glucometers for (R#285 with [DIAGNOSES REDACTED].#45 with [DIAGNOSES REDACTED]. LPN DD demonstrated the cleaning procedure of the glucometer. The LPN created a clean field, set-up cleaning supplies (disinfectant wipes) and plastic cup. LPN DD performed hand hygiene and donned gloves; then inspected glucometer for traces of dried blood then obtained one Santi Cloth Bleach towel wiping the entire machine; then obtained a second wipe and continued to sanitize the machine for two minutes (checking his watch) and then placed the machine in the plastic cup to let it air dry for one minute. LPN DD stated the glucometers for these two residents are not be shared with other diabetic residents on the unit. The residents with [MEDICAL CONDITIONS] to have their own glucometers. LPN DD stated he had received his training on 9/20/18. Observation of the medication cart for 300 Hall with LPN OO on 9/22/18 at 2:15 p.m. revealed the cart contained one glucometer for the secured unit. The nurse identified one resident receiving blood glucose monitoring (R#62). LPN OO explained the procedure for cleaning the glucometers as follows: Before using the meter on a resident staff clean/sanitize the meter using Santi Cloth Bleach wipes cleaning both sides two minutes then let it air dry for one minute and repeat the procedure after obtaining the resident's finger stick blood sugar. LPN OO also stated if a resident is infectious disease [DIAGNOSES REDACTED]. The same cleaning procedure will be used, and their glucometers will be kept in a plastic bag with the resident's name. Observation of the 500 Hall medication cart with LPN AA (works full time and has been employed for [AGE] years and usually works the 500 Hall for the past year prior) on 9/22/18 at 2:45 p.m. revealed two glucometers in separate plastic bags for residents (R#234 with [DIAGNOSES REDACTED].#19 with [DIAGNOSES REDACTED]. LPN AA then used hand sanitizer again and donned gloves removed glucometer from the plastic bag and wiped glucometer with Sani wipe according to new policy for two minutes. LPN AA timed himself by watching the wall clock then placed the glucometer in a plastic cup to air dry. LPN AA stated residents [MEDICAL CONDITIONS] have their own glucometer and do not share glucometers with other residents to avoid transmission of infectious diseases. Observation on 9/22/18 3:10 p.m. of all four medication carts and the medication supply revealed the containers of Santi Cloth Bleach disinfectant wipes. Observations on 9/22/18 at 2:00 p.m. 5:30 p.m. of the 100/200, 300, 400, and 500 Hall medication carts revealed those residents with infectious disease [DIAGNOSES REDACTED]. Observation also revealed the medication carts were with stocked with the appropriate Sani Cloth Germicidal Wipes for disinfecting the glucometers. Observation on 200 Hall with LPN FF (employed six months and usually works the evening shift) on 9/22/18 at 4:20 p.m. LPN FF stated she received training last Thursday and Friday. LPN FF used hand sanitizer and then setup a clean field with paper towels then donned gloves and used Santi Cloth to sanitize glucometer for two minutes. LPN FF timed herself by watching the clock on the wall and then placed the glucometer in a clean cup to air dry for a minute. Then preceded to perform resident's finger stick (followed procedure for blood testing) LPN FF returned to med cart and performed sanitizing procedure on the glucometer without any problems. Observation on the 500 Hall on 9/22/18 at 5:00 p.m. revealed LPN PP (has been employed four to five months and usually works the 3-11 shift) receiving training from Regional Nurse Consultant (RNC) on sanitizing the glucometers. LPN PP did a return demonstration to the Regional Consultant without any difficulty. LPN PP then preceded to perform blood testing on female resident (resident does not have [DIAGNOSES REDACTED]. Returned to med cart discarded used blood testing items, hand hygiene, set-up clean field and preceded with sanitizing the glucometer for two minutes (counting time to herself) and placed in clean cup to air dry for a minute and then returned to storage of med cart. Observation on 9/22/18 at 5:30 p.m. on the 300 Hall revealed LPN EE preparing to demonstrate hand sanitizing process for the glucometers. This LPN works the 3-11 shift as needed, employments started less than 10 days ago. LPN EE used hand sanitizer and created clean field. Wiped the glucometer for 30 sec with Santi cloth and obtained a clean Santi cloth and wrapped the glucometer in the same cloth and placed in clean plastic cloth. Asked LPN EE if this was how she was trained? LPN stated she works at another LTC facility and that's they do it. LPN EE was asked to sanitize the glucometer the way she was trained. LPN EE repeated the procedure this time set-up another clean field, used hand sanitizer donned gloves, then wiped the meter front and back, sides, insertion site, then pulled another Santi cloth and continued with the sanitizer method for the two minutes and then placed in clean cup to air dry for one minute. Interview with the RNC on 9/23/18 at 10:10 a.m. in the conference room revealed that she and the ADON will be responsible for monitoring the licensed staff for compliance. Audits will be conducted daily on the different shifts to identify any deficient practice. If a deficient practice is identified, then that employee will receive remedial training. The RNC also stated the audits and training records will be presented in the scheduled QAPI meetings. An interview with the ADON on 9/23/18 at 10:30 a.m. in the conference room revealed that she is also responsible for staff education. The ADON stated that she has included sanitation and storage training of the glucometers in the new employees' orientation schedule. The ADON further stated all licensed staff will receive competency training on the glucometers annually. Observation on 9/23/18 at 5:57 a.m. on the 500 Hall revealed LPN QQ (hired 60 days ago usually works the 11-7 shift) LPN QQ started to sanitize the meter when she realized that she had not set-up clean field, no hand hygiene and not wearing gloves. LPN identified these areas herself and requested to start over again. Used hand sanitizer, created a clean field, and donned gloves then used to two Santi-Cloth Bleach wipes to clean meter for two minutes (according to policy) then placed in clean plastic cup to air dry for one minute. LPN QQ explained those residents with [DIAGNOSES REDACTED]. Those glucose meters are not be shared with other diabetic residents to avoid cross contaminations. Observation on 9/23/18 at 6:25 a.m. on the 200 Hall with LPN RR (hired a year ago as PRN assumed full time status five months ago usually works 11-7 shift and is a floater). LPN RR also stated that she initially received training last Friday over the telephone. LPN RR had an instruction sheet on the medication cart for guidance in performing the procedure. LPN performed the sanitizing procedure without any difficulty. The findings include: An interview was conducted on 9/21/18 at 10:52 a.m. in the facility's conference room with the Administrator. Per the Administrator, the Director of Nursing (DON) never made him aware that the licensed staff were not routinely cleaning glucometers per manufacturer recommendations. The DON was expected to monitor for the proper sanitizing of glucometers by nursing staff as her role of facility Infection Preventionist. The Administrator also reported the DON was responsible for the training of nursing staff of the proper cleaning technique of glucometers. The Administrator reported there was no documentation available to demonstrate nursing staff ever received glucometer cleaning training per manufacturer's recommendations. The Administrator also reported during the interview, the facility also conducted surveillance of medication administration by facility nursing staff through a contractual agreement with an outside pharmacy service. The contracted pharmacy service provides a nurse consultant who conducts monthly onsite visits. The onsite visits consist of the nurse consultant making direct observations of facility nursing staff during their routine medication administration times. Regular reports are submitted to the facility by the nurse the consultant for review. The reports are intended to identify any irregularities that need to be addressed by facility administration and management. Neither the facility's DON, nor the contracted Pharmacy Nurse Consultant had made the Administrator aware of any problems regarding t (TRUNCATED)

Based on observation, record review, policy and procedure review and staff interviews, the facility failed to revise a care plan or interventions for one (1) cognitively impaired (1) resident (42) to reflect the incidents in which she was physically harmed by her roommate or provisions for her safety. The facility failed to revise a care plan for one (1) cognitively impaired resident (6) with poor safety awareness and behavior of removing items from the housekeeping cart. Resident (R) 42 and R6 resided on the 300 Hall (locked) Behavior Unit. The Behavior Unit census was thirteen (13). The sample was fifty two (52) residents. (Refer F323) Record review for R42 revealed she was hit twice in the face by her roommate (R63) on 3/29/16 at 1:30 p.m. and on 3/29/16 at 10:50 p.m. during altercations. A third altercation and injury took place on 4/4/16 at 7:20 p.m., when R42 was bitten by R63. Care plan review indicated no revisions to reflect these three (3) incidents or new interventions related to ensuring her safety. Record review for R6 revealed in a nurse Resident Progress Note on 6/1/16 at 8:40 p.m. revealed she was observed by staff with a broom and then observed with a laceration on her forehead and bloody nose. A second nurse Resident Progress Note on 6/1/16 at 9:12 p.m. revealed she was observed to throw the broom to the floor and observed with a laceration to her forehead and a bloody nose. Care plan review indicated no revisions to reflect this known behavior or new interventions related to ensuring her safety. The facility's failure to review and revise care plans for R42 and R6, and ensure interventions to address the individualized needs of R42 and R6 were implemented, has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 8/30/16 and determined to exist on 3/12/16. The facility was notified of the Immediate Jeopardy on 8/30/16. An acceptable Allegation of Compliance (AoC) was received on 9/15/16 and the State Survey Agency validated the Immediate Jeopardy was removed on 9/16/16 as alleged, The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the policy titled Care Plans dated 3/30/16 documented: The resident care plan is reviewed/revised no less than quarterly during the resident's stay. It is also reviewed/revised annually or whenever there is a significant change in a resident's condition or as needed to enhance resident ability to meet his/her objectives. Care plan interventions are reflective of changes in resident condition as well as changes in physician orders [REDACTED]. Record review for R42 indicated an admission to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) was not conducted, the resident was rarely/never understood. Review of the nurse Resident Progress Notes for Resident R42 revealed the following: On 3/29/16 at 2:20 p.m., R63 (roommate) was yelling. R42 asked R63 to be quiet because she wanted to take a nap. R63 struck R42 on the left side of the face causing redness and a scratch under her chin. The scratch was treated with a triple antibiotic (TOA), the Nurse Practitioner (NP) and family was notified. The incident was unwitnessed. (The event occurred at 1:30 p.m.) On 3/29/16 at 11:03 p.m., R42 had been hit again, in the face with a shoe by R63 with no injury noted. The incident was witnessed by the Certified Nursing Assistant (CNA). R42 was crying from the hit and was transferred to a different room for her safety. (The event occurred at 10:50 p.m.) On 3/30/16 at 6:26 a.m., R42 had redness to the left side of her face and two scratches to the chin area. R42 refused to go back to her room with the previous roommate stating She's going to hit me again and I ' m not going back in there! A nurse's note at 2:51 p.m. revealed the resident continued in a room on the 200 Hall. The resident stated she does not want to go back to her previous room. On 3/31/16 at 10:42 p.m. R42 was returned to the room with R63. R42 was yelling and screaming I don't want to be in the room with (name), she is evil and a killer! Take me back to the other room before she kills me! Madam, why did you put me back in the same room with this wicked woman? R42 yelled and complained of being in the same room with R63 for three to five hours. On 4/4/16 at 10:32 p.m., R42 was heard yelling from her room stating that R63 had bitten her on the chest. R42 had redness and teeth marks that penetrated the skin on the left side of her chest. The incident report indicated the Nurse Practitioner (NP) was notified. (The event occurred at 7:20 p.m.) On 4/5/16 at 6:56 a.m., R42 had a bite area to the left breast that was reddened, purple and blue. Review of the care plan for R42 with a Problem Start Date of 5/24/13 and a Long Term Goal Target Date through 11/10/16, identified cognitive loss/dementia. She is alert and oriented times two and able to make most of her needs known. The care plan also identified a problem with communication and she usually understands what is being said to her. Continued review of R42's Mood State care plan identified an alteration in mood and behavior r/t [DIAGNOSES REDACTED]. She is easily agitated and will yell out continuously. She also has periods where she gets into verbal altercations with other residents. The revision was dated 9/13/16 (five 5 months after the last altercation with R63 on 4/4/16) and indicated as follows: Does not like others in her personal space or to touch her. The facility failed to revise the care plan to include the altercations on 3/29/16 at 1:30 p.m. and 10:50 p.m. and on 4/4/16 at 7:20 p.m. resulting in injuries to R42. No approaches are included in the care plan to provide for the safety and supervision and monitoring of R42 when she was moved back into the same room with R63 on 3/31/16. She was bitten by R63 on 4/4/16 at 7:20 p.m. and the care plan does not include further interventions to provide for her safety, supervision and monitoring. She remained in the same room with R63 until 8/26/16. 2. Review of the clinical record for R6 revealed [DIAGNOSES REDACTED]. Review of the current updated care plan for June 2016, received on request from the MDS nurse, revealed a care plan for cognitive loss with and approach dated 2/11/16 indicating resident loves to sweep using a broom for her activities at times. Another approach indicated she loves to sweep the hallways and rooms. A care plan for ADL Function dated 9/19/13 indicated she was able to ambulate independently and able to rebalance herself when her gait is unsteady. This care plan was updated to include being transferred to ER for evaluation and treatment on 6/1/16. A care plan for falls dated 9/19/16 with updates for falls on 4/28/16 and 5/25/16 revealed R6 was at risk for falls related to a history of falls. Review of nurse Resident Progress Notesdated 6/1/16 at 8:40 p.m. Resident was observed with a broom sweeping door when she dropped the broom and stepped out of her shoes some blood was observed on the floor after resident calmed down enough she was observed with a skin tear to her left frontal she allowed nursing staff to clean her frontal at this blood was also observed from nose unable to determine what occurred so resident was prepared to be sent to hospital. An additional entry in the nurse Resident Progress Notes 6/1/16 9:12 p.m. was reviewed as follows: Resident was observed with the broom in her hand swinging it on the door in a sweeping fashion. Incident was unobserved so it was not able to determine how it occurred, since she was also bleeding from nose she was sent to ER for evaluation (eval). Nurse Resident Progress Notes dated 6/2/16 at 1:00 a.m. revealed resident returned from Emergency Department at 1:00 a.m. with wound adhesive closure on facial laceration. Review of Event Report dated 6/1/16 this event occurred at 6:30 p.m. in the Behavioral Unit Hallway and was unwitnessed. Review of entity reported investigation of this event by Administrator revealed this is usual behavior for R6 and the use of the broom was suspected to have been the source of the injury. The resident had no adverse responses to the incident and R6 is to be closely monitored when the housekeeping carts are on the floor. Interview 9/7/16 at 3:10 p.m. with CNA AA revealed R6 interacts with staff very well and shows no aggression, does not hit or shout or take others food. She just has to be watched around the housekeeping equipment because she will try to use it. Interview 9/7/16 at 3:20 p.m. with Administrator revealed R6 was usually supervised by Activities staff when she wanted to sweep, but must have gained access to a broom unobserved on 6/1/16. According to her investigation of the incident no one had given her a broom and she was observed sweeping a door, then observed with a facial laceration and bloody nose. No one knows how she was injured because no one witnessed the injury. Interview 9/15/16 at 11:55 a.m. with the Director of Nurses (DON) revealed she expects each residents care plan to be revised each time there is an Event Report and should have interventions for each separate occurrence. The DON indicated all the charge nurses are responsible for updating, and revising care plans and adding interventions for each problem. Interview 9/14/16 at 4:15 p.m. with the Resident Care Coordinator (RCC) Registered Nurse (RN) revealed she completes the initial care plan for each resident and reviews each care plan quarterly. The RCC revealed that all resident incidents should be included on the care plan with the date of the incident and the intervention that was put into place. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility policy, Staffing for Behavior Unit, was developed on August 30, 2016, and has been reviewed with (5 of 5) facility RN's, (15 of 15) facility LPN's, and (28 of 28) facility Certified Nursing Assistants as part of an inservice education session. 100% of this education has been completed as of September 12, 2016. Copy of policy attached. 2. The facility staffing pattern and workflow has been reviewed and revised to reflect the presence of a licensed nurse on the Behavior Unit at all times. The facility will maintain staffing of no less than two (2) nursing staff members, one of which is a licensed nurse, the other a Certified Nursing Assistant, in the Behavior Unit on all shifts as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. To be considered qualified staff for the Behavior Unit, a staff member must be a licensed nurse or a certified nursing assistant since both of these categories have received basic first aid instruction as well as [MEDICATION NAME] maneuver education. These nursing staff members, one of which is a licensed nurse, the other a certified nursing assistant, will have completed [MEDICATION NAME] maneuver training; staff without [MEDICATION NAME] maneuver training will not be considered relief staff. This staffing pattern was effective as of September 8, 2016. Copy of monthly nursing staffing schedule attached. A review of the nursing staffing pattern for the remainder of the month of September, 2016, was conducted September 9. 2016, revealed 100% coverage of one (1) licensed nurse assigned to the Behavior Unit each shift, each day and at least one (1) certified nursing assistant assigned to the Behavior Unit for each shift, each day. The results of this review attached. 3. An inservice for (5 of 5) facility RN s, (15 of 15) facility LPNs, (28 of 28) facility CNA, (4 of 4) Administrative staff, (4 of 7) Housekeeping staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff and (1 of 1) Social Service staff, regarding Supervision and Monitoring of Residents in the Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. This inservice will include discussion of the PANIC BUTTON located in the Day Area of the Behavior Unit, how to activate this device, that it sounds at the First Floor nursing station and that any staff within hearing distance when the PANIC BUTTON is activated are responsible for responding to the PANIC BUTTON by entering the unit and assisting unit staff as needed. As of September 12, 2016, 100% of this education has been achieved for nursing staff, 88% for all staff. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 4. (5 of 5) facility RNs, (15 of 15) facility LPNs, and (28 of 28) facility CNAs have been informed as part of the inservice, Supervision and Monitoring of Residents in the Behavior Unit, of the process for relieving Behavior Unit staff during breaks/meal times so that consistent staffing of two (2) is maintained in the Behavior Unit at all times. The licensed nurse assigned to the Behavior Unit will be relieved at break/meal time by the First Floor licensed nurse, the Assistant Director of Nursing or the Weekend Supervisor. Behavior Unit CNAs will be relieved by First Floor CNAs or Restorative CNAs for break/meal times; these break/meal times will be designated on the daily assignment sheets. As of September 12, 2016, 100% of this training has been achieved. This process began on September 8, 2016 and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. Inservice record attached. 5. An inservice for facility staff with (5 of 5) facility RNs, (15 of 15) facility LPNs, (26 of 28) facility CNAs, (4 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff, regarding Mealtime Supervision in Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. As of September 12, 2016, 86 % of this education has been achieved, 100% of this training will be completed by September 16, 2016, and facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 6. A facility qualified nursing staff member will be present in the common Dining Areas of the Behavior Unit during resident meal times to provide monitoring, supervision, and assistance as needed. Residents will be encouraged to eat meals in the common Dining Areas but those choosing to eat in their rooms will be observed approximately every 5-8 minutes during meal time. Implementation of this intervention began September 9. 2016, and will be completed by September 14, 2016, as 100% of this training is completed. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 7. On September 8, 2016, the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing reviews the daily nursing staffing schedule and assignment sheet at the beginning of the shift, Monday through Friday, for first and second shift, to determine that the Behavior Unit is properly staffed with a licensed nursing staff member (LPN) and at least one (1) CNA on each shift, each day and that the Behavior Unit staff has coverage for break/meal times. This review will be completed by the 100/200 Hall LPN for third shift and the weekend Supervisor on Saturday and Sunday for both 12 hour shifts. This process is to be a permanent procedure with management staff conducting these audits every shift for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. Audit tool attached. 8. On September 9, 2016, the facility initiated a new procedure by which the Administrator, Director of Nursing or Assistant Director of Nursing observes the dining areas of the Behavior Unit daily, Monday through Friday, to determine that a nursing staff member that has completed the facility education, Mealtime Supervision in Behavior Unit, is present during the resident meal times. This review will be completed by the weekend Supervisor on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting these audits for first and second shifts for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. 9. On September 9, 2016, the facility implemented a procedure by which the results of the audits referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding staffing for the behavior unit and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for September 14, 2016 and then the first monthly meeting for October 5, 2016. 10. On September 13, 2016, the facility policy, Care Plans, was reviewed with the facility Administrator, Director of Nursing, Assistant Director of Nursing and MDS Coordinator. The review resulted in no changes to the current policy and the facility will begin implementing the current policy on September 13, 2016. Policy and acknowledgement of review attached. The Care Plan of each resident residing on the 300 Hall Behavior Unit will be reviewed and revised to reflect the current resident care status and care needs. This review/revision process will be 100% completed by September 14, 2016. Care plan revisions will be written on the current care plan in the paper chart and communicated to licensed nursing staff daily by MDS Coordinator. This information will be passed on to other licensed staff during shift to shift report. The Nurse Aide Kardex for each resident on the 300 Hall Behavior Unit will be reviewed/revised daily to effectively communicate resident needs and care requirements to facility CNA staff. This review/revision process will be 100% completed by September 14, 2016. 11. An inservice for facility nursing staff, RNs, LPNs, CNAs, regarding Care Plans is in process. As of September 13, 2016, with (5 of 5) RNs, (14 of 15) LPNs, and (22 of 28) CNAs having completed the education. 85% of this education has been completed. 100% of the education will be completed by September 16, 2016. Nursing staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 12. On September 12, 2016, the facility initiated a new procedure by which the Director of Nursing, Assistant Director of Nursing, or the MDS Coordinator, Monday through Friday, will review the Care Plan and Nurse Aide Kardex of each resident on the 300 Hall Behavior Unit to determine that the care plan is reflective of current resident needs and care requirements. The weekend Supervisor will complete this review on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting daily audits for 30 days and then weekly audits as a permanent procedure. This process began on September 12, 2016 and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. 13. On September 12, 2016, the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding Care Plans and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for September 14, 2916, and the first monthly meeting for October 5, 2016. 14. A lock was installed on the door to the 300 Hall shower area on September 6, 2016. This shower area will remain locked when not in use by an authorized facility staff member. Authorized staff members are facility nursing staff, facility housekeeping staff and facility maintenance staff. 15. This locked shower area can be accessed by authorized facility staff members via key kept on the 300 Hall nurse's key ring as well as spare keys kept in the First Floor Medication Room and at First Floor Nursing Station. 16. An inservice for facility RNs, LPNs, CNAs, housekeeping and maintenance staff regarding Shower Area Safety has been completed. As of September 12, 2016, (5 of 5) RNs, (15 of 15) LPNs, (27 of 28) CNAs, (7 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff; 97% of the education has been achieved, 100% will be achieved by September 16, 2016. Staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. 17. On September 9, 2016, the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing will monitor the shower area on 300 Hall, Monday through Friday, on first and second shift to determine that the door is locked when not in use, that the area is free of hazardous chemicals and objects and that the key to the area is accessible to authorized staff; the 300 Hall LPN will complete this monitoring duty on third shift. The weekend Supervisor will complete this review on Saturday and Sunday for the 12 hour shifts. This audit will be conducted each shift for 30 days, then daily for the following 30 days, then weekly audits as a permanent procedure. Audit tool attached. 18. On September 9, 2016, the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding securing the 300 Hall shower area and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for September 14, 2016 and the first monthly meeting for October 5, 2016. 19. On September 13, 2016 the facility policy Quality Assurance Committee, was reviewed with facility Administrator and Department Directors. Copy of policy and acknowledgement of review attached. On September 14, 2016, the responsibilities of the facility Medical Director were reviewed with the facility Administrator and Medical Director. Acknowledgement of review attached. 20. On September 14, 2016, the facility initiated a system process by which a formal Quality Assurance Committee meeting to identify occurrences, patterns and trends related to events, as well as other quality issues that affect resident well-being, will be held on a monthly basis with the first meeting scheduled for September 14, 2016; the next meeting is scheduled for October 5, 2016. This monthly process is to be a permanent process. A written record of the items discussed, actions approved and staff attending will be produced for each Quality Assurance meeting held. These written records will serve as audit/monitoring tools and will be available for surveyor review when requested. The State Survey Agency (SSA) validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. The facility policy Staffing for Behavior Unit, developed on 8/30/16, was reviewed. The policy revealed there will be two (2) qualified nursing staff members present on the Behavior Unit at all times. One (1) will be a licensed nurse and there will be at least one Certified Nursing Assistant (CNA). Facility Staff who have received [MEDICATION NAME] maneuver training and basic first aid instruction will be considered qualified staff. The Behavior Unit charge nurse will schedule meals and break times for the CNA's at the beginning of each shift. Those times will be staggered so that CNA's can provide relief coverage for each other. Other facility staff may also be used as needed for relief coverage during staff meal/break times. The first floor charge nurse, the Assistant Director of Nursing (ADON) or the weekend supervisor will be responsible for relieving the licensed nurse on the Behavior Unit for meals/ break times. The first floor charge nurse will be relieved for meal/break time by the Director of Nursing (DON), ADON or the weekend supervisor. Should the first floor charge nurse be unavailable for relief duty, then the Assistant Director of Nursing and/or the DON and/or weekend Supervisor will be available to relieve Behavior Unit staff for meal/break times. Course content included the following topics: *Routine monitoring *Observation of Residents *Implementation of Actions to Meet Resident Needs *Staffing Coverage Review of the roster for the inservice education titled Behavior Unit Supervision and Staffing confirmed 100 % of all facility staff including RN's, LPN's, CNA's, housekeeping, maintenance, dietary, activities, social services, and laundry. Interviews were conducted with the following staff on 9/16/16 to verify the facility provided education to ensure knowledge of how many qualified staff needed to be present at all times according to the Staffing on Behavior Unit policy and were able to verbalize the facility policy for staffing on the Behavioral Unit and revealed they attended the in-service provided by the facility: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AAA at 3:09 p.m., CNA BB at 3:11 p.m., LPNFF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. Observations of the Behavior Unit staffing on 9/16/16 at 3:45 p.m. and 9/19/16 at 12:25 p.m. revealed one Licensed Practical Nurse (LPN) and two CNA's were present on the Behavioral Unit assisting residents. 2. Review of the Daily Staffing Sheets from 9/8/16 through 9/19/16 were verified by comparison of time card punch records and the actual work schedule. The Behavior Unit staffing conformed to the staffing policy of one LPN and one CNA on each shift. The AOC revealed all RN's LPN's and CNA's have received training in the [MEDICATION NAME] maneuver. Review of educational rosters titled Performing the [MEDICATION NAME] maneuver conducted on 1/22/16 and 5/29/16, compared with list of current RN's LPN's and CNA's revealed all have received [MEDICATION NAME] maneuver training as required by facility policy titled Education :Required In-services. The following in-services or drills will be provided on an annual basis: [MEDICATION NAME] maneuver. Review of the facility audit of staffing pattern on the Behavior Unit conducted on 9/9/16 verified one LPN and one CNA scheduled every shift from 9/8/16 through 9/30/16. Review of assignment sheets for the Behavior Unit from 9/8/16 through 9/16/16 verify the assignment of CNA relief coverage for the CNA and LPN coverage for the LPN. Interviews were conducted with the following staff to verify qualified staff were present on the Behavior Unit and had attended in-services for [MEDICATION NAME] maneuver within the last year and had received first aid training as part of licensure and certification: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AA at 3:09 p.m., CNA BB at 3:11 p.m., LPN FF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. Observations of the Behavior Unit staffing on 9/16/16 at 3:45 p.m. and 9/19/16 at 12:25 p.m. revealed one LPN and two CNA's were present on the Behavioral Unit assisting residents. 3. Review of inservice education titled Supervision and Monitoring of Residents in the Behavior Unit included the following: *Routine monitoring *Observation of Residents *Implementation of Actions to Meet Resident Needs *Staffing Coverage Review of education rosters for the inservice titled Supervision and Monitoring of Residents in the Behavior Unit revealed 100% of facility staff were educated as of 9/17/16. Interviews were conducted with the following staff to verify attendance of the inservice titled Supervision and Monitoring of Residents in the Behavior Unit and verified knowledge of location of the Panic Button on the Behavior Unit, how to activate the button, where the Panic Button sounds outside the Behavior Unit, and who is responsible for responding after the Panic Button is activated: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AA at 3:09 p.m., CNA BB at 3:11 p.m., LPN FF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. An observation conducted on 9/16/16 at 2:55 p.m. on the Behavior Unit included the testing of the Panic Button by the Administrator and the Maintenance Director. An interview conducted on 9/16/16 at 3:00 p.m. with the Administrator revealed the facility will be conducting drills in the future for staff to remain aware of what the panic button sounds like and what to do in case of an emergency on the unit. 4. Review of education inservice titled Supervision and Monitoring of Residents in the Behavior Unit relief for breaks and meal education has been completed with 100% of RN's LPN's and CNA's being educated as of 9/12/16. The staffing assignment sheets, schedules and time card records confirm two CNA's and one LPN are scheduled every shift, every day and have been present every shift since 9/8/16. The daily assignment sheets reviewed from 9/8/16 to 9/16/16, the two CNA's relieve each other and the LPN assigned to 100 Hall and 200 Hall relieves the LPN on the Behavior Unit. Interview 9/16/16 at 2:20 p.m. with the Administrator and DON revealed the DON and ADON and Patient Care Coordinator and weekend supervisors are also available to relieve the Behavior Unit LPN and 100% of current and active nursing staff have received this education and know they are expected to comply. Interviews were conducted with the following staff to verify the process for relieving Behavior Unit staff during breaks and meal times to maintain two qualified staff on the Behavior Unit at all times. And all the following staff were able to verbalize and acknowledge the inservice education provided regarding how to relieve qualified nursing staff on the Behavior Unit: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AA at 3:09 p.m., CNA BB at 3:11 p.m., LPN FF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. Observation on 9/16/16 at 2:30 p.m. revealed the Resident Care Coordinator RN relieved LPN EE while she used the telephone to call a Physician. 5. Review of in-service records regardin Mealtime Supervision revealed 100% education achieved by 9/16/16. Course content included the following topics: *What is supervision?<b

Based on observations, record review, policy and procedure review, and staff interviews, the facility failed to ensure care was provided in accordance with the written plan of care related to supervision for four (4) of thirteen (13) residents on the Behavior Unit, Resident (R) 63, R30, R60, and R72. Additionally, for one (1) resident (R24) with long, jagged, dirty fingernails that required total assistance with personal hygiene. The sample was fifty two (52) residents. R63 struck her roommate twice on [DATE]. R63 stated to staff She's always trying to interrupt me every time I am talking with my mother on the phone. I am sick and tired of her. She needs to get out of my room! On [DATE], R63 bit her roommate (R42) on the left side of her chest. The care plan for behavioral symptoms includes an approach to determine if hallucinations pose a danger to the resident or others and to provide supervision with locomotion on the unit. R30 was found in the shower room on [DATE] at 4:45 p.m. seated on the floor after being unobserved for ninety minutes. R30 became unresponsive and was transported to the hospital by ambulance. R30 was pronounced deceased at 5:49. The care plan for R30 indicated to provide supervision with locomotion on the unit. R60 had aggressive behaviors and on [DATE], he hit R48 in the face that resulted in injury to R48. The incident was unwitnessed. The care plan indicated to provide supervision with locomotion on the unit. Observations on the Behavioral Unit on [DATE] revealed R72 exiting the dining area on the 300 Hall (locked) Behavior Unit unassisted and unobserved. R72 then entered the shower room unsupervised. The care plan for R72 indicated to provide supervision with locomotion on the unit. The facility's failure to provide supervision in accordance with each resident's written plan of care has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility policy titled Care Plans revealed care plan interventions are reflective of changes in resident condition as well as changes in physician orders and nursing interventions. 1. Review of the clinical record for R63, a resident on the Behavior Unit, revealed a Significant Change MDS assessment dated on [DATE]. The resident had a Brief Interview for Mental Status (BIMS) summary score of 5, indicating severe cognitive impairment. Section E: Behaviors indicated R63 experiences hallucinations, delusions, and put others at significant risk for physical injury. Section N- Medications indicated R63 received antipsychotic and antianxiety medications. Section V- Care Area Assessment (CAA) indicated the decision to care plan for Behavioral Symptoms. Review of the care plan for R63 with a Problem Start Date of [DATE] and a Long Term Goal Target Date through [DATE] identified alteration in Activities of Daily Living (ADL) care with an intervention that included supervision with locomotion on the unit. The care plan identified alteration in mood and behavior related to her being very impulsive, easily agitated and demanding. She has [DIAGNOSES REDACTED]. She can be physically and verbally aggressive at times toward residents and staff. The last episode was on [DATE] when she pushed another resident that wandered into her room. She was sent to (name) behavioral center and returned on [DATE]. An intervention included to determine if hallucinations pose danger to the resident or others, intervene as necessary. Review of R63 nurse Resident Progress Notes dated [DATE] at 2:20 p.m. revealed R63 was screaming and hollering that she wanted to go home. Her roommate (R42) asked her to be quiet. R63 then struck R42 on the left side of her face. The nurse writing the note had asked R63 why she had struck R42 and R63 replied that she did not get along with R42. (Time of the unwitnessed incident was 1:30 p.m.) On [DATE] at 10:50 p.m. The Certified Nursing Assistant (CNA) observed R63 hit her roommate (R42) in her face with shoes. (R42) was moved to another room for her safety. On [DATE], R42 was moved back into the room with R63. Another unwitnessed incident occurred on [DATE] when R63 bit R42 on the chest. An interview with LPN EE on [DATE] at 9:50 a.m. revealed that R42 was returned to her previous room (on [DATE]) with the same roommate (R63) because she needed to be on the locked unit and there was no other bed available in the locked unit. An interview with the DON on [DATE] at 11:55 a.m. revealed that R63 was transferred to a different unit on [DATE]. The transfer of R63 was related to a decline in her condition and not was not related to the resident to resident altercations. She stated that she had dropped the ball. The DON could not provide an explanation why R63 remained in the room with R42 or why interventions were not implemented to protect R42 from R63. An interview with LPN EE on [DATE] at 12:10 p.m. revealed that she kept an eye on R42 and R63. She would check on them frequently and separate them if they became loud. LPN EE confirmed there were no formal interventions or plan initiated to supervise R42 and R63, such as checking them at designated frequencies. (Refer F323 and F353) 2. Clinical record review for R30, a resident on the Behavioral Unit, revealed readmission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] for R30 revealed in Section C: Cognition BIMS scoring could not be completed because resident could rarely or never be understood. Section G: Supervision was required for ambulation in corridor and on the unit, for the seven (7) days of the look back period. Review of the care plan for R30, dated [DATE] indicated a Problem Start Date of [DATE] for Activities of Daily Living (ADL) with an approach to provide supervision with locomotion on the unit. A care plan for Mood State dated [DATE] revealed an Approach Start Date of [DATE] to provide supervision with locomotion on the unit. Review of Event Report for R30 revealed on [DATE] at 4:45 p.m. an unwitnessed fall occurred in the shower room. R30 had no apparent injury and was more lethargic after the event. Vital signs included a blood pressure of ,[DATE], heart rate of 45, oxygen saturation 81%. 911 was called. Review of the nurse Resident Progress Notes dated [DATE] at 4:45 p.m. revealed after being discovered in the shower room on the floor, R30 was unable to speak and she was half dressed. R 30 became unconscious, Emergency Medical Services (EMS) arrived and continued Cardio [MEDICAL CONDITION] Resuscitation, initiated by the first responders from the fire department, and transported R30 to the hospital. Review of the emergency room Report dated [DATE] revealed attempts at resuscitation were unsuccessful and R30 was pronounced deceased at 5:49 p.m. Interview on [DATE] at 4:50 p.m. with LPN JJ revealed she had not seen R30 since her first rounds at 3:15 p.m. LPN JJ revealed the CNA had found R30 on the floor in the shower and also had not seen R30 since 3:15 p.m. on first rounds. R30 had been in her room at 3:15 p.m. and had told LPN JJ she was feeling fine. LPN JJ acknowledged R30 required assistance per care plan but had ambulated to the shower from her room unsupervised and was in the shower room for an unknown period of time. Interview [DATE] at 12:30 p.m. with the Director of Nurses (DON) indicated she expects all care planned interventions to be followed. She revealed that supervision on the care plans of the residents on the Behavioral Unit did not mean one to one supervision, but supervision did not mean one to thirteen either. The DON revealed on [DATE] she had been informed that effective [DATE] staffing would be reduced to one (1) CNA for all shifts on the Behavior Unit. The DON acknowledged she had objected to Corporate Quality Assurance Nurse SS and the Administrator on [DATE], indicating to them and was told she would have to manage the Behavioral Unit with one (1) CNA. (Refer F323 and F353) 3. Record review for R60 revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] documented a BIMS summary score of 2, indicating severe cognitive impairment. The resident exhibited behaviors not directed towards others and wandering. The resident received antidepressant medication. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS summary score of 1, indicating severe cognitive impairment. The resident exhibited behaviors not directed towards others, rejection of care and wandering. The resident received antipsychotic and antidepressant medications. Review of the care plan for R60 identified Behavioral Symptoms with a Problem Start Date of [DATE] and a Long Term Target Goal Target Date through [DATE]. He resides on the behavioral secured unit. He is very dramatic, very energetic and hyperactive most times with staff and other residents. He will pace up and down the hallway at times. An intervention included he needs re-direction when wandering in other resident's room. The care plan identified R60 is at risk for falls with a Problem Start Date of [DATE] and a Long Term Goal Target Date through [DATE]. An intervention included to provide supervision with locomotion on unit. Record review for R60 revealed on [DATE] at 6:55 p.m., R60 hit another resident (R48) in the dayroom. R48 was found to be sitting next to R60 and had a bleeding lip. An interview on [DATE] at 2:50 p.m. with the Certified Nursing Assistant (CNA) QQ revealed she was sitting in the dining area across the hall when she heard shouting. Upon entry to the dayroom, R60 and R48 were seated next to each other at a table. R48's lip was bleeding. CNA QQ asked R60 if he had hit R48 and he responded that he did hit R48. Interview on [DATE] at 10:20 a.m. with the Administrator revealed she expects all care planned interventions for residents on the Behavioral Unit, including supervision and assistance, to be followed and was unaware supervision and assistance was not being provided in accordance with care plans. The Administrator revealed one to one supervision was not possible for any facility to provide but had not identified one to thirteen supervision would not be adequate to provide care in accordance with care planning. (Refer F323 and F353) 4. Review of the clinical record for R72, a resident on the Behavioral Unit, revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed in Section C: Cognition R72 had a Brief Interview for Mental Status Score of one (1). Further review of the MDS Section E: Behaviors revealed wandering occurred daily. Section G: Functional Status revealed R72 required the limited assistance of one person to ambulate in the halls, on and off the unit. Section G revealed R72 was only able to stabilize with human assistance with transfers and ambulation in corridors on and off the unit Review of the care plan dated [DATE] for falls revealed R72 was a fall risk related to unsteady gait, [MEDICAL CONDITION] and history of falls. The care plan reveals in approach, start date [DATE] an intervention to provide staff assistance X 1 with locomotion on and off the unit. Observation of Behavioral Unit on [DATE] revealed at 12:56 p.m. R72 left the dining area and entered the shower room unobserved while CNA DD attended a resident in their room. When R72 opened the shower room door there were wheelchairs and a Hoya lift visible, close to the doorway. CNA DD returned to the dining areas at 12:57 p.m. Interview on [DATE] at 12:57 p.m. with CNA DD attending the Behavioral Unit without assistance, revealed she was unaware of the location of R72. CNA DD indicated R72 was not supposed to be in the shower room unsupervised. (Refer F323 and F353) 5. Record review for Resident (R) 24 revealed an admission the facility on [DATE] with the relevant [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had sever cognitive impairment and required total assistance with personal hygiene. Review of the care plan dated [DATE] for R24 identified alteration in Activities of Daily Living (ADL) function related to decreased mobility, left sided [MEDICAL CONDITION] and status [REDACTED]. An intervention included to provide assistance with nail care and trim nails as needed. Observations of R24 revealed his fingernails were long, jagged and had a brown substance under the nails on [DATE] at 2:00 p.m., on [DATE] at 9:30 a.m. and on [DATE] at 10:20 a.m. A review of the Resident Progress Notes from [DATE]- [DATE] revealed no documentation related to the resident presenting with behaviors of rejection of care. Interview on [DATE] at 12:31 p.m. with the DON revealed the CNA is responsible for cleaning and trimming a residents fingernails when the resident is bathed. If a resident has a [DIAGNOSES REDACTED]. The Nurse is responsible for trimming nails for a resident with a [DIAGNOSES REDACTED]. On [DATE] at 12:32 p.m. the Licensed Practical Nurse (LPN) EE and the DON made an observation of R24's fingernails. The DON stated that the expectation is that due to the resident ' s medical condition of Diabetes, she expects that the LPN file down the resident's nails. The DON instructed LPN EE to file the R24's nails at this time. (Refer F312) The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility policy, Staffing for Behavior Unit, was developed on [DATE], and has been reviewed with (5 of 5) facility RN's, (15 of 15) facility LPN's, and (28 of 28) facility Certified Nursing Assistants as part of an inservice education session. 100% of this education has been completed as of [DATE]. Copy of policy attached. 2. The facility staffing pattern and workflow has been reviewed and revised to reflect the presence of a licensed nurse on the Behavior Unit at all times. The facility will maintain staffing of no less than two (2) nursing staff members, one of which is a licensed nurse, the other a Certified Nursing Assistant, in the Behavior Unit on all shifts as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. To be considered qualified staff for the Behavior Unit, a staff member must be a licensed nurse or a certified nursing assistant since both of these categories have received basic first aid instruction as well as [MEDICATION NAME] maneuver education. These nursing staff members, one of which is a licensed nurse, the other a certified nursing assistant, will have completed [MEDICATION NAME] maneuver training; staff without [MEDICATION NAME] maneuver training will not be considered relief staff. This staffing pattern was effective as of [DATE]. Copy of monthly nursing staffing schedule attached. A review of the nursing staffing pattern for the remainder of the month of September, 2016, was conducted [DATE]. 2016, revealed 100% coverage of one (1) licensed nurse assigned to the Behavior Unit each shift, each day and at least one (1) certified nursing assistant assigned to the Behavior Unit for each shift, each day. The results of this review attached. 3. An inservice for (5 of 5) facility RN s, (15 of 15) facility LPNs, (28 of 28) facility CNA, (4 of 4) Administrative staff, (4 of 7) Housekeeping staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff and (1 of 1) Social Service staff, regarding Supervision and Monitoring of Residents in the Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. This inservice will include discussion of the PANIC BUTTON located in the Day Area of the Behavior Unit, how to activate this device, that it sounds at the First Floor nursing station and that any staff within hearing distance when the PANIC BUTTON is activated are responsible for responding to the PANIC BUTTON by entering the unit and assisting unit staff as needed. As of [DATE], 100% of this education has been achieved for nursing staff, 88% for all staff. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 4. (5 of 5) facility RNs, (15 of 15) facility LPNs, and (28 of 28) facility CNAs have been informed as part of the inservice, Supervision and Monitoring of Residents in the Behavior Unit, of the process for relieving Behavior Unit staff during breaks/meal times so that consistent staffing of two (2) is maintained in the Behavior Unit at all times. The licensed nurse assigned to the Behavior Unit will be relieved at break/meal time by the First Floor licensed nurse, the Assistant Director of Nursing or the Weekend Supervisor. Behavior Unit CNAs will be relieved by First Floor CNAs or Restorative CNAs for break/meal times; these break/meal times will be designated on the daily assignment sheets. As of [DATE], 100% of this training has been achieved. This process began on [DATE] and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. Inservice record attached. 5. An inservice for facility staff with (5 of 5) facility RNs, (15 of 15) facility LPNs, (26 of 28) facility CNAs, (4 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff, regarding Mealtime Supervision in Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. As of [DATE], 86 % of this education has been achieved, 100% of this training will be completed by [DATE], and facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 6. A facility qualified nursing staff member will be present in the common Dining Areas of the Behavior Unit during resident meal times to provide monitoring, supervision, and assistance as needed. Residents will be encouraged to eat meals in the common Dining Areas but those choosing to eat in their rooms will be observed approximately every ,[DATE] minutes during meal time. Implementation of this intervention began [DATE]. 2016, and will be completed by [DATE], as 100% of this training is completed. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 7. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing reviews the daily nursing staffing schedule and assignment sheet at the beginning of the shift, Monday through Friday, for first and second shift, to determine that the Behavior Unit is properly staffed with a licensed nursing staff member (LPN) and at least one (1) CNA on each shift, each day and that the Behavior Unit staff has coverage for break/meal times. This review will be completed by the ,[DATE] Hall LPN for third shift and the weekend Supervisor on Saturday and Sunday for both 12 hour shifts. This process is to be a permanent procedure with management staff conducting these audits every shift for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. Audit tool attached. 8. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing or Assistant Director of Nursing observes the dining areas of the Behavior Unit daily, Monday through Friday, to determine that a nursing staff member that has completed the facility education, Mealtime Supervision in Behavior Unit, is present during the resident meal times. This review will be completed by the weekend Supervisor on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting these audits for first and second shifts for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. 9. On [DATE], the facility implemented a procedure by which the results of the audits referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding staffing for the behavior unit and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE] and then the first monthly meeting for [DATE]. 10. On [DATE], the facility policy, Care Plans, was reviewed with the facility Administrator, Director of Nursing, Assistant Director of Nursing and MDS Coordinator. The review resulted in no changes to the current policy and the facility will begin implementing the current policy on [DATE]. Policy and acknowledgement of review attached. The Care Plan of each resident residing on the 300 Hall Behavior Unit will be reviewed and revised to reflect the current resident care status and care needs. This review/revision process will be 100% completed by [DATE]. Care plan revisions will be written on the current care plan in the paper chart and communicated to licensed nursing staff daily by MDS Coordinator. This information will be passed on to other licensed staff during shift to shift report. The Nurse Aide Kardex for each resident on the 300 Hall Behavior Unit will be reviewed/revised daily to effectively communicate resident needs and care requirements to facility CNA staff. This review/revision process will be 100% completed by [DATE]. 11. An inservice for facility nursing staff, RNs, LPNs, CNAs, regarding Care Plans is in process. As of [DATE], with (5 of 5) RNs, (14 of 15) LPNs, and (22 of 28) CNAs having completed the education. 85% of this education has been completed. 100% of the education will be completed by [DATE]. Nursing staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 12. On [DATE], the facility initiated a new procedure by which the Director of Nursing, Assistant Director of Nursing, or the MDS Coordinator, Monday through Friday, will review the Care Plan and Nurse Aide Kardex of each resident on the 300 Hall Behavior Unit to determine that the care plan is reflective of current resident needs and care requirements. The weekend Supervisor will complete this review on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting daily audits for 30 days and then weekly audits as a permanent procedure. This process began on [DATE] and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. 13. On [DATE], the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding Care Plans and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE], and the first monthly meeting for [DATE]. 14. A lock was installed on the door to the 300 Hall shower area on [DATE]. This shower area will remain locked when not in use by an authorized facility staff member. Authorized staff members are facility nursing staff, facility housekeeping staff and facility maintenance staff. 15. This locked shower area can be accessed by authorized facility staff members via key kept on the 300 Hall nurse's key ring as well as spare keys kept in the First Floor Medication Room and at First Floor Nursing Station. 16. An inservice for facility RNs, LPNs, CNAs, housekeeping and maintenance staff regarding Shower Area Safety has been completed. As of [DATE], (5 of 5) RNs, (15 of 15) LPNs, (27 of 28) CNAs, (7 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff; 97% of the education has been achieved, 100% will be achieved by [DATE]. Staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. 17. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing will monitor the shower area on 300 Hall, Monday through Friday, on first and second shift to determine that the door is locked when not in use, that the area is free of hazardous chemicals and objects and that the key to the area is accessible to authorized staff; the 300 Hall LPN will complete this monitoring duty on third shift. The weekend Supervisor will complete this review on Saturday and Sunday for the 12 hour shifts. This audit will be conducted each shift for 30 days, then daily for the following 30 days, then weekly audits as a permanent procedure. Audit tool attached. 18. On [DATE], the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding securing the 300 Hall shower area and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE] and the first monthly meeting for [DATE]. 19. On [DATE] the facility policy Quality Assurance Committee, was reviewed with facility Administrator and Department Directors. Copy of policy and acknowledgement of review attached. On [DATE], the responsibilities of the facility Medical Director were reviewed with the facility Administrator and Medical Director. Acknowledgement of review attached. 20. On [DATE], the facility initiated a system process by which a formal Quality Assurance Committee meeting to identify occurrences, patterns and trends related to events, as well as other quality issues that affect resident well-being, will be held on a monthly basis with the first meeting scheduled for [DATE]; the next meeting is scheduled for [DATE]. This monthly process is to be a permanent process. A written record of the items discussed, actions approved and staff attending will be produced for each Quality Assurance meeting held. These written records will serve as audit/monitoring tools and will be available for surveyor review when requested. The State Survey Agency (SSA) validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. The facility policy Staffing for Behavior Unit, developed on [DATE], was reviewed. The policy revealed there will be two (2) qualified nursing staff members present on the Behavior Unit at all times. One (1) will be a licensed nurse and there will be at least one Certified Nursing Assistant (CNA). Facility Staff who have received [MEDICATION NAME] maneuver training and basic first aid instruction will be considered qualified staff. The Behavior Unit charge nurse will schedule meals and break times for the CNA's at the beginning of each shift. Those times will be staggered so that CNA's can provide relief coverage for each other. Other facility staff may also be used as needed for relief coverage during staff meal/break times. The first floor charge nurse, the Assistant Director of Nursing (ADON) or the weekend supervisor will be responsible for relieving the licensed nurse on the Behavior Unit for meals/ break times. The first floor charge nurse will be relieved for meal/break time by the Director of Nursing (DON), ADON or the weekend supervisor. Should the first floor charge nurse be unavailable for relief duty, then the Assistant Director of Nursing and/or the DON and/or weekend Supervisor will be available to relieve Behavior Unit staff for meal/break times. Course content included the following topics: *Routine monitoring *Observation of Residents *Implementation of Actions to Meet Resident Needs *Staffing Coverage Review of the roster for the inservice education titled Behavior Unit Supervision and Staffing confirmed 100 % of all facility staff including RN's, LPN's, CNA's, housekeeping, maintenance, dietary, activities, social services, and laundry. Interviews were conducted with the following staff on [DATE] to verify the facility provided education to ensure knowledge of how many qualified staff needed to be present at all times according to the Staffing on Behavior Unit policy and were able to verbalize the facility policy for staffing on the Behavioral Unit and revealed they attended the in-service provided by the facility: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AAA at 3:09 p.m., CNA BB at 3:11 p.m., LPNFF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. Observations of the Behavior Unit staffing on [DATE] at 3:45 p.m. and [DATE] at 12:25 p.m. revealed one Licensed Practical Nurse (LPN) and two CNA's were present on the Behavioral Unit assisting residents. 2. Review of the Daily Staffing Sheets from [DATE] through [DATE] were verified by comparison of time card punch records and the actual work schedule. The Behavior Unit staffing conformed to the staffing policy of one LPN and one CNA on each shift. The AOC revealed all RN's LPN's and CNA's have received training in the [MEDICATION NAME] maneuver. Review of educational rosters titled Performing the [MEDICATION NAME] maneuver conducted on [DATE] and [DATE], compared with list of current RN's LPN's and CNA's revealed all have received [MEDICATION NAME] maneuver training as required by facility policy titled Education :Required In-services. The following in-services or drills will be provided on an annual basis: [MEDICATION NAME] maneuver. Review of the facility audit of staffing pattern on the Behavior Unit conducted on [DATE] verified one LPN and one CNA scheduled every shift from [DATE] through [DATE]. Review of assignment sheets for the Behavior Unit from [DATE] through [DATE] verify the assignment of CNA relief coverage for the CNA and LPN coverage for the LPN. Interviews were conducted with the following staff to verify qualified staff were presen

Based on observations, record review, staff interview and review of the Behavior Unit Guidelines, the facility failed to provide adequate supervision on the 300 Hall (locked) Behavior Unit to prevent two (2) cognitively impaired Residents (R) (R30 and R72) from entering the shower room unattended, prevent one (1) cognitively impaired resident (R6) from accessing the housekeeping cart unattended, and provide a safe environment for two (2) cognitively impaired residents (R42 and R48) who were struck and/or bitten by residents with aggressive behaviors. The Behavior Unit census was thirteen (13). The sample size was fifty-two (52). On [DATE] at 12:45 p.m. an observation of the Behavior Unit included a shower room door with no lock. Observations of the Behavior Unit during lunch on [DATE] at 12:15 p.m. revealed one (1) Certified Nursing Assistant (CNA) supervising the unit alone, serving trays to both dining areas and a resident that was eating in their room. There were residents in the two (2) dining areas unsupervised. The Behavior Unit was observed on [DATE] at 12:00 p.m. with no staff in attendance on the unit. The Licensed Practical Nurse (LPN) EE in charge of the unit was outside the locked door sitting at the 200 Hall nurses' station and the CNA assigned to the unit was at lunch. On [DATE] at 12:30 p.m. an observation of the Behavior Unit revealed one (1) CNA alone on the unit passing trays to residents in the two (2) dining areas and a resident in their room. The CNA was not in the dining areas when two (2) residents began to have a verbal altercation, one resident began to choke but was able to cough up her food and R72, a resident with severe cognitive impairment and hemiparesis, exited the dining area and entered the shower room door, with wheelchairs and a Hoya lift visible through the open door. On [DATE] at 1:30 p.m. R42, a resident on the Behavioral Unit with severe cognitive impairment, was struck in the face by her roommate R63, a cognitively impaired resident with aggressive behaviors. R42 was struck by R63 with a shoe on [DATE] at 10:50 p.m. R42 was moved to another unit for two (2) nights. On [DATE], R42 was moved back to her room on the Behavior Unit and cried and pleaded not to be returned to a room with R63 and told staff she feared R63 would kill her. On [DATE] at 7:20 p.m. R63 bit R42 on the left side of her chest, leaving teeth marks, broken skin and blue and purple bruising. R42 and R63 continued to share a room until [DATE]. On [DATE] at 6:30 p.m. R6, a resident on the Behavior Unit with severe cognitive impairment, was observed with a broom she had obtained from the housekeeping cart, while unsupervised. R6 was sweeping a door. R6 was observed throwing the broom to the floor and was bleeding from a laceration on her forehead and from her nose. On [DATE] at 4:45 p.m. R30 was found in the shower room by a CNA. R30 had not been observed since 3:15 p.m. by the LPN JJ or the CNA. R30 was awake but unable to speak, had no visible injury, and had a blood pressure of ,[DATE]. LPN JJ called for Emergency Medical Services (EMS) and when they arrived they continued Cardio Pulmonary Resuscitation (CPR) started by first responders. R30 was transferred to the hospital with CPR in progress and pronounced dead at 5:49 p.m. Interview with the Administrator on [DATE] at 5:30 p.m. revealed the Behavioral Unit staffing had been decreased from two (2) CNA's to one (1) CNA on all shifts effective [DATE]. The facility's failure to provide adequate supervision to protect residents from hazardous equipment, hazardous areas, and aggressive residents placed residents on the Behavior Unit at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the guideline titled Behavioral Unit Guidelines with no date, revealed two (2) staff members will be present at all times and a remote, signaling button with a distinctive ring tone will be located in the Dining/Living Room Area to alert other facility staff that additional help is needed on the unit. On page 82 , staff should never leave a confused resident unattended during bathing because falls commonly occur in the bathroom. Showers and bathtubs are dangerous for both residents and staff or caregiver. On page 83, Do not leave the resident unattended in the bath area to retrieve bathing items. Observation [DATE] at 12:45 p.m. on Behavioral Unit revealed there is no lock on the shower room door. On [DATE] at 12:15 p.m. a dining observation was conducted in the 300 Hall (locked) Behavior Unit. Upon entering the secured unit (300 Hall) there were two (2) areas being utilized for resident dining. One dining room was on the right side of the hall and a second dining room/day room was on the left side of the hall, directly across from one another. Six (6) residents were seated at tables in the right side dining area and three (3) residents were seated at tables on the left side dining. CNA CC was the only staff member on the unit and was serving meal trays to residents in both dining areas and in a resident's room. Throughout this observation, the residents in the dining areas were left unattended on multiple occasions. There were residents yelling, screaming and growling in the dining room on the right. The Licensed Practical Nurse (LPN) EE entered the Behavior Unit through the locked door and into the dining room on the right, where residents were yelling. She asked a resident if she would like to be moved somewhere quieter and she said Yes, I don't like noise. LPN EE was observed to escort the resident to her room then exited the Behavior Unit leaving CNA CC to attend the residents by herself. At 12:30 p.m. CNA CC was not in either dining room when a resident in the right dining area walked over to a table and began eating food from a plate left by another resident. Another resident was observed trying to drink from another resident's drink. CNA CC entered the dining and re-directed the residents, then left the dining room to escort one of the residents back to her room. At 12:35 p.m. five (5) residents remained in the dining on the right unsupervised when two (2) residents began screaming loudly at each other. CNA CC returned to the dining room and separated the two (2) residents. One of the residents was yelling I mean, don't bring her around where I'm at! An interview on [DATE] at 11:10 a.m. with the Administrator revealed that there is supposed to be one (1) staff member at all times on the Behavior Unit and one (1) staff member is expected to rotate between the two (2) dining areas during meals. The nurse assigned to the Behavior Unit is also assigned to care for residents on the 200 Hall, outside of the locked unit. The Administrator stated that there were thirteen (13) residents residing on the secured unit but it had the capacity for sixteen (16) residents. When the Behavior Unit is at capacity of sixteen (16) residents there is no change or increase in staffing. The Administrator confirmed that there are residents on the Behavior Unit with a history of violent behaviors and that the staff had attended in-services. The Administrator further stated that This is a behavioral unit and there is a glass window that staff (outside of the unit) can see through the door. An observation of the Behavioral Unit on [DATE] at 12:00 p.m. revealed there was no staff present on the unit. Further observation revealed there was no nurses' station or telephone on the unit. At 12:04 p.m. the Licensed Practical Nurse (LPN) EE, assigned to the Behavior Unit, was sitting at the 200 Hall nurses' station. An interview with LPN EE at the time of the observation revealed she was covering for CNA DD also assigned to the Behavior Unit, while they were on break. LPN EE further stated that she was not on the Behavior Unit because she had to take a phone call at the 200 Hall nurses' station. Observation on [DATE] at 12:30 p.m. revealed CNA DD on the Behavior Unit by herself. During an interview with CNA DD at 12:41 p.m. she was asked how she manages to supervise all thirteen (13) residents by herself in which she replied I do the best I can. CNA DD further stated that there have been times that she has to leave the unit to get assistance when there is no one at the nursing station (on the 200 Hall) that she can call from the door. She confirmed that there has been resident on resident altercations and that there are residents on the unit that have violent behaviors. At 12:49 p.m. the dining room on the left was unsupervised when a verbal altercation took place between two (2) residents (R48 and R10). R10 was yelling and screaming loudly when she began to choke on her food with her face turning red. At 12:50 p.m. CNA DD and LPN EE (who was outside the unit on the 200 Hall) came into the dining room. R10 coughed up the food at this time and calmed down. CNA DD escorted R10 back to her room and LPN EE exited the Behavior Unit. 1. Record review for Resident (R) 42 (victim) indicated an admission to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) was not conducted, the resident was rarely/never understood. Section N- Medication indicated the resident received antipsychotic and antidepressant medications 7 out of 7 days. A Quarterly MDS assessment dated [DATE] documented in section N that the resident received antipsychotic, antianxiety and antidepressant medications 7 out of 7 days. A Quarterly MDS assessment dated [DATE] documented in Section N that the resident received antipsychotic, antianxiety and antidepressant medications 7 out of 7 days. Review of the care plan for R42 with a Problem Start Date of [DATE] and a Long Term Goal Target Date through [DATE], identified cognitive loss/dementia. She is alert and oriented times two and able to make most of her needs known. The care plan also identified a problem with communication and she usually understands what is being said to her. Review of the nurse Resident Progress Notes for R42 revealed the following: On [DATE] at 2:20 p.m., R63 (roommate) was yelling. R42 asked R63 to be quiet because she wanted to take a nap. R63 struck R42 on the left side of the face causing redness and a scratch under her chin. The scratch was treated with a triple antibiotic (TOA), the Nurse Practitioner (NP) and family was notified. The incident was unwitnessed and occurred at 1:30 p.m. On [DATE] at 11:03 p.m., R42 had been hit again, in the face with a shoe by R63 with no injury noted. The incident was witnessed by the Certified Nursing Assistant (CNA). R42 was crying from the hit and was transferred to a different room for her safety. On [DATE] at 6:26 a.m., R42 had redness to the left side of her face and two scratches to the chin area. R42 refused to go back to her room with the previous roommate stating She's going to hit me again and I'm not going back in there! A nurse's note at 2:51 p.m. revealed the resident continued in a room on the 200 Hall. The resident stated she does not want to go back to her previous room. A nurse's note at 10:54 p.m. revealed the resident's entire body was reassessed as a follow up to the altercation with roommate on [DATE] during the 3:00 p.m. - 11:00 p.m. shift. On [DATE] at 10:42 p.m. R42 was returned to the room with R63. R42 was yelling and screaming she did not want to be in the room with R63, yelling and screaming I don't want to be in the room with (name), she is evil and a killer! Take me back to the other room before she kills me! Madam, why did you put me back in the same room with this wicked woman? R42 yelled and complained of being in the same room with R63 for three to five hours. (the event occurred at 7:20 p.m.) On [DATE] at 10:32 p.m., R42 was heard yelling from her room stating that R63 had bitten her on the chest. R42 had redness and teeth marks that penetrated the skin on the left side of her chest. The incident report indicated the Nurse Practitioner (NP) was notified. On [DATE] at 6:56 a.m., R42 had a bite area to the left breast that was reddened, purple and blue. Record review for R63 (aggressor) revealed a Significant Change MDS assessment dated [DATE] which documented in Section C- Cognitive Pattern that the resident had a BIMS summary score of 5, indicating severe cognitive impairment. Section E- Behaviors documented the resident had hallucinations and delusions, behavioral symptoms not directed towards others and puts others at significant risk for physical injury. Section N- Medication documented the resident received antipsychotic and antianxiety medications. Section V- Care Area Assessment (CAA) triggered Behavioral Symptoms with the decision to be care planned. Review of the care plan for R63 with a Problem Start Date of [DATE] and a Long Term Target Date through [DATE] identified alteration in Activities of Daily Living (ADL) care with an intervention that included supervision with locomotion on the unit. The care plan identified alteration in mood and behavior related to her being very impulsive, easily agitated and demanding. She has [DIAGNOSES REDACTED]. She can physically and verbally aggressive at times toward residents and staff. The last episode was on [DATE] when she pushed another resident that wandered into her room. She was sent to (name) behavioral center and returned on [DATE]. An intervention included to determine if hallucinations pose danger to the resident or others, intervene as necessary. Review of the nurse Resident Progress Notes for R63 revealed the following: On [DATE] at 2:36 p.m. R63 was screaming and hollering saying that she wanted to go home when her roommate (R42) asked her to please be quiet so that she could take a nap. R63 hit her roommate (R42) on the left side of her face. Asked R63 why she did that and she replied that she and her roommate don't get along. Explained to R63 next time to tell the CNA or nurse the problem. R63 stated okay. NP notified. (The incident occurred at 1:30 p.m.) On [DATE] at 10:39 p.m. Staff noted R63 hit her roommate (R42) in her face with shoes. Resident is encouraged to calm down. Roommate (R42) moved to another room for her safety. R63 stated She's always trying to interrupt me every time I am talking with my mother on the phone. I am sick and tired of her. She needs to get out of my room. On [DATE] R63 at 9:34 a.m. R63 was involved in an incident were she was noted twice to hit her roommate. The resident was asked about her behavior, she stated that her roommate accused her of not paying her rent and interrupted her when she was on the phone with her mother. Resident was encouraged not to hit her roommate and to report her problems to the staff. Resident verbalized understanding. On [DATE] at 10:55 p.m. Behavioral pattern- violent behavior: threatens staff and other residents. On [DATE] at 5:30 p.m. Behavioral pattern- violent behavior: threatens staff and other residents. On [DATE] at 10:40 p.m. R63 was asked why she bit her roommate (R42), she stated She is in my room and I told her to get the f .k out and she does not want to get out of my room! I'm sick of seeing her in my room! I need her out of my room! On [DATE] at 8:30 a.m. R63 pushed a resident that wandered into her room. R63 was agitated and aggressive, screaming and hollering. NP and family notified. On [DATE] at 1:51 p.m. R63 continues with aggressive behavior. R63 pushed a resident that was in her room. On [DATE] at 2:33 p.m. R63 was sent to (name) hospital due to aggressive behavior. On [DATE] at 10:38 a.m. R63 was sent to (name) emergency room for evaluation related to increase aggressive behavior outburst. She was noted to hit, bits and push other residents. Dr (name) Psychiatric physician was called between incidents and medication adjusted but behavior continued until the day of transfer. R63 was re-admitted to the facility on [DATE] to the same room, in which R42 still resided. R63 and R42 remained roommates until [DATE] when R63 was transferred to a room on the 500 Hall due to an unrelated decline in condition. An interview with LPN EE on [DATE] at 9:50 a.m. revealed that R42 was returned to her previous room (on [DATE]) with the same roommate (R63) because she needed to be on the locked unit and there was no other bed available in the locked unit. An interview with the Administrator on [DATE] at 10:30 a.m. revealed that she was aware R42 was transferred to another room after the incident on [DATE] with R63. She stated that the R42 was returned to her room with R63 because she requested to be returned. She stated that she was not aware of the resident crying and begging the staff not to put her in the room with R63. The Administrator further stated that R63 is no longer sharing the same room with R42. An interview conducted on [DATE] 2:30 p.m. with the Administrator, Director of Nursing (DON), Corporate Quality Assurance Nurse SS and the Director of Social Services (DSS) revealed that it was the responsibility of the DON to follow up on resident to resident altercations. The DON stated that she was not aware of the resident to resident altercations between R42 and R63 and had not followed up on them. An interview with the DON on [DATE] at 11:55 a.m. revealed that R63 was transferred to a different unit on [DATE]. The transfer of R63 was related to a decline in her condition and not was not related to the resident to resident altercations. She stated that she had dropped the ball. The DON could not provide an explanation why R63 remained in the room with R42 or why interventions were not implemented to protect R42 from R63. An interview with LPN EE on [DATE] at 12:10 p.m. revealed that she kept an eye on R42 and R63. She would check on them frequently and separate them if they became loud. LPN EE confirmed there were no formal interventions or plan initiated to protect R42 from R63, such as checking them at designated frequencies. 2. Review of the clinical record for R6, a resident on the Behavioral Unit, revealed [DIAGNOSES REDACTED]. Review of the current updated care plan for [DATE], received on request from the MDS nurse, revealed a care plan for cognitive loss with and approach dated [DATE] indicating resident loves to sweep using a broom for her activities at times. Another approach indicated she loves to sweep the hallways and rooms. A care plan for ADL Function dated [DATE] indicated she was able to ambulate independently and able to rebalance herself when her gait is unsteady. This care plan was updated to include being transferred to ER for evaluation and treatment on [DATE]. A care plan for falls dated [DATE] with updates for falls on [DATE] and [DATE] revealed R6 was at risk for falls related to a history of falls. Review of Quarterly MDS assessment dated [DATE] revealed R6 was not steady ambulating but able to stabilize without human assistance, and required supervision with locomotion on the unit. Her Brief Interview for Mental Status score was not assessed because she could rarely or never be understood. A fall risk assessment dated [DATE] revealed R6 was at high risk for falls due to confusion, Dementia, diminished safety awareness, unsteady gait, use of antidepressants and antipsychotic/neuroleptics. Her total score for fall risk was 12, with 9 and above being high risk. Review of nurse Resident Progress Notes dated [DATE] at 8:40 p.m., revealed R6 was observed with a broom sweeping door. When she dropped the broom and stepped out of her shoes some blood was observed on the floor. After resident calmed down enough she was observed with a skin tear to her left frontal (sic) she allowed nursing staff to clean her frontal at this blood was also observed from nose. Unable to determine what occurred so resident was prepared to be sent to hospital. An additional entry in the nurse Resident Progress Notes dated [DATE] at 9:12 p.m. revealed the incident was unobserved so it was not able to determine how it occurred, since she was also bleeding from nose she was sent to ER for evaluation (eval). A nurse Resident Progress Notes dated [DATE] at 1:00 a.m. revealed R6 returned from the Emergency Department (ED) at 1:00 a.m. with wound adhesive closure on facial laceration. Review of Event Report dated [DATE] indicated this event occurred at 6:30 p.m. in the Behavioral Unit Hallway and was unwitnessed. Review of entity reported investigation of this event by the Administrator revealed this is a usual behavior for R6 and the use of the broom was suspected to have been the source of the injury. The resident had no adverse responses to the incident and R6 is to be closely monitored when the housekeeping carts are on the floor. Interview [DATE] at 3:10 p.m. with CNA AA revealed R6 interacts with staff very well and shows no aggression, does not hit or shout or take others food. She just has to be watched around the housekeeping equipment because she will try to use it. Interview [DATE] at 3:20 p.m. with the Administrator revealed R6 was usually supervised by Activities staff when she wanted to sweep, but must have gained access to a broom unobserved on [DATE]. According to her investigation of the incident no one had given her a broom and she was observed sweeping a door, then observed with a facial laceration and bloody nose. No one knows how she was injured because no one witnessed the injury. 3. Review of the clinical record for R30, a resident of the secured 300 Hall Behavioral Unit, revealed [DIAGNOSES REDACTED]. Review of the care plan revealed an Activities of Daily Living (ADL) care plan, dated [DATE], related to [DIAGNOSES REDACTED]. Review of a care plan for mood state, dated [DATE] related to history of elopement attempts, revealed an intervention to provide supervision with locomotion on the unit. Review of the quarterly Minimum (MDS) data set [DATE] indicated in Section G, Functional Status, R30 required supervision to walk in corridor on unit. Review of Event Reports revealed R30 was observed sitting on the floor in the 300 Hall shower room on [DATE] at 4:45 p.m. The report indicated the event was unwitnessed, with no apparent injuries. Further review revealed the resident was more lethargic after this event. Vital signs (VS) included a heart rate (HR) of 45 beats per minute, blood pressure (BP) of ,[DATE], oxygen (O2) saturation (SAT) 81%. Review of nurse Resident Progress Notes dated [DATE] at 4:45 p.m. revealed the following: Resident was observed sitting in shower room on the floor half dressed, non verbal responsive to stimuli cooperative with attempt to check vital signs (VS). Certified Nursing Assistant (CNA) reported a BP ,[DATE] after she checked BP resident laid on floor 911 was called and in route. Resident has become unconscious, oxygen saturation (SAT) 81%, heart rate (HR) 45. Before O2 was started firemen arrived, received and conducted their assessment and procedure to include starting intravenous (IV) fluids and administering O2 via nasal cannula (NC) The Automated External Defibrillator (AED) was used that instructed them to start Cardio Pulmonary Resuscitation (CPR) 2 man CPR was started by Fireman Department (Dept.) Paramedics arrived assessment and procedures continued after awhile the AED was replaced and instruction was to start CPR. CPR was restarted. 5:30 p.m. R30 was transferred via stretcher to emergency room (ER) in ambulance by Fire Dept. CPR continued. This entry was created by LPN JJ. Interview on [DATE] at 4:50 p.m. with LPN JJ revealed R30 was not seen going into the shower room on [DATE]. She had observed R30 in her room on initial rounds, between 3:00 p.m. and 3:15 p.m. and she was feeling fine with normal speech, no variation from her usual mentation, and no signs of physical illness. At 4:45 p.m. the CNA had notified her that R30 was sitting on the floor in the shower room and when she asked, the CNA had not observed R30 since she had been in her room between 3:00 p.m. and 3:15 p.m. and did not witness R30 going into the shower room. LPN JJ revealed R30 had occasionally used the toilet in the unlocked shower room. LPN JJ had gone to the shower room at 4:45 p.m. and discovered R30 seated on the floor with her shirt on the floor beside her. R30 was alert, awake and unable to speak. LPN JJ had checked an O2 SAT and found it to be in the 90's. She had no signs of physical injury. The CNA was taking VS while she called for Emergency Medical Services (EMS). On EMS arrival they completed an assessment, started an IV, applied O2 then applied the AED and initiated CPR. LPN JJ further stated she had worked in other long term care facilities and the showers were always kept locked. Review of EMS Pre-Hospital Care Report for R30, dated [DATE] revealed the call for R30 was received at 4:52 p.m. for person down. EMS was at the patient's side at 5:02 p.m. Her physical findings did not include any signs of physical trauma. Her EKG showed Ventricular Fibrillation. She was pulseless and apneic on EMS arrival to the shower room. CPR was in progress by the first responders. The care of R30 was transferred to a physician and Registered Nurse (RN) at (name) Emergency Department. Review of emergency room Report dictated by the emergency room Physician revealed after a pulse check with ultrasound R30 was pronounced deceased at 5:49 p.m. [DIAGNOSES REDACTED]. Interview [DATE] at 11:20 a.m. with the Administrator revealed R30 used the shower as her bathroom unsupervised on a regular basis. The Administrator did not regard this as a hazardous area, just another bathroom for the residents to use if they wished to use it. There had never been a lock on the Behavior Unit shower door and she did not know of any resident having a problem in there. She was not aware of R72 entering the shower room unobserved on [DATE] at 12:56 p.m. or of other times he may have entered the shower room with no supervision. Interview [DATE] at 12:10 p.m. with the Administrator revealed she was aware of wheelchairs and Hoya lift being stored in the shower room but did not consider that to be hazardous. Interview [DATE] at 10:20 a.m. with the Administrator revealed she did not consider R30 being in the shower room unobserved for an unknown period of time as a safety concern. 4. Record Review for Resident (R) 48 (victim) revealed she was admitted to the facility on [DATE] and resides on the 300 Hall (locked) Behavior Unit. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented in Section C- Cognitive Pattern that a Brief Interview for Mental Status (BIMS) was not conducted, the resident was rarely/never understood. Section G- Functional Status documented the resident required supervision with locomotion on unit. No behaviors exhibited during the assessment period. The resident received antipsychotic and antidepressant medications. Review of the care plan dated [DATE] for R48 identified alteration in communication and she is unable to make her needs known. The care plan identified Behavioral Symptoms. She has inappropriate behaviors, allowing male residents to touch her inappropriately. On [DATE], she was involved in a physical altercation. R48 took some food from another resident's plate. The other resident reacted by hitting R48 in the face with a plate. A skin tear was noted to her forehead and she received treatment and ordered. A skull x-ray was ordered and the results were negative for fracture. An intervention included to assess whether the behavior endangers the resident and/or others. The care plan identified the resident is at risk for falls with an intervention that included to observe the whereabouts frequently when out of bed (OOB). Review of the Event Report for R48 dated [DATE] at 6:55 p.m. indicated the resident had been slapped on the left cheek by another resident (R60) in the dayroom. The incident was witnessed. Swelling/Edema to left cheek. MD and family notified. An interview on [DATE] at 2:50 p.m. with the Certified Nursing Assistant (CNA) QQ revealed that she did not actually witness R60 hit R48 on [DATE]. CNA QQ was sitting in the dining room on the 300 Hall Behavior Unit when she heard shouting coming from the dayroom across the hall. CNA QQ got up and went to the dayroom an observed R48 and R60 sitting side by side at a table. R48 had an injury to her lip and it was bleeding. CNA QQ asked R60 if he had hit R48. R60 grunted and stated that he did hit R48. Review of the nurse Resident Progress Notes for R48 revealed the following: On [DATE] at 1:59 a.m., R48 alert and in bed after altercation with other resident. Ice placed to left cheek for about an hour for edema. Will continue to monitor and follow care plan. On [DATE] at 7:00 a.m., R48 assessed with [REDACTED]. On [DATE] at 10:02 a.m. R48 had swelling in face, more on the left than right. Some swelling in the lip area. Discoloration under left eye and cheek. See new MD orders. On [DATE] at 2:00 p.m., R48 continues with discoloration and swelling to left side of face. X-ray completed. On [DATE] at 6:08 a.m. R48 had bruising with discoloration to left jaw and left eye. On [DATE] at 6:29 a.m. R48 had bruising and discoloration to the left jaw, slight swelling to the left eye area. On [DATE] at 9:52 a.m., Discoloration to left cheek and eye fading. Review of the Radiology Report dated [DATE] for R48 revealed unremarkable skull. Record review for R60 (aggressor) revealed an admission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] documented a BIMS summary score of 2, indicating severe cognitive impairment. The resident exhibited behaviors not directed towards others and wandering. The resident received antidepressant medication. The Care Area Assessment (CAA) triggered Behavioral Symptoms with the decision not to be care planned. Review of the Quarterly MDS assessment revealed a BIMS summary score of 1, indicating severe cognitive impairment. The resident exhibited behaviors not directed towards others, rejection of care and wandering. The resident received antipsychotic and antidepressant medications. Review of the care plan for R60 identified Behavioral Symptoms with a Problem Start Date of [DATE] and a Long Term Target Goal Target Date through [DATE]. He resides on the behavioral secured unit. He is very dramatic, very energetic and hyperactive most times with staff and other residents. He will pace up and down the hallway at times. An intervention included he needs re-direction when wandering in other resident's room. The care plan identified R60 is at risk for falls with a Problem Start Date of [DATE] and a Long Term Goal Target Date through [DATE]. An intervention included to pr

Based on observation, record review, review of the Behavior Unit Guidelines and interviews, the facility failed to provide sufficient staff to prevent harm to three (3) of thirteen (13) residents with cognitive impairment and/or aggressive behaviors residing on the 300 Hall (locked) Behavior Unit. Residents (R) 6, R42 and R30. This failure had the potential to affect all thirteen (13) residents on the Behavior Unit. The sample size was fifty two (52) residents. (Refer to F323) Review of facility Behavior Unit Guidelines revealed the Behavior Unit is to have two (2) staff members present at all times. Residents of the Behavior Unit were not to be left unattended in the bathing area because showers and bathtubs are dangerous for both residents and staff. Observation [DATE] at 12:45 p.m. revealed the Behavior Unit shower room door had no lock. Observation of Behavior Unit dining on [DATE] at 12:15 p.m. revealed one Certified Nursing Assistant (CNA) serving trays to residents in rooms and in two (2) dining areas. The CNA was observed to leave the dining areas multiple times and the residents were unattended. On [DATE] at 12:00 p.m. an observation of the Behavior Unit revealed no staff on the unit. Licensed Practical Nurse (LPN) EE, assigned to the Behavior Unit was observed at 12:04 p.m. sitting at the 200 Hall nurses' station outside of the locked unit. Interview [DATE] at 12:04 p.m. with LPN EE revealed the Certified Nursing Assistant (CNA) was at lunch and she had to take a phone call regarding a resident. During an interview on [DATE] at 11:10 a.m. with the Administrator revealed the Behavior Unit is currently staffed with one (1) CNA at all times, including during meals. The Administrator revealed this staffing level has been in effect since [DATE] when the facility was informed by corporate management of the need to reduce staffing on the Behavior Unit to one (1) CNA for each shift. On [DATE] at 12:30 p.m. a dining observation revealed one (1) CNA present on the Behavior Unit, passing trays to the residents in two dining areas and a resident's room. At 12:49 p.m., while the CNA was in a resident room, two (2) residents in the dining area began to shout at each other. One of the shouting residents began to choke but was able to cough up her food. One (1) resident left the dining area and entered the unlocked shower room, with wheelchairs and a Hoya lift visible through the doorway. On [DATE] at 6:30 p.m. R6, a Behavior Unit resident, was observed with a broom she had obtained while unobserved, from the housekeeping cart. Staff had observed R6 sweeping the door in the hallway of the Behavior Unit. She then dropped the broom and noted by a staff member to be bleeding from her nose and had a laceration on her forehead. On [DATE] at 4:45 p.m. R30, a resident on the Behavior Unit with severe cognitive impairment and multiple psychiatric diagnoses, was discovered sitting on the shower room floor after not being observed since 3:15 p.m. R30 was unable to respond verbally. Emergency Medical Service (EMS) was called and when they arrived Cardio [MEDICAL CONDITION] Resuscitation was in progress by first responders. R30 was transferred to the hospital with CPR in progress and pronounced deceased at the Emergency Department (ED) at 5:49 p.m. During an interview on [DATE] at 11:20 a.m. the Administrator revealed there had never been a problem that she could recall with allowing the Behavior Unit residents unlimited access to the shower room to use as another bathroom. The Administrator acknowledged the presence of a bathtub and the use of the shower room to store a Hoya lift and wheelchairs made the shower room more hazardous than a resident bathroom. Clinical record review for R42, a resident on the Behavior Unit with severe cognitive impairment, revealed she had been struck on the face by R63, with whom she shared a room, in an unwitnessed incident on [DATE] at 1:30 p.m. Staff observed R42 had redness and a scratch on the left side of her face under her chin. At 10:50 p.m., R42 was struck in the face by R63 with a shoe. This was witnessed by a CNA. No injury was noted and R42 was removed from the room on [DATE] for two (2) days. R42 was moved back to her shared room with R63 on [DATE] and cried and pleaded not to be returned to a room with R63. On [DATE] at 7:20 p.m. she was heard shouting and told staff R63 had bitten her on the chest. The bite mark with skin penetration was visible on the left side of her chest. An interview conducted on [DATE] at 10:30 a.m. with the Administrator revealed R42 had requested to return to her room and R63 had refused to leave the room and there was no other room to move R42 to. R42 and R63 continued to share a room until R63 was moved off the Behavior Unit on [DATE] due to a decline in her condition. The facility's failure to provide supervision by adequate staffing of the Behavior Unit placed residents at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facilities Behavior Unit Guidelines with no date, revealed the Behavioral Unit is to be staffed by 2 staff members at all times. Observation of the Behavior Unit on [DATE] at 12:45 p.m. revealed the shower door could not be locked. During an observation of the Behavior Unit on [DATE] at 12:15 p.m. one (1) CNA CC was serving lunch to a resident in their room as well as the two (2) dining areas. CNA CC was observed to be the only staff in the unit and was observed to leave the dining areas multiple times to attend to a resident in their room and back and forth in the two (2) dining areas. In the dining area on the right side of the hall, residents were heard screaming and growling. LPN EE entered the unit through the locked door and asked a resident if she would like to be moved somewhere with less noise. LPN EE escorted the resident to her room and left the unit. At 12:30 p.m. in the dining area on the right a resident was observed to be eating food from trays left behind by other residents. CNA CC arrived and escorted this resident to her room, leaving no staff in the dining areas. Two (2) residents in the right dining area began to shout at each other. CNA CC returned to the dining room and separated the residents involved in the verbal altercation. During an interview conducted on [DATE] at 11:10 a.m. with the Administrator she revealed since [DATE] the Behavior Unit should be staffed at all times with one (1) CNA. The CNA should circulate between the two dining areas. The CNA should be relieved for meals and breaks by a float CNA that also relieves for meals and breaks on the other two (2) first floor halls. An interview conducted with the Director of Nursing (DON) on [DATE] at 11:36 a.m. revealed the current Behavior Unit Census is thirteen (13) residents and it can hold (16) sixteen. There is one CNA assigned to this area and one LPN who is responsible for the Behavior Unit residents and ten (10) residents on the 200 Hall. The DON revealed there were residents on the Behavior Unit that had violent behaviors and two (2) residents that require feeding assistance. The DON revealed the LPN in charge of the Behavior Unit (when sitting at the 200 Hall nurses' station round the corner of the Behavior Unit) was able to know if she was needed on the unit because she could hear through the locked door. During an observation on the Behavior Unit on [DATE] at 12:00 p.m., there was no staff on the unit. A resident was observed ambulating in the hall without proper footwear. Several residents were wandering through the hall. LPN EE was observed at the 200 Hall nurse's station desk. An interview with LPN EE on [DATE] at 12:04 p.m. that was assigned to the Behavior Unit, revealed she had to take a phone call and the CNA was at lunch. A second dining observation on the Behavior Unit conducted on [DATE] at 12:30 p.m. revealed one (1) CNA DD alone on the unit. CNA DD was observed passing trays in the two (2) dining areas and a resident in their room. On [DATE] at 12:41 an interview was conducted with CNA DD and she revealed she has had to leave resident to resident altercations on the unit to get assistance when there was no one at the 200 Hall nurses' station to hear her call for assistance. At 12:49 p.m. (2) two residents in the left dining area, R48 and R10 began to have a verbal altercation. R10 began to choke but was able to cough up her food. CNA DD returned to the dining area and escorted R10 to her room. LPN EE entered the unit through the locked door and exited the unit again. At 12:56 p.m., R72 was observed leaving the dining room and entered the unlocked shower room. A Hoyer lift and wheelchairs were visible through the shower room door when it was opened. CNA DD returned to the dining area at 12:57 p.m. and was asked by the surveyor if R72 was allowed to be in the shower room unattended. CNA DD confirmed he was not supposed to be in there unsupervised, then escorted him back to the dining area. Interview on [DATE] at 1:12 p.m. with the DON revealed the Behavior Unit is not supposed to be left completely unsupervised. A float CNA is supposed to cover when the Behavior Unit CNA is at lunch or on breaks. The float CNA is also responsible for covering the meals and breaks for the CNA's working on the 100 Hall and the 200 Hall. The DON acknowledged this was not assigned but was just expected to happen. The DON revealed she had received complaints from the Behavior Unit staff since the staffing was cut to one (1) CNA regarding one (1) CNA being unable to watch all the residents at once. 1. Record review for R6, a Behavior Unit Resident, revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated in Section G: Functional Status that R6 requires supervision moving between locations in her room and adjacent corridor. Section C indicated R6 could not be interviewed for the Brief Interview for Mental Status (BIMS) because she was rarely or never understood. A fall risk assessment completed on [DATE] indicated she was a high fall risk and had poor safety awareness. Review of the entity reported complaint (GA 3786) dated [DATE] revealed on [DATE] at 6:30 p.m. R6 was observed to have a laceration to her left forehead and a bloody nose. Review of nurse Resident Progress Notes dated [DATE] at 9:12 p.m. revealed R6 had been observed with a broom sweeping a door in the corridor prior to the facial laceration and bloody nose. R6 was transferred to the hospital by ambulance and returned to the facility on [DATE] at 1:00 a.m. with laceration closure by wound adhesive. Review of Event Report for [DATE] revealed this was an unwitnessed event. Review of hospital emergency room Report dated [DATE] for R6 revealed an unwitnessed injury occurred, and R6 was assessed to have a bleeding nose and hematoma to the left forehead with a laceration closure by wound adhesive. Radiology results were negative for facial and skull fractures and R6 was returned to the facility with no new orders. Interview [DATE] at 3:20 p.m. with the Administrator revealed according to her investigation R6 had taken the broom on [DATE] without being observed and no one witnessed how her injuries occurred. The Administrator acknowledged housekeeping equipment can be hazardous and R6 should be supervised around housekeeping equipment. 2. Clinical record review for R30, revealed she resided on the Behavior Unit. Her [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE] revealed she required supervision to walk in corridor and on unit. Review of the current care plan dated [DATE] revealed interventions to supervise R30 with locomotion on the unit related to Activities of Daily Living (ADL) and elopement risk. Review of nurse Resident Progress Notes created by LPN JJ dated [DATE] at 4:45 pm, revealed R30 had been discovered in the shower room and had no apparent injury. She was unable to give verbal response. Emergency Medical Service (EMS) was called at 4:52 p.m. R30 had a blood pressure of ,[DATE], an oxygen saturation of 81% and a pulse of 45. EMS arrived and applied an Automated External Defibrillator (AED) and began CPR. R30 was transferred by EMS to a local Emergency Department with Cardio [MEDICAL CONDITION] Resuscitation (CPR) in progress. Review of facility Event Report for R30 on [DATE] revealed she had been found in the shower room sitting on the floor and did not have any sign of injuries. This event had been unwitnessed. Review of EMS Pre- Hospital Care Report dated [DATE] for R30 revealed no physical trauma was observed. CPR had been started by first responders and was continued by EMS. R6 was transferred to the Emergency Department with CPR in progress. Review of emergency room Report dated [DATE] revealed no signs of trauma on physical exam. R6 was pronounced dead at 5:49 p.m. with the following Diagnoses: [REDACTED]. Interview on [DATE] at 3:30 p.m. with CNA AA revealed the Behavior Unit residents are all mobile. CNA AA revealed she had informed the Administrator of having problems trying to watch residents and prevent altercations and falls while working alone on the Behavior Unit. Interview with LPN JJ on [DATE] at 4:50 p.m. revealed on [DATE] when the evening CNA on the Behavior Unit informed her that R30 was sitting on the floor in the shower room, LPN JJ had not seen R30 since 3:15 p.m. on first rounds. R30 had seemed fine and was in her room. LPN JJ asked the CNA how long she had been in the shower room and the CNA told her she had also not seen R30 since first rounds at 3:15 p.m. and did not see the resident go into the shower room. Interview on [DATE] at 10:20 a.m. with the Administrator revealed she had not considered the shower room on the Behavior Unit a hazardous area. The shower room door could not be locked after R30 was found in the shower room unobserved for 90 minutes because there was no lock on the door. The Administrator revealed she had not considered the Behavior Unit residents as needing more staff for supervision than one (1) CNA to thirteen (13) residents. The Administrator revealed the facility could not have one to one staffing and because these residents are all mobile and all have behaviors and they would continue to have behaviors regardless of how many staff were present. Interview on [DATE] at 4:12 p.m. with the Director of the Behavior Unit acknowledged he was not aware the staffing had dropped to one (1) CNA for the unit. He revealed one (1) CNA was not enough for the residents on the Behavior Unit. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility policy, Staffing for Behavior Unit, was developed on [DATE], and has been reviewed with (5 of 5) facility RN's, (15 of 15) facility LPN's, and (28 of 28) facility Certified Nursing Assistants as part of an inservice education session. 100% of this education has been completed as of [DATE]. Copy of policy attached. 2. The facility staffing pattern and workflow has been reviewed and revised to reflect the presence of a licensed nurse on the Behavior Unit at all times. The facility will maintain staffing of no less than two (2) nursing staff members, one of which is a licensed nurse, the other a Certified Nursing Assistant, in the Behavior Unit on all shifts as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. To be considered qualified staff for the Behavior Unit, a staff member must be a licensed nurse or a certified nursing assistant since both of these categories have received basic first aid instruction as well as [MEDICATION NAME] maneuver education. These nursing staff members, one of which is a licensed nurse, the other a certified nursing assistant, will have completed [MEDICATION NAME] maneuver training; staff without [MEDICATION NAME] maneuver training will not be considered relief staff. This staffing pattern was effective as of [DATE]. Copy of monthly nursing staffing schedule attached. A review of the nursing staffing pattern for the remainder of the month of September, 2016, was conducted [DATE]. 2016, revealed 100% coverage of one (1) licensed nurse assigned to the Behavior Unit each shift, each day and at least one (1) certified nursing assistant assigned to the Behavior Unit for each shift, each day. The results of this review attached. 3. An inservice for (5 of 5) facility RN s, (15 of 15) facility LPNs, (28 of 28) facility CNA, (4 of 4) Administrative staff, (4 of 7) Housekeeping staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff and (1 of 1) Social Service staff, regarding Supervision and Monitoring of Residents in the Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. This inservice will include discussion of the PANIC BUTTON located in the Day Area of the Behavior Unit, how to activate this device, that it sounds at the First Floor nursing station and that any staff within hearing distance when the PANIC BUTTON is activated are responsible for responding to the PANIC BUTTON by entering the unit and assisting unit staff as needed. As of [DATE], 100% of this education has been achieved for nursing staff, 88% for all staff. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 4. (5 of 5) facility RNs, (15 of 15) facility LPNs, and (28 of 28) facility CNAs have been informed as part of the inservice, Supervision and Monitoring of Residents in the Behavior Unit, of the process for relieving Behavior Unit staff during breaks/meal times so that consistent staffing of two (2) is maintained in the Behavior Unit at all times. The licensed nurse assigned to the Behavior Unit will be relieved at break/meal time by the First Floor licensed nurse, the Assistant Director of Nursing or the Weekend Supervisor. Behavior Unit CNAs will be relieved by First Floor CNAs or Restorative CNAs for break/meal times; these break/meal times will be designated on the daily assignment sheets. As of [DATE], 100% of this training has been achieved. This process began on [DATE] and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. Inservice record attached. 5. An inservice for facility staff with (5 of 5) facility RNs, (15 of 15) facility LPNs, (26 of 28) facility CNAs, (4 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff, regarding Mealtime Supervision in Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. As of [DATE], 86 % of this education has been achieved, 100% of this training will be completed by [DATE], and facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 6. A facility qualified nursing staff member will be present in the common Dining Areas of the Behavior Unit during resident meal times to provide monitoring, supervision, and assistance as needed. Residents will be encouraged to eat meals in the common Dining Areas but those choosing to eat in their rooms will be observed approximately every ,[DATE] minutes during meal time. Implementation of this intervention began [DATE]. 2016, and will be completed by [DATE], as 100% of this training is completed. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 7. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing reviews the daily nursing staffing schedule and assignment sheet at the beginning of the shift, Monday through Friday, for first and second shift, to determine that the Behavior Unit is properly staffed with a licensed nursing staff member (LPN) and at least one (1) CNA on each shift, each day and that the Behavior Unit staff has coverage for break/meal times. This review will be completed by the ,[DATE] Hall LPN for third shift and the weekend Supervisor on Saturday and Sunday for both 12 hour shifts. This process is to be a permanent procedure with management staff conducting these audits every shift for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. Audit tool attached. 8. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing or Assistant Director of Nursing observes the dining areas of the Behavior Unit daily, Monday through Friday, to determine that a nursing staff member that has completed the facility education, Mealtime Supervision in Behavior Unit, is present during the resident meal times. This review will be completed by the weekend Supervisor on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting these audits for first and second shifts for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. 9. On [DATE], the facility implemented a procedure by which the results of the audits referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding staffing for the behavior unit and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE] and then the first monthly meeting for [DATE]. 10. On [DATE], the facility policy, Care Plans, was reviewed with the facility Administrator, Director of Nursing, Assistant Director of Nursing and MDS Coordinator. The review resulted in no changes to the current policy and the facility will begin implementing the current policy on [DATE]. Policy and acknowledgement of review attached. The Care Plan of each resident residing on the 300 Hall Behavior Unit will be reviewed and revised to reflect the current resident care status and care needs. This review/revision process will be 100% completed by [DATE]. Care plan revisions will be written on the current care plan in the paper chart and communicated to licensed nursing staff daily by MDS Coordinator. This information will be passed on to other licensed staff during shift to shift report. The Nurse Aide Kardex for each resident on the 300 Hall Behavior Unit will be reviewed/revised daily to effectively communicate resident needs and care requirements to facility CNA staff. This review/revision process will be 100% completed by [DATE]. 11. An inservice for facility nursing staff, RNs, LPNs, CNAs, regarding Care Plans is in process. As of [DATE], with (5 of 5) RNs, (14 of 15) LPNs, and (22 of 28) CNAs having completed the education. 85% of this education has been completed. 100% of the education will be completed by [DATE]. Nursing staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 12. On [DATE], the facility initiated a new procedure by which the Director of Nursing, Assistant Director of Nursing, or the MDS Coordinator, Monday through Friday, will review the Care Plan and Nurse Aide Kardex of each resident on the 300 Hall Behavior Unit to determine that the care plan is reflective of current resident needs and care requirements. The weekend Supervisor will complete this review on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting daily audits for 30 days and then weekly audits as a permanent procedure. This process began on [DATE] and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. 13. On [DATE], the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding Care Plans and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE], and the first monthly meeting for [DATE]. 14. A lock was installed on the door to the 300 Hall shower area on [DATE]. This shower area will remain locked when not in use by an authorized facility staff member. Authorized staff members are facility nursing staff, facility housekeeping staff and facility maintenance staff. 15. This locked shower area can be accessed by authorized facility staff members via key kept on the 300 Hall nurse's key ring as well as spare keys kept in the First Floor Medication Room and at First Floor Nursing Station. 16. An inservice for facility RNs, LPNs, CNAs, housekeeping and maintenance staff regarding Shower Area Safety has been completed. As of [DATE], (5 of 5) RNs, (15 of 15) LPNs, (27 of 28) CNAs, (7 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff; 97% of the education has been achieved, 100% will be achieved by [DATE]. Staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. 17. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing will monitor the shower area on 300 Hall, Monday through Friday, on first and second shift to determine that the door is locked when not in use, that the area is free of hazardous chemicals and objects and that the key to the area is accessible to authorized staff; the 300 Hall LPN will complete this monitoring duty on third shift. The weekend Supervisor will complete this review on Saturday and Sunday for the 12 hour shifts. This audit will be conducted each shift for 30 days, then daily for the following 30 days, then weekly audits as a permanent procedure. Audit tool attached. 18. On [DATE], the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding securing the 300 Hall shower area and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE] and the first monthly meeting for [DATE]. 19. On [DATE] the facility policy Quality Assurance Committee, was reviewed with facility Administrator and Department Directors. Copy of policy and acknowledgement of review attached. On [DATE], the responsibilities of the facility Medical Director were reviewed with the facility Administrator and Medical Director. Acknowledgement of review attached. 20. On [DATE], the facility initiated a system process by which a formal Quality Assurance Committee meeting to identify occurrences, patterns and trends related to events, as well as other quality issues that affect resident well-being, will be held on a monthly basis with the first meeting scheduled for [DATE]; the next meeting is scheduled for [DATE]. This monthly process is to be a permanent process. A written record of the items discussed, actions approved and staff attending will be produced for each Quality Assurance meeting held. These written records will serve as audit/monitoring tools and will be available for surveyor review when requested. The State Survey Agency (SSA) validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. The facility policy Staffing for Behavior Unit, developed on [DATE], was reviewed. The policy revealed there will be two (2) qualified nursing staff members present on the Behavior Unit at all times. One (1) will be a licensed nurse and there will be at least one Certified Nursing Assistant (CNA). Facility Staff who have received [MEDICATION NAME] maneuver training and basic first aid instruction will be considered qualified staff. The Behavior Unit charge nurse will schedule meals and break times for the CNA's at the beginning of each shift. Those times will be staggered so that CNA's can provide relief coverage for each other. Other facility staff may also be used as needed for relief coverage during staff meal/break times. The first floor charge nurse, the Assistant Director of Nursing (ADON) or the weekend supervisor will be responsible for relieving the licensed nurse on the Behavior Unit for meals/ break times. The first floor charge nurse will be relieved for meal/break time by the Director of Nursing (DON), ADON or the weekend supervisor. Should the first floor charge nurse be unavailable for relief duty, then the Assistant Director of Nursing and/or the DON and/or weekend Supervisor will be available to relieve Behavior Unit staff for meal/break times. Course content included the following topics: *Routine monitoring *Observation of Residents *Implementation of Actions to Meet Resident Needs *Staffing Coverage Review of the roster for the inservice education titled Behavior Unit Supervision and Staffing confirmed 100 % of all facility staff including RN's, LPN's, CNA's, housekeeping, maintenance, dietary, activities, social services, and laundry. Interviews were conducted with the following staff on [DATE] to verify the facility provided education to ensure knowledge of how many qualified staff needed to be present at all times according to the Staffing on Behavior Unit policy and were able to verbalize the facility policy for staffing on the Behavioral Unit and revealed they attended the in-service provided by the facility: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AAA at 3:09 p.m., CNA BB at 3:11 p.m., LPNFF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. Observations of the Behavior Unit staffing on [DATE] at 3:45 p.m. and [DATE] at 12:25 p.m. revealed one Licensed Practical Nurse (LPN) and two CNA's were present on the Behavioral Unit assisting residents. 2. Review of the Daily Staffing Sheets from [DATE] through [DATE] were verified by comparison of time card punch records and the actual work schedule. The Behavior Unit staffing confor

Based on observation, record review,review of the Administrator job description and staff interviews, the facility failed to be administered in a manner that used resources effectively to ensure adequate supervision to cognitively impaired residents and/or residents with aggressive behaviors, on the 300 Hall (locked) Behavior Unit. Residents (R) 42, R63, R30, R6, R48, R60, R72. This failure had the potential to affect all thirteen (13) residents on the Behavior Unit. The sample size was fifty two (52) residents. (Refer F280, F282, F323, F353 and F520) The facility failed to protect residents from hazardous areas, and implement the Behavior Unit Guidelines related to staffing requirements and unattended residents in the bathing area. Review of Behavior Unit Guidelines revealed two (2) staff should be present at all times. Residents of the Behavior Unit were not to be left unattended in the bathing area because showers and bathtubs are dangerous for both residents and staff. On [DATE] at 12:15 p.m. a dining observation on the 300 Hall (locked) Behavior Unit revealed one (1) Certified Nursing Assistant, (CNA) CC alone on the unit. CNA CC was observed to leave the dining areas multiple times, leaving the residents unattended. Observation on [DATE] at 12:00 p.m. revealed the Behavior Unit was unattended by any staff. On [DATE] at 12:30 p.m. a second dining observation on the Behavior Unit revealed CNA DD alone during meal service on the Behavior Unit. Interview on [DATE] at 12:41 p.m. with CNA DD revealed there are times when she has to leave the unit to get assistance when there is no one at the nurses station outside the locked door. A verbal altercation between R10 and R48 started at 12:35 p.m. R48 began to choke but was able cough up her food. No staff were present in the dining area. R72 left the dining room at 12:56 p.m. unwitnessed by staff, and entered the shower room, with no lock on the door. At 12:58 p.m. CNA DD returned from a resident's room she was asked if R72 was supposed to be in the shower room unattended and she revealed he was not to be unattended in the shower room. On [DATE] at 1:30 p.m. and 10:50 p.m., R42 on the Behavior Unit, was struck in the face by her roommate (R63) while in their room. R42 was moved to another room for two (2) nights. On [DATE] R42 was returned to the same room with R63. R42 had expressed fear and cried. R42 requested not to be returned to the room with R63. R42 was heard shouting on [DATE] and told staff she had been bitten by R63. Review of the nurse Resident Progress Notes dated [DATE] at 10:32 p.m. revealed at 7:20 p.m. R42 was screaming. On assessment, R42 had teeth marks with skin penetration on the left side of her chest. R42 and R63 remained in the same room until [DATE], when R63 was moved for an unrelated change in condition. R30 was found sitting on the floor of the unlocked Behavior Unit shower room on [DATE], with no signs of injury. R30 was unable to speak. Vital signs revealed a blood pressure of ,[DATE]. R30 had last been observed in her room ninety (90) minutes prior to being found on the floor in the shower room. R30 became unresponsive. 911 was called. After first responders arrival and assessment an Automated External Defibrillator (AED) applied to R30 advised Cardiopulmonary Resuscitation (CPR). CPR was initiated. Emergency Medical Services (EMS) arrived and continued CPR. R30 was transported to the local hospital where she was pronounced deceased . Review of emergency room Report dated [DATE], at 6:04 p.m. indicated [DIAGNOSES REDACTED]. R6 was observed with a broom she obtained from the housekeeping cart on [DATE] at 6:30 p.m. R6 was later observed with a bleeding laceration to her left forehead and a bloody nose. R6 was sent to the Emergency Department. R6 was evaluated, treated, and returned to the facility. Interview with the Administrator on [DATE] at 10:30 a.m. revealed R42 and R63 had continued to share a room without additional events until [DATE] when R63 was moved to a different area due to a decline in her condition. The Administrator indicated when R42 was moved, it was off the Behavior Unit and she had not been able to leave her there because of her behaviors. The Administrator revealed there had not been another open room on the Behavior Unit to move her to and she had asked to go back to her room. The Administrator acknowledged she had been aware of R42 being struck by her roommate twice and bitten after being returned to the room and did not identify the need for any additional supervision for R63 to prevent further injury to R42. On [DATE] at 4:00 p.m. R60 hit a resident (R38) in the 300 Hall Behavior Unit dayroom. The incident was witnessed and there were no apparent injuries to R38. Three (3) hours later that day at 6:55 p.m., R60 hit another resident (R48) that resulted in an injury to her lip with bleeding. Over several days, the injury progressed to swelling and discoloration to R48's left eye, cheek, jaw and some swelling of her lip. CNA QQ was sitting in the dining room on the 300 Hall Behavior Unit when she heard shouting coming from the dayroom across the hall. CNA QQ got up and went to the dayroom an observed R48 and R60 sitting side by side at a table. R48 had an injury to her lip and it was bleeding. CNA QQ asked R60 if he had hit R48. R60 grunted and stated that he did hit R48. The facility's failure to have an effective Administration related to protection of residents from hazards and providing adequate supervision to ensure resident safety has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of facility Behavior Unit Guidelines, not dated, revealed two (2) staff members shall be present on the unit at all times. Continued review of the guidelines revealed residents should not be unattended in the bathing area because falls commonly occur in the bathing area. Review of the facility job description titled Administrator indicated the Administrator must evaluate quality of care and evaluate needs of the resident. The Administrator must take a proactive approach in identifying facility weaknesses. An observation on [DATE] at 12:45 p.m. on the Behavior Unit revealed one shower room with no lock on the door. Dining observation on [DATE] at 12:15 p.m. revealed the only staff on the Behavior Unit for lunch service was CNA CC. Observations of CNA CC serving trays revealed she left the 2 dining areas to serve and set up trays in a resident room and the residents in the 2 dining areas were unsupervised. Residents in the dining area on the right were observed growling and screaming. Licensed Practical Nurse (LPN) EE entered the Behavior Unit through the locked door and a resident back to her room. LPN EE then left the Behavior Unit through the locked door. At 12:30 p.m. in the dining area on the right a resident was eating food from other resident's tray. The Administrator was interviewed on [DATE] at 11:10 a.m. and revealed staffing was decreased on the Behavior Unit on [DATE] from two (2) CNA's to one (1) CNA on all shifts. The Administrator acknowledged there should always be one (1) CNA on the Behavior Unit and she should float between the two (2) dining areas. The CNA on the Behavior Unit should be relieved for meals and breaks by the float CNA who relieves the two (2) other CNA's on the first floor. This is expected to happen but has never been assigned. In an interview on [DATE] at 11:36 a.m. the Director of Nurses (DON) indicated the Behavior Unit can accommodate sixteen (16) residents. The current census is thirteen (13). There are residents on this unit with violent and aggressive behaviors and two (2) that requires assistance to eat. The DON revealed the residents on the Behavior Unit can be seen through the glass window on the locked door and heard through the locked door as long as the nurse was at the desk of the 200 Hall nurses' station. The DON acknowledged the LPN assigned to the Behavior Unit also was responsible for ten additional residents on the 200 Hall. An observation of the Behavior Unit on [DATE] at 12:00 p.m. revealed no staff were present behind the Behavior Unit locked door. An interview conducted on [DATE] at 12:04 p.m. with LPN EE revealed she was taking a phone call at the 200 Hall nurses' station at the desk outside the locked door and the CNA was at lunch. Dining observation on [DATE] at 12:30 p.m. on the Behavior Unit revealed CNA DD was the only staff member on the unit. CNA DD was observed taking a lunch tray to a resident room and leaving the residents in the two (2 )dining areas unattended. CNA DD was not in the dining area when a verbal altercation began between R48 and R10. R10 began to choke on her food but was able to cough it up. R72 left the dining area at 12:56 p.m. and was observed entering the shower room door. Visible through the open shower room door was a Hoyer lift and wheelchairs. Interview [DATE] at 12:41 p.m. with CNA DD revealed she has had to leave resident to resident altercations and leave the unit to get assistance when there was no one at the nurses station outside the locked door to hear her requesting assistance. Continued interview with CNA DD on [DATE] at 12:57 p.m. revealed R72 was not supposed to be in the shower room unsupervised. Interview [DATE] at 1:12 p.m. with the DON revealed the Behavior Unit should never be left unsupervised. The first floor float CNA is supposed to cover meals and breaks for the CNA's on the 100 Hall, 200 Hall and Behavior Unit. The DON revealed this was not written on the assignment sheets and should just happen without being assigned. The DON revealed staff had complained to her about the decrease in staffing on the Behavior Unit that took place in [DATE], but she was unable to provide dates, times or names. Interview [DATE] at 3:25 p.m. with CNA BB revealed a staff meeting was held by the DON a few days before the Behavior Unit staffing decreased from two (2) CNA's to one (1) CNA in [DATE]. CNA BB revealed the staff present at this meeting had all told the DON this was not going to work and that the residents needed more than one CNA because they are all so mobile and have behavior problems. She revealed someone said the Behavior Unit was the wrong area to cut staff. CNA BB did not know of any employee that had filed a formal grievance or wrote an email or letter about this staffing cut. CNA BB further stated she had told the Administrator she had problems watching all the residents at the same time because they move around so much and some have aggressive or violent behaviors. Interview [DATE] at 5:30 p.m. with the Administrator revealed the Behavior Unit did not have a telephone but the CNA's could use their own cell phones if they were having a problem with a resident. The Administrator stated that a long time ago there was a telephone on the Behavior Unit but it was removed because the residents kept using it to call 911. The Administrator revealed one dining area has a red panic button but could not recall any CNA recently using it. The Administrator revealed the call lights in resident rooms and bathrooms and shower room could be used. The Administrator acknowledged the call light system may not be effective in getting immediate assistance because the staff outside the locked door would expect the CNA inside the locked door to answer the call light. Interview [DATE] at 3:30 p.m. with CNA AA revealed within the last three months she had told the Administrator about having problems trying to watch the Behavior Unit residents and keep them from having altercations and injuries since the staffing dropped from two (2) CNA's to one (1) CNA. CNA AA was unable to give a date when she spoke to the Administrator about staffing on the Behavior Unit and had nothing in writing. CNA AA indicated there have probably been altercations that could have been avoided if there had been a staff person close by but was unable to provide an example. 1. Record review for R30, residing on the Behavior Unit, revealed [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section G: Functional Status indicated R30 required supervision to ambulate in the corridor and on the unit. Section C - Cognition indicated R30 could rarely or never be understood. Section E - Behaviors revealed she rejected care daily. The current care plan dated [DATE] was reviewed and revealed Activities of Daily Living and Mood State care plans requiring R30 be provided with supervision while ambulating on the unit Review of the nurse Resident Progress Notes for R30 revealed on [DATE] she had been found seated on the floor of the shower room unable to speak at 4:45 p.m. R30 had no signs of injury. 911 was called by LPN JJ at 4:45 p.m. R30's vital signs revealed a blood pressure of ,[DATE], heart rate 45 and oxygen saturation of 81%. On EMS arrival Cardio [MEDICAL CONDITION] Resuscitation (CPR) was in progress by first responders and R30 was transported to the hospital with CPR in progress. Interview LPN JJ on [DATE] at 4:50 p.m. revealed R30 had not been observed entering the Behavioral Unit shower room and had been in there for an unknown length of time. LPN JJ indicated she had asked the CNA who had found her in the shower room how long R30 had been there and the CNA had not seen R30 since their initial shift rounds at 3:15 p.m. LPN JJ revealed she also had not seen R30 since 3:15 p.m. LPN JJ revealed R30 had no signs of physical injury. LPN JJ further state she had been employed by other facilities in the past and shower room were always kept locked. Review of hospital emergency room Record for R30, dated [DATE] indicated R30 had no response to EMS treatment of [REDACTED]. Interview [DATE] at 11:20 a.m. with the Administrator revealed R30 used the Behavior Unit shower room as her bathroom. The Administrator revealed she did not regard the shower room as a hazardous area and did not identify any need to keep residents from unobserved areas with a bathtub and where a Hoya lift and wheelchairs are kept as being a hazardous area. The Administrator revealed she had reviewed the Event Report for R30 on [DATE] and had not identified any need for residents to not be unsupervised in the shower room, or the need to implement any changes after this incident. 2. Clinical record review for R6, a resident on the Behavior Unit, revealed [DIAGNOSES REDACTED]. The current care plan dated [DATE], indicated R6 enjoyed housekeeping activities. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R6 was rarely or never understood and required supervision ambulating on the unit. A fall risk assessment dated [DATE] revealed she had poor safety awareness and was at high risk for falls. Record review of the Event Report dated [DATE] at 6:30 p.m. revealed R6 had been observed with a broom, sweeping a door in the hallway of the Behavior Unit. She later was observed throwing the broom to the floor and bleeding from her nose and a laceration on the left side of her forehead. The injury was unwitnessed. Interview on [DATE] at 3:10 p.m. with CNA AA revealed R6 will try to get hold of the housekeeping equipment so she requires extra supervision when she is seen in the area of the housekeeping cart. Interview [DATE] at 3:20 p.m. with the Administrator revealed R6 was usually supervised by Activities staff when she wanted to sweep, but must have gained access to a broom unobserved on [DATE]. According to her investigation of the incident no one had given her a broom and she was observed sweeping a door, then observed with a facial laceration and bloody nose. No one knows how she was injured because no one witnessed the injury. The Administrator confirmed she reviewed this Event Report on [DATE] and did not consider R6 gaining access to equipment on the housekeeping cart and using it with no supervision to be a problem with staffing or supervision at that time. The Administrator revealed she had told housekeeping and nursing staff to watch this resident and not let her get to the housekeeping equipment due to the possibility of an injury. 3. Record review for Resident (R) 42 revealed [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed BIMS scoring could not be conducted due to R42 was rarely or never understood. Review of the care plan for R42 dated [DATE] indicated a problem of cognitive loss/dementia with an explanation that she is alert and oriented times two and able to make her needs known, has a problem with communication and usually understands what is being said to her. The care plan identified alteration in Activities of Daily Living (ADL) self performance with an intervention to provide supervision with locomotion on the unit. Review of nurse Resident Progress Notes for R42 dated [DATE] at 2:20 p.m. revealed R63 was yelling when R42 asked her to be quiet so she could take a nap. R63 struck R42 on the face in an unwitnessed incident that occurred at 1:30 p.m. R42 sustained a scratch and redness to the left side of her face. Continued review indicated R42 was struck with a shoe by R63 on [DATE] at 10:50 p.m. This was witnessed by a CNA. R42 was crying and moved to another room. According to nursing documentation, on [DATE], R42 was moved back to the room with R63. R42 was yelling and screaming she did not want to be in the room with R63 because she was evil and a killer. R42 continued to complain and yell for three to five hours. Further review of nurse Resident Progress Notes revealed on [DATE] at 10:32 p.m. R42 was heard shouting from her room that R63 had bitten her. R42 was assessed and teeth marks with skin penetration was observed on her left chest. On [DATE] R42 was noted to have a bite area to her left chest that was reddened, purple and blue. Record review for R63 (aggressor) revealed a Significant Change MDS assessment dated [DATE] which documented in Section C- Cognitive Pattern - BIMS summary score of 5. Section E- Behaviors- hallucinations and delusions, behavioral symptoms not directed towards others and puts others at significant risk for physical injury. Section N- Medication - antipsychotic and antianxiety medications. Section V- Care Area Assessment (CAA) triggered Behavioral Symptoms with the decision to be care planned. Review of the care plan for R63 dated [DATE] and a Long Term Target Date through [DATE] - Activities of Daily Living (ADL) care: intervention that included supervision with locomotion on the unit. The care plan identified alteration in mood and behavior related to her being very impulsive, easily agitated and demanding. She has [DIAGNOSES REDACTED]. She can be physically and verbally aggressive at times toward residents and staff. The last episode was on [DATE] when she pushed another resident that wandered into her room. She was sent to (name) behavioral center and returned on [DATE]. An intervention included to determine if hallucinations pose danger to the resident or others, intervene as necessary. Review of the nurse Resident Progress Notes for R63 revealed on [DATE] at 2:36 p.m. R63 was screaming and hollering saying that she wanted to go home when her roommate (R42) asked her to please be quiet so that she could take a nap. R63 hit her roommate (R42) on the left side of her face. The nurse asked R63 why she did that and she replied that she and her roommate don't get along. Explained to R63 next time to tell the CNA or nurse the problem. R63 stated okay. NP notified. The incident occurred at 1:30 p.m. Review of the nurse Resident Progress Notes dated [DATE] at 10:39 p.m. noted R63 hit her roommate (R42) in her face with shoes. Resident is encouraged to calm down. Roommate (R42) moved to another room for her safety. R63 stated She's always trying to interrupt me every time I am talking with my mother on the phone. I am sick and tired of her. She needs to get out of my room. On [DATE] R63 at 9:34 a.m. R63 was involved in an incident were she was noted twice to hit her roommate. The resident was asked about her behavior, she stated that her roommate accused her of not paying her rent and interrupted her when she was on the phone with her mother. Resident was encouraged not to hit her roommate and to report her problems to the staff. Resident verbalized understanding. On [DATE] at 10:55 p.m. Behavioral pattern- violent behavior: threatens staff and other residents. On [DATE] at 5:30 p.m. Behavioral pattern- violent behavior: threatens staff and other residents. On [DATE] at 10:40 p.m. R63 was asked why she bit her roommate (R42), she stated She is in my room and I told her to get the f .k out and she does not want to get out of my room! I'm sick of seeing her in my room! I need her out of my room! On [DATE] at 8:30 a.m. R63 pushed a resident that wandered into her room. R63 was agitated and aggressive, screaming and hollering. NP and family notified. On [DATE] at 1:51 p.m. R63 continues with aggressive behavior. R63 pushed a resident that was in her room. On [DATE] at 2:33 p.m. R63 was sent to (name) hospital due to aggressive behavior. On [DATE] at 10:38 a.m. R63 was sent to (name) emergency room for evaluation related to increase aggressive behavior outburst. She was noted to hit, bits and push other residents. Dr (name) Psychiatric physician was called between incidents and medication adjusted but behavior continued until the day of transfer. R63 was re-admitted to the facility on [DATE] to the same room, in which R42 still resided. R63 and R42 remained roommates until [DATE] when R63 was transferred to a room on the 500 Hall due to an unrelated decline in condition. An interview with LPN EE on [DATE] at 9:50 a.m. revealed that R42 was returned to her previous room (on [DATE]) with the same roommate (R63) because she needed to be on the locked unit and there was no other bed available in the locked unit. An interview with the Administrator on [DATE] at 10:30 a.m. revealed that she was aware R42 was transferred to another room after the incident on [DATE] with R63. She stated that the R42 was returned to her room with R63 because she requested to be returned. She stated that she was not aware of the resident crying and begging the staff not to put her in the room with R63. The Administrator further stated that R63 is no longer sharing the same room with R42. An interview conducted on [DATE] 2:30 p.m. with the Administrator, Director of Nursing (DON), Corporate Quality Assurance Nurse SS and the Director of Social Services (DSS) revealed that it was the responsibility of the DON to follow up on resident to resident altercations. The DON stated that she was not aware of the resident to resident altercations between R42 and R63 and had not followed up on them. An interview with the DON on [DATE] at 11:55 a.m. revealed that R63 was transferred to a different unit on [DATE]. The transfer of R63 was related to a decline in her condition and not was not related to the resident to resident altercations. She stated that she had dropped the ball. The DON could not provide an explanation why R63 remained in the room with R42 or why interventions were not implemented to protect R42 from R63. An interview with LPN EE on [DATE] at 12:10 p.m. revealed that she kept an eye on R42 and R63. She would check on them frequently and separate them if they became loud. LPN EE confirmed there were no formal interventions or plan initiated to protect R42 from R63, such as checking them at designated frequencies. Interview on [DATE] at 10:30 a.m. Interview with the Administrator indicated when R42 was moved it was off the Behavior Unit and she had not been able to leave her there because of her behaviors. The Administrator revealed there had not been another open room on the Behavior Unit to move her to and she had asked to go back to her room. The Administrator acknowledged she had been aware of R42 being struck by her roommate twice and bitten after being returned to the room and did not identify the need for additional supervision to prevent R42 from R63's aggressive behaviors. Interview [DATE] at 10:55 a.m. with CNA CC revealed she had informed the Administrator and DON after staffing to the Behavior Unit was decreased from two(2) CNA's to one (1)CNA that it was not enough to watch all the residents and keep them from harm. CNA CC did not remember exactly when she had discussed staffing on the Behavioral Unit with the DON and Administrator and acknowledged no one she knows filed a grievance. Interview [DATE] at 11:05 a.m. LPN EE revealed she had attended a staff meeting on approximately [DATE] and it was in this meeting that the nursing staff were informed that staffing would be decreased to one CNA on the Behavior Unit. The staff present told the DON that the Behavior Unit was not the place to cut staff. LPN EE acknowledged she had spoken to the Administrator about this also but could not remember dates or times. LPN EE revealed when the Behavior Unit CNA is giving a resident a shower the residents are sometimes without any supervision if she is with a resident on the 200 Hall or a physician or family phone call, giving medications and cannot leave what she is doing to go on the locked unit. Interview on [DATE] at 11:55 a.m. with the Administrator revealed she had never been informed of unsafe or insufficient staffing by any Registered Nurse (RN), LPN or CNA, had not received any family complaints regarding lack of staffing or had any Resident Council complaints about staffing. The Administrator revealed she was aware no one liked the staffing cut but no one ever likes less staff. The Administrator revealed she had heard the DON complain about not enough staff on the Behavior Unit but she had complained when the staffing was 4.0 hours per resident per day. The Administrator revealed no one collects data to track or trend unwitnessed events. The Administrator revealed she had not taken any action to restore staffing because she had not identified that she needed to restore staffing on the Behavior Unit. The Administrator acknowledged she was aware the Behavior Unit Guidelines indicated there were to be two (2) staff members present on the Behavior Unit at all times. She revealed the guidelines had been written when the Behavior Unit was on the 200 Hall. The Administrator confirmed she had not identified the need to secure the shower room because she considered this another bathroom for the residents. She acknowledged the individual resident bathrooms do not contain hazardous items such as a bathtub or Hoya lift or wheelchairs. Review of the grievance log from [DATE] through [DATE] revealed there were no grievances about lack of staffing. Review of the Resident Council Meetings for the last 12 months revealed there were no complaints about lack of staffing. Interview [DATE] at 12:30 p.m. with the DON revealed on [DATE] she had been notified that effective on [DATE] she was directed to staff the Behavior Unit with one (1) CNA for all shifts by Corporate Quality Assurance Nurse SS. The DON indicated she had informed the Corporate Compliance Nurse and the Administrator on that day that one (1) CNA was not enough for the Behavior Unit. The DON revealed she had informed the entire Interdisciplinary Team (IDT), which included the Administrator and all department heads, at daily morning meetings, on many occasions, that there seemed to be more unobserved injuries and unwitnessed events since decreasing the staff on the Behavior Unit because one CNA is not enough to provide for thirteen to sixteen mobile residents with behavior problems. The DON revealed she was not given a choice or a solution to the problem but was told to manage the Behavior Unit with one (1) CNA as directed. The DON revealed she had emailed someone at the main corporate office about her objections to the decreased staffing on the Behavior Unit but was unable to tell me who she emailed, or retrieve the email. The DON confirmed it is her process to retrieve all event reports from the two nurse's stations every morning before the daily morning meeting and review all the events at the meeting. Interview [DATE] at 10:20 a.m. with the Administrator revealed the facility could not have one to one staffing and had considered one to thirteen staffing to be sufficient. The Administrator acknowledged the residents on the Behavior Unit are all very mobile and have behavioral problems and are expected to have behavioral problems regardless of how much supervision they have. The Administrator confirmed she had not been aware of the Behavior Unit having no staff present during any meals or breaks until this was observed by surveyors on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility policy, Staffing for Behavior Unit, was developed on [DATE], and has been reviewed with (5 of 5) facility RN's, (15 of 15) facility LPN's, and (28 of 28) facility Certified Nursing Assistants as part of an inservice education session. 100% of this education has been completed as of [DATE]. Copy of policy attached. 2. The facility staffing pattern and workflow has been reviewed and revised to reflect the presence of a licensed nurse on the Behavior Unit at all times. The facility will maintain staffing of no less than two (2) nursing staff members, one of which is a licensed nurse, the other a Certified Nursing Assistant, in the Behavior Unit on all shifts as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. To be considered qualified staff for the Behavior Unit, a staff member must be a licensed nurse or a certified nursing assistant since both of these categories have received basic first aid instruction as well as [MEDICATION NAME] maneuver education. These nursing staff members, one of which is a licensed nurse, the other a certified nursing assistant, will have completed [MEDICATION NAME] maneuver training; staff without [MEDICATION NAME] maneuver training will not be considered relief staff. This staffing pattern was effective as of [DATE]. Copy of monthly nursing staffing schedule attached. A review of the nursing staffing pattern for the remainder of the month of September, 2016, was conducted [DATE]. 2016, revealed 100% coverage of one (1) licensed nurse assigned to the Behavior Unit each shift, each day and at least one (1) certified nursing assistant assigned to the Behavior Unit for each shift, each day. The results of this review attached. 3. An inservice for (5 of 5) facility RN s, (15 of 15) facility LPNs, (28 of 28) facility CNA, (4 of 4) Administrative staff, (4 of 7) Housekeeping staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff and (1 of 1) Social Service staff, regarding Supervision and Monitoring of Residents in the Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. This inservice will include discussion of the PANIC BUTTON located in the Day Area of the Behavior Unit, how to activate this device, that it sounds at the First Floor nursing station and that any staff within hearing distance when the PANIC BUTTON is activated are responsible for responding to the PANIC BUTTO

Based on observations, record review, review of policy and procedure, review of the Behavior Unit Guideline and interviews, the facility failed to maintain a Quality Assurance committee that identified, developed and implemented corrective action plans for safety and supervision of residents with cognitive impairment and/or aggressive behaviors on the Behavior Unit. Residents (R) 42, R63, R30, R6, R48, R60, R72. This failure had the potential to affect all thirteen (13) residents on the Behavior Unit. The sample size was fifty two (52) residents. (Refer F280, F282, F323 and F353) Observations of the 300 Hall Behavior Unit revealed none (0) to one (1) staff member supervising thirteen (13) cognitively impaired residents, some with aggressive behaviors on [DATE] at 12:15 p.m., [DATE] at 12:00 p.m. and [DATE] at 12:30 p.m. Interview [DATE] at 11:10 a.m. with the Administrator revealed the Behavior Unit has been staffed with one (1) CNA for each shift since [DATE]. On [DATE] at 1:30 p.m. and 10:50 p.m., R42 was struck in the face by her roommate (R63). R42 was moved from the room to another hall and returned to her room with R63 on [DATE] and cried and pleaded for three to five hours not to be in the same room with R63. On [DATE] at 10:32 p.m., R42 was bitten on the left side of her chest by R63 leaving redness, teeth marks, broken skin, and subsequent blue and purple marks. R42 and R63 remained in the same room until R63 was transferred to a different hall due to a decline in her condition on [DATE]. On [DATE] at 6:30 p.m. R6 was observed by staff sweeping a door with a broom she obtained unobserved from the housekeeping cart. R6 was later observed with a bloody nose and a laceration on her forehead and sent to the Emergency Department for evaluation and treatment. R30 was discovered in the shower room unsupervised, on [DATE] at 4:45 p.m., after being unobserved for ninety minutes. R30 had no signs of trauma but was unable to speak and hypertensive. R30 was transferred by Emergency Medical Services (EMS) with Cardio [MEDICAL CONDITION] Resuscitation (CPR) in progress. R30 was pronounced deceased on [DATE] at 5:49 p.m. On [DATE] at 4:00 p.m. R60 hit a resident (R38) in the 300 Hall Behavior Unit dayroom. The incident was witnessed and there were no apparent injuries to R38. Three (3) hours later that day an unwitnessed incident at 6:55 p.m., R60 hit another resident (R48) that resulted in an injury to her lip with bleeding. Over several days, the injury progressed to swelling and discoloration to R48's left eye, cheek, jaw and some swelling of her lip. The facility's failure of the Quality Assurance committee to identify that their established guidelines for Behavior Unit staffing and safety in the bathing area were not being followed and therefore failed to implement corrective actions to address reports of unwitnessed events has caused or is likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a E while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility Behavior Unit Guidelines with no date, indicated the Behavior Unit shall have two (2) staff member present at all times. Continued review revealed residents of the Behavior Unit were not to be left unattended in the bathing area because showers and bathtubs are dangerous for both residents and staff. Review of the facility policy titled Quality Improvement and Assurance dated ,[DATE], revealed quality improvement and assurance activities are to help identify issues that require priority attention, focus improvement activities on areas within the facility that represent the greatest potential opportunities for improvement and measure resident outcomes. 1. On [DATE] at 12:45 p.m. observations made of the Behavior Unit revealed the shower room door did not have a lock. Observation on [DATE] at 12:15 p.m. of dining on the Behavior Unit revealed the residents in the two (2) dining areas were unattended as Certified Nursing Assistant (CNA) CC served meals and attended residents in their rooms. Observation on [DATE] at 12:00 p.m. revealed no staff on the Behavior Unit. Observation on [DATE] at 12:30 p.m. a second dining observation revealed CNA DD present, passing trays to both dining areas and a resident dining in their room. A verbal altercation and a resident choking occurred unattended. Observation on [DATE] at 12:56 p.m. of R72, a resident with severe cognitive impairment and at high risk for falls, leaving the dining area with no staff supervising and entering the unlocked shower room. A Hoya lift and wheelchairs, stored in the shower room, were visible through the open door. Interview conducted on [DATE] at 12:57 p.m. with CNA DD revealed R72 should not be in the shower room alone. Interview with Licensed Practical Nurse EE on [DATE] at 11:05 a.m. revealed R72 likes to use the shower room bathroom and goes there unattended if he is not watched closely. R72 is a fall risk and should not be in the shower room unsupervised. Interview [DATE] at 11:20 a.m. with the Administrator revealed she was unfamiliar with R72 and did not know he was a fall risk and had been using the shower room bathroom unattended. 2. R30, a resident on the Behavior Unit, was discovered on [DATE] at 4:45 p.m., alone in the shower room, sitting on the floor. An Event Report dated [DATE] revealed this fall was unwitnessed. Interview on [DATE] at 4:50 p.m. with LPN JJ revealed she was in charge of the 300 Hall (locked) Behavior Unit on [DATE] for the 3:00 p.m. to 11:00 p.m. shift. LPN JJ indicated she and the CNA had observed R30 at 3:15 p.m. in her room and then did not see her again until she was found on the floor of the shower room by the CNA with her blouse off, unable to speak, at 4:45 p.m. LPN JJ had been at the 200 Hall nurses station desk, outside the locked unit when she was notified R30 was on the floor in the shower room. Her blood pressure was ,[DATE] and Emergency Medical Services (EMS) was called. On EMS arrival Cardio [MEDICAL CONDITION] Resuscitation (CPR) was in progress by the first responders and R30 was transferred to the local Emergency Department with CPR in progress. LPN JJ revealed she had worked at other facilities and the shower room doors are always locked. Review of the emergency room Record revealed CPR was abandoned after no response and R30 was pronounced dead at 5:49 p.m. Interview with the Administrator on [DATE] at 10:20 a.m. revealed she is the Quality Assurance (QA) Coordinator and all the Event Reports for falls and non falls are reviewed monthly in the QA meetings looking for patterns and trends and events that require interventions. No possible quality concern had been identified related to lack of supervision or unlimited access to the shower room on the Behavior Unit when the Event Report for R30 on [DATE] was reviewed. 3. Review of nurse Resident Progress Notes for R6, a resident on the Behavior Unit with severe cognitive impairment and poor safety awareness, was observed by staff sweeping a door in the hallway of the Behavior Unit. The next observation of R6 at 9:12 p.m. revealed she had thrown the broom on the floor and was bleeding from her nose and a laceration on her forehead. The Event Report for R6, dated [DATE] revealed this event was unwitnessed. She was evaluated and treated at the emergency room and returned to the facility the same night with her wound closed by wound adhesive. Interview [DATE] at 3:20 p.m. with the Administrator revealed she had investigated this event and discovered R6 had gained access to the broom off the housekeeping cart unsupervised and after being seen using the broom remained unsupervised with the broom. This Event Report had been reviewed by the QA committee and the committee had not identified a lack of staffing or supervision to have contributed to this event. 4. Review of the clinical record for R42, a resident with severe cognitive impairment residing on the Behavior Unit, revealed on [DATE] at 1:30 p.m. R42 was struck on the face by her roommate (R63). Physical assessment revealed a scratch and redness on the left side of her face. On [DATE] at 10:50 p.m., in their room, R63 hit R42 in the face with a shoe. Event Report for R42 revealed the first time R42 was struck the event was unwitnessed. The second event at 10:50 p.m. was witnessed by a CNA. R42 was moved to a room outside the Behavior Unit. On [DATE] R42 was returned to her prior room with R63. She was pleading and crying not to be returned to the room with R63, shouting that R63 would kill her. She remained agitated for ,[DATE] hours according to nurse Resident Progress Notes. On [DATE] according to an Event Report R42 was heard shouting at 7:20 p.m. and when staff entered the room she told them R63 bit her on the chest. This Event Report indicated this was an unwitnessed event. Physical assessment of R42 revealed teeth marks with skin penetration on her left chest. An assessment of R42 on [DATE] revealed her left chest had teeth marks surrounded by a purple and blue area. R42 and R63 remained in the same room until [DATE] when R63 was moved to another hall due to a change in her condition. Interview [DATE] at 12:20 p.m. with the Administrator/ QA Coordinator, revealed the QA Committee was made aware of the incidents of [DATE] at 1:30 p.m. and 10:50 p.m. when R42 was struck twice by her roommate (R63). The QA Committee also was aware of the incident on [DATE] at 7:20 p.m. when R42 was bitten on the left chest by her roommate (R63). All events on the Event Reports are discussed by the QA Committee. The Administrator indicated unwitnessed events on the Behavior Unit are not tracked. The QA committee looks at all events to there are patterns and trends and any additional possible interventions that might be needed. The QA Committee was notified of the decrease in staffing on the Behavior Unit and no interventions were developed or implemented to adjust to the decrease in staffing and supervision. The Administrator revealed specific interventions in response to specific events have never been recorded by the QA Committee. The Administrator acknowledged the interventions for any events on the Behavior Unit had been developed prior to the QA meetings and no additional interventions were considered necessary by the QA Committee. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The facility policy, Staffing for Behavior Unit, was developed on [DATE], and has been reviewed with (5 of 5) facility RN's, (15 of 15) facility LPN's, and (28 of 28) facility Certified Nursing Assistants as part of an inservice education session. 100% of this education has been completed as of [DATE]. Copy of policy attached. 2. The facility staffing pattern and workflow has been reviewed and revised to reflect the presence of a licensed nurse on the Behavior Unit at all times. The facility will maintain staffing of no less than two (2) nursing staff members, one of which is a licensed nurse, the other a Certified Nursing Assistant, in the Behavior Unit on all shifts as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. To be considered qualified staff for the Behavior Unit, a staff member must be a licensed nurse or a certified nursing assistant since both of these categories have received basic first aid instruction as well as [MEDICATION NAME] maneuver education. These nursing staff members, one of which is a licensed nurse, the other a certified nursing assistant, will have completed [MEDICATION NAME] maneuver training; staff without [MEDICATION NAME] maneuver training will not be considered relief staff. This staffing pattern was effective as of [DATE]. Copy of monthly nursing staffing schedule attached. A review of the nursing staffing pattern for the remainder of the month of September, 2016, was conducted [DATE]. 2016, revealed 100% coverage of one (1) licensed nurse assigned to the Behavior Unit each shift, each day and at least one (1) certified nursing assistant assigned to the Behavior Unit for each shift, each day. The results of this review attached. 3. An inservice for (5 of 5) facility RN s, (15 of 15) facility LPNs, (28 of 28) facility CNA, (4 of 4) Administrative staff, (4 of 7) Housekeeping staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff and (1 of 1) Social Service staff, regarding Supervision and Monitoring of Residents in the Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. This inservice will include discussion of the PANIC BUTTON located in the Day Area of the Behavior Unit, how to activate this device, that it sounds at the First Floor nursing station and that any staff within hearing distance when the PANIC BUTTON is activated are responsible for responding to the PANIC BUTTON by entering the unit and assisting unit staff as needed. As of [DATE], 100% of this education has been achieved for nursing staff, 88% for all staff. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 4. (5 of 5) facility RNs, (15 of 15) facility LPNs, and (28 of 28) facility CNAs have been informed as part of the inservice, Supervision and Monitoring of Residents in the Behavior Unit, of the process for relieving Behavior Unit staff during breaks/meal times so that consistent staffing of two (2) is maintained in the Behavior Unit at all times. The licensed nurse assigned to the Behavior Unit will be relieved at break/meal time by the First Floor licensed nurse, the Assistant Director of Nursing or the Weekend Supervisor. Behavior Unit CNAs will be relieved by First Floor CNAs or Restorative CNAs for break/meal times; these break/meal times will be designated on the daily assignment sheets. As of [DATE], 100% of this training has been achieved. This process began on [DATE] and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. Inservice record attached. 5. An inservice for facility staff with (5 of 5) facility RNs, (15 of 15) facility LPNs, (26 of 28) facility CNAs, (4 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff, regarding Mealtime Supervision in Behavior Unit is in process by the Director of Nursing and the Assistant Director of Nursing. As of [DATE], 86 % of this education has been achieved, 100% of this training will be completed by [DATE], and facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 6. A facility qualified nursing staff member will be present in the common Dining Areas of the Behavior Unit during resident meal times to provide monitoring, supervision, and assistance as needed. Residents will be encouraged to eat meals in the common Dining Areas but those choosing to eat in their rooms will be observed approximately every ,[DATE] minutes during meal time. Implementation of this intervention began [DATE]. 2016, and will be completed by [DATE], as 100% of this training is completed. Facility staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 7. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing reviews the daily nursing staffing schedule and assignment sheet at the beginning of the shift, Monday through Friday, for first and second shift, to determine that the Behavior Unit is properly staffed with a licensed nursing staff member (LPN) and at least one (1) CNA on each shift, each day and that the Behavior Unit staff has coverage for break/meal times. This review will be completed by the ,[DATE] Hall LPN for third shift and the weekend Supervisor on Saturday and Sunday for both 12 hour shifts. This process is to be a permanent procedure with management staff conducting these audits every shift for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. Audit tool attached. 8. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing or Assistant Director of Nursing observes the dining areas of the Behavior Unit daily, Monday through Friday, to determine that a nursing staff member that has completed the facility education, Mealtime Supervision in Behavior Unit, is present during the resident meal times. This review will be completed by the weekend Supervisor on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting these audits for first and second shifts for 30 days, then daily audits for the following 30 days and then weekly audits as a permanent procedure. 9. On [DATE], the facility implemented a procedure by which the results of the audits referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding staffing for the behavior unit and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE] and then the first monthly meeting for [DATE]. 10. On [DATE], the facility policy, Care Plans, was reviewed with the facility Administrator, Director of Nursing, Assistant Director of Nursing and MDS Coordinator. The review resulted in no changes to the current policy and the facility will begin implementing the current policy on [DATE]. Policy and acknowledgement of review attached. The Care Plan of each resident residing on the 300 Hall Behavior Unit will be reviewed and revised to reflect the current resident care status and care needs. This review/revision process will be 100% completed by [DATE]. Care plan revisions will be written on the current care plan in the paper chart and communicated to licensed nursing staff daily by MDS Coordinator. This information will be passed on to other licensed staff during shift to shift report. The Nurse Aide Kardex for each resident on the 300 Hall Behavior Unit will be reviewed/revised daily to effectively communicate resident needs and care requirements to facility CNA staff. This review/revision process will be 100% completed by [DATE]. 11. An inservice for facility nursing staff, RNs, LPNs, CNAs, regarding Care Plans is in process. As of [DATE], with (5 of 5) RNs, (14 of 15) LPNs, and (22 of 28) CNAs having completed the education. 85% of this education has been completed. 100% of the education will be completed by [DATE]. Nursing staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. Inservice record attached. 12. On [DATE], the facility initiated a new procedure by which the Director of Nursing, Assistant Director of Nursing, or the MDS Coordinator, Monday through Friday, will review the Care Plan and Nurse Aide Kardex of each resident on the 300 Hall Behavior Unit to determine that the care plan is reflective of current resident needs and care requirements. The weekend Supervisor will complete this review on Saturday and Sunday. This process is to be a permanent procedure with management staff conducting daily audits for 30 days and then weekly audits as a permanent procedure. This process began on [DATE] and will be in effect as long as the 300 Hall area of the facility is utilized as a secured Behavior Unit. 13. On [DATE], the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding Care Plans and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE], and the first monthly meeting for [DATE]. 14. A lock was installed on the door to the 300 Hall shower area on [DATE]. This shower area will remain locked when not in use by an authorized facility staff member. Authorized staff members are facility nursing staff, facility housekeeping staff and facility maintenance staff. 15. This locked shower area can be accessed by authorized facility staff members via key kept on the 300 Hall nurse's key ring as well as spare keys kept in the First Floor Medication Room and at First Floor Nursing Station. 16. An inservice for facility RNs, LPNs, CNAs, housekeeping and maintenance staff regarding Shower Area Safety has been completed. As of [DATE], (5 of 5) RNs, (15 of 15) LPNs, (27 of 28) CNAs, (7 of 7) Housekeeping staff, (4 of 4) Administrative staff, (1 of 2) laundry staff, (1 of 2) Activities staff, (2 of 2) Maintenance staff, (8 of 12) Dietary staff, and (1 of 1) Social Service staff; 97% of the education has been achieved, 100% will be achieved by [DATE]. Staff will not be allowed to perform their duties on the Behavior Unit until this education is completed. 17. On [DATE], the facility initiated a new procedure by which the Administrator, Director of Nursing, or Assistant Director of Nursing will monitor the shower area on 300 Hall, Monday through Friday, on first and second shift to determine that the door is locked when not in use, that the area is free of hazardous chemicals and objects and that the key to the area is accessible to authorized staff; the 300 Hall LPN will complete this monitoring duty on third shift. The weekend Supervisor will complete this review on Saturday and Sunday for the 12 hour shifts. This audit will be conducted each shift for 30 days, then daily for the following 30 days, then weekly audits as a permanent procedure. Audit tool attached. 18. On [DATE], the facility implemented a procedure by which the results of the audit referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance (QA) Committee each month by the Administrator and/or DON to allow the QA Committee to monitor staff compliance with the facility's policies regarding securing the 300 Hall shower area and to ensure that this policy/system is in compliance. The facility has scheduled a QA Committee meeting for [DATE] and the first monthly meeting for [DATE]. 19. On [DATE] the facility policy Quality Assurance Committee, was reviewed with facility Administrator and Department Directors. Copy of policy and acknowledgement of review attached. On [DATE], the responsibilities of the facility Medical Director were reviewed with the facility Administrator and Medical Director. Acknowledgement of review attached. 20. On [DATE], the facility initiated a system process by which a formal Quality Assurance Committee meeting to identify occurrences, patterns and trends related to events, as well as other quality issues that affect resident well-being, will be held on a monthly basis with the first meeting scheduled for [DATE]; the next meeting is scheduled for [DATE]. This monthly process is to be a permanent process. A written record of the items discussed, actions approved and staff attending will be produced for each Quality Assurance meeting held. These written records will serve as audit/monitoring tools and will be available for surveyor review when requested. The State Survey Agency (SSA) validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. The facility policy Staffing for Behavior Unit, developed on [DATE], was reviewed. The policy revealed there will be two (2) qualified nursing staff members present on the Behavior Unit at all times. One (1) will be a licensed nurse and there will be at least one Certified Nursing Assistant (CNA). Facility Staff who have received [MEDICATION NAME] maneuver training and basic first aid instruction will be considered qualified staff. The Behavior Unit charge nurse will schedule meals and break times for the CNA's at the beginning of each shift. Those times will be staggered so that CNA's can provide relief coverage for each other. Other facility staff may also be used as needed for relief coverage during staff meal/break times. The first floor charge nurse, the Assistant Director of Nursing (ADON) or the weekend supervisor will be responsible for relieving the licensed nurse on the Behavior Unit for meals/ break times. The first floor charge nurse will be relieved for meal/break time by the Director of Nursing (DON), ADON or the weekend supervisor. Should the first floor charge nurse be unavailable for relief duty, then the Assistant Director of Nursing and/or the DON and/or weekend Supervisor will be available to relieve Behavior Unit staff for meal/break times. Course content included the following topics: *Routine monitoring *Observation of Residents *Implementation of Actions to Meet Resident Needs *Staffing Coverage Review of the roster for the inservice education titled Behavior Unit Supervision and Staffing confirmed 100 % of all facility staff including RN's, LPN's, CNA's, housekeeping, maintenance, dietary, activities, social services, and laundry. Interviews were conducted with the following staff on [DATE] to verify the facility provided education to ensure knowledge of how many qualified staff needed to be present at all times according to the Staffing on Behavior Unit policy and were able to verbalize the facility policy for staffing on the Behavioral Unit and revealed they attended the in-service provided by the facility: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AAA at 3:09 p.m., CNA BB at 3:11 p.m., LPNFF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. Observations of the Behavior Unit staffing on [DATE] at 3:45 p.m. and [DATE] at 12:25 p.m. revealed one Licensed Practical Nurse (LPN) and two CNA's were present on the Behavioral Unit assisting residents. 2. Review of the Daily Staffing Sheets from [DATE] through [DATE] were verified by comparison of time card punch records and the actual work schedule. The Behavior Unit staffing conformed to the staffing policy of one LPN and one CNA on each shift. The AOC revealed all RN's LPN's and CNA's have received training in the [MEDICATION NAME] maneuver. Review of educational rosters titled Performing the [MEDICATION NAME] maneuver conducted on [DATE] and [DATE], compared with list of current RN's LPN's and CNA's revealed all have received [MEDICATION NAME] maneuver training as required by facility policy titled Education :Required In-services. The following in-services or drills will be provided on an annual basis: [MEDICATION NAME] maneuver. Review of the facility audit of staffing pattern on the Behavior Unit conducted on [DATE] verified one LPN and one CNA scheduled every shift from [DATE] through [DATE]. Review of assignment sheets for the Behavior Unit from [DATE] through [DATE] verify the assignment of CNA relief coverage for the CNA and LPN coverage for the LPN. Interviews were conducted with the following staff to verify qualified staff were present on the Behavior Unit and had attended in-services for [MEDICATION NAME] maneuver within the last year and had received first aid training as part of licensure and certification: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AA at 3:09 p.m., CNA BB at 3:11 p.m., LPN FF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. Observations of the Behavior Unit staffing on [DATE] at 3:45 p.m. and [DATE] at 12:25 p.m. revealed one LPN and two CNA's were present on the Behavioral Unit assisting residents. 3. Review of inservice education titled Supervision and Monitoring of Residents in the Behavior Unit included the following: *Routine monitoring *Observation of Residents *Implementation of Actions to Meet Resident Needs *Staffing Coverage Review of education rosters for the inservice titled Supervision and Monitoring of Residents in the Behavior Unit revealed 100% of facility staff were educated as of [DATE]. Interviews were conducted with the following staff to verify attendance of the inservice titled Supervision and Monitoring of Residents in the Behavior Unit and verified knowledge of location of the Panic Button on the Behavior Unit, how to activate the button, where the Panic Button sounds outside the Behavior Unit, and who is responsible for responding after the Panic Button is activated: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05 p.m., CNA NN at 2:10 p.m., CNA PP at 2:28 p.m., LPN EE at 2:35 p.m., CNA AA at 3:09 p.m., CNA BB at 3:11 p.m., LPN FF at 3:15 p.m., CNA AA at 3:19 p.m., LPN OO at 3:25 p.m., CNA CCC at 3:35 p.m., ADON LL at 3:40 p.m., CNA BBB at 3:44 p.m. and LPN JJ at 3:50 p.m. An observation conducted on [DATE] at 2:55 p.m. on the Behavior Unit included the testing of the Panic Button by the Administrator and the Maintenance Director. An interview conducted on [DATE] at 3:00 p.m. with the Administrator revealed the facility will be conducting drills in the future for staff to remain aware of what the panic button sounds like and what to do in case of an emergency on the unit. 4. Review of education inservice titled Supervision and Monitoring of Residents in the Behavior Unit relief for breaks and meal education has been completed with 100% of RN's LPN's and CNA's being educated as of [DATE]. The staffing assignment sheets, schedules and time card records confirm two CNA's and one LPN are scheduled every shift, every day and have been present every shift since [DATE]. The daily assignment sheets reviewed from [DATE] to [DATE], the two CNA's relieve each other and the LPN assigned to 100 Hall and 200 Hall relieves the LPN on the Behavior Unit. Interview [DATE] at 2:20 p.m. with the Administrator and DON revealed the DON and ADON and Patient Care Coordinator and weekend supervisors are also available to relieve the Behavior Unit LPN and 100% of current and active nursing staff have received this education and know they are expected to comply. Interviews were conducted with the following staff to verify the process for relieving Behavior Unit staff during breaks and meal times to maintain two qualified staff on the Behavior Unit at all times. And all the following staff were able to verbalize and acknowledge the inservice education provided regarding how to relieve qualified nursing staff on the Behavior Unit: CNA DD at 12:50 p.m., CNA CC at 12:59 p.m., Housekeeper ZZ at 1:50 p.m., LPN RR at 2:05

Based on policy and procedure review, record review and staff interviews, the facility failed to revise the Care Plan interventions in an effort to reduce the likelihood of subsequent falls and /or injuries related to falls for one (1) resident (D) with severe cognitive impairment, [MEDICAL CONDITION] disorder and physical behaviors. The sample was (6) residents. Resident D fell eleven (11) times from August 2015 through November 2015. Review of the Care Plan titled Falls dated 1/30/14 identified Resident D was at risk for falls. The Goal documented the resident will not suffer injury from a fall for the next three (3) months. The Long Term Target Date was 10/29/15, then updated through 1/21/16. Resident D had three (3) falls without injuries on 8/13/15, 9/8/15, 9/28/15 and one (1) fall with injury on 9/23/15 before a new intervention was added the Care Plan titled Falls. On 9/28/15 a new intervention was added to monitor the resident and re-direct as needed. After the new intervention had been implemented, Resident D had four (4) falls without injury on 10/2/15, 10/6/15, 10/7/15 and 10/8/15 and one (1) fall with an injury on 10/13/15. New interventions were not added until 10/13/15 and 10/22/15. A new intervention was added to the Care Plan titled Falls on 10/13/15 to start Occupational Therapy to assist with Activities of Daily Living (ADL) care, therapeutic exercises and neuromuscular re-education. On 10/22/15 a new intervention was added to the Care Plan titled Falls, to remind the resident to not transfer without assistant. However, review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] and the Annual MDS assessment dated [DATE] for Resident D both revealed a Brief Interview for Mental Status (BIMS) summary score of 01, indicating severe cognitive impairment. After the interventions were added on 10/13/15 and 10/22/15, Resident D had one (1) fall with injury on 11/9/15 and one (1) fall with no new injury, however, continued evidence of an injury from the fall on 11/9/15. No new interventions were added to the Care Plans after either fall. (Refer F323) The facility's failure to revise the Care Plan interventions in an effort to reduce the likelihood of subsequent falls and/or injuries related to falls, resulted in actual harm for Resident D when an unwitnessed fall on 9/23/15 resulted in a head injury that required staples. On 10/13/15 when an unwitnessed fall resulted in bruising and swelling of the left eye. On 11/9/15 when an unwitnessed fall resulted in re-injury to the left eye with bruising and swelling. On 11/18/15, Resident D was sent to the hospital and diagnosed with [REDACTED]. Findings include: Review of the policy titled Care Plans documented: It is the policy of this facility to establish and maintain a care plan for each resident on admission and thereafter. The resident care plan is reviewed no less than quarterly during the resident's stay. It is also reviewed whenever there is a significant change in resident condition. The resident care plan interventions are reflective of changes in resident condition as well as Physician orders [REDACTED]. Review of the policy titled Falls Management Program documented: Any resident who experiences a fall will have the circumstances surrounding the incident evaluated to reduce the likelihood of subsequent falls. Monitoring identifies changes in the resident's pattern of risk of falls and allows proactive alteration in the resident's plan of care to eliminate or reduce the risk of falls. Monitor and document the resident's response to interventions intended to reduce falling or its risks. For continuing falls, evaluate possible causes and reconsider current preventative measure. Evaluate and adjust the falls prevention program using interdisciplinary team efforts. Re-evaluate the fall prevention plan in the resident's care plan. Review of the policy titled Post Fall Review documented: It is the policy of this facility to review the circumstances surrounding resident falls and initiate interventions to prevent future falls. Care interventions will be indicated on the resident Care Plan. Review of the Care Plan titled Falls with a Problem Start Date of 1/30/14 identified the resident is at risk for fall related to unsteady gait and unable to see secondary to diabetic retinopathy and history of [MEDICAL CONDITION] disorder. The resident had eye surgery in July 2014 which triggered multiple falls. The resident had fall on 8/13/15 and 9/8/15 without injury. On 9/23/15 the resident was found lying face down. She had a head injury, was sent to the ER and returned the same day with staples. On 9/28/15 the resident had a fall with no injury noted. On 10/2/15 the resident was found on the floor in the day room. On 10/6/15 the resident was in the hallway and fell , no injury noted. On 10/7/15 the resident was found on the floor. On 10/8/15 the resident was found on the floor in the day room and was screaming stating she did not fall. On 10/13/15 the resident had a fall with swelling noted over her left eye. On 11/9/15 the resident had a fall with minor injury, the left eye had bruising and was swollen. On 11/12/15 the resident was observed on the floor in the day room. No injury noted. The interventions included: Approach Start Date 4/22/14- Her vision has decline related to diabetic [MEDICAL CONDITION] and diabetic retinopathy. Eye MD visit on 4/7/15 Approach Start Date 9/8/14- Make sure room is clutter free to prevent injury from fall. Staff to assist with guided assistance in hallway while ambulating Approach Start Date 1/30/14- Use call light when she needs assistance from staff Approach Start Date 1/30/14- Supervision by staff while ambulating in hallway related to poor vision Approach Start Date 1/30/14- Encourage her to calm down when she is agitated Approach Start Date 1/30/14- Administer [MEDICATION NAME] as ordered and prn [MEDICATION NAME] as ordered Approach Start Date 1/30/14- Make sure she takes her medication Approach Start Date 1/30/14- Monitor for signs and symptoms of [MEDICAL CONDITION] disorder like lethargy, increase agitation or increase restlessness, call MD immediately Approach Start Date 1/30/14- [MEDICATION NAME] as ordered, [MEDICATION NAME] level on 9/1/15. Approach Start Date 10/13/15- Occupational Therapy to assist with ADL care and therapeutic exercises and neuro-muscular re-education Approach Start Date 10/22/15- Remind resident to not transfer without assistance. Record review for Resident D revealed three (3) falls without injury (8/13/15, 9/8/15 and 9/28/15) and one (1) fall (9/23/15) with an injury before new interventions were added to the Care Plan titled Falls. On 9/28/15 an intervention was added to monitor the resident and re-direct as needed. On 8/13/15 8:00 p.m. the resident had a witnessed fall in the 200 dining room. No injuries were noted and the MD was notified. Review of the Care Plan titled Falls updated 8/13/15 documented the fall with no injuries, PT/OT Screen and continue with interventions. On 9/8/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the Nurse Practitioner (NP) was notified. Review of the Care Plan titled Falls updated 9/8/15 documented the resident was observed on the floor with no injuries and PT/OT Screen. There is no evidence of new/revised interventions to the care plans. Interview on 3/29/16 at 9:58 a.m. with the Registered Nurse (RN) Resident Care Coordinator (RCC) revealed she is sure this fall was discussed as a team but she was unable to provide documentation. The team consisted of the Director of Nursing (DON), the Administrator, Therapy staff, Nursing, RCC and herself. The RN RCC further revealed she was the Assistant RCC up until December 2015 and she has been the RCC for about three (3) weeks now. She confirmed there were no new interventions in place after the falls occurred on 8/13/15 or 9/8/15. On 09/23/15 at 11:35 a.m. the resident had an unwitnessed fall on the 200 hall. The resident had an injury to the head that required being sent to the emergency room (ER). The resident returned the same day with staples to the wound on the back of the head. Review of the Care Plan titled Falls updated 9/23/15 documented the resident fell and was face down on the floor, sent to the emergency room (ER) for evaluation and treatment. Open area on the head. PT/OT Screen. Interview on 3/29/15 at 10:03 a.m. with the RN/RCC revealed she did attend the team meeting related to this fall, however, there is no documentation of the meeting. The meetings are held every morning after any falls but there is no sign-in sheets or documentation of the morning meetings. She confirmed there were no interventions placed after this fall and that she was not the RCC at this time. She said she cannot speak for the previous RCC and does not know why new interventions were not put into place after a fall with injuries. She said the resident was non-compliant, had behavioral issues and had vision problems. On 09/28/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. Review of the Care Plan titled Falls updated 9/28/15 documented the resident was observed sitting on the floor with no injuries noted. PT/OT Screen. Monitor resident and re-direct as needed. Interview on 3/29/15 at 8:30 a.m. with the LPN YY revealed she was the direct care nurse at the time of this fall. LPN YY revealed she was aware of the resident's care plan interventions and that the effectiveness of the interventions are to be documented by the nurse taking care of the resident. However, she did not have any documentation related to the effectiveness of the existing interventions. The MDS/Care Plan Coordinator is responsible for documenting new interventions. LPN YY further revealed she knows a bed alarm was never added as an assistive device because the resident mainly fell in the day room. Interview on 3/29/15 at 10:10 a.m. with the RN/RCC revealed an new intervention was placed to monitor the resident and re-direct the resident as needed. The RN/RCC could not explain what type of monitoring that was to be conducted, just monitoring in general. Further, the RN/RCC said that the resident does not respond to re-direction. Continued record review for Resident D revealed after the intervention was added to the Care Plan titled Falls on 9/28/15, the resident had four (4) falls (10/2/15, 10/6/15, 10/7/15 and 10/8/15) without injury and one (1) fall (10/13/15) with an injury before a new intervention was added to care plan on 10/13/15 and 10/22/15. On 10/02/15 at 10:45 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the NP was notified. Review of the Care Plan titled Falls updated 10/2/15 documented the resident was found on the floor in the day room. Neurocheck list done. Continue with current care. On 10/06/15 at 1:50 p.m. the resident had an unwitnessed fall in the 200 Hall hallway. No injuries noted and the NP was notified. Review of the Care Plan titled Falls updated 10/6/15 documented the resident was standing in the hall and fell . No injuries. PT/OT Screen. Continue with the current care plan. On 10/07/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the NP was notified. Review of the Care Plan titled Falls updated 10/7/15 documented the resident was found on the floor. No injury. There was no evidence of new/revised interventions after this fall. On 10/08/15 at 11:15 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. Review of the Care Plan titled Falls updated 10/8/15 documented the resident was found on the floor. The resident said she did not fall. PT/OT screening. There was no evidence of new/revised interventions after this fall Interview on 3/29/16 at 10:18 a.m. with the RN/RCC revealed the existing interventions were continued after the falls on 10/2/15, 10/6/15, 10/7/15 and 10/8/15. She said she could not speak for the previous RCC or why new interventions were not developed after the resident had four (4) falls in six (6) days. She said that every fall was discussed with the team in morning meeting. The RN/RCC further said that it is the role as the RCC to develop or revise interventions to try and prevent further falls. On 10/13/15 at 1:25 a.m. the resident had an unwitnessed fall in the resident's room. The resident sustained [REDACTED]. The NP was notified. Review of the Care Plan titled Falls updated 10/13/15 documented the resident was found on the floor in room. Swelling over the left eye. A new intervention documented Occupational Therapy (OT) started on 10/13/15. On 10/22/15 a new intervention was included to remind the resident to not transfer without assistance. Continued record review for Resident D revealed after the intervention was added to the Care Plan titled Falls on 10/13/15 and 10/22/15, the resident had one (1) unwitnessed fall (11/9/15) with an injury and one (1) fall (11/12/15) without injury. There is no evidence that the care plans were updated with new/revised interventions after either fall. Interview on 3/29/15 at 8:00 a.m. with the nightshift (11:00 p.m. - 7:00 a.m.) LPN XX revealed on 10/13/15, Resident D was found on the floor by the CNA. Upon her assessment, there was swelling to the left temporal area but no bruising at that time. On 10/14/15, the left eye was swollen and bruising appeared. LPN XX revealed she does not document in the residents clinical chart or care plan if the current interventions are not working. The interventions are discussed in the morning meeting after a resident has a fall and she thinks new interventions are documented in the care plan by the MDS nurse. Interview on 3/29/16 at 10:21 a.m. with the RN/RCC revealed due to the resident's cognitive status, interventions related to reminders for the resident would not be an appropriate intervention and not the intervention she would have chosen however, she was not the RCC at the time of the fall on 10/13/15. Further, the intervention added on 10/22/15 was placed after the patient care conference. The RN/RCC said the main intervention for this resident is supervision and that the staff is supposed to be supervising the resident. On 11/09/15 at 2:15 p.m. the resident had an unwitnessed fall in the 200 Hall day room. The resident sustained [REDACTED]. The NP was notified. Review of the Care Plan titled Falls updated 11/9/15 documented a fall with minor injury. Left eyebrow swollen. PT/OT Screen. There is no evidence of a new/revised intervention after this fall. Interview on 3/29/15 at 10:23 a.m. with the RN/RCC revealed that during the discussion with the team, the current interventions would have been looked at after this fall. Further, the RN/RCC said that no new interventions were developed and the interventions at the time of the fall on 11/9/15 were continued. On 11/12/15 at 7:50 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No new injuries were noted but bruising and swelling of the left eye from the fall on 11/9/15 continued to be evident. The NP was notified. Review of the Care Plan titled Falls updated 11/12/15 documented the resident was observed on the floor in the day room. No evidence of a new/revised intervention after this fall. An update on 11/13/15 documented bruising to the left eye. An update on 11/18/15 documented the resident was sent to DeKalb Medical Center. Interview on 3/29/15 at 10:26 a.m. with the RN/RCC revealed the nurses hand writes new interventions on the main Care Plans that remain in the resident's chart. The Care Plans in the resident's chart is the most updated care plan. After each quarterly patient care conference, all the new interventions that were hand written on the main care plan is added to the care plans in the computer. Review of the Care Conference Report documented a quarterly care conference was conducted on 7/30/15 with four (4) names in attendance and 10/22/15 with six (6) names in attendance. An interview was conducted on 3/29/15 at 11:26 a.m. with the Administrator and the DON. The Administrator revealed she was aware that Resident D has had multiple falls that included several injuries. All resident falls are discussed during the morning meetings with all departments heads and therapies. The discussion includes the determining factors and route cause of a resident's falls and actions to be taken. The Administrator said the staff try to monitor and supervise the resident closely but there has never been one on one supervision for Resident D. When the CNA's have any down time, they will sit in the day room with the residents but they cannot be in there all the time. As soon as the staff would leave Resident D, within minutes she would get out of the chair and start walking around. The DON revealed Resident D wanted to be independent and whatever they would tell her to do, she would do the opposite. They did not provide one on one supervision and the minute they would turn their back, the resident was walking around again. The DON said the resident was seen in April 2015 by the eye doctor. PT/OT did screened the resident after the falls. OT was started. They checked the resident for UTI's and order labs after the falls in November but could not explain why additional, appropriate interventions were not developed after multiple falls or after the falls with injuries.

Based on review of policy and procedure, record review and staff interviews, the facility failed to ensure adequate supervision for one (1) resident (D) with a history of multiple falls. The sample was six (6) residents. Resident D had a total of eleven (11) falls from August 2015 through November 2015. Ten (10) of the eleven (11) falls were unwitnessed (9/8/15, 9/23/15, 9/2815, 10/2/15, 10/6/15, 10/7/15, 10/8/15, 10/13/15, 11/9/15 and 11/12/15). Three (3) of the eleven (11) falls resulted in jury for Resident D (9/23/15, 10/13/15 and 11/9/15). Resident D had three (3) care plans that documented the resident's need for supervision. A Care Plan titled Visual Function documented in Approach with a start date of 1/30/14, that the resident needs supervision while ambulating in the hallway. A Care Plan titled Activities of Daily Living (ADL) Function/Rehabilitation Potential documented in Approach with a start date of 1/30/14 that the resident needs supervision and at times guided assistance while in hallway related to poor vision. A Care Plan titled Falls documented in Approach with a start date of 1/30/14 that the resident needs supervision by staff while ambulating in the hallway related to poor vision. Interview on 3/29/16 at 10:21 a.m. with the Registered Nurse (RN) Resident Care Coordinator (RCC) revealed the main intervention for this resident is supervision and that the staff is supposed to be supervising the resident. The facility's failure to ensure adequate supervision for a resident with a history of multiple falls caused actual harm for Resident D. On 9/23/15 the resident had an unwitnessed fall in the 200 Hall day room and sustained a head injury that required staples. On 10/13/15 the resident had an unwitnessed fall in her room and sustained an injury to the left eye with bruising and swelling. On 11/9/15 the resident had an unwitnessed fall in the 200 Hall day room and sustained a bleeding open wound to the left side of her head and swelling to the left eye. On 11/12/15 the resident had an unwitnessed fall in the 200 Hall day room and did not sustain any new injuries however, bruising and swelling of the left eye remained evident. Resident D began to show decline on 11/16/15 when she was not eating or drinking. The MD was not notified at this time and the Licensed Practical Nurse (LPN) XX continued to monitor the resident. On 11/17/15 the resident did not have any output of urine. The Nurse Practitioner was notified and an order was received for a straight catheterize, Urinalysis and labs (CBC and CMP). On 11/18/15 the resident was having difficulty swallowing and continued to have swelling of the left eye and left jaw. Resident D was sent to a hospital emergency room (ER) for evaluation on 11/18/15. On 11/19/15, the hospital reported to the nursing home facility that Resident D had an Acute Mandibular Fracture. The resident was transferred to a different hospital for continued management and treatment of [REDACTED]. Findings include: Review of the policy titled Falls Management Program documented: It is the policy of this facility to accurately assess each resident's s condition for prompt recognition of the risk of falls and to minimize injury to the resident. Each resident will be assessed for the risk of falls upon admission and quarterly. Any resident who experiences a fall will have the circumstances surrounding the incident evaluated to reduce the likelihood of subsequent falls. Careful management of the identified risk and underlying conditions for a resident can eliminate or reduce the risk of falls and may include: limits to treatment or managing the resident, managing the cause of fall(s) and managing factors that may increase the risk of serious consequences of falling. Monitoring identifies changes in the resident's pattern of risk of falls and allows proactive alteration in the resident's plan of care to eliminate or reduce the risk of falls. Record review for Resident D revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C- Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) summary score of 01, indicating severe cognitive impairment. Section G-functional Status documented the resident required supervision/oversight for walking in room, walking in corridor and locomotion on unit assisted by set-up only. The resident required limited assistance for locomotion off unit with one person physical assistance. Section J- Health Conditions documented the resident had two (2) or more falls without injury, one (1) fall with a minor injury and one (1) fall with a major injury. The Care Area Assessment (CAA) triggered Cognitive Loss/Dementia, Visual Function and Falls with the decision to be care planned. Review of the Quarterly MDS assessment dated [DATE] documented in Section C- Cognitive Patterns that the resident had a BIMS summary score of 01, indicating severe cognitive impairment. Section G-functional Status documented the resident required supervision/oversight for walking in room,walking in corridor and locomotion on unit assisted by set-up only. The resident required limited assistance for locomotion off unit with one person physical assistance. Resident D had three (3) care plans that documented the resident's need for supervision. A Care Plan titled Visual Function documented in Approach with a start date of 1/30/14, that the resident needs supervision while ambulating in the hallway. A Care Plan titled Activities of Daily Living (ADL) Function/Rehabilitation Potential documented in Approach with a start date of 1/30/14 that the resident needs supervision and at times guided assistance while in hallway related to poor vision. A Care Plan titled Falls documented in Approach with a start date of 1/30/14 that the resident needs supervision by staff while ambulating in the hallway related to poor vision. Interview on 2/24/15 at 2:35 p.m. with the dayshift (7:00 a.m. - 3:00 p.m.) Licensed Practical Nurse (LPN) CC revealed Resident D resided on the locked behavioral unit. Resident D was a good resident but had behavior symptoms such as hollering out, and required re-direction. Resident D had a vision problem and would often fall and/or bump into things. At times the resident would walk up on other residents, which caused altercations. The facility was unaware that Resident D had a fractured jaw. An investigation was completed to figure out what happened to Resident D and when it happened. Interview on 2/24/16 at 3:20 p.m. with the evening shift (3:00 p.m. - 11:00 p.m.) Certified Nurse Assistant (CNA) GG revealed that Resident D was going blind, was a wanderer and she was a fighter. Resident D wanted attention and attention seeking was one of the resident's behaviors. Sometimes Resident D would fight when she was being re-directed. CNA GG further stated that she did not know that Resident D had a fracture. Interview on 2/24/16 at 3:25 p.m. with the evening shift (3:00 p.m. - 11:00 p.m.) LPN HH revealed that Resident D needed assistance for walking and was a wanderer. She revealed that the resident's vision was not good after she had eye surgery. LPN HH further stated she did not know what was going on with all of falls for Resident D . After each fall, the nurses would assess the resident, check vital signs, and notify the Nurse Practitioner (NP), Responsible Party (RP), and Medical Doctor (MD). Interview on 2/24/16 at 3:30 p.m. with LPN II of the 3-11 shift revealed that Resident D was none compliant, and would get up and try to walk; she would some times fall. She revealed that Resident D did not have a steady balance. She revealed that the resident fell during the morning shift. She revealed that she received a report that the Resident D fell and hit her head. She revealed that Resident D had a bruise to left eye and that her jaw was swollen because the resident had a tooth ache. She revealed that she did not know when the resident's jaw was injured. She revealed that NP and family was notified. Interview on 2/24/16 at 4:40 p.m. with Clinical Nurse LL she revealed that the Resident D was sent to the hospital emergency room and that her head was wrapped. The resident was examined that day (11/17/15) by a Nurse Practitioner (NP). Clinical Nurse LL further state that there was no swelling or discoloration noted to resident's jaw. Review of the Event Reports for Resident D revealed one (1) witnessed fall (8/13/15) without injury, seven (7) unwitnessed falls (9/8/15, 9/28/15, 10/2/15, 10/6/15, 10/7/15, 10/8/15 and 11/12/15) without injury and three (3) unwitnessed falls with injury (9/23/15, 10/13/15 and 11/9/15). On 8/13/15 at 8:00 p.m. the resident had a witnessed fall in the 200 Hall dining room. No injuries were noted and the MD was notified. On 9/8/15 at 1:02 p.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the Nurse Practitioner (NP) was notified. On 9/23/15 at 11;20 a.m. the resident had an unwitnessed fall in the 200 Hall day room. The resident sustained [REDACTED]. Review of the Resident Progress Notes dated 9/23/15 by the LPN documented the resident was laying face down with her head turned towards the side in the dining room. Moderate amount of blood on the floor next to the resident's head. Notified the NP and received orders to transfer the resident to the hospital for evaluation and treatment. Review of the Resident Progress Notes dated 9/23/15 by the LPN documented the resident returned from the hospital at 9:10 p.m. Neurochecks continued. Three (3) staples noted at the back of the resident's head. Will continue to monitor. Review of the hospital emergency room (ER) Report for Resident D dated 09/23/15 documented, in part: the resident presents from the nursing home after a fall. The resident was found on the ground. The residents states that she thinks that she was turning too quickly, at which point she lost her balance and fell . Per reports from the staff there, she was actually calling for help after she fell . The resident does report pain in the back part of her head, mild in severity. Again, it was an unwitnessed fall. Plan: resident instructed as well, in discharge note that within 12-14 days she is to have staples taken out. Diagnosis: [REDACTED]. Mechanical Fall. Procedure Note: For her laceration repair, occipital region, approximately one centimeter (1 cm) in length, linear. The staples were applied with good approximation. On 9/28/15 at 11:55 a.m. the resident had an unwitnessed fall in the in the 200 Hall day room. No injuries noted and the NP was notified. On 10/2/15 at 10:45 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. On 10/6/15 at 1:50 p.m. the resident had an unwitnessed fall in the 200 Hall hallway. No injuries noted and the NP was notified. On 10/7/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. On 10/8/15 at 11:15 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. On 10/13/15 at 1:25 a.m. the resident had an unwitnessed fall in her room. The resident received an injury to the left temporal area with complaints of pain. As needed (PRN) pain medication given. The NP was notified. There is no documentation in the report of orders received. Review of the Resident Progress Notes dated 10/13/15 at 2:25 a.m. by the LPN documented the resident was found on the floor in room. Resident stated I got up because I was hungry. Injury to the left temporal area with complaints of pain. PRN medication given and effective. Call light within reach. Will continue to monitor and NP notified. On 10/13/15 at 6:27 a.m. a LPN documented: due to fall, resident has some swelling over left eye. On 10/14/15 at 6:25 a.m. a LPN documented: swelling of left eye with bruising. Neurochecks in progress. On 10/15/15 at 6:40 a.m. a LPN documented: swelling of the left eye with bruising. Neurochecks in progress. On 10/15/15 at 9:58 p.m. a LPN documented: eye still swollen at site of fall. Discoloration of eye still present. Resident encouraged to call for help, call light within reach. On 10/16/15 at 6:40 a.m. a LPN documented: slight swelling on the left eye and bruising. Neurochecks in progress. There is no evidence of nursing progress notes from 10/17/15 through 10/23/15 and no further documentation related the injury of the left eye as a result of the fall on 10/13/15. Review of the Progress Notes dated 10/13/15 written by the Nurse Practitioner (NP) and signed by the Physician on 10/16/15 at 3:32 p.m. documented the patient has a history of repeated falls. No further evidence of visible injuries. Physical Therapy to evaluate for strengthening. Review of the Physician order [REDACTED]. On 11/9/15 at 2:15 p.m. the resident had an unwitnessed fall in the 200 Hall day room. The resident was observed on the floor. There was small bleeding area to the left side of the head and the left eye swollen. The NP was notified and neurochecks started. There is no documentation in the report of orders received. Review of the Resident Progress Notes dated 11/9/15 at 2:31 p.m. written by a LPN documented: resident was observed on the floor in the dayroom 200 Hall. Resident is agitated and could not tell why she was on the floor. Resident fighting while trying to stop bleeding to small area to left side of head. Left eye swollen. MD notified. Start neurochecks. Will continue to observe. On 11/9/15 at 10:50 p.m. a LPN documented: eye still swollen at top left eye, left jaw also still swollen at site of fall. Discoloration of eye present, noted. Signs of pain and discomfort noted at this time, Resident was given pain medication. Resident took all medications without difficulty. Resident encouraged to call for help, call light within reach. On 11/10/15 at 6:34 a.m. a LPN documented: complaints of pain, PRN medication given and effective. Left eye swollen and purple in color. Call light within reach. Will continue to monitor. On 11/11/15 at 6:09 a.m. a LPN documented: complaints of pain, PRN medication given and effective. Left eye swollen and purple in color. Call light within reach. Will continue to monitor. On 11/12/15 at 6:04 a.m. a LPN documented: Left eye swollen and purple in color. Call light within reach and will continue to monitor. There is no evidence of Progress Notes by the NP or MD after this fall. Review of the Physician order [REDACTED]. On 11/12/15 at 7;50 a.m. the resident had a fall in the 200 Hall day room. No new injuries noted but bruising and swelling to the left eye from a previous fall on 11/9/15 remained evident. The NP was notified. Review of the Resident Progress Notes dated 11/12/15 at 9:50 a.m. the LPN documented: resident observed on the floor in the 200 Hall day room by the Certified Nursing Assistant (CNA). No new injuries noted. Continue with swelling and discoloration of the right eye. NP notified. Start neurochecks. Will continue to observe. On 11/13/15 at 6:43 a.m. a LPN documented: left eye slight swelling. Call light within reach. Will continue to monitor. On 11/15/15 at 4:43 a.m. a LPN documented: resident has bruise and edema around the left eye. Encouraged to use the call light. Will continue to observe. On 11/16/15 at 1:55 a.m. a LPN documented: no complaints or pain or discomfort. Resident consumed 0% for breakfast and 0% for lunch and no liquids. Resident encouraged to eat and drink. Will continue to observe. On 11/17/15 at 12:00 p.m a LPN documented: resident noted to not have any output. Fluids pushed. NP and MD in the building, assessed the resident and stated to continue to push fluids. New order for CBC and CMP. Will continue to observe. On 11/17/15 at 2:02 p.m. a LPN documented: resident continues with no output. NP called. New order for straight catheterize. Output was 400 cc. NP notified. New order for Urinalysis (UA) with Culture and Sensitivity (C&S). Continue to observe resident for output and for next shift to call if no output. Continue to push fluids. On 11/18/15 at 6:39 a.m. a LPN documented: no output for this shift, but straight catheterize for UA output 250 cc. Left eye slight swelling. Call light within reach. Will continue to monitor. On 11/18/15 at 10:02 a.m. a LPN documented: resident had difficulty swallowing. Left eye and left jaw still swollen due to previous fall. Resident unable to eat or drink any food or fluids. No urine output. Still pushing fluids per physician orders. Weakness in upper and lower extremities, barely responsive to tactile stimuli. Unable to squeeze hands in response or follow simple commands. Stiffness in head and neck. NP notified and order obtained to transfer to the hospital for evaluation and treatment. On 11/19/15 at 6:35 a.m. a LPN documented: received call from MD of hospital stating the resident has been transferred to another hospital with a mandible fracture and will be admitted . Review of the hospital emergency room (ER) Report for resident D dated 11/18/15 at 15:07 hours documented the resident is a [AGE] year old female with a prior history of dementia, retinopathy, hypertension and epilepsy, who presents after being brought by ambulance by EMS here for difficulty swallowing. Initially EMS states the patient's last normal mental status was on Monday per the nursing staff there. The patient has noted bruising around her left eye. the patient had a fall on November 11, 2015. The patient did not go to any medical facility after this fall. The patient upon further discussion with the nursing staff, the nurse told that the patient was sent over to the ER and stated that the patient had difficulty swallowing, was not taking her med's and states that previously she had been taking her med's and this was new and thus they sent her here to be evaluated. The nurse states she talked to the Physician's Assistant (PA) at this facility and they sent her here for evaluation. The patient is legally blind, currently is oriented to person and to place, and here in the emergency department, does not verbalize any complaints. The patent has mild swelling noted in the left mandibular region as well. Cat Scan (CT) of the face showed an acute comminuted fracture of the left mandibular ramus, age indeterminate, fracture of the left orbit 11 is appreciated; however, given likely hematoma and inflammatory changes, it is likely and old injury. Diagnosis: [REDACTED]. Review of the CT Facial Bones w/o contrast report for Resident D dated 11/18/15 at 16:30 documented: The mandible is fractured at the left ramus with small comminuted fracture fragment. The remainder of the mandible is grossly intact. Impression: 1. Comminuted Fracture of the Left Mandibular Ramus. 2. Age indeterminate Fracture of the left orbit lamina papyracea. However, given the lack of Hematoma or Inflammatory stranding, this likely is old injury. 3. Left periorbital soft tissue swelling. Interview on 2/25/16 at 1:40 p.m. with Occupational Therapist NN he revealed that the resident had vision difficulty, balance problems, and that her gait fluctuates. He revealed that Resident D had a set back, a decline with her ADL about a week before going to hospital. He revealed that he did not recall any swelling in Resident D's face. He revealed that because of the decrease in Resident D ADL's, she was lethargic and had difficulty eating and drinking. Interview on 2/25/16 at 1:52 p.m. with the Director of Nursing (DON) revealed that Resident D had a fall (11/9/15) and was sent to the hospital on [DATE]. The DON said she was told that the resident had a fall with swelling to the jaw. The DON observed Resident D with swelling from left eye to the jaw. Neurological checks were conducted. X-rays are taken if ordered by the MD, however no x-rays were ordered at that time. The DON further stated according tow the Quality Assurance (QA) report, the NP reported that Resident D had a fractured jaw that occurred on 11/9/16. She revealed that the resident did not return to the facility. She revealed that there is no documentation in the Resident Ds record that indicates a fractured jaw and the facility did not know when the fracture occurred. Interview on 2/25/16 at 5:25 p.m. by telephone with the Medical Director (MD) OO revealed that he received a report from the facility on 11/17/15 that Resident D had recent falls. He revealed that a screening exam was done on the chest, and the bump on Resident Ds head. The resident was not eating or drinking and was sent to the hospital on [DATE] because of a change in her condition. The MD OO said that the resident did not have a fracture, however, he did not palpate the resident's mandible during his assessment. He revealed that there were no signs of pain in the jaw area. He revealed that the resident was checked for eye movement and that he obtained lab work. He revealed that there were no complaints of pain from the resident. The MD OO further stated there is a possibility that the fracture was there, but he did not identify one during his assessment on 11/17/15. Anytime a resident has swelling a x-ray is ordered but he was not aware that Resident D had a swollen jaw. He revealed that he did not feel that the resident's fall had anything to do with her decline in health. Interview on 3/29/15 at 8:00 a.m. with the nightshift (11:00 p.m. - 7:00 a.m.) LPN XX revealed she took care of Resident D on a regular basis. Resident D had always had poor vision. She was ambulatory but required guidance. LPN XX further stated she had seen Resident D ambulating through the hallway without staff supervision on numerous occasions and had to call for assistance to guide her back to bed. She would also find the resident in her bathroom or standing behind her bed. LPN XX stated that she provided supervision of the resident by performing every two (2) hour visual checks. At times, Resident D would already be up and out of her bed and hollering out. The resident was confused all the time. She would provide the resident with the call light button but Resident D could not see it. Once it was placed in the resident's hand she would just drop it. LPN XX revealed on 10/13/15, Resident D was found on the floor by the CNA. Upon her assessment, there was swelling to the left temporal area but no bruising at that time. She called the NP and received orders to start neurological checks and monitor for changes in condition. LPN XX said the next day, 10/14/15, the left eye was swollen and bruising appeared. She noticed swelling and bruising of the left eye through 10/16/15. LPN XX said she did not work with the resident again until 10/19/15 and she did not notice any further swelling or bruising to the resident's left eye. Interview on 3/29/15 at 8:30 a.m. with LPN YY revealed she worked with Resident D on a regular basis on the dayshift (7:00 a.m. - 3:00 p.m.). Resident D was consistently confused. Resident D was able to walk on her own but she was legally blind and required assistance. LPN YY often saw the resident wandering the halls by herself and she would immediately intervene and assist the resident with whatever her need was at that time. The staff would assist her to the 200 Hall day room so that they could better supervise her but the staff does not stay in the day room at all times. The CNA's will sit in the day room with the residents when they could and they would conduct frequent visual checks. She would try and supervise Resident D by keeping her cart close to the dayroom. LPN YY stated there was no one (1) on one (1) supervision for Resident D. The LPN is split between two (2) halls and there is only one (1) CNA assigned to that end of the hall. It was impossible to watch Resident D constantly. On 9/28/15, another resident alerted her that Resident D was on the floor in the 200 Hall dayroom. There was no staff supervision in the day room when she arrived to assess the resident. The resident did not appear to have any injuries and she reported it to the NP. LPN YY further stated she does remember the resident having bruising and swelling to the left eye in October after a fall. LPN YY revealed she was the nurse on duty when Resident had a fall on 11/9/15. The resident was found on the floor in the 200 Hall day room. There was no staff supervision in the day room when the resident fell but was sure that the CNA had just stepped out of the room. Upon her assessment, Resident D had a small open and bleeding area to the left eye and it was swollen. She said this was new bruising and swelling. The bruising and swelling from the fall in October had since subsided. LPN YY revealed that she documented the right eye in her notes on 11/12/15 and that this was an error. It was the left eye that was injured. Interview on 3/29/15 at 9:19 a.m. with the CNA ZZ revealed she worked with Resident D on a regular basis on the dayshift (7:00 a.m. - 3:00 p.m.). The CNA ZZ stated Resident D was confused and would not listen to instructions. The resident was constantly walking around her room, into other resident's rooms, in the hallways and in the 200 Hall day room. Resident D would tell the staff she could do what she wanted. She would assist Resident D in the hallway until the resident would tell her she no longer needed her help. The CNA ZZ stated they would instruct the resident to hold onto the side rails and she was able to guide herself. Some days the resident could ambulate safely by herself and other times she would bump into the walls. CNA 'ZZ further revealed the staff would try to place her in the 200 Hall day room so that they could better supervise her but the resident was all over the place. She would try and stay in the day room as much as possible but she could not provide one (1) on one (1) supervision because she had other residents to take care of. CNA ZZ said she would check on the resident frequently and she always reported to the nurse if she was in the shower room with another resident. Interview on 3/29/16 at 11:05 a.m. with the Nurse Practitioner (NP) revealed the nursing staff did report to her when the resident had a fall. If the fall was unwitnessed with no injuries she would tell the nurse to start neurological checks and monitor the resident for any changes in condition. The NP stated she reports all falls to the MD. The NP revealed that she does remember the resident had an injury in the past that required staples to her head and she was sent to the hospital. The NP further stated that she is in the facility every Tuesday either by herself or with the MD. If the nature of an injury after a fall was minor, she would assess the resident on the next Tuesday visit. She does not remember seeing any bruising or swelling to the resident's left eye on any of her assessments after the resident had a fall in October or November. An interview was conducted on 3/29/15 at 11:26 a.m. with the Administrator and the DON. The Administrator said the staff try to monitor and supervise the resident closely but there has never been one on one supervision for Resident D. When the CNA's have any down time, they will sit in the day room with the residents but they cannot be in there all the time. As soon as the staff would leave Resident D, within minutes she would get out of the chair and start walking around. The DON revealed Resident D wanted to be independent and whatever they would tell her to do, she would do the opposite. They did not provide one on one supervision and the minute they would turn their back, the resident was walking around again.