Every finding on record at Heritage Place of Decatur

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 residents (Resident #1, Resident #2, and Resident #3) of 10 residents reviewed for infection control. The LPC, who was a vendor at the facility, failed to use appropriate PPE according to the facility's IPCP when visiting Residents #1, #2, and #3, who were on isolation precautions with confirmed COVID. This failure could place residents at risk for spread of infection through cross-contamination.Findings included: Resident #1Record review of Resident #1's Quarterly MDS Assessment, dated 12/04/25, reflected the resident was an [AGE] year-old female who was admitted to the facility on [DATE]. She had a BIMS score of 14, which indicated her cognition was intact. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 1's active diagnoses included Alzheimer's Disease (brain disorder that affects memory, thinking, and behavior), depression (a mood disorder that causes persistent feelings of sadness and loss of interest), seizure disorder (chronic neurological disorder that causes recurrent changes in movement, behavior, and consciousness), and respiratory distress (difficulty breathing). Record review of Resident #1's Care Plan, revised 02/24/26, reflected the resident had an acute care plan for COVID-19 infection with interventions that included: allowing the resident to get rest, encouraging fluids, encouraging covering mouth when sneezing and coughing, ensuring infection control measures and PPE is used during care, staying in room and away from people as much as possible, and monitoring labs. Resident #2Record review of Resident #2's Quarterly MDS Assessment, dated 02/05/26, reflected the resident was a [AGE] year-old female who was readmitted to the facility on [DATE]. She had a BIMS score of 14, which indicated cognition was intact. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 1's active diagnoses included hypertension (high blood pressure), viral hepatitis (inflammation of the liver), bipolar disorder (chronic mood disorder that cause extreme mood swings), and asthma (chronic respiratory disease). Record review of Resident #2's Care Plan, revised 02/24/26, reflected the resident had an acute care plan for COVID-19 infection with interventions that included: allowing the resident to get rest, encouraging fluids, encouraging covering mouth when sneezing and coughing, ensuring infection control measures and PPE is used during care, staying in room and away from people as much as possible, having oxygen available as ordered, and monitoring vital signs. Resident #3Record review of Resident #3's Quarterly MDS Assessment, dated 01/26/26, reflected the resident was a [AGE] year-old male who was readmitted to the facility on [DATE]. He had a BIMS score of 13, which indicated cognition was intact. The MDS Assessment under Section I-Active Diagnoses, reflected Resident # 1's active diagnoses included hypertension (high blood pressure), anemia (deficiency of red blood cells), diabetes mellitus (the body's inability to regulate blood sugar levels), bipolar disorder (chronic mood disorder that cause extreme mood swings), and asthma (chronic respiratory disease). Record review of Resident #3's Care Plan, revised 02/26/26, reflected the resident had an acute care plan for COVID-19 infection with interventions that included: allowing the resident to get rest, encouraging fluids, encouraging covering mouth when sneezing and coughing, ensuring infection control measures and PPE is used during care, staying in room and away from people as much as possible, having oxygen available as ordered, listening to lung sounds, and monitoring vital signs. In an observation on 02/27/26 at 8:45 AM, the facility had a sign on the front door that alerted all visitors that the facility had experienced a case of COVID-19 in the last 14 days and masks were required. In an observation on 02/27/26 from 10:42 AM-10:45 AM, the LPC visited with Resident #1 and Resident #2 in their room, which had been designated an isolation room. He then visited Resident #3, who was also in an isolation room. The LPC only wore a cloth face mask when visiting with the residents. He did not put on any of the PPE that was available outside of each isolation room. Each resident's room was also observed to have a sign on the door that informed staff and visitors of the appropriate PPE and precautions to take when entering the room. In an interview on 02/27/26 at 10:45 AM, the LPC stated he noticed the signs at the front door and on resident doors, but he did not read them thoroughly. He stated when he entered the facility, he was not informed by staff that there was a COVID outbreak or informed to wear PPE. The LPC stated he was there to provide counseling services to a few of the residents who happened to be on the isolation hall, and that was how he realized there was an outbreak. The LPC stated he was looking for someone to advise how to proceed. In an interview on 02/27/26 at 10:52 AM, the Administrator stated the facility followed their policy and the CDC guidelines regarding isolation precautions and infection control for COVID. She stated there was currently a COVID outbreak at the facility and they were unsure of the root cause. The Administrator stated it was the facility's policy for contracted workers or vendors to read the posted signs and abide by the policy and procedures. The Administrator stated family members were the only visitors who were encouraged to follow the policy but could not be forced to do so, according to state guidelines. The DON stated the LPC was immediately educated on the facility's infection control policy and told to wear PPE when entering isolation room. The DON also stated she began in-servicing staff on correcting vendors who were not following protocol and reporting to the DON and Administrator. In an interview on 02/27/26 at 3:12 PM with the ED and DON, the DON stated the expectation was for all vendors to follow the facility's infection control policy the same as staff. The DON stated vendors not following the infection prevention policy and isolation precautions could place residents at risk of infection. The Administrator stated the facility followed stated regulations by posting signs at the front door of the facility and on each of the isolation rooms to alert everyone of the COVID outbreak and appropriate protocols. The Administrator revealed it was expected that everyone would read the signs and follow appropriate protocols. Record review of an in-service titled Vendors, dated 02/27/26, reflected staff were educated on informing vendors in the facility to follow policies related to isolation precautions and infection prevention and reporting to the DON or Administrator. Record review of the facility's Infection Control Plan: Overview policy, dated March 2024, reflected the following: Infection ControlThe facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Infection Control ProgramThe facility will establish an Infection Control Program under which it - Investigates, controls, and prevents infections in the facility. Decides what procedures, such as isolation, should be applied to an individual resident; and maintains a record of incidents and corrective actions related to infections.Preventing Spread of InfectionWhen the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility will isolate the resident.The facility will require staff to [NAME] and Doff PPE before and after contact with resident who needs isolation to prevent the spread of infection to others in the facility. Review of the Center for Disease Control and Prevention website, <https://www.cdc.gov/covid/hcp/infection-control/index.html>, updated 06/24/24, reflected in part the following.Personal Protective EquipmentHCP who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) VisitationFor the safety of the visitor, in general, patients should be encouraged to limit in-person visitation while they are infectious. However, facilities should adhere to local, territorial, tribal, state, and federal regulations related to visitation. Additional information about visitation from the Centers for Medicare & Medicaid Services (CMS) is available at Policy & Memos to States and Regions | CMS.Counsel patients and their visitor(s) about the risks of an in-person visit.Encourage use of alternative mechanisms for patient and visitor interactions such as video-call applications on cell phones or tablets, when appropriate.Facilities should provide instruction, before visitors enter the patient's room, on hand hygiene, limiting surfaces touched, and use of PPE according to current facility policy.Visitors should be instructed to only visit the patient room. They should minimize their time spent in other locations in the facility.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen and failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated for food service safety in the facility's only kitchen. 1. The facility failed to ensure the deep fryer was cleaned in accordance with professional standards. 2. The facility failed to ensure food items was properly labeled, dated, and thawed in accordance with professional standards. 3. The facility failed to ensure food items stored in the freezer were properly discarded. These failures could place residents at risk from food contamination and food-borne illness. Findings included:Observation on 09/28/25 at 9:08 AM, revealed the deep fryers was layered in grease with food spills and food particles. Observation on 09/28/25 at 9:11 AM, of the refrigerators revealed the following: - a plastic container with pineapple slices, with no label or date; - three packages of cheese in sealed plastic bags with no label or date; - ham in a sealed plastic bag with no label or date; - a clear bag of lettuce that was unsealed and did not have a label or date; and -facility's refrigerator revealed an unopened ham lying in the opened case of petite tomatoes. Observation on 09/28/25 at 9:19 AM, of the facility's freezer revealed the following: -Cookie dough that had been thawed and refrozen because it had freezer shelf lines. The cookie dough was in a clear plastic bag and was not sealed properly, and the bag was not labeled or dated. - A sealed plastic bag with frozen chicken was unlabeled and undated in the freezer as well. - A large plastic bucket with a red frozen substance and a large knife sticking out of it was also in the freezer with no label or date. Observation on 09/28/25 at 9:21 AM, of the facility's kitchen area revealed a case of unopened defrosted breaded cauliflower on the floor. Interview on 09/28/25 at 9:25 AM, [NAME] A revealed he had been employed at the facility about two months as the weekend cook. [NAME] A stated the facility policy was that he should be wearing a beard guard. [NAME] A said he forgot to put his beard guard on that morning. He stated not wearing a beard guard could cause hair to get into the residents' food. [NAME] A stated beard nets was available for the staff. He stated the case of unfrozen cauliflower had been taken out of the freezer during a morning shift on another day and then had been left lying in the floor and had defrosted. He revealed he forgot to throw it out. [NAME] A stated all foods placed in refrigerators and freezers should be labeled, dated, and sealed in plastic bags or containers. He also said serving unlabeled and undated food to residents was dangerous because it could be spoiled and could cause residents to get sick. He stated he was unsure of the contents of the red substance in the freezer with knife in it or who or when it was placed in the freezer. He revealed the ham lying in the case of cherry tomatoes could have led to cross contamination. [NAME] A said he was unsure when the deep fryer had last been cleaned. He stated foods in refrigerators should be on the correct shelving when thawing, and it was the Cook's responsibility to ensure that it was done correctly to prevent cross contamination. He revealed all staff in the kitchen should be wearing hair nets as well as beard guards if they have facial hair. He also said that the deep fryer should be cleaned by the cook. [NAME] A revealed all these items should have been reported to the Dietary Manager when he arrived to work. He stated he could not recall his last in-service. Interview on 09/29/25 at 9:21 AM, the Dietary Manager revealed he had been employed at the facility for about four months. The Dietary Manager stated he was scheduled to start the Certified Dietary Manager class on 10/10/25. The Dietary Manager said that staff should all be wearing hair nets and beard guards if they had facial hair to prevent cross contamination of food. The Dietary Manager revealed he last opened and reviewed the contents of the refrigerators and freezers on 09/25/25. The Dietary Manager revealed the policy on opened items was they should have the date they were opened, the name of the item, the date it expired, and the person's initials who put it in the container or sealed plastic bag. The Dietary Manager said that all items must be in sealed containers or sealed plastic bags. The Dietary Manager also revealed that who is responsible for labeling the items correctly would be the individual who pulled the item out of the refrigerator or freezer. The Dietary Manager said the red substance in the freezer with a knife in it was frozen gelatin, and he did not know who or why a knife was placed in it in the freezer. The Dietary Manager revealed he was responsible for ensuring the facility's policies was followed correctly. The Dietary Manager stated he was informed about the case of cauliflower on Saturday. He stated he was unsure about when it was taken out of the freezer and left out. He said he instructed staff to throw it away on Saturday morning. He stated the cookie dough should not have been refrozen after thawing. He stated unlabeled, undated, unsealed items, no beard guards, foods left out of the freezer, and refrozen items could all lead to food poisoning and other food borne illnesses which could make residents sick. The Dietary Manager said it was everyone's responsibility to properly label, date, and store items correctly as well as wear the appropriate hair nets and beard guards. The Dietary Manager also revealed after every meal the deep fryer and other equipment should be wiped down after every meal as part of the cleaning process. The Dietary Manager said he did have access to the facility's dietary policies. The Dietary Manager revealed it was his responsibility to ensure all dietary policies were properly in place and followed. The Dietary Manager stated he last provided an in-service training to his staff about a month ago. A copy of the in-service was requested; however, the in-service record was not provided to the survey team. Interview on 09/29/25 at 1:19 PM, [NAME] B revealed she had been employed at the facility for eight years and worked Monday through Thursday. She stated the facility policy was to throw away all fried foods into the trash after they are cooked as well as all frozen foods that was left out and defrosted. She stated the facility policy was when something was defrosted, it could not be refrozen. She stated she was unaware of the frozen red substance in the freezer with the knife in it and said she had not seen it in the freezer when she worked her last shift. [NAME] B then said that baked foods and other types of items that are stored in the refrigerator and the freezer should be labeled and dated for seven days from the date they are placed in the refrigerator or freezer and in a sealed container or sealed plastic bag. She revealed the facility policy was to clean all equipment after each meal served. She stated meat should never be stored on top of vegetables because it could contaminate the vegetables. She stated meat should be put in a pan and defrosted in a pan alone. She revealed all hair should be covered or shaved so no hair would get into the food and that it was everyone's responsibility. She stated all these policies were to prevent residents from getting sick. She stated if she saw these items, she would report them to the Dietary Manager. Interview on 09/29/25 at 1:32 PM, the Corporate Traveling CDM revealed she had trained the Dietary Manager twice for four days each time. The Corporate Traveling CDM stated foods should be placed in a food grade sealed container and labeled with its name, date opened and use by date when placing the items in refrigerators. The Corporate Traveling CDM also stated food should not be refrozen after it was defrosted. The Corporate Traveling CDM said that the ham should not have been placed on the cherry tomatoes due to cross contamination risk. The Corporate Traveling CDM explained that there is signage in the kitchen that shows what shelf everything should be on in refrigerators to prevent food borne illnesses. The Corporate Traveling CDM stated frozen breaded cauliflower should stay in the freezer until time to be fried or baked. The Corporate Traveling CDM continued by stating that the [NAME] should be wiped down after every shift. Finally, The Corporate Traveling CDM stated staff should be wearing hair nets and beard coverings, if they have facial hair, in the kitchen. Record review of undated facility policy, Food Storage and Supplies, reflected: All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects.4. Open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened. 10. Frozen items that should be thawed before preparation should be stored under refrigeration until thawed and should be dated with the date removed from the freezer and used within 7 days. Some items that are nearing expiration may be frozen prior to expiration to preserve food safety and should be dated when removed from freezer to maintain proper time frame for food safety.If a frozen food does not have an expiration date or a dated shipping label it will be dated when received or is removed from original packaging. Record review of the facility's Dietary Service Policy and Procedure Manual, revised 04/09/25, reflected: Policy: We will ensure that all employees practice infection control in the Food and Nutrition Services Department, and maintain sanitary food preparation. Procedure:.5. All kitchenware and food contact used in the preparation and/or serving of food are cleaned and sanitized before use and cleaned after each meal preparation. Record review of the Federal Drug Administration Food Code, dated 2017, section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils reflected the following: .(A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris Section 3-305.11 Food Storage. (A) Except as specified in (B) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under S 4-204.122. 3-305.14 Food Preparation. During preparation, UNPACKAGED FOOD shall be protected from environmental sources of contamination. 3-307.11 Miscellaneous Sources of Contamination. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. 92 3-501.13 revealed Thawing: TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at .(41 [degrees] F) or less; or (B) Completely submerged under running water: (1) At a water temperature of . (70 [degrees] F) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow. The facility was asked to provide its policy regarding the defrosting of food; however, the policy was not provided to the team prior to exit.

Based on interview and record review the facility failed to implement its advance directives policy regarding obtaining and placing advanced directives in the clinical record for 1 of 4 residents (Resident #9), reviewed for do not resuscitate status. The facility failed to upload Resident #9's OOH DNR to her clinical record to ensure all staff were aware of her elected resuscitation status. This failure could place residents at risk of not having their end-of-life wishes honored.Findings included: Record review of Resident #9's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The residents' diagnoses included respiratory failure, and she had severe cognitive impairment with a BIMS score (mental assessment) of 5. Record review of Resident #9's care plan initiated on [DATE] and revised on [DATE] reflected the resident was a full code status. The care plan interventions included initiating BLS CPR if the resident was without a heartbeat or not breathing. Record review of Resident #9's [DATE] physician orders reflected there was an order for a OOHDNR with a start date of [DATE]. Interview on [DATE] at 2:34 PM, the Social Worker revealed she worked at the facility two days a week and she and the nurses was responsible for ensuring each resident's clinical record had the appropriate advanced directives in place. The Social Worker said Resident #9's family was undecided if they wanted the resident to be a DNR, so the resident was to remain a full code. The Social Worker further stated no one had communicated to her that the resident had become a DNR. Interview on [DATE] at 11:17 AM, the ADON revealed they had asked Resident #9's family about the resident's code status, and initially the family did not want the resident to be a DNR status. After the resident had a hospital stay, Resident #9's family elected for the resident to have a DNR status. The ADON stated Resident #9's family member told the facility staff they had given the OOHDNR to a nurse. The family member could not tell them which nurse, so they asked the family member to bring them another copy of the DNR. She stated she was not aware the OOHDNR had not been uploaded to the resident's clinical record. Interview on [DATE] at 1:34 PM, the DON revealed Resident #9's family was initially undecided whether they wanted the resident to be a DNR. She stated that after the resident came back to the facility following a hospital stay, the family decided the resident would be a DNR status. The order for the DNR was put in the system on [DATE], and the resident's family emailed her a copy on [DATE]. The DON stated she forgot to upload the OOHDNR to Resident #9's clinical record. She stated it was important to have the document in the clinical record to ensure they did right by the resident's wishes. Record review of the facility's current, undated Self Determination End of Life Measures policy reflected the following: .Policy.3. If the resident has already executed advanced directive, the facility will obtain a copy and place it on the clinical record.

Based on observations and interviews, the facility failed to provide comfortable and safe temperature levels between 71 to 81 degrees Fahrenheit for 3 of 8 residents (Residents #11, #15, and #38) reviewed for environment.The facility failed to maintain comfortable temperature levels in Residents #11, #15, and #38's rooms.The failure placed residents at risk of a decreased quality of life. Findings included: Observations on 09/28/25 from 10:00 AM-10:30 AM revealed Resident #38 was sitting in his wheelchair in his room with a blanket wrapped around him. Observation on 9/28/25 at 10:10 AM, Resident #15 was sitting in her recliner in her room with a thick jacket on with a heavy blanket covering her.Observation on 9/28/25 at 10:30 AM, Resident #11 in bed with multiple blankets covering her. Observation om 9/28/25 at 10:20 AM of the thermostat in Hall A revealed it was set to 72 degrees F and Cooling. Observation of temperatures, using an ambient thermometer 0n 9/28/25 room temperatures were as follows:At 10:35 AM Resident #38's room temperature was 70 degrees F.At 10:40 AM Resident #15's room temperature was 69 degrees F.At 10:47 AM Resident #11's room temperature was 70 degrees F. Interview on 09/28/25 at 10:00 AM, Resident #38 revealed at night his hands got so cold he could not stand to touch himself anywhere. Interview on 09/28/25 at 10:23 AM, Resident #15 revealed she had to wear her down jacket all the time because her room was always too cold. She stated she also slept with a heavy comforter on her bed at night because of the cold. Interview on 09/28/25 at 10:30 AM, Resident #11 revealed the facility got very cold at night, and she had to keep asking the staff to get her another blanket. She stated sometimes she had 3-4 blankets on her by morning. When she asked staff to turn up the heat, they told her they were not allowed to. Interview on 09/28/25 at 12:48 PM, the Maintenance Director revealed staff was complaining the facility was too warm in the morning, so he turned the thermostat down to 72 degrees from 74 degrees. He stated he tried to keep the temperatures between 70 and 75 degrees. He stated the standard was to keep the temperature between 71 and 81 degrees. He stated the residents needed a comfortable environment to promote well-being. He stated residents having to use extra blankets or winter coats to keep warm was not acceptable. The Maintenance Director stated he would adjust the thermostat.Interview on 09/28/25 at 2:15 PM, CNA C revealed some residents was cold and some was hot. She stated for residents, who was cold, she would cover them up and try to keep their door shut to keep warm air in. She stated she had told Maintenance about it, and they had been told not to touch the thermostats because they must stay in a certain range. She stated Residents #15 and #38 was always complaining of it being cold.Interview on 09/29/25 at 2:00 PM, the DON revealed staff was busy running around, and they sometimes did not notice that residents who was not so active could be cold. She stated it was important to make sure the residents was comfortable as the facility was their home.Interview on 09/30/25 at 3:15 PM, the Regional Nurse Consultant revealed the facility addressed room temperatures and followed the federal regulations, but they did not have a policy about room temperatures or homelike environment.

Based on observation, interview, and record review, the facility failed to coordinate assessments with the PASRR program under Medicaid in subpart C of this part to the maximum extent practicable for 2 of 5 residents (Residents #6 and #29) reviewed for PASRR Level 1 screenings.The facility did not correctly identify Resident #6 and #29 as having a mental illness and did not complete a new PASRR Level 1 Screening.These failures could place residents at risk of not being evaluated for PASRR services.Findings included:Record review of Resident #6's Quarterly MDS Assessment, dated 09/01/25, reflected the resident was a [AGE] year-old female initially admitted on [DATE] and re-admitted on [DATE]. Her diagnoses included: schizophrenia (disruptions in thought processes, perceptions emotional responsiveness, and social interactions), bipolar disorder (is a mental illness that causes clear shifts in a person's mood, energy activity levels, and concentrations), anxiety disorder (a condition that occurs when there is dread, worry, or fear that is out of proportion to the situation), and major depressive disorder (a mood disorder causes a persistent feeling of sadness and loss of interest for at least two weeks). Record review of Resident #6's care plan, dated 09/29/25, reflected the resident's diagnoses included schizophrenia, bipolar, and depression for which she was currently taking medications. Record review of Resident #6's PASARR Level 1 Screening, dated 12/09/21, reflected she did not have mental illness. Interview on 09/29/25 at 10:25 AM, the MDS Coordinator revealed she had been employed at the facility for about three years. The MDS Coordinator stated Resident #6 was admitted to the facility with a negative Level I PASARR screening and a diagnosis of schizophrenia. The MDS Coordinator stated a new Level I should have been completed due to the resident's mental illness diagnoses. The MDS Coordinator said not having an accurate Level I prevented Resident #6 from possibly receiving PASARR special services. The MDS Coordinator said it was her responsibility to ensure PASARR screenings was completed and accurate. The MDS Coordinator stated they did not review residents' charts to ensure PASARR documents was updated and accurate. The MDS Coordinator stated she should report any issues to her corporate manager. The MDS Coordinator said she was in-serviced about 3-4 months ago on PASARR. Interview on 09/29/25 at 10:45 AM, the DON revealed Resident #6 should have a positive PASARR based on her mental illness diagnoses. The DON stated it was the MDS Coordinator's responsibility to complete an accurate PASARR and any additional forms such as Form 1012. The DON continued by stating that inaccurate PASARRs affected residents by possibly preventing them from receiving PASARR services. The DON stated the DON and the MDS Coordinator reviewed diagnoses in their daily stand-up meetings so they knew what needed to be completed and what services could be offered. The DON could not recall the last time the MDS Coordinator was in-serviced on PASARR.Record review of Resident #29's quarterly MDS assessment reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included anxiety disorder, depression, and bipolar disorder. Resident #29's cognition was intact with a BIMS score of 15.Record review of Resident #29's care plan initiated on 11/25/25 reflected she had a mood problem related to the disease process of bipolar major depressive disorder. Interventions included to monitor/record/ report to MD mood patterns of signs and symptoms of depression, anxiety, said mood, as per facility behavior monitoring protocols. Record review of Resident #29's PASARR Level 1 Screening dated 11/07/22 reflected NO had been answered on question C0100 where it asked if there was evidence or an indicator that this was an individual that had a mental illness. Interview on 09/30/25 at 11:15 AM, the MDS Nurse revealed she was working at the facility at the time Resident #29 transferred from another facility. The MDS Nurse said she was responsible for completing and reviewing the PASRR Level 1 Screenings and she did not realize the screening had been marked NO on the question that asked if the resident had a mental illness. The MDS Nurse stated Resident #29 should have had another PASARR Level 1 Screening had she noticed the mental illness questions was answered wrong, so the resident could have had a PASARR Level II evaluation. The MDS Nurse further stated it was important to make sure the PASARR screenings were correct to ensure all the residents had access to PASRR services. Record review of the facility's PASARR Level 1 Screen Policy and Procedure, revised 03/6/19, reflected: Policy: It is the policy of Creative Solutions in Healthcare facility to obtain a PL1 screening form from the RE (referring entity) prior to admission to the NF. The PL1 will be submitted via [PASRR system] timely per PASRR Regulator timeframes. PASRR is a federally mandated program requiring all states to prescreen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payor source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible. PASRR Program has 3 Goals:1. To Identify individuals with MI, ID, or DD/RC (this includes adults and children);2. To ensure appropriate placement, whether in a community or in a NF;3. To ensure individuals receive the required services for their MI, ID, or DD.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #11) reviewed for comprehensive care plans. The facility failed to ensure Resident #11's psychosocial needs was identified in her care plan. This failure could place residents at risk of not receiving the care they need. Findings included:1.Record review of Resident #11's admission MDS, dated [DATE], reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included anxiety disorder, depression, psychotic disorder, and schizophrenia. The resident's cognition was intact with a BIMS score of 15. Record review of Resident #11's care plan, dated 08/16/25, reflected it addressed the resident's use of anti-psychotic medications related to schizophrenia but did not specifically address her diagnosis of schizophrenia, which would include goals and interventions. Interview on 09/30/25 at 12:34 PM, the MDS Coordinator revealed she was responsible for ensuring care plans were complete and up to date. She learns of new issues that need to be added to a resident's care plan during the facility's Standards of Care meetings. She stated it was important to have accurate care plans, so the residents have all their needs met. Interview on 09/30/25 at 2:34 PM, the DON revealed accurate care plans were necessary to ensure each resident received the appropriate care, and their needs were being met. Record review of the facility's current, undated Comprehensive Care Planning policy reflected: The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the 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 comprehensive assessment.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #9) observed for wound care. RN D failed to sanitize his hands between gloves changes when providing wound care for Resident #9.The failure placed residents at risk for infection.Findings included: Record review of Resident #9's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The residents' diagnosis included respiratory failure. Resident #9 had a BIMS of 5 which indicated the resident had severe cognitive impairment. The MDS further reflected Resident #9 was at risk of developing pressure ulcers/injuries.Record review of Resident #9's care plan revised on 09/22/25 reflected that she had a pressure ulcer to her left heel. Interventions included to clean left heel with wound cleanser, pat dry, apply thin layer Iodosorb to gauze, place on open wound and cover with dry dressing daily and as needed. Record review of Resident #9's September 2025 physician orders reflected the following: Woundcare: left heel: Clean left heel with wound cleanser, pat dry, apply thin layer of iodosorb to gauze, place on open wound. Cover with dry dressing. Change daily and prn. every day shift for woundcareObservation on 09/29/25 at 9:37 PM, revealed RN D had all the wound care supplies set up on Resident #9's bedside table to treat the wound on Resident #9's left heel. The supplies included hand sanitizer. CNA E was assisting RN D, and she held up Resident #9's left foot. Both RN D and CNA E was wearing a gown and gloves. CNA E took the resident's sock off, while RN D took the old bandage off the resident's left heel and threw it in the trash bag. RN D then took off his dirty gloves and applied new ones without sanitizing his hands. RN D next cleansed the wound with wound cleanser. Afterwards, RN D removed his dirty gloves and applied new gloves, without sanitizing his hands. RN D then got a new bandage and applied a thin layer of Iodosorb (an antimicrobial gel) to the bandage and placed the bandage on the resident's left heel. Next, RN D put Resident #9's sock back on her left foot, removed his gloves, and applied hand sanitizer to his hands. Interview on 09/29/25 at 3:13 PM, RN D revealed hand hygiene should be done before starting wound care, any time gloves were removed, before new gloves was put on, and when wound care was complete. When asked about Resident #9's wound care procedure, he said he thought he had used hand sanitizer in between his glove changes. RN D said it was important to sanitize his hands during wound care to keep from spreading bacteria and cross contamination. Interview on 09/30/25 at 11:12 AM, the ADON revealed hand hygiene should be performed before starting wound care, after removing dirty gloves and before applying new gloves and when the treatment is done. The ADON said it was important to perform hand hygiene during wound care to prevent germs and infection to the wound. Interview on 09/30/25 at 1:34 PM, the DON revealed hand hygiene should be performed before the wound care procedure, each time gloves were changed, and after the treatment was completed. The DON said hand hygiene was important to prevent infections and cross contamination. Record review of the facility's Pressure Injury: Prevention, Assessment and Treatment policy, revised 05/05/25, reflected the following: Procedure1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. Record review of the facility's undated Dressing Change Checklist the nurses are to follow reflected the following: .Preparation for Dressing ChangeWashes hands.Dressing RemovalWashes hands prior to applying gloves, when changing gloves and upon removal of gloves throughout the dressing procedure. Changes gloves and wash/sanitize hands after removal of dressing.Cleansing Wound (Clean Technique) .Applies new gloves and cleanses wound per orders and facility policyChanges gloves and wash/sanitize hands Dressing Application (Clean Technique)Open dressings and then applies new gloves.When completed reposition patient remove gloves and wash hands.

Based on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly group meeting for 12 of 12 confidential residents reviewed for resident council. The facility failed to provide a private space for resident group meetings. This failure could place residents, who attended resident group meetings, at risk of not being able to voice concerns due to a lack of privacy. Findings included: Observation and interview on 08/07/24 beginning at 10:05 AM, during a confidential resident group meeting with 12 residents, revealed the meeting was held in the front lobby of the facility near the front door and the Administrator's office door. During this meeting, there were two signs posted. However, multiple staff walked through the space as well as people from the community. One resident stated she did not feel comfortable talking about issues due to staff and administration interrupting the meeting as well as when they have their monthly meetings. Interview on 08/08/24 at 03:54 PM, the Activity Director revealed she became the AD on 08/05/24. She stated she was responsible for organizing the resident council meetings. She stated the resident council meeting should be held in a private area. She said she asked the residents where they would like to hold the meeting on 08/07/24. She stated the Resident Council President told her a vote was taken, and the residents voted to have the meeting in the lobby which was near the front door and the Administrator's door. The Activity Director stated before the meeting began on 08/07/24, she posted two signs that read, Resident Council Meeting in Process and This is Where They Chose to Have It. The Activity Director stated she posted the signs in spots near the residents' group meeting. The Activity Director said the next resident council meeting would be held in an area that allowed for the residents' privacy. The Activity Director revealed the risk to the residents was that the residents were not comfortable or able to voice their concerns in an open area where staff could hear them. Interview on 08/08/24 at 6:19 PM, the Administrator revealed the resident council meeting was supposed to be held in a place of privacy. The Administrator stated it was the Activity Director's responsibility to ensure the meeting was held in a private area. The Administrator said that she had not received complaints about the meeting not being held in a private location. The Administrator stated she would ensure the residents had a private area for next month's resident council meeting. Record review of the resident council minutes revealed no requests for a private area. Record review of Resident Council policy dated 12/13/16 revealed: The facility will provide the resident council with private space .

Based on observation, interview, and record review, the facility failed to ensure that menus were followed for 1 of 5 meals (breakfast [08/07/24]) reviewed for meal accuracy. The facility failed to follow the menu for breakfast on 08/07/24. This failure could place residents at risk for poor intake and weight loss. Findings included: Record review for breakfast menu for 08/07/24 reflected the following: Choice of juice, hot or cold cereal, fresh pasteurized eggs, bacon or sausage, breakfast bread, margarine/jelly, milk, coffee. Interview on 08/07/24 beginning at 10:05 AM, during a confidential resident group meeting with 12 residents, revealed residents were told they could not have eggs for breakfast on 08/07/24 because the kitchen was out of eggs. Observation of the kitchen on 08/07/24 at 11:29 AM revealed the kitchen had no eggs to serve for breakfast on 08/07/24. However, further observation revealed the foodservice company did deliver the eggs on 08/07/24 at 11:45 AM. Interview on 08/07/24 at 11:35 AM with the Dietary Manager revealed she had been employed for three months at the facility. She stated it was her responsibility for ordering food. She stated the kitchen had run out of eggs the previous day and could not provide residents with eggs for breakfast on 08/07/24. Interview on 08/08/24 at 6:23 PM with Administrator revealed that based on the facility's census, the dietary manager knew how much of each item to order per recipe to ensure that enough food is cooked for the residents. Record review of undated dietary services policy and procedure manual 2012 titled, Preparation Of Foods revealed . We will establish safe and nutritional preparation of food. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value.

Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 washing machine (Washer A) of 2 reviewed for essential equipment. The facility failed to maintain a laundry washing machine (Washer A) in operating condition. This failure could place residents at risk of not having clean linen for their beds. Findings included: Interview on 08/08/24 at 9:40 AM, Resident #39 stated the facility seemed to have a problem keeping up with linen. He stated a week prior he had to sleep on six bath towels after he had soiled his linen and staff said there were no clean sheets available. Resident #39 stated as President of the Resident Counsel he talked with all the residents, several of whom reported delays in getting their clothing back from laundry and a shortage of linen, especially on the weekends. Interview on 08/08/24 at 10:00 AM. the Laundry Aide stated one washing machine (Washer A) was out of service for a part on order, leaving her with one functioning washer. She stated the washer had been out of service for two months at least. The Laundry Aide stated linen took priority over resident clothing. She stated she has had to take clothes to the laundry mat sometimes in order to keep up. Interview on 08/08/24 at 10:30 AM, the Maintenance Specialist stated the washing machine had been out of service since April 2024. He stated the two inlet valves were coming from overseas and had not been delivered yet. He stated he kept checking in with the supplier for updates. He supplied an email chain detailing his conversations with the supplier. Record review of email chain provided by the Maintenance Specialist reflected: 04/25/24 - Area Maintenance Specialist inquired about the part, requested two parts. 04/26/24 - Supplier acknowledge the order 04/30/24 - Maintenance Specialist asks for update on order. Supplier did not know, part comes from Spain. 05/21/24 - Maintenance Specialist asks for another update. Supplier had no answer, still waiting for manufacturer. 06/10/24 - Maintenance Specialist asks for another update. Interview on 08/08/24 at 5:00 PM, the Administrator stated she was aware of the washing machine being out of service. She stated when the laundry staff get behind, she supplies them with money to go to the local laundry mat to wash resident clothes. The Administrator stated laundry staff seemed to be able to keep up with the linen as she had not had any complaints of being short on linen. She had not spoken to Corporate about possibly replacing the machine due to delays in getting replacement parts.

Based on observation, interview, and record review, the facility failed to ensure at the time each resident was admitted the facility had a physician order for the resident's immediate care for 1 of 1 resident (Resident #43) reviewed for residents receiving care and services upon admission. The facility failed to ensure Resident #43 had a current physician's order for use of an indwelling catheter as well as its treatment and maintenance after readmission to the facility. The failure could place residents atresidents at risk for not receiving the necessary care and services. Findings included: Review of Resident #43's admission record dated 08/08/24 reflected the resident was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses that included unspecified fracture of left femur, unspecified fracture of right wrist and hand, vascular dementia, and retention of urine. Review of Resident #43's admission MDS assessment, dated 07/17/24, reflected a BIMS score was 00 indicating severely impaired cognition. Her functional status indicated she was dependent on staff for toileting. The MDS assessment indicated Resident #43 admitted with an indwelling catheter. Review of Resident #43's care plan, dated 08/08/24, reflected the resident was incontinent. The care plan reflected: Resident has bladder incontinence. Goals: Resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Incontinent: care at least q2h and apply moisture barrier after each episode. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever chills, altered mental status, change in behavior, change eating patterns. Monitor/document report to MD PRN possible medical causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, stroke, medication side effects. and report signs of urinary tract infection to physician. Review of Resident #43's undated physician orders reflected no physician orders for a urinary catheter. Observation and interview on 08/07/24 at 2:08 PM, Resident #43 was in her room in her bed r resting. Resident #43 had a catheter line with clear yellow fluid draining into her foley drain bag which was covered by the privacy cover. Resident stated that she had no urinary pain. Interview on 08/07/24 at 02:50 PM, LVN A revealed Resident #43 entered the facility with a catheter. LVN A stated that she did not remember checking to see if there was an order for the catheter, and assumed there was an order. LVN A revealed that there should be an order for all catheters including the gauge of the catheter as well as an order to change it. LVN A also said that it was the admitting nurse's responsibility to input the order for the catheter when a resident comes to the facility with the catheter in place. LVN A revealed it was all oncoming nurses' responsibility to verify that there were orders for Resident #29's catheter. LVN A also stated that without orders to document input/output of urine, there is a risk that the nurse will not know if the catheter is flowing properly. LVN A revealed there is a risk of infection if the resident's catheter is not changed. Interview on 08/07/24 at 03:08 PM, the ADON revealed that Resident #43 did not have physician's orders for a catheter. The ADON stated that all residents who have catheters should have orders. The ADON also stated that it is the admitting nurses' responsibility to input the order for the catheter if the resident comes to facility with the catheter. The ADON said that it is the ADON and the DONs responsibility to ensure the order is input correctly in the EHR. The ADON revealed the oncoming nurses should have a continuum of care and make sure orders are in the chart. The ADON stated if there is no order for the resident's catheter, the risk to the resident is infection and/or injury to the resident. The ADON concluded by stating that nurses are in-serviced on infection prevention and catheter care 1-2 times per month. Interview on 08/07/2024 at 3:45 PM, the DON revealed Resident #43 did not have an order for a catheter. The DON stated the resident entered the facility with a catheter. The DON said it was the admitting nurses' responsibility to input the order and then the oncoming nurses' responsibility to [NAME] the orders are correct. The DON revealed it is the ADON and DONs responsibility to ensure the orders are correct. The DON said that if there are no physician's orders for catheters, that the resident can risk infections, sepsis, and other possible health risks. The DON concluded by stating that she in-services her staff at least one time per month on infection prevention, peri-care, and catheter care. Interview on 08/08/24 at 9:31 AM with corporate nurse revealed the facility did not have a policy addressing the topic of inputting and following physician's order.

Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 8 residents (Residents #29), reviewed for care plans. The facility failed to revise and update Resident #29's comprehensive care plan with new diet orders. These failures could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of the Admission Record dated 8/8/24 revealed Resident #29 was a [AGE] year-old male initially admitted on [DATE] and readmitted on [DATE] with diagnoses including end stage renal disease, diabetes mellitus, acquired absence of right leg below the knee, congestive heart failure, unspecified protein-calorie malnutrition, and morbid obesity. Record review of the quarterly MDS dated [DATE] revealed Resident #29 had a BIMS of 15 meaning, Resident #29 was cognitively intact. MDS Section K0520 revealed that Resident #29 did not receive a therapeutic diet. Record review of Resident #29's undated care plan revealed Resident #29 has a diet order other than Regular and is at risk for unplanned weight loss or gain. Resident #29's care plan goal revealed Resident will maintain ideal weight and receive proper nutrition daily x 90 days. Resident #29's Intervention revealed The resident has a low concentrated sweets diet. The resident's low concentrated sweets diet was discontinued on 8/11/21 and the care plan did not reflect the current diet order. Record review of the undated physician's diet orders indicated Resident #29's diet order was a regular diet, mechanical soft texture, regular consistency with a start date of 7/10/24 and revision date of 7/20/24. Interview on 08/08/24 at 5:12 PM, the MDS Coordinator revealed care plans should be reviewed quarterly and updated. MDS Coordinator also stated that she does the standard care plans, but she does not do the acute clinical care plan. MDS Coordinator said diets should be updated quarterly. MDS also revealed that it is her responsibility to ensure care plans are accurate. MDS coordinator stated that she was last in-serviced on care plans about a month ago. Interview on 08/08/24 at 5:20 PM with DON revealed care plans should be updated when there is a diet change or order change. DON stated when dietary and speech do evaluations, she has asked that the results be given to her as well as the MDS coordinator to ensure that care plans be updated. DON said that it is her responsibility to make sure the care plans reflect current orders. DON also revealed that she last in-serviced the staff about a month ago on the importance of accurate care plans. Record review of undated policy and procedure titled, Care Planning Policy revealed .The resident's care will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions .

Based on interview and record review, the facility failed to designate a person to serve as the director of food and nutrition services who met at a minimum one of the following qualifications: a certified dietary manager or certified food service manager, or had a similar national certification for food service management and safety from a national certifying body, or had an associate's or higher degree in food service management or in hospitality, or had 2 or more years of experience in the position of food and nutrition services in a nursing faciltiy and had completed a course of study in food safety management for one of one Dietary Manager reviewed for qualifications. The Dietary Manager did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition. Findings included: Record review of the staff roster provided by the facility, undated, reflected the hire date for the Dietary Manager was 04/22/24. Record review of the Dietary Manager's records reflected she had completed a Food Handler Essentials Course. There was no evidence the Dietary Manager met any of the requirements for a Dietary Manager, which were: a certified dietary manager or certified food service manager, or had a similar national certification for food service management and safety from a national certifying body, or had an associate's or higher degree in food service management or in hospitality, or had 2 or more years of experience in the position of food and nutrition services in a nursing faciltiy and had completed a course of study in food safety management Record review of facility employee files revealed the facility's Registered Dietitian worked eight full time hours during the month of July 2024. During an interview on 08/06/24 at 8:55 AM with the Dietary Manager, it was revealed she had been employed at the facility for approximately three months. She stated she had not started taking any dietary manger classes because she was short-staffed and had to work as a cook on shifts that she was short a cook. She stated she did not have a certificate evidencing she had completed the Certified Food Protection Manager. The Dietary Manager confirmed there was no personnel working in the kitchen that was a trained and certified Food Protection Manager. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with S2-102.12.

Based on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments and under proper temperature controls and permitted only authorized personnel to have access to the keys for two of thirteen residents (Resident #1 and #2) reviewed for storage of medication. The facility failed to securely store Residents #1 and #2's medication; Resident #1 had a bottle of Fluticasone nasal spray on the bedside table and Resident #2 had a medication cup containing one pill each of Lisinopril and Carvedilol on the bedside table. This failure could place residents at risk of consuming unsafe medications. Findings include: 1. Record review of Resident #1's face sheet, dated 02/06/2023, revealed a [AGE] year-old male with an initial admitted [DATE]. Resident #1 had diagnoses which included peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), major depressive disorder, gout (inflammatory arthritis), anemia in chronic kidney disease (a chronic renal disease), and hypertension (high blood pressure. Record review of Resident #1's quarterly MDS (Minimum Data Set) assessment, dated 12/29/2022, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated the resident cognition was moderately impaired. Record review of Resident #1's, undated, care plan reflected, limited assistance and supervision with activities of daily living. Resident #1 had an altered respiratory status and required Fluticasone as ordered. Record review of Resident #1's physician order, dated 12/11/2021, revealed an order for Fluticasone Propionate Suspension 50 MCG twice daily every 12 hours for allergies. Record review of Resident #1's MAR revealed DON A administered Fluticasone Propionate Suspension on 02/06/2023 at 9:32 AM. 2. Record review of Resident #2's face sheet, dated 02/06/2023, revealed a [AGE] year-old male with an initial admitted [DATE]. Resident #2's diagnoses included heart disease, chronic obstructive pulmonary disease (inflammatory lung disease causing obstructed air flow to the lungs), Alzheimer's disease and dementia (memory loss), bipolar disorder II (form of mental illness), atrial fibrillation (an irregular heart rhythm), and chronic systolic heart failure (left ventricle can't pump blood efficiently). Record review of Resident #2's admission MDS (Minimum Data Set) assessment, dated 12/07/2022, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 3, which indicated the resident cognition was severely impaired. Record review of Resident #2's, undated, care plan reflected, extensive assistance and supervision with activities of daily living and was on hospice services. Resident #2 had required Lisinopril and Carvedilol for hypertension as ordered. Record review of Resident #2's physician order, dated 01/13/2023, revealed an order for Carvedilol tablet 6.25 MG two times daily and Lisinopril tablet 2.5 MG one time daily. Record review of Resident #2's MAR revealed DON A administrated both AM doses on 02/06/2023 of Carvedilol and Lisinopril. Observation and interview on 02/06/2023 at 2:34 PM revealed Resident #1 was in the room and in bed. There was a bottle of Fluticasone on the bedside table. In an interview with the resident, he stated he knew he had the Fluticasone in his room and he used the medication whenever he needed for allergies. He said he did not know which nurse gave him the medication. An observation on 02/06/2023 at 2:34 PM revealed Resident #2 in the same room as Resident #1 and in bed sleeping. There was a medication cup which contained two round white pills on the bedside table. In an interview with DON B on 02/6/2023 at 2:40 PM she stated the resident had the medication in the room. She stated she was the DON from another facility and came to the facility to assist today. She stated she was not aware Resident #1 had the medications. She said if the resident wanted to keep the medication in his room there should be an assessment in the medical record and noted in the care plan. She said neither were in the medical record. She stated DON A worked the hall and administered the Fluticasone at 9:32 AM. DON B stated the medication cup on Resident #2's bedside table contained one pill each of Lisinopril and Carvedilol. She said medications should not be left on any resident's bedside table and nurses dispensing medications should observe the administration. She said all medications should be secured in the medication cart at all times to prevent other residents from getting into the medication. An interview on 02/06/2023 at 3:20 PM with the Regional Compliance Nurse revealed Residents #1 and #2 were not supposed to have medications at their bedside because neither had been assessed to self-administer medications. She stated there could be medications interactions with other medications when the primary care provider was not aware of self-administering the medications. She said she expected staff to follow the facility's policy for medication administration. An interview on 02/06/2023 at 4:20 PM with DON A revealed she did sign the MAR for both residents #1 and #2. She stated she did watch Resident #2 take the medications, but he must have spit them back out into the cup. She said she was not aware Resident #1 had Fluticasone in his room. She said medications should never be left unattended and in any resident's room. She said if resident #1 wanted to keep the Fluticasone in his room there would have to be an assessment and the medication would have to be locked up to prevent other residents from having access to it. She said Resident #1 was not assessed for self-administering medication. In an interview on 02/06/2023 at 5:00 PM with the administrator, she said she expected staff to supervise residents while they took any medication. She said that was the facility's policy. She stated if medications were left in any room it placed residents at risk of harm because they could take medications that were not ordered for them or not take them at all. Record review of the facility provided policy titled Medication Administration Procedures, Oral Solid Medication Administration stated under section 3-4.02A Make sure that the resident swallows the mediations. After the medication administration process is completed, the medication cart bust be completely locked .

Based on interviews, and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #1) of 5 residents reviewed for pharmacy services. 1. The facility failed to administer Resident #1's Eliquis twice a day for 14 consecutive days due to not ordering the medications timely and reconciling hospital discharge paperwork. These failures could place residents at risk of neglect leading to decreased quality of life, exacerbation of disease processes Findings include: Review of face sheet for Resident #1, dated 1/11/23, revealed she was a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of Atrial Flutter (abnormal heart rhythm); paraplegia (paralysis of lower body); Stage 4 pressure ulcer; Cutaneous (skin) abscess of buttocks; Depressive disorder. Review of hospital discharge paperwork for Resident #1 dated 11/18/22 revealed Resident #1 had been admitted to the hospital on 11/16/22 with a new diagnosis of Atrial flutter (abnormal heart rhythm) she was started on new medication Eliquis (blood thinning medication). She was discharged from the hospital on 11/18/22 with discharge summary stating to continue taking Eliquis 5mg by mouth 2 times a day. Review of Resident #1's Medication Administration Record for November 2022 revealed no administration or documentation of an order for Eliquis 5mg PO twice a day. Review of Resident #1's Medication Administration Record for December 1, 2022, revealed order for Eliquis 5 mg 1 tablet twice a day which had first dose administered evening of 12/1/22. Review of Physician's order for Resident #1 dated December 1, 2022 revealed Eliquis 5mg give 1 tablet twice a day. An interview on 1/11/23 at 9:30 AM with the DON revealed Resident #1 had gone to the hospital on 11/16/22 for new onset A fib. She said that she (Resident #1) had started the Eliquis at the hospital, on her hospital discharge paperwork, the hospital had the medication (Eliquis) listed as an old medication and to continue it at the facility. The DON said that the nurse (unnamed) had reviewed the hospital discharge paperwork when Resident #1 returned from the hospital. She stated that she assumed the nurse just missed the medication thinking Resident #1 had been on the medication, prior to going out to hospital. Nurse reviewed the orders and just missed that med since she was not on it before. The DON stated that the nurse that completed the readmission had entered all the new orders from the discharge paperwork then she (the DON) reviewed the hospital discharge paperwork as well for any new medications and that she (the DON) had missed the Eliquis as well. The DON said that Resident #1 had gone to a hospital follow up appointment on December 1, 2022, with her Cardiologist. When Resident #1 returned to the facility from the appointment she (Resident #1) told the Administrator and the DON that the doctor was mad that she had not been receiving the Eliquis. She then gave the DON the doctors order stating to start the resident on Eliquis 5mg twice a day for 90 days. The DON found the discharge paperwork from the hospital, dated 11/18/22, and reviewed the medications listed on the discharge paperwork revealing Eliquis was listed on there. DON stated that she contacted Resident #1's PCP and alerted him of the medication error. DON said that she thought the reason the medication was missed was because of where the medication was listed on the discharge paperwork. The DON stated that the medication had been missed by the nurse that completed the readmission and by herself. She said that when a resident is admitted or readmitted , the admitting nurse completed a medication review reviewing all medications listed on the hospital discharge paperwork and compared it to what was listed in PCC. Once the nurse completed the medication review, then she gave the paperwork to the DON who also completed a medication review. She stated that the medication was overlooked by both the admitting nurse (RN A) and herself. An interview on 1/11/23 at 10:45 AM with RN A revealed she was the admitting nurse for Resident #1's return from the hospital on 11/18/22. RN A said that she had never completed an admission, that was her first one, and she was being assisted by LVN B. RN A said that she had an admission checklist that she had worked from and that she did recall seeing review all medications on the checklist. She did not recall how she missed the Eliquis since it was the first medication listed on the discharge paperwork. RN A complained about the admission checklist being too extensive and was too time consuming. RN A said that she was unsure how both she and the DON had overlooked the Eliquis on the discharge paperwork. RN A said after completing the admission checklist, she would haveinitialed off everything she had completed on the list and then given it to the DON. An interview on 1/11/23 at 12:55 PM with LVN B revealed she recalled the readmission for Resident #1. She said that she was helping RN A with the readmission and that she had told her to make sure and review all the medications for any new or changed medications. LVN A said that she recalled seeing a new medication listed at the top (was not the Eliquis) but had assumed that RN A had completed an entire medication review as told by LVN B. LVN B said that during the readmission the nurse has the admission checklist beside her and either checks off or initials next to the item listed on the checklist. LVN B said that she did not recall reviewing the checklist after RN A completed the admission and had just assumed all the medications had been reviewed and any new medications had been added into PCC. During a phone interview with the Cardiologist on 1/11/23 at 3:03 PM, he recalled Resident #1 coming into his office for a hospital follow up on 12/1/22. He said that Resident #1 had told him that she was mad that she had not been receiving the Eliquis that was started during her previous hospital admission 11/16/22 - 11/18/22. The Cardiologist said that he completed a thorough assessment on Resident #1 and found no ill effects from not receiving the Eliquis for 14 days (26 doses). He said that he had seen her when she had gotten admitted to the local hospital for Atrial Fibrillation and had started her on Eliquis 5mg PO twice. He said she had her first few doses while she was in the hospital and that he had wrote orders for her to continue the Eliquis on hospital discharge back to the facility. The Cardiologist reviewed the medication list that Resident #1 brought from the facility to her follow up appointment and did not see the Eliquis listed. He said he then wrote an order for her to start the Eliquis that day (12/1/22) on return to the facility. The Cardiologist said that the medication Eliquis was a blood thinner that was being given to Resident #1 to control her Atrial Fibrillation in which she had none during her visit to his office on 12/1/22. He said without the Eliquis Resident #1 could have had a stroke or recurrence of Atrial Fibrillation (abnormal heart rhythm) in which she did not have a stroke or Atrial Fibrillation. Review of an undated blank copy of the facility's Admission Process checklist page 1 revealed Pull an admission packet form .check off and initial each step as you complete them. Use your working copy of the checklist, check off meds as verified and entered. Once the checklist is completed place the completed copy in the DON box in which the DON and the ADON will review all medications and ensure that all orders including pharmacy orders are completed and accurate. Page 2 of the admission packet revealed a checklist of items to be completed on admission/readmission. Item number 4 on the checklist under the Nursing Admission Checklist was Review medication reconciliation and Enter admission medication orders and fax to pharmacy ASAP. The last sentence on page number 2 revealed '***Complete the Drug Regimen Review Assessment. Review of facility policy on Physician's Orders dated 2015 revealed Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Written Orders by the Physician or Nurse Practitioner 1. Nurse will review the order . 2. The nurse will enter the order into PCC for resident. 3. The receiving nurse will contact other department or external facilities as required, i.e., pharmacy. Based on interviews, and record review, the facility failed to provide pharmaceutical services including the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #1) of 5 residents reviewed for pharmacy services. 1. The facility failed to administer Resident #1's Eliquis twice a day for 14 consecutive days due to not ordering the medications timely and reconciling hospital discharge paperwork. These failures could place residents at risk of neglect leading to decreased quality of life, exacerbation of disease processes Findings include: Review of face sheet for Resident #1, dated 1/11/23, revealed she was a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of Atrial Flutter (abnormal heart rhythm); paraplegia (paralysis of lower body); Stage 4 pressure ulcer; Cutaneous (skin) abscess of buttocks; Depressive disorder. Review of hospital discharge paperwork for Resident #1 dated 11/18/22 revealed Resident #1 had been admitted to the hospital on 11/16/22 with a new diagnosis of Atrial flutter (abnormal heart rhythm) she was started on new medication Eliquis (blood thinning medication). She was discharged from the hospital on 11/18/22 with discharge summary stating to continue taking Eliquis 5mg by mouth 2 times a day. Review of Resident #1's Medication Administration Record for November 2022 revealed no administration or documentation of an order for Eliquis 5mg PO twice a day. Review of Resident #1's Medication Administration Record for December 1, 2022, revealed order for Eliquis 5 mg 1 tablet twice a day which had first dose administered evening of 12/1/22. Review of Physician's order for Resident #1 dated December 1, 2022 revealed Eliquis 5mg give 1 tablet twice a day. An interview on 1/11/23 at 9:30 AM with the DON revealed Resident #1 had gone to the hospital on 11/16/22 for new onset A fib. She said that she (Resident #1) had started the Eliquis at the hospital, on her hospital discharge paperwork, the hospital had the medication (Eliquis) listed as an old medication and to continue it at the facility. The DON said that the nurse (unnamed) had reviewed the hospital discharge paperwork when Resident #1 returned from the hospital. She stated that she assumed the nurse just missed the medication thinking Resident #1 had been on the medication, prior to going out to hospital. Nurse reviewed the orders and just missed that med since she was not on it before. The DON stated that the nurse that completed the readmission had entered all the new orders from the discharge paperwork then she (the DON) reviewed the hospital discharge paperwork as well for any new medications and that she (the DON) had missed the Eliquis as well. The DON said that Resident #1 had gone to a hospital follow up appointment on December 1, 2022, with her Cardiologist. When Resident #1 returned to the facility from the appointment she (Resident #1) told the Administrator and the DON that the doctor was mad that she had not been receiving the Eliquis. She then gave the DON the doctors order stating to start the resident on Eliquis 5mg twice a day for 90 days. The DON found the discharge paperwork from the hospital, dated 11/18/22, and reviewed the medications listed on the discharge paperwork revealing Eliquis was listed on there. DON stated that she contacted Resident #1's PCP and alerted him of the medication error. DON said that she thought the reason the medication was missed was because of where the medication was listed on the discharge paperwork. The DON stated that the medication had been missed by the nurse that completed the readmission and by herself. She said that when a resident is admitted or readmitted , the admitting nurse completed a medication review reviewing all medications listed on the hospital discharge paperwork and compared it to what was listed in PCC. Once the nurse completed the medication review, then she gave the paperwork to the DON who also completed a medication review. She stated that the medication was overlooked by both the admitting nurse (RN A) and herself. An interview on 1/11/23 at 10:45 AM with RN A revealed she was the admitting nurse for Resident #1's return from the hospital on 11/18/22. RN A said that she had never completed an admission, that was her first one, and she was being assisted by LVN B. RN A said that she had an admission checklist that she had worked from and that she did recall seeing review all medications on the checklist. She did not recall how she missed the Eliquis since it was the first medication listed on the discharge paperwork. RN A complained about the admission checklist being too extensive and was too time consuming. RN A said that she was unsure how both she and the DON had overlooked the Eliquis on the discharge paperwork. RN A said after completing the admission checklist, she would have initialed off everything she had completed on the list and then given it to the DON. An interview on 1/11/23 at 12:55 PM with LVN B revealed she recalled the readmission for Resident #1. She said that she was helping RN A with the readmission and that she had told her to make sure and review all the medications for any new or changed medications. LVN A said that she recalled seeing a new medication listed at the top (was not the Eliquis) but had assumed that RN A had completed an entire medication review as told by LVN B. LVN B said that during the readmission the nurse has the admission checklist beside her and either checks off or initials next to the item listed on the checklist. LVN B said that she did not recall reviewing the checklist after RN A completed the admission and had just assumed all the medications had been reviewed and any new medications had been added into PCC. During a phone interview with the Cardiologist on 1/11/23 at 3:03 PM, he recalled Resident #1 coming into his office for a hospital follow up on 12/1/22. He said that Resident #1 had told him that she was mad that she had not been receiving the Eliquis that was started during her previous hospital admission 11/16/22 - 11/18/22. The Cardiologist said that he completed a thorough assessment on Resident #1 and found no ill effects from not receiving the Eliquis for 14 days (26 doses). He said that he had seen her when she had gotten admitted to the local hospital for Atrial Fibrillation and had started her on Eliquis 5mg PO twice. He said she had her first few doses while she was in the hospital and that he had wrote orders for her to continue the Eliquis on hospital discharge back to the facility. The Cardiologist reviewed the medication list that Resident #1 brought from the facility to her follow up appointment and did not see the Eliquis listed. He said he then wrote an order for her to start the Eliquis that day (12/1/22) on return to the facility. The Cardiologist said that the medication Eliquis was a blood thinner that was being given to Resident #1 to control her Atrial Fibrillation in which she had none during her visit to his office on 12/1/22. He said without the Eliquis Resident #1 could have had a stroke or recurrence of Atrial Fibrillation (abnormal heart rhythm) in which she did not have a stroke or Atrial Fibrillation. Review of an undated blank copy of the facility's Admission Process checklist page 1 revealed Pull an admission packet form .check off and initial each step as you complete them. Use your working copy of the checklist, check off meds as verified and entered. Once the checklist is completed place the completed copy in the DON box in which the DON and the ADON will review all medications and ensure that all orders including pharmacy orders are completed and accurate. Page 2 of the admission packet revealed a checklist of items to be completed on admission/readmission. Item number 4 on the checklist under the Nursing Admission Checklist was Review medication reconciliation and Enter admission medication orders and fax to pharmacy ASAP. The last sentence on page number 2 revealed '***Complete the Drug Regimen Review Assessment. Review of facility policy on Physician's Orders dated 2015 revealed Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment orders, and ADL order for each resident. Written Orders by the Physician or Nurse Practitioner 1. Nurse will review the order . 2. The nurse will enter the order into PCC for resident. 3. The receiving nurse will contact other department or external facilities as required, i.e., pharmacy.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 7 residents reviewed for infection control. 1. The facility failed to ensure that Resident #1, who was COVID-19 positive, was not cohorting with a COVID-19 negative Resident #2 who both shared a bathroom. 2. The facility failed to ensure that Resident #3, who was C-Diff positive, was isolated and not cohorted with Resident #4 in which they shared a bathroom. Resident #4 had 4 episodes of diarrhea on 9/22/22. 3. LVN A failed to wash or sanitize his hands after he checked the vital signs of Resident #4 then entered another resident room on the cold hall to check their vital signs. 4. CNA B failed to don PPE when she entered Resident #3's room who was C-Diff positive. 5. CNA B failed to wash her sanitize her hands after exiting Resident #3's room who was C-Diff positive. 6. DON failed to educate staff on appropriate hand washing technique as identified in the Facility's hand washing policy. An Immediate Jeopardy (IJ) was identified on 9/22/22 at 4:00 PM and the IJ template was provided to the facility Administrator and DON on 9/22/22 at 5:00 PM. While the immediate jeopardy was removed on 9/23/22/22 at 7:30 PM, the facility remained out of compliance at a severity no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns. These failures could place all residents at risk for harm or possibly death due to facility not providing proper isolation measures for residents who have a diagnosis that requires isolation. Findings include: Review of Resident #1's face sheet dated 09/22/22 revealed that she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of unspecified dementia (inability to think, remember, learn); hyperlipidemia (high fats in the blood); heart failure (heart doesn't pump blood like it should); major depressive disorder (feeling of sadness); pain; secondary hypertension (high blood pressure); and muscle weakness. Review of Resident #1's care plan, dated 7/27/22, revealed Resident had an ADL Self Care Deficit The care plan detailed that Resident #1 was assistance needed the assistance of 1 staff person for toileting. Review of Resident #1's MDS assessment. dated 8/10/22, revealed Resident #1's functional status with transfers, walk in room, and toilet use was setup only. Her toilet use was a 1 on self-performance, meaning no help or staff oversight. Resident #1's ADL support was coded as a 2 which indicated she would need one-person physical assist. Review of Resident #1's progress notes dated 9/22/22 revealed LVN C documented on 9/21/22 at 1:40 PM Covid test was performed and showed a possible positive result, so another test was performed and it showed a positive result. Progress note dated 9/22/22 at 7:16 AM documented by LVN B revealed Resident #1 asked LVN B where she was at because her personal belongings were not in the room with her. LVN B told Resident #1 that she had been moved to another room after testing positive or COVID. Review of Resident #2's face sheet dated 9/22/22 revealed he was a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses of Chronic obstructive pulmonary disease (inflammation in the lungs that affects the air flow); Paroxysmal Atrial Fibrillation (irregular and fast heart beat); Hypertensive urgency (elevation in blood pressure); Pericardial effusion (fluid collected in between the heart and the lining of the chest wall); Multiple rib fractures; Emphysema (lung condition). Review of Resident #2's MDS assessment, dated 8/29/22, revealed Resident #2 was completely mobile and needed no assistance with ambulating, toileting and needed no assistance with ADLs. Interview with Resident #2 on 9/22/22 at 12:15 PM revealed that he shared a bathroom with a resident that was COVID positive, and he did not think that was a good idea. Resident #2 said that the bathroom door leading from Resident #1's room was always left open. Interview with the Administrator on 9/22/22 at 10:12 AM revealed there was only one COVID-19 positive resident in the facility. He said that the resident (Resident #1) tested positive on 9/21/22 and was moved out to the COVID (hot) hall for isolation. The Administrator said that all residents were tested and that all other residents tested negative. Interview with the DON on 9/22/22 at 10:50 AM revealed that Resident #1 tested positive on 9/21/22 after her hospice aide requested Resident #1 be tested . DON said that Resident #1 had not been feeling well the few days prior to 9/21/22. Resident #1 was moved to a room on the hot hall which had a connecting bathroom that was shared between Resident #1 and Resident #2 who was on the cold hall and was COVID-19 negative. The DON stated that Resident #1 and Resident #2 shared a bathroom; however, Resident #1's bathroom door is never open. She said that she did not think it would be a problem with sharing a bathroom between an isolation room and a non-isolation room. Interview on 9/22/22 at 11:34 AM with Resident #1's hospice aide revealed that Resident #1 was moved to a hot room on 9/21/22 after she tested positive for COVID-19 and was symptomatic. She said that she was concerned about the bathroom that Resident #1 shared with Resident #2 because Resident #2 was in a cold room and was COVID negative. The hospice aide said that she would use the bathroom that was shared between the two rooms and felt that it was an infection control problem that could subject Resident #2 to COVID. Review of Resident #3's face sheet, dated 9/22/22, revealed he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease (final stage of kidney disease); Autistic disorder (developmental disability); Stage 2 pressure ulcer; Folate Deficiency Anemia (lack of vitamin B12); Hallucinations (perception of something that is not present). Review of Resident #3's physician's order dated 9/9/22 revealed that [Facility Physician] ordered Vancomycin to give 2.5ml by mouth four times a day for C-Diff for 100 days; give 2.5mg which equals 25mg PO 4 times daily for 10 days. Review of Resident #3's progress note, dated 9/8/22 at 3:07 AM written by LVN D, revealed Resident c/o feeling lethargic, had 4 watery stools within last 4 hours. Review of Resident #3's progress note, dated 9/8/22 at 3:31 AM written by LVN D, revealed that Resident transported to hospital. Review of Resident #3's progress note, dated 9/8/22 at 5:59 AM written by LVN D, revealed received report form [local hospital] that resident [Resident #3] was being discharged and had tested positive for C-Diff. Review of facility's Infection Control log, dated 9/22/22, revealed all facility residents with a diagnosis of an infection. The report was for the month of September. Page 4 of the report had Resident #3's name and that he was on antibiotic Vancomycin for a 100- days for a diagnosis of C-Diff and the prescribing provider was the facility physician. Interview on 9/22/22 at 1:15 PM with LVN C revealed that Resident #3 was C-Diff positive and was being treated for C-Diff. She said that she did not think he was ambulatory but used a bed pan. LVN C said that Resident #3 and Resident #4 shared a bathroom, and that Resident #4 did not have a diagnosis of C-Diff. She said that Resident #4 had several diarrheal bowel movements on 9/22/22 and that Resident #4 was ambulatory and used the bathroom that was shared with Resident #3. LVN C stated that she did not think that isolation residents and non-isolation residents should share a bathroom, that it would be a risk of contamination. Although Resident #3 did not physically use the bathroom he did use a bedpan that was emptied in the shared bathroom of Resident #4. Staff also washed their hands in the shared bathroom of Resident #3 and Resident #4. Interview with the Administrator on 9/23/22 at 1:33 PM who stated that he was not made aware that Resident #3 was C-Diff positive. The Administrator said that he knew that Resident #3 had been sent to the hospital a few times but continued to be sent back to the facility. The Administrator said that he had been told that Resident #3 had tested negative for C-Diff at one of his last hospital visits (unknown date). He said that he leaves clinical stuff to the DON and the physician. Observation on 9/22/22 at 2:20 PM revealed CNA B entered the room of Resident #3 and did not don full PPE (gown, gloves, shoe covers) only wearing a N95 mask; she turned off his call light and pushed the curtain open with her bare hands. She then exited the room and used hand sanitizer. Interview on 9/22/22 at 3:05 PM revealed CNA B stated that 9/22/22 was her first day to work on the hot hallway. She stated that she did not know why Resident #3 was on isolation and she had not asked anyone (other staff) why he was on isolation. CNA B stated that she knew that Resident #1 was on isolation for COVID but did not know why Resident #3 was on isolation. CNA B stated that she thought the 2 residents (Resident #1 and Resident #3 were both COVID positive since both were in COVID rooms. Interview with Resident #3 on 9/22/22 at 3:45 PM revealed that he had C-Diff and had tested positive for C-Diff at the hospital. He said that he had been C-Diff positive on several occasions prior to that date (9/22/22). Resident #3 said that he was being treated for C-Diff with some prescribed medications. Review of Resident #4's face sheet dated 9/22/22 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of Hypertension (high blood pressure); Altered mental status; Restless legs syndrome (involuntary movements of the legs); Pain; Anxiety. Review of Resident #4's progress notes revealed on 9/22/22 at 9:26 AM Miralax held due to having loose stools. Progress note dated 9/22/22 at 11:00 AM LVN C documented that Resident had a large liquid stool and abdominal cramps. New order obtained for Imodium. Review of Resident #3's hospital records dated 9/5/22 revealed history and physical: Diarrhea concern for recurrent C-Diff, started on Vancomycin for C-Diff. Observation on 9/22/22 3:47 PM revealed LVN A entered the room of Resident #4 obtained her vital signs and then exited her room without hand hygiene. LVN A then entered the room of a resident on the cold hall with the same vital sign equipment to obtain that resident's vital signs. Interview on 9/22/22 at 3:50 PM with LVN A revealed he should wash his hands before entering a resident's room and after exiting the resident's room. He stated he did not wash his hands after obtaining the vital signs of Resident #4 (who had diarrhea) nor did he wash his hands before entering another resident's room on the cold hall. He said, I forgot. LVN A also said that he should sanitize his equipment in between every resident. Interview with the DON on 9/22/22 at 1:39 PM revealed that Resident #3 did not have C-Diff; that he had some sort of developmental disorder and had gone to the hospital multiple times on his insistence and that he wanted to have C-Diff. So, the hospital started him on Vancomycin which is used to treat C-Diff. She stated that Resident #3 was currently on Vancomycin for C-Diff. DON also stated that the facility's attending physician was not a big fan on keeping residents on antibiotics. She said that the facility was treating him as though he had C-Diff. So, they would follow contact isolation precautions for him. DON stated that when staff assisted Resident #3 or go into his room, they would wash their hands in his bathroom before exiting or just use hand sanitizer when they exit the room; it does not matter what type of isolation they are on. She also stated that It was my understanding that staff should wash their hands if their hands are visibly soiled. If their hands are not visibly soiled, then they can just use hand sanitizer. DON said that there was no maximum number of times that staff could use hand sanitizer before they would wash their hands. DON stated They (staff) would not have to wash their hands if they had assisted a resident on isolation if their hands are not visibly soiled, they could just use hand sanitizer when they leave the room. Review of Facility Policy dated October 2018 titled Clostridium Difficile Policy Statement Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. Difficile to prevent transmission to other residents. Page 2 of policy bullet point number 9. Residents with diarrhea associated with C Difficile, (i.e., residents who are colonized and symptomatic) are placed on Contact Precautions. 10. Residents with diarrhea and suspected CDI are placed on Contact Precautions while awaiting laboratory results. 11. Residents who are colonized with C. Difficile are asymptomatic do not require Contact Precautions. 13. Residents with CDI are placed in a private room if available. If a private room is not available, residents will be cohorted with a dedicated commode for each resident. Review of Facility policy dated 2018 Titled Preventing Spread of Illness Related to MDROs. The MDRO's found in facilities include, but are not limited to MRSA, VRE, and Clostridium Difficile (C Difficile). Page 1 of facility policy Contact Precautions: Contact precautions are intended to prevent transmission of infectious agents. A single room is preferred for patients who require Contact Precautions. When a single room is not available, consultation with infection control personnel is recommended. Donning PPE upon entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Droplet Precautions: When a single patient is not available; consultation with infection personnel is recommended to assess the various risks associated with other patient placement options (e.g., cohorting, keeping the patient with an existing roommate). Procedure for Droplet Precautions: 3. A private room is indicated for the resident. However, cohorting is an option for residents who are infected with the same organism. Review of Facility's policy titled Infection Prevention and Control dated 6/3/21. Page 4 of 14 of the policy stated Isolation: once a case of COVID-19 is identified in the facility, immediate action must be taken to isolate the resident or HCP who is positive for COVID-19 away from other residents - cold zone. Residents: Residents with known or probable COVID-19 do not need to be placed into an airborne infection isolation room (AIIR) but should be placed in a private room - cohorting in hot zone is allowed. Page 5 of 14 of the policy revealed Zoning: Warm zone - Presumptive (known exposure) and/or symptomatic; do not cohort. Hot zone- confirmed positive; safe to cohort. Review of Facility's policy titled Infection Control Plan: Overview Page 2 of 27 Implement hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross contamination Page 15 of 27 stated: Hand Hygiene hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: before and after entering isolation precaution settings; Page 7 of 27 stated ensured that reusable equipment is appropriately cleaned, disinfected, or reprocessed. On 9/22/22 at 5:00 PM, The Administrator and DON were notified that an Immediate Jeopardy had been determined. The Administrator was given the IJ template at 5:00 PM on 9/22//22 and a Plan of Removal was requested at that time. The Facility's Plan of Removal was accepted 9/23/22 at 4:45 PM. Heritage Place of Decatur 09/22/2022 Plan of Removal ALLEGED ALLEGATION: Infection Control: The facility failed to ensure that resident who was Covid positive was not cohorting with Covid negative resident, who both share a bathroom. The facility failed to ensure that resident with c-diff was isolated and not cohorted with resident which they share a bathroom and now resident #4 has diarrhea. Staff failed to wash and sanitize hands after checking vital signs and then entered another room on cold hall to check vital signs. Staff failed to don PPE and wash and sanitize hands on resident in isolation. The facility failed to follow cohorting policy for residents who are COVID-19 positive. The facility failed to follow Facility's hand hygiene guidance. DON failed to educate staff on the appropriate hand washing technique as identified in the Facility's policy. Interventions: On 9/22/22 Facility moved covid unknown status resident #2 to sister facility, [name of facility in same town], for 7 days isolation due to exposure to COVID positive. He will remain in facility until Wednesday 9/28/22 when he discharges to ALF. On 9/22/22 facility moved resident #4 to private room with contact and airborne precautions for potential C. diff symptoms and COVID-19 exposure. On 9/22/22 Facility completed deep cleaning and sanitation to room [ROOM NUMBER] and 128. On 9/22/22 The facility assessed resident #4 for signs/symptoms of c. diff, order for stool sample obtained. On 9/22/22 Facility moved residents according to cohort policy for COVID-19, residents exposed to COVID-19 but not testing positive for COVID are deemed warm. Residents that have tested positive are deemed HOT. All residents not exposed and are testing negative to COVID-19 are deemed cold. Residents with COLD status may cohort together. Residents with HOT status may cohort together. Residents with WARM status cannot cohort unless no other beds are available in the facility. Regional Nurse Consultant 1:1 in-serviced DON on proper hand hygiene, PPE Donning/Doffing according to hand washing policy. DON to complete CDC train Infection Preventionist Training by 9/30/22. On 9/23/22 at 1030 am DON to view CDC Clean Hands Instructional Video, o Clean Hands Video: https://youtu.be/xmYMUly7qiE On 9/22/22, Regional Nurse Consultant will assume Interim Infection Preventionist for the building until Certificate of Completion is provided by DON on or before 9/30/22. The following in-services were initiated and completed by the DON, ADON and Regional Nurse Consultant on 9/22/2022. Any staff member not present or in-serviced on 9/22/2022, will not be allowed to assume their duties until in-serviced. New Hires and Agency staff will be in-serviced prior to resident care. o Staff will be Inservice on the following: Inservice staff on Infection Control Policy Inservice staff on proper PPE use on residents in isolation In-service staff on proper Donning / Doffing PPE Inservice began staff on proper hand hygiene techniques Inservice all staff on all isolation procedures and the PPE to use in each case. The medical director [MD] was notified of the immediate jeopardy situation on 09/22/2022 at 5:00pm. Policy reviewed with medical director, and he agreed with plan. Monitoring Admin/DON/Designee will review every room assignment prior to residents being placed in the room and submit to Regional Nurse Consultant for approval on room changes and admissions. Admin/DON/Designee will ensure all staff complete skill competency check on PPE donning/doffing and hand hygiene procedures by 9/23/22. All staff that do not attend, must complete competency by start of next scheduled shift. The DON / designee will observe PPE use by randomly selecting 10 staff members weekly on various shifts for 6 weeks. Admin/DON/Designee will observe equipment sanitation between residents 5 times per week for 6 weeks. The QA committee will review findings and makes changes as needed. Monitoring of the Facility's Plan of Removal included: Observation on 9/23/22 at 10:30 AM, Resident #4 had been moved to room [ROOM NUMBER] from room [ROOM NUMBER]. Resident #1 had an isolation cart next to her door in the hallway with all appropriate PPE (gown, gloves, face shields, shoe covers) and signage of droplet precautions. Inside her room there were 2 biohazard boxes for doffing PPE, and she had a private bathroom that did not have access from the room adjoining. So, she did not share a bathroom with any other resident. Observation on 9/23/22 at 4:40 PM revealed that resident rooms #127 and room [ROOM NUMBER] had both been deep cleaned and smelled of cleaning solution. Observation on 9/23/22 8:40 AM revealed Resident #5 and Resident #6 were on droplet isolation for possible exposure to COVID-19 from Resident #1 prior to her moving to the HOT hall on 9/21/22. Review of Progress note for Resident #2 dated 9/23/22 at 9:04 AM documented by Administrator revealed Administrator and DON spoke with the resident (Resident #2) last night (9/22/22) and he (Resident #1) consented to be transferred to sister facility [name of accepting facility], for 7 days isolation due to exposure to COVID. He will remain in the (receiving) facility until Wednesday 9/28/22 when he discharges to ALF. 9/22/22 evening resident #2 was transferred to another facility where he will be on COVID isolation due to exposure from Resident #1. Resident #2 will discharge from the other facility to an ALF on Wednesday 9/28/22 which was already the discharge plan for him. Review of Resident #4's physician's orders, dated 9/22/22 at 6:49 PM, from [Physician] Stool for c-diff x 3 samples, every shift for diarrhea x 3 specimens. Review of Resident #4's Assessment titled GI Disturbance Note 8 Hr. dated 9/22/22 at 6:28 PM revealed resident has documented diarrhea; bowel sounds in all 4 quadrants of the abdomen and hyperactive (very active); abdomen was soft; no pain; PRN medications Imodium given. Review of in-service sheet dated 9/22/22 at 5:00 PM Inservice Topic: Hand Hygiene, PPE; donning/doffing Inservice was a 1:1 in-service presented by Regional Nurse Consultant to DON. Signature of DON present on the sign in sheet. Review of facility in-service dated 9/22/22 and titled Droplet isolation Precautions presented by Regional Compliance Nurse. The in-service had a total of 40 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled Infection Control: Overview, Outbreak control presented by Regional Compliance Nurse. The in-service had a total of 41 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled Hand hygiene presented by Regional Compliance Nurse. The in-service had a total of 39 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled Airborne Isolation Precautions presented by Regional Compliance Nurse. The in-service had a total of 40 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled PPE Donning/Doffing presented by Regional Compliance Nurse. The in-service had a total of 39 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled C-Diff Specialty Information presented by Regional Compliance Nurse. The in-service had a total of 39 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled Enhanced Barrier Precautions presented by Regional Compliance Nurse. The in-service had a total of 40 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled COVID-19 Policy presented by Regional Compliance Nurse. The in-service had a total of 35 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Review of facility in-service dated 9/22/22 and titled Deep Cleaning Process with Special Precautions presented by Regional Compliance Nurse. The in-service had a total of 38 staff member signatures on the sheet. The staff members were from every department in the facility, including dietary, housekeeping, maintenance, and nursing. Interview with CNA B on 9/23/22 at 2:20 PM revealed she was in-serviced on 9/22/22 and 9/23/22 regarding hand washing, donning and doffing PPE when entering an isolation room. CNA B also stated that she was taught the different types of isolation (droplet, contact, airborne) and what type of PPE should be worn into each type of isolation room. Interview with Regional Nurse Consultant on 9/23/22 at 5:27 PM who stated she would be present in the facility for several weeks to assist with monitoring compliance. Interview on 9/23/22 at 5:59 PM with LVN A who stated he had several in-services on 9/22/22 and 9/23/22 on PPE, hand washing (he did a return demonstration). He also said that he had in-services on the different types of isolations and knew what PPE should be worn into each room. LVN A said he should wash his hands after bathroom breaks, going into a resident and room coming out of a room, wash hands in between treatments on residents. LVN A said he should have sanitized medical equipment in between residents. Interviews with 18 facility staff members on 9/23/22 between 5:35 PM and 6:30 PM which included 13 staff that work directly with residents (CNA's and nurses). All the staff stated that they received several in-services on 9/22/22 and 9/23/22. The in-services received were on infection control, PPE (what to wear when and how to don and doff their PPE), hand hygiene (with return demonstration), and the different types of isolation. The in-service covered staff from all shifts. Interview with DON on 9/23/22 at 6:17 PM revealed she received an in-service by the Regional Nurse Consultant on hand washing, donning and doffing PPE and isolation for residents. She also watched a video on hand washing. An Immediate Jeopardy (IJ) was identified on 9/22/22 at 4:00 PM and the IJ template was provided to the facility Administrator and DON on 9/22/22 at 5:00 PM. While the immediate jeopardy was removed on 9/23/22/22 at 7:30 PM the facility remained out of compliance at a severity no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent further concerns.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs for 1 of 5 residents observed during medication pass. (Resident #22) LVN A administered Med Pass 2.0 Nutritional Supplement and a Multiple Vitamin that was expired to Resident #22. This deficient practice could place residents at risk of receiving less than therapeutic benefits from medications. Findings include: Review of the Face Sheet, dated 4/29/22, revealed she was a [AGE] year-old woman admitted [DATE] and readmitted to the facility 3/25/22 with diagnoses of [CONDITION(S)] (a disorder that affects ability to speak and/or understand words), [CONDITION(S)], speech/language deficits, [CONDITION(S)] (difficulty breathing caused by smoking, asthma, chemicals and other factors), difficulty in walking, cognitive communication deficit, depression, muscle weakness, personality and behavior disorder and Pseudobulbar Affect (a nervous system disorder that causes inappropriate involuntary laughing or crying). Review of Physician Orders dated 4/29/22 revealed Resident #22 had an order for MedPass 2.0 120 milliliters three times each day for nutrition, and a Multiple Vitamin Tablet Give 1 tablet by mouth one time per day related to Other Symbolic Dysfunctions. During observation of a medication pass on 04/28/22 at 7:07 AM, LVN A administered Med Pass 90 milliliters (ML) with a manufacturer's expiration date of 10/14/21 and Multiple vitamin 1 tablet with manufacturer's expiration date of 03/2022 to Resident #22. During an interview on 4/28/22 at 7:35 AM, LVN A stated she forgot to check expiration dates on Med Pass Nutritional Supplement and Multiple Vitamin prior to administering to Resident #22 . LVN A stated she usually checked expiration dates of medications and discarded anything out of date. LVN A stated giving expired medications could cause nausea/vomiting. During an interview on 4/29/22 at 10:16 AM, Compliance RN stated medication expiration dates should be checked prior to medication administration and stated administering expired medications could prevent the resident from receiving therapeutic dose. During phone interview on 5/03/22 at 10:00 AM with a Registered Pharmacist stated medicines had a certain rate of loss over time and should be used prior to expiration date to ensure patient received a therapeutic dose. Review of current facility's policy, Medication Administration Procedures dated 10/25/17 did not address expired medications.

Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary and comfortable environment, and to prevent the transmission of communicable diseases and infections for 3 (Residents #14, #29, #23) of 6 residents observed for medication administration. LVN A failed to wash or sanitize hands after return from medication room and prior to preparing and administering medications to Resident #14. LVN A failed to disinfect Pulse Oximeter after obtaining pulse rate of Resident #29 and failed to wash hands or use hand sanitizer after using Pulse Oximeter and prior to administering medications to Resident #29. LVN A failed to use infection control prevention methods after placing Resident #14's medications in 2 dose cups and then stacked cups, one on top of the other, contaminating medications contained in bottom cup and carried stacked cups into Resident #14's room where LVN A administered medications. LVN A failed to disinfect blood pressure wrist cuff after obtaining blood pressure of Resident #14 and prior to obtaining blood pressure of Resident #23. These failures could affect residents who received medications placing them at risk for cross-contamination and infections/diseases. Findings included: An observation on 4/28/22 at 6:52 AM, LVN A entered the room of Resident #29 and removed a Pulse Oximeter from LVN A's pocket, checked Resident #29's pulse rate and returned the Pulse Oximeter to LVN A's pocket without sanitizing oximeter. LVN A return to medication cart, prepared and administered medications without washing hands or using sanitizer. An observation on 4/28/22 at 7:43 AM, LVN A prepared medications for Resident #29 which she placed in two dose cups and stacked one cup of pills on top of the other cup of pills contaminating pills contained in the bottom cup; LVN A then administered both cups of pills to Resident #29. An observation on 4/28/22 at 7:43 AM, LVN A used a wrist blood pressure cuff to Check Resident #14's blood pressure and return to the medication cart and placed the cuff on the top left of the cart without sanitizing it. An observation on 4/28/22 at 8:17 AM, LVN A removed wrist cuff from the medication cart without sanitizing cuff and placed the wrist cuff on Resident #23. Continuous observation from 4/28/22 at 7:43 AM until 4/28/22 at 8:17 AM revealed wrist cuff was never disinfected between the three residents. Interview on 4/28/22 at 8:22 AM, LVN A stated she forgot to clean the blood pressure wrist cuff and pulse oximeter between uses. LVN A stated she must have forgotten to perform hand hygiene. LVN A stated she had received many in-services related to hand hygiene. She stated hand hygiene was required prior to setting up medications, before and after any encounter. LVN A stated she should have cleaned the blood pressure wrist cuff and the pulse oximeter with a disinfectant wipe after each use and placed both on the med cart to dry after cleaning. LVN A stated she was not thinking when she stacked dose cups containing pills; she stated the pills were contaminated by stacking. LVN A stated failure to clean hands or equipment could cause spread of infection. LVN A stated the surveyor made her nervous. Interview on 4/29/22 at 8:34 AM, Compliance RN stated blood pressure cuffs should be cleaned after each use with a disinfectant wipe. The compliance RN stated dry time was 2 minutes. The compliance RN stated pulse oximeters and glucometers should be cleaned after each use. The compliance RN stated hand hygiene should be performed prior to pulling meds and after administering meds. The compliance RN stated hands should be cleaned upon return to med cart. The compliance RN stated she monitored hand hygiene every day . Interview on 4/29/22 at 10:24 AM, the Administrator stated he expected re-useable equipment to be cleaned after each use. The Administrator stated sanitizing wipes were used to clean equipment or as the manufacturer suggested and he expected staff to clean hands after each encounter. Review of the facility's Infection Control Plan dated 2019 revealed: Infection Control The facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Preventing Spread of Infection (3) The facility will require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. Intent Prevent and control outbreaks and cross-contamination using transmission-based precautions in addition to standard precautions. Review of the facility's Hand Hygiene Policy, undated revealed: You may use alcohol based hand cleaner or soap/water for the following: >Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure . Review of the facility's policy Cleaning and Disinfection of Resident-Care Items and Equipment Revised October 2018 revealed: Policy Statement Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Review of (Disinfection and Sterilization Guidelines) accessed on (5/03/22date) at https://www.cdc.gov/infectioncontrol/guidelines/disinfection indicated disinfect noncritical medical devices (e.g., blood pressure cuff) with an EPA-registered hospital disinfectant using the label's safety precautions and use directions . [1] The proper cleaning of these cuffs ensures that dangerous bacteria does not spread between patients.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of COVID-19 for 4 of 9 staff reviewed for infection control. The facility failed to screen the RCN, the ADON, LVN A and LVN B for signs, symptoms and exposure to COVID-19 before entering the facility on 2/14/2022. This failure placed residents at risk of exposure to COVID-19. FINDINGS INCLUDE: Observation on 2/14/2022 at 10:10a.m. revealed the RCN entered the facility, walked by the screening station and went into her office. The RCN didn't take her temperature, use hand sanitizer or answer the screening questions regarding COVID-19 signs, symptoms and exposure. At 10:11 a.m. on 2/14/2022, in an interview with RCN revealed she had just left the doctor's office and was in a hurry to get into facility and on her way back to entrance to complete screening. The RCN stated she had been at the facility since December 2021 as the interim DON. The RCN stated she had not been exposed to COVID-19 and was fully vaccinated. The RCN stated that everyone regardless of vaccinated or not must be screened at entrance. The RCN stated the facility did not have any positive COVID-19 cases at this time. The RCN stated her expectations were for staff and anyone else to be screened before entering the building. The RCN stated staff knew to screen, because they were walked through the process when they first started, and the facility had signage up reflecting to screen. The RCN stated they also had an in-service back in December 2021. The RCN stated the facility policy was to follow the CDC guidelines. The RCN stated she would complete in-service on screening properly at arrival today. At 11:35 a.m. on 2/14/2022, in an interview with LVN A, revealed her shift began at 6:00 a.m. but she didn't screen for COVID-19 until 10:29 a.m. LVN A stated she was trained by staff, but unsure by who, on proper screening. LVN A stated she was an agency worker. LVN A stated she forgot to screen because she began talking to someone. LVN A stated not screening could cause COVID-19 and any other kind of infection control diseases. At 11:46 am on 2/14/2022, in an interview with LVN B, revealed she had worked at the facility since September 2021. LVN B stated when she arrived at 6:00 a.m. she did take her temperature but, didn't answer the COVID-19 screening questions. LVN B stated she was aware of the screening process and was trained by the former DON. LVN B stated the screening process is to see if anyone has signs or symptoms of COVID-19. LVN B stated not screening is a risk of an infection. At 1:14 p.m. on 2/14/2022, in an interview with the ADON, revealed she screened in late because there was a resident having a stroke when she arrived. The ADON stated she arrived at 9:00 a.m. and that she didn't screen until 10:27 a.m. The ADON stated she normally screens in when she enters the facility before shift. The ADON stated it is important to screen to keep COVID-19 down and everyone healthy. The ADON stated her expectations are for staff to screen in prior to work. The ADON stated the facility follow CDC guidelines. Record review of Screening Log for 2/01/2022 through 2/14/2022 revealed late documentation for RCN, ADON and LVN A and no documentation for LVN B for COVID-19 signs, symptoms, and exposure on 2/14/2022. Screening log documents name, date, time and type of visit (employee/visitor). Record review of the in-service, dated 12/10/2021 for COVID-19 Response Plan, Infection Control and Prevention, dated 12/10/2021 and Screening properly at arrival, dated 2/14/2022. Record review of facility's policy titled Infection Prevention and Control COVID-19 Response Plan, dated June 2021, reflected on pg.1, All those who enter the facility are required to screen, including, but not limited to, Administrator (LFNA) , Registered Nurse(RN), Nurse Practitioner, Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA), Physicians (MD/DO), Physician Assistant (PA), Respiratory Therapist (RT), Rehabilitation Therapists (Physical or Occupational Therapy), External Consultants (Pharmacy, Lab, Wound Care, Podiatrist), Case Management, Environmental Services, Dietary Services, paramedics, students, volunteers and visitors. Record review of facility policy titled Infection Control Plan: Overview, dated 2019, reflected on pg.1 The facility will establish and maintain Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

Based on observation, interview and record review the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to hold food at proper temperatures. This could affect residents who receive meals from the kitchen and place them at risk for food borne illnesses. Findings included: An observation on 03/25/21 at 12:00 PM, revealed no thermometers were available in room 103 where the facility meals were being prepared for distribution. The Dietary Manager had to leave the room to go to the kitchen to retrieve thermometers and when he returned, he had two electronic thermometers, one resembling an oral thermometer and the other a standard kitchen thermometer. He did not calibrate either thermometer before taking temperatures of the foods. Observation on 03/25/21 at 12:26 PM of Dietary Manager checking the temperature with a digital thermomete the regular textured beef enchiladas upon surveyor request revealed the temperature before plating into a foam covered plate, was 140 degrees F, and the puree mixture was at 141 degrees F. The Dietary Manager used an alcohol wipe to clean the thermometer then went to the next dish. A dietary aide asked the Dietary Manager what he was doing and said she had not seen him do that before. The Spanish rice, both regular and puree texture, were at 135 degrees F. The Dietary Manager did not clean the thermometer and then checked the containers of refried beans for their temperatures. The regular texture was at 138 degrees F and the puree was at 137 degrees F. Interview with the Dietary Manager on 03/25/21 at 12:28 PM revealed his concern was at the beginning of plating the food. He stated the plating and serving of the meal to the residents was very time consuming and he was concerned about the foods temperature dropping into the danger zone and how long it would be in the zone. Review of U.S. Department of Health and Human Services Food Code 2017 page 148, revealed, Section 4-701.10 Food-Contact Surfaces and Utensils. Equipment Food Contact Surfaces and Utensils shall be sanitized. Section 4-702.11 Before Use After Cleaning. Utensils and food contact surfaces of equipment shall be sanitized before use after cleaning

Based on observation, interview, and record review, the facility failed to ensure each resident had the right to free from neglect for four (Residents #1, #2, #3, and #4) of six residents reviewed for neglect. The DON, who was the facility's designated Infection Control Professional, failed to isolate Residents #1, #3, #4, #5, and #6 after they were treated for [REDACTED]. Resident #2 died at the hospital after developing influenza and complications on [DATE]. Resident's #2, #3, #4, #5, and #6 developed influenza after Resident #1 was removed from isolation earlier than CDC guidance and recommendations. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures could affect the 40 residents residing in the facility by placing them at risk for influenza infection and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was offered the influenza vaccine, but declined. The resident's cognitive status was severely impaired. Resident #1's Immunization record, dated [DATE], reflected he was allergic to the influenza vaccine. Resident #1's Nurse's Notes reflected: [DATE] at 7:40 p.m. Nurse was called to the resident's room by his roommate. Resident #1 was lying in the bathroom after falling. [DATE] at 8:20 p.m. Resident #1 was sent to the hospital due to his inability to stand. [DATE] at 1:00 a.m. Resident #1 returned to the facility with a new order for [MEDICATION NAME] (medication used to treat influenza). The resident was moved to another and placed on droplet isolation precautions. [DATE] at 10:00 a.m. Resident #1 took his final dose of [MEDICATION NAME]. He continued to have an occasional dry cough. Resident #1's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment [DATE] Resident placed on droplet isolation precautions due to [DIAGNOSES REDACTED].>[DATE] [MEDICATION NAME] 75mg by mouth every 12 hours for five days [DATE] Discontinue droplet isolation due to resident being afebrile for 24 hours Resident #1's Facility Medication Administration Record [REDACTED] An interview with Resident #1 on [DATE] at 9:30 a.m. revealed he had been sick with influenza, he was unsure of the date, and was placed in another room in the facility in isolation. A subsequent interview with Resident #1 on [DATE] at 10:50 a.m. revealed he returned back to his regular room, unsure of date, after being isolated but he was still taking medication for his influenza infection when he was removed from isolation. An interview with the DON, who was the facility's designated Infection Control Professsional, on [DATE] at 11:45 a.m. revealed a resident was supposed to remain in droplet isolation until they completed their medication and their symptoms subsided. She stated Resident #1's isolation was discontinued per physician recommendations. A subsequent interview with the DON on [DATE] at 9:10 a.m. revealed she was responsible for the logging, tracking, and trending of facility infections. She reported she identified an issue with influenza in the building when Resident #1 was diagnosed with [REDACTED].#1 was removed from isolation per physician order [REDACTED]. She reported she followed her facility policy and that in order to remove a resident from droplet isolation; the resident had to be fever free for 24 hours and free of influenza signs and symptoms. She added she followed whatever the doctor ordered. She reported the Administrator had contacted the Health Department, date unknown, and that the CDC recommendations were for the residents to remain in isolation for 7 days. She reported they did not follow CDC recommendations; they followed their policy instead and felt it was an effective solution. She reported she did not have any specialized infection control training, but did keep up with trends in infections especially influenza. However, she said she followed facility policy and physician orders. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed a resident was supposed to stay in droplet isolation until they completed their dose of [MEDICATION NAME] for influenza and were free of fever for 72 hours. She stated she discontinued the isolation for Resident #1 because he had been free of fever for 72 hours and she thought he had completed his treatment. She reported the facility was supposed to follow their policy. The facility map, received on [DATE] from the DON reflected Resident #1's isolation room was directly across from Resident #2's room. Resident #1 was transferred back to his regular room on [DATE] that he shared with Resident #3. Resident #2's MDS assessment, dated [DATE], reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was moderately impaired. Resident #2's Immunization record, dated [DATE], reflected she received the influenza vaccine on [DATE]. Resident #2's Nurse's Notes reflected: [DATE] at 4:00 p.m. Resident complained of shortness of breath and pain. Resident was transferred to the hospital and admitted . Resident #2's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment Resident #2's Hospital Admission record, dated [DATE], reflected the resident was admitted with influenza, [MEDICAL CONDITION] pneumonia, [MEDICAL CONDITION]. At 5:34 p.m. the resident's symptoms of cough with rattling in her chest were incapacitating. The resident had labored breathing with an oxygen saturation of 77% (normal reading ,[DATE]%), and a low blood pressure reading of ,[DATE] (normal reading is ,[DATE]) at 5:38 p.m. The resident's influenza test taken at 5:40 p.m. tested positive for influenza type B. The resident's temperature was 101.1 degrees Fahrenheit at 6:17 p.m. and increased to 101.7 degrees Fahrenheit by 6:47 p.m. The resident was transferred to the critical care unit at 8:31 p.m. Resident #2's Hospital Short Stay Summary, dated [DATE], reflected the resident died on [DATE]. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed when Resident #2 was admitted to the critical care unit she required mechanical assistance to assist with her breathing, but she refused. An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #2 had been very active in the facility and rarely stayed in her room. The facility map, received on [DATE] from the DON reflected Resident #1's isolation room was directly across from Resident #2's room. Resident #3's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine outside the facility. The resident's cognitive status was intact. Resident #3's Influenza Declination form, dated [DATE], reflected the resident refused the influenza vaccine. Resident #3's Nurse's Notes reflected: [DATE] at 2:30 p.m. Resident #3 was sitting in dining room, shivering with puffy eyes, inability to finish his sentences, and a temperature of 100.1 F. Resident was sent to the ER. [DATE] at 5:00 p.m. Resident #3 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. Resident #3's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment Resident #3's Hospital Records, dated [DATE], reflected the resident was admitted with Influenza and placed in droplet isolation. Resident was ordered to start [MEDICATION NAME]. Resident #3's Facility Medication Administration Record [REDACTED] An interview with Resident #3 on [DATE] at 9:15 a.m. revealed he had been sick with influenza and was hospitalized . He reported when he returned to the facility he was not placed in isolation. He reported his roommate, Resident #1, also had influenza before him and was placed in isolation. Resident #3 reported he thought he caught influenza from Resident #1 because he was removed from isolation too early. A subsequent interview with Resident #3 on [DATE] at 12:00 p.m. revealed when his roommate, Resident #1, returned to his room he still had a cough. Resident #3 stated he immediately got sick after Resident #1 returned to his room. Resident #3 reported he felt better after returning to the facility from the hospital, but still had respiratory symptoms when he returned. An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #3 returned from the hospital, but was not placed in isolation because she did not receive orders to do so. She reported Resident #3 was very active in the facility and rarely stayed in his room. An interview with the DON on [DATE] at 9:10 a.m. revealed Resident #3 was never placed in isolation at the facility and she was ok with that because he did not have any signs or symptoms of infection. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed she did not know why Resident #3 was never placed in isolation at the facility. The facility map, received on [DATE] from the DON reflected Resident #1 was transferred back to his regular room on [DATE] that he shared with Resident #3. The facility investigation report, dated [DATE], reflected Residents #1, #2, and #3 were all diagnosed with [REDACTED].#3 had completed his [MEDICATION NAME] dose at the hospital. The provider response interventions included: contacted the local health department, and assessed staff and residents for signs and symptoms of influenza daily and as needed. In-services were completed on [DATE] with staff including Relias Learning: H1N1 Influenza in Post-Acute Settings, The CDC recommends that isolation precautions be continued for 7 days from the time symptoms are first seen until they are no longer present. Resident #4's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was offered and declined the influenza vaccine. The resident's cognitive status was severely impaired. Resident #4's Influenza Declination form, dated [DATE], reflected the resident's family refused the influenza vaccine due to the resident's allergy to eggs. Resident #4's Nurse's Notes reflected: [DATE] at 10:30 a.m. Resident confused with occasional cough and emesis. 7:35 p.m. Resident transferred to hospital. [DATE] at 9:35 p.m. Resident #4 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. [DATE] Isolation discontinued due to resident completing antibiotics [DATE] 2:00 p.m. Resident with hoarseness and occasional non-productive cough Resident #4's Hospital Records, dated [DATE], reflected the resident was admitted [MEDICAL CONDITION] secondary to influenza. Resident was ordered to start [MEDICATION NAME]. Resident #4's Physician order [REDACTED].>[DATE] [MEDICATION NAME] 75mg twice daily for 5 days [DATE] Transfer to emergency room for evaluation due to change in condition and elevated temperature [DATE] [MEDICATION NAME] 75mg twice daily for 1 day, droplet isolation precautions [DATE] Discontinue isolation due to completion of antibiotics Resident #4's February 2017 MAR indicated [REDACTED] The facility investigation report, dated [DATE], reflected Resident #4 was diagnosed with [REDACTED]. Resident #4 was confirmed as positive with Influenza Type A and returned to the facility and was placed on droplet isolation precautions for one day. The provider response interventions included: contacted the local health department again and staff in-services completed. An observation of Resident #4 on [DATE] at 11:35 a.m. revealed she was in her room. There were no isolation signs on her door. There was no isolation equipment available. An interview with the DON on [DATE] at 11:45 a.m. revealed Resident #4 was placed in isolation, and then it was discontinued when the doctor said it was ok. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed she remembered placing Resident #4 in isolation and discontinuing the isolation, but could not remember the dates. Resident #5's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was severely impaired. Resident #5's Influenza Consent form, dated [DATE], reflected the resident received the influenza vaccine on [DATE]. Resident #5's Nurse's Notes reflected: [DATE] Resident was very agitated, refused to sit down, and had elevated white blood cells. Nurse Practitioner notified and ordered resident to start [MEDICATION NAME]. Resident #5's Physician order [REDACTED].>[DATE] [MEDICATION NAME] 75mg twice daily for 5 days, Urine Analysis with culture and sensitivity, [MEDICATION NAME] twice daily x 3 days An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #5 had developed an URI and was on [MEDICATION NAME] also. Resident #5 was not placed in isolation. The facility map, received on [DATE] from the DON, reflected Residents #5 and #6 shared a room which was directly across the hall from Residents #1's and #3's room. Resident #6's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was moderately impaired. Resident #6's Influenza Consent form, dated [DATE], reflected the resident received the influenza vaccine on [DATE]. Resident #6's Nurse's Notes reflected: [DATE] Resident was very lethargic, physician notified and [MEDICATION NAME] ordered due to Resident #5's (roommate) possible [DIAGNOSES REDACTED]. [DATE] Resident #6's temperature was 98.9 degrees Fahrenheit and resident's cheeks were flushed. The resident had nasal stuffiness, congestion, and an occasional, dry, non-productive cough. Resident #6's Physician order [REDACTED].>[DATE] Z-Pak ([MEDICATION NAME]) as directed for Upper Respiratory Infection [DATE] [MEDICATION NAME] 75 mg twice daily for 5 days An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #6 was started on [MEDICATION NAME] because he was taking a Z-pak ([MEDICATION NAME]) for an infection, but was still declining. Resident #6 was not placed in isolation. The facility map, received on [DATE] from the DON, reflected Residents #5 and #6 shared a room which was directly across the hall from Residents #1's and #3's room. An interview with LVN A on [DATE] at 2:30 p.m. revealed there were no residents in the facility on isolation. An interview with the Administrator on [DATE] at 4:45 p.m. revealed she did not know when a resident's droplet isolation should be discontinued and she would have to find out. She reported she did not necessarily want to follow the CDC recommendations because they were just recommendations. She reported the facility was doing surveillance to ensure no one else had influenza. A subsequent interview with the Administrator on [DATE] at 2:15 p.m. the corporate email: Flu Outbreak 2017 were guidelines, and the facility followed the physician orders [REDACTED]. She reported she felt the facility policy was effective and the influenza cases were not related. Corporate email: Flu Outbreak 2017, 1. Droplet precautions for residents with confirmed flu with MD orders. Set up droplet precautions per Daybreak policy and procedure. 2. Droplet precautions for residents being treated [MEDICATION NAME] with MD orders. 3. Daily: assess residents for signs/symptoms of respiratory concerns. 4. Daily: assess staff for signs and symptoms of respiratory concerns, staff are not to work when ill. An interview with the Medical Director on [DATE] at 5:20 p.m. revealed he did not know what the facility isolation policy was for influenza. He reported he would contact the Administrator immediately and probably inform her to follow CDC recommendations regarding isolation for residents with influenza to immediately address the issue. An interview with the Corporate RN on [DATE] at 11:00 a.m. revealed a corporate email: Flu Outbreak 2017 was sent to the facility on [DATE] regarding placing residents with influenza in isolation. Additionally the facility received a monitoring tool for residents and staff to assess for signs and symptoms of influenza. Facility Policy and Procedure, Infection Control-Precautions-Initiating and Discontinuing, dated [DATE], reflected the following: .It is the policy of this home that isolation precautions will be initiated when there is reason to believe that a resident has an infectious of communicable disease. They will remain on isolation preventions until the attending physician orders [REDACTED]. Discontinuation .The nurse in charge of the section in which the resident resides shall be responsible for notifying the DON and other appropriate department heads of the decision to discontinue isolation. Facility Policy and Procedure, Infection Control-Precautions-Categories and Notices, dated [DATE], reflected the following: It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Droplet precautions must be implemented for a resident documented or suspected to be infected with influenza. The Centers for Disease Control and Prevention, www.cdc.gov, accessed on [DATE] reflected the following: Droplet precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. Because residents with influenza may continue to shed [MEDICAL CONDITION] while on [MEDICAL CONDITION] treatment, infection control measures to reduce transmission, including following standard and droplet precautions should continue while the resident is taking [MEDICAL CONDITION] therapy. Implement daily active surveillance for respiratory illness among ill residents, health care personnel, and visitors to the facility. Facility Policy and Procedure, Abuse- Reportable Events, dated [DATE], reflected, Neglect: the failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. An Immediate Jeopardy was identified on [DATE]. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 2:10 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 4:00 p.m. and reflected the following: Immediate Action for Identified Resident: Identified resident no longer has Influenza and is no longer a threat to other residents as of [DATE] per physician order. Resident was treated with [MEDICATION NAME] and signs and symptoms resolved. Who Has Potential to be affected: We identify that all residents had the potential to be affected by this resident's infection. Action Taken to Correct Alleged Deficient Practice: In-services start immediately- RN, Regional Nurse Consultant started in servicing nurse managers on the Daybreak Policy and Procedure for care of residents with Influenza utilizing the Policy and Procedure for: Influenza Outbreak Infection Control Precautions Initiating and Discontinuing Infection Control Categories and Notices Hand washing These policies and procedures follow the CDC guidelines and will be followed by the facility staff. These in-services will then be presented to the all staff by the DON, ADON or designees. Started-- [DATE] Completed-[DATE] No staff will be allowed to work until they have completed the above in-services. Monitoring-all residents and staff will be assessed, to include complete vital signs, for signs and symptoms of Influenza. Started [DATE] Completed [DATE] These assessments will be completed by the DON, ADON or designee. Residents suspected of having Influenza will be placed in Droplet Precautions and a Flu swab done to confirm infection or not; staff will not be allowed to return to work until they have been cleared by their physician if/when they have a positive Flu swab. Surveillance of the flu and other respiratory infections will be conducted on an ongoing basis. The surveillance will include assessing residents and staff for flu like symptoms, tracking the prevalence, monitoring staff absenteeism and trending to determine if the facility needs to implement measures to further control the spread of the infection. The surveillance tool (the line listing tool) will be utilized to monitor staff and/or residents. The Infection Control Committee will oversee the surveillance. Droplet precautions for residents with confirmed flu will remain on isolation x 7 days or until end of symptoms per Medical Director recommendation based on best practice per CDC guidelines. Droplet precautions for residents being treated [MEDICATION NAME] for the flu will remain on isolation x 7 days or until end of symptoms per Medical Director recommendation based on best practice per CDC guidelines. The Administrator will be responsible to monitor that all of the above actions are followed through and completed as noted. To verify the faciltiy implements their Plan of Removal interviews were conducted on [DATE] starting at 9:40 a.m. and continued through [DATE] at 4:00 p.m. Fourteen staff members from various shifts were interviewed, they were: LVN A, LVN B, LVN D, LVN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, Laundry M, Laundry N, and CNA O. Responses revealed the staff received in-services regarding resident influenza infection symptom identification, droplet isolation, isolation orders, influenza isolation timeframes, hand washing, and staff influenza illness. The staff members were able to: identify the signs and symptoms a resident with influenza might have, verbalize the action to take if they identified a resident with signs/symptoms of influenza, explain when droplet isolation was required and the equipment needed, identify persons responsible for obtaining isolation orders, explain the CDC recommended timeframe for influenza isolation, describe the hand washing process, and describe the actions they would take if they became sick with influenza symptoms. An interview with the Administrator and DON on [DATE] at 5:00 p.m. revealed going forward the facility would follow best practice guidelines including residents with signs/symptoms of influenza would be placed on droplet isolation immediately and would continue the isolation for 7 days or longer depending on the signs and symptoms of the resident and the physician orders. Additionally, surveillance would continue to monitor every resident and staff member for signs/symptoms of influenza. The Administrator and DON were notified on [DATE] at 5:45 p.m. the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility's census, dated [DATE], reflected 40 residents resided in the facility.

Based on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent neglect for four (Residents #1, #2, #3, and #4) of six residents reviewed for neglect. The DON, who was the facility's designated Infection Control Professional, failed to isolate Residents #1, #3, #4, #5, and #6 after they were treated for [REDACTED]. Resident #2 died at the hospital after developing influenza and complications on [DATE]. Resident's #2, #3, #4, #5, and #6 developed influenza after Resident #1 was removed from isolation earlier than CDC guidance and recommendations. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures could affect the 40 residents residing in the facility by placing them at risk for influenza infection and death. Findings included: Facility Policy and Procedure, Abuse- Reportable Events, dated [DATE], reflected, Neglect: the failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. Facility Policy and Procedure, Infection Control-Precautions-Initiating and Discontinuing, dated [DATE], reflected, It is the policy of this home that isolation precautions will be initiated when there is reason to believe that a resident has an infectious of communicable disease. They will remain on isolation preventions until the attending physician orders [REDACTED]. Procedure: 3. The failure of the attending physician or his/her alternate to take appropriate action concerning a suspected or confirmed infectious communicable disease shall be promptly reported to the administrator. 4. In the event the attending physician fails to take appropriate action, the administrator, director of nursing services, or the infection control coordinator shall have the authority to implement precautions. Discontinuation: 3. The nurse in charge of the section in which the resident resides shall be responsible for notifying the DON and other appropriate department heads of the decision to discontinue isolation. Facility Policy and Procedure, Infection Control-Precautions-Categories and Notices, dated [DATE], reflected, It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Droplet precautions must be implemented for a resident documented or suspected to be infected with influenza. The Centers for Disease Control and Prevention, www.cdc.gov, accessed on [DATE] reflected the following: Droplet precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. Because residents with influenza may continue to shed [MEDICAL CONDITION] while on [MEDICAL CONDITION] treatment, infection control measures to reduce transmission, including following standard and droplet precautions should continue while the resident is taking [MEDICAL CONDITION] therapy. Implement daily active surveillance for respiratory illness among ill residents, health care personnel, and visitors to the facility. Resident #1's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was offered the influenza vaccine, but declined. The resident's cognitive status was severely impaired. Resident #1's Immunization record, dated [DATE], reflected he was allergic to the influenza vaccine. Resident #1's Nurse's Notes reflected: [DATE] at 7:40 p.m. Nurse was called to the resident's room by his roommate. Resident #1 was lying in the bathroom after falling. [DATE] at 8:20 p.m. Resident #1 was sent to the hospital due to his inability to stand. [DATE] at 1:00 a.m. Resident #1 returned to the facility with a new order for [MEDICATION NAME] (medication used to treat influenza). The resident was moved to another and placed on droplet isolation precautions. [DATE] at 10:00 a.m. Resident #1 took his final dose of [MEDICATION NAME]. He continued to have an occasional dry cough. Resident #1's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment [DATE] Resident placed on droplet isolation precautions due to [DIAGNOSES REDACTED].>[DATE] [MEDICATION NAME] 75mg by mouth every 12 hours for five days [DATE] Discontinue droplet isolation due to resident being afebrile for 24 hours Resident #1's Facility Medication Administration Record [REDACTED] An interview with Resident #1 on [DATE] at 9:30 a.m. revealed he had been sick with influenza, he was unsure of the date, and was placed in another room in the facility in isolation. A subsequent interview with Resident #1 on [DATE] at 10:50 a.m. revealed he returned back to his regular room, unsure of date, after being isolated but he was still taking medication for his influenza infection when he was removed from isolation. An interview with the DON, who was the facility's designated Infection Control Professsional, on [DATE] at 11:45 a.m. revealed a resident was supposed to remain in droplet isolation until they completed their medication and their symptoms subsided. She stated Resident #1's isolation was discontinued per physician recommendations. A subsequent interview with the DON on [DATE] at 9:10 a.m. revealed she was responsible for the logging, tracking, and trending of facility infections. She reported she identified an issue with influenza in the building when Resident #1 was diagnosed with [REDACTED].#1 was removed from isolation per physician order [REDACTED]. She reported she followed her facility policy and that in order to remove a resident from droplet isolation; the resident had to be fever free for 24 hours and free of influenza signs and symptoms. She added she followed whatever the doctor ordered. She reported the Administrator had contacted the Health Department, date unknown, and that the CDC recommendations were for the residents to remain in isolation for 7 days. She reported they did not follow CDC recommendations; they followed their policy instead and felt it was an effective solution. She reported she did not have any specialized infection control training, but did keep up with trends in infections especially influenza. However, she said she followed facility policy and physician orders. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed a resident was supposed to stay in droplet isolation until they completed their dose of [MEDICATION NAME] for influenza and were free of fever for 72 hours. She stated she discontinued the isolation for Resident #1 because he had been free of fever for 72 hours and she thought he had completed his treatment. She reported the facility was supposed to follow their policy. The facility map, received on [DATE] from the DON reflected Resident #1's isolation room was directly across from Resident #2's room. Resident #1 was transferred back to his regular room on [DATE] that he shared with Resident #3. Resident #2's MDS assessment, dated [DATE], reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was moderately impaired. Resident #2's Immunization record, dated [DATE], reflected she received the influenza vaccine on [DATE]. Resident #2's Nurse's Notes reflected: [DATE] at 4:00 p.m. Resident complained of shortness of breath and pain. Resident was transferred to the hospital and admitted . Resident #2's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment Resident #2's Hospital Admission record, dated [DATE], reflected the resident was admitted with influenza, [MEDICAL CONDITION] pneumonia, [MEDICAL CONDITION]. At 5:34 p.m. the resident's symptoms of cough with rattling in her chest were incapacitating. The resident had labored breathing with an oxygen saturation of 77% (normal reading ,[DATE]%), and a low blood pressure reading of ,[DATE] (normal reading is ,[DATE]) at 5:38 p.m. The resident's influenza test taken at 5:40 p.m. tested positive for influenza type B. The resident's temperature was 101.1 degrees Fahrenheit at 6:17 p.m. and increased to 101.7 degrees Fahrenheit by 6:47 p.m. The resident was transferred to the critical care unit at 8:31 p.m. Resident #2's Hospital Short Stay Summary, dated [DATE], reflected the resident died on [DATE]. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed when Resident #2 was admitted to the critical care unit she required mechanical assistance to assist with her breathing, but she refused. An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #2 had been very active in the facility and rarely stayed in her room. The facility map, received on [DATE] from the DON reflected Resident #1's isolation room was directly across from Resident #2's room. Resident #3's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine outside the facility. The resident's cognitive status was intact. Resident #3's Influenza Declination form, dated [DATE], reflected the resident refused the influenza vaccine. Resident #3's Nurse's Notes reflected: [DATE] at 2:30 p.m. Resident #3 was sitting in dining room, shivering with puffy eyes, inability to finish his sentences, and a temperature of 100.1 F. Resident was sent to the ER. [DATE] at 5:00 p.m. Resident #3 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. Resident #3's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment Resident #3's Hospital Records, dated [DATE], reflected the resident was admitted with Influenza and placed in droplet isolation. Resident was ordered to start [MEDICATION NAME]. Resident #3's Facility Medication Administration Record [REDACTED] An interview with Resident #3 on [DATE] at 9:15 a.m. revealed he had been sick with influenza and was hospitalized . He reported when he returned to the facility he was not placed in isolation. He reported his roommate, Resident #1, also had influenza before him and was placed in isolation. Resident #3 reported he thought he caught influenza from Resident #1 because he was removed from isolation too early. A subsequent interview with Resident #3 on [DATE] at 12:00 p.m. revealed when his roommate, Resident #1, returned to his room he still had a cough. Resident #3 stated he immediately got sick after Resident #1 returned to his room. Resident #3 reported he felt better after returning to the facility from the hospital, but still had respiratory symptoms when he returned. An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #3 returned from the hospital, but was not placed in isolation because she did not receive orders to do so. She reported Resident #3 was very active in the facility and rarely stayed in his room. An interview with the DON on [DATE] at 9:10 a.m. revealed Resident #3 was never placed in isolation at the facility and she was ok with that because he did not have any signs or symptoms of infection. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed she did not know why Resident #3 was never placed in isolation at the facility. The facility map, received on [DATE] from the DON reflected Resident #1 was transferred back to his regular room on [DATE] that he shared with Resident #3. The facility investigation report, dated [DATE], reflected Residents #1, #2, and #3 were all diagnosed with [REDACTED].#3 had completed his [MEDICATION NAME] dose at the hospital. The provider response interventions included: contacted the local health department, and assessed staff and residents for signs and symptoms of influenza daily and as needed. In-services were completed on [DATE] with staff including Relias Learning: H1N1 Influenza in Post-Acute Settings, The CDC recommends that isolation precautions be continued for 7 days from the time symptoms are first seen until they are no longer present. Resident #4's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was offered and declined the influenza vaccine. The resident's cognitive status was severely impaired. Resident #4's Influenza Declination form, dated [DATE], reflected the resident's family refused the influenza vaccine due to the resident's allergy to eggs. Resident #4's Nurse's Notes reflected: [DATE] at 10:30 a.m. Resident confused with occasional cough and emesis. 7:35 p.m. Resident transferred to hospital. [DATE] at 9:35 p.m. Resident #4 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. [DATE] Isolation discontinued due to resident completing antibiotics [DATE] 2:00 p.m. Resident with hoarseness and occasional non-productive cough Resident #4's Hospital Records, dated [DATE], reflected the resident was admitted [MEDICAL CONDITION] secondary to influenza. Resident was ordered to start [MEDICATION NAME]. Resident #4's Physician order [REDACTED].>[DATE] [MEDICATION NAME] 75mg twice daily for 5 days [DATE] Transfer to emergency room for evaluation due to change in condition and elevated temperature [DATE] [MEDICATION NAME] 75mg twice daily for 1 day, droplet isolation precautions [DATE] Discontinue isolation due to completion of antibiotics Resident #4's February 2017 MAR indicated [REDACTED] The facility investigation report, dated [DATE], reflected Resident #4 was diagnosed with [REDACTED]. Resident #4 was confirmed as positive with Influenza Type A and returned to the facility and was placed on droplet isolation precautions for one day. The provider response interventions included: contacted the local health department again and staff in-services completed. An observation of Resident #4 on [DATE] at 11:35 a.m. revealed she was in her room. There were no isolation signs on her door. There was no isolation equipment available. An interview with the DON on [DATE] at 11:45 a.m. revealed Resident #4 was placed in isolation, and then it was discontinued when the doctor said it was ok. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed she remembered placing Resident #4 in isolation and discontinuing the isolation, but could not remember the dates. Resident #5's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was severely impaired. Resident #5's Influenza Consent form, dated [DATE], reflected the resident received the influenza vaccine on [DATE]. Resident #5's Nurse's Notes reflected: [DATE] Resident was very agitated, refused to sit down, and had elevated white blood cells. Nurse Practitioner notified and ordered resident to start [MEDICATION NAME]. Resident #5's Physician order [REDACTED].>[DATE] [MEDICATION NAME] 75mg twice daily for 5 days, Urine Analysis with culture and sensitivity, [MEDICATION NAME] twice daily x 3 days An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #5 had developed an URI and was on [MEDICATION NAME] also. Resident #5 was not placed in isolation. The facility map, received on [DATE] from the DON, reflected Residents #5 and #6 shared a room which was directly across the hall from Residents #1's and #3's room. Resident #6's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was moderately impaired. Resident #6's Influenza Consent form, dated [DATE], reflected the resident received the influenza vaccine on [DATE]. Resident #6's Nurse's Notes reflected: [DATE] Resident was very lethargic, physician notified and [MEDICATION NAME] ordered due to Resident #5's (roommate) possible [DIAGNOSES REDACTED]. [DATE] Resident #6's temperature was 98.9 degrees Fahrenheit and resident's cheeks were flushed. The resident had nasal stuffiness, congestion, and an occasional, dry, non-productive cough. Resident #6's Physician order [REDACTED].>[DATE] Z-Pak ([MEDICATION NAME]) as directed for Upper Respiratory Infection [DATE] [MEDICATION NAME] 75 mg twice daily for 5 days An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #6 was started on [MEDICATION NAME] because he was taking a Z-pak ([MEDICATION NAME]) for an infection, but was still declining. Resident #6 was not placed in isolation. The facility map, received on [DATE] from the DON, reflected Residents #5 and #6 shared a room which was directly across the hall from Residents #1's and #3's room. An interview with LVN A on [DATE] at 2:30 p.m. revealed there were no residents in the facility on isolation. An interview with the Administrator on [DATE] at 4:45 p.m. revealed she did not know when a resident's droplet isolation should be discontinued and she would have to find out. She reported she did not necessarily want to follow the CDC recommendations because they were just recommendations. She reported the facility was doing surveillance to ensure no one else had influenza. A subsequent interview with the Administrator on [DATE] at 2:15 p.m. the corporate email: Flu Outbreak 2017 were guidelines, and the facility followed the physician orders [REDACTED]. She reported she felt the facility policy was effective and the influenza cases were not related. Corporate email: Flu Outbreak 2017, 1. Droplet precautions for residents with confirmed flu with MD orders. Set up droplet precautions per Daybreak policy and procedure. 2. Droplet precautions for residents being treated [MEDICATION NAME] with MD orders. 3. Daily: assess residents for signs/symptoms of respiratory concerns. 4. Daily: assess staff for signs and symptoms of respiratory concerns, staff are not to work when ill. An interview with the Medical Director on [DATE] at 5:20 p.m. revealed he did not know what the facility isolation policy was for influenza. He reported he would contact the Administrator immediately and probably inform her to follow CDC recommendations regarding isolation for residents with influenza to immediately address the issue. An interview with the Corporate RN on [DATE] at 11:00 a.m. revealed a corporate email: Flu Outbreak 2017 was sent to the facility on [DATE] regarding placing residents with influenza in isolation. Additionally the facility received a monitoring tool for residents and staff to assess for signs and symptoms of influenza. An Immediate Jeopardy was identified on [DATE]. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 2:10 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 4:00 p.m. and reflected the following: Immediate Action for Identified Resident: Identified resident no longer has Influenza and is no longer a threat to other residents as of [DATE] per physician order. Resident was treated with [MEDICATION NAME] and signs and symptoms resolved. Who Has Potential to be affected: We identify that all residents had the potential to be affected by this resident's infection. Action Taken to Correct Alleged Deficient Practice: In-services start immediately- RN, Regional Nurse Consultant started in servicing nurse managers on the Daybreak Policy and Procedure for care of residents with Influenza utilizing the Policy and Procedure for: Influenza Outbreak Infection Control Precautions Initiating and Discontinuing Infection Control Categories and Notices Hand washing These policies and procedures follow the CDC guidelines and will be followed by the facility staff. These in-services will then be presented to the all staff by the DON, ADON or designees. Started-- [DATE] Completed-[DATE] No staff will be allowed to work until they have completed the above in-services. Monitoring-all residents and staff will be assessed, to include complete vital signs, for signs and symptoms of Influenza. Started [DATE] Completed [DATE] These assessments will be completed by the DON, ADON or designee. Residents suspected of having Influenza will be placed in Droplet Precautions and a Flu swab done to confirm infection or not; staff will not be allowed to return to work until they have been cleared by their physician if/when they have a positive Flu swab. Surveillance of the flu and other respiratory infections will be conducted on an ongoing basis. The surveillance will include assessing residents and staff for flu like symptoms, tracking the prevalence, monitoring staff absenteeism and trending to determine if the facility needs to implement measures to further control the spread of the infection. The surveillance tool (the line listing tool) will be utilized to monitor staff and/or residents. The Infection Control Committee will oversee the surveillance. Droplet precautions for residents with confirmed flu will remain on isolation x 7 days or until end of symptoms per Medical Director recommendation based on best practice per CDC guidelines. Droplet precautions for residents being treated [MEDICATION NAME] for the flu will remain on isolation x 7 days or until end of symptoms per Medical Director recommendation based on best practice per CDC guidelines. The Administrator will be responsible to monitor that all of the above actions are followed through and completed as noted. To verify the faciltiy implements their Plan of Removal interviews were conducted on [DATE] starting at 9:40 a.m. and continued through [DATE] at 4:00 p.m. Fourteen staff members from various shifts were interviewed, they were: LVN A, LVN B, LVN D, LVN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, Laundry M, Laundry N, and CNA O. Responses revealed the staff received in-services regarding resident influenza infection symptom identification, droplet isolation, isolation orders, influenza isolation timeframes, hand washing, and staff influenza illness. The staff members were able to: identify the signs and symptoms a resident with influenza might have, verbalize the action to take if they identified a resident with signs/symptoms of influenza, explain when droplet isolation was required and the equipment needed, identify persons responsible for obtaining isolation orders, explain the CDC recommended timeframe for influenza isolation, describe the hand washing process, and describe the actions they would take if they became sick with influenza symptoms. An interview with the Administrator and DON on [DATE] at 5:00 p.m. revealed going forward the facility would follow best practice guidelines including residents with signs/symptoms of influenza would be placed on droplet isolation immediately and would continue the isolation for 7 days or longer depending on the signs and symptoms of the resident and the physician orders. Additionally, surveillance would continue to monitor every resident and staff member for signs/symptoms of influenza. The Administrator and DON were notified on [DATE] at 5:45 p.m. the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility's census, dated [DATE], reflected 40 residents resided in the facility.

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection, and follow standard and transmission-based precautions to prevent the spread of communicable diseases and infections for four (Residents #1, #2, #3, and #4) of six residents reviewed for influenza infections. The DON, who was the facility's designated Infection Control Professional, failed to isolate Residents #1, #3, #4, #5, and #6 after they were treated for [REDACTED]. Resident #2 died at the hospital after developing influenza and complications on [DATE]. Resident's #2, #3, #4, #5, and #6 developed influenza after Resident #1 was removed from isolation earlier than CDC guidance and recommendations. An Immediate Jeopardy was identified on [DATE]. While the Immediate Jeopardy was removed on [DATE] the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures could affect the 40 residents residing in the facility by placing them at risk for influenza infection and death. Findings included: Resident #1's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was offered the influenza vaccine, but declined. The resident's cognitive status was severely impaired. Resident #1's Immunization record, dated [DATE], reflected he was allergic to the influenza vaccine. Resident #1's Nurse's Notes reflected: [DATE] at 7:40 p.m. Nurse was called to the resident's room by his roommate. Resident #1 was lying in the bathroom after falling. [DATE] at 8:20 p.m. Resident #1 was sent to the hospital due to his inability to stand. [DATE] at 1:00 a.m. Resident #1 returned to the facility with a new order for [MEDICATION NAME] (medication used to treat influenza). The resident was moved to another and placed on droplet isolation precautions. [DATE] at 10:00 a.m. Resident #1 took his final dose of [MEDICATION NAME]. He continued to have an occasional dry cough. Resident #1's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment [DATE] Resident placed on droplet isolation precautions due to [DIAGNOSES REDACTED].>[DATE] [MEDICATION NAME] 75mg by mouth every 12 hours for five days [DATE] Discontinue droplet isolation due to resident being afebrile for 24 hours Resident #1's Facility Medication Administration Record (MAR), dated February 2017, reflected the resident took [MEDICATION NAME] starting on [DATE] at 8:00 p.m. and ending on [DATE] at 8:00 a.m. An interview with Resident #1 on [DATE] at 9:30 a.m. revealed he had been sick with influenza, he was unsure of the date, and was placed in another room in the facility in isolation. A subsequent interview with Resident #1 on [DATE] at 10:50 a.m. revealed he returned back to his regular room, unsure of date, after being isolated but he was still taking medication for his influenza infection when he was removed from isolation. An interview with the DON, who was the facility's designated Infection Control Professsional, on [DATE] at 11:45 a.m. revealed a resident was supposed to remain in droplet isolation until they completed their medication and their symptoms subsided. She stated Resident #1's isolation was discontinued per physician recommendations. A subsequent interview with the DON on [DATE] at 9:10 a.m. revealed she was responsible for the logging, tracking, and trending of facility infections. She reported she identified an issue with influenza in the building when Resident #1 was diagnosed with [REDACTED].#1 was removed from isolation per physician order [REDACTED]. She reported she followed her facility policy and that in order to remove a resident from droplet isolation; the resident had to be fever free for 24 hours and free of influenza signs and symptoms. She added she followed whatever the doctor ordered. She reported the Administrator had contacted the Health Department, date unknown, and that the CDC recommendations were for the residents to remain in isolation for 7 days. She reported they did not follow CDC recommendations; they followed their policy instead and felt it was an effective solution. She reported she did not have any specialized infection control training, but did keep up with trends in infections especially influenza. However, she said she followed facility policy and physician orders. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed a resident was supposed to stay in droplet isolation until they completed their dose of [MEDICATION NAME] for influenza and were free of fever for 72 hours. She stated she discontinued the isolation for Resident #1 because he had been free of fever for 72 hours and she thought he had completed his treatment. She reported the facility was supposed to follow their policy. The facility map, received on [DATE] from the DON reflected Resident #1's isolation room was directly across from Resident #2's room. Resident #1 was transferred back to his regular room on [DATE] that he shared with Resident #3. Resident #2's MDS assessment, dated [DATE], reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was moderately impaired. Resident #2's Immunization record, dated [DATE], reflected she received the influenza vaccine on [DATE]. Resident #2's Nurse's Notes reflected: [DATE] at 4:00 p.m. Resident complained of shortness of breath and pain. Resident was transferred to the hospital and admitted . Resident #2's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment Resident #2's Hospital Admission record, dated [DATE], reflected the resident was admitted with influenza, viral pneumonia, and sepsis. At 5:34 p.m. the resident's symptoms of cough with rattling in her chest were incapacitating. The resident had labored breathing with an oxygen saturation of 77% (normal reading ,[DATE]%), and a low blood pressure reading of ,[DATE] (normal reading is ,[DATE]) at 5:38 p.m. The resident's influenza test taken at 5:40 p.m. tested positive for influenza type B. The resident's temperature was 101.1 degrees Fahrenheit at 6:17 p.m. and increased to 101.7 degrees Fahrenheit by 6:47 p.m. The resident was transferred to the critical care unit at 8:31 p.m. Resident #2's Hospital Short Stay Summary, dated [DATE], reflected the resident died on [DATE]. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed when Resident #2 was admitted to the critical care unit she required mechanical assistance to assist with her breathing, but she refused. An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #2 had been very active in the facility and rarely stayed in her room. The facility map, received on [DATE] from the DON reflected Resident #1's isolation room was directly across from Resident #2's room. Resident #3's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine outside the facility. The resident's cognitive status was intact. Resident #3's Influenza Declination form, dated [DATE], reflected the resident refused the influenza vaccine. Resident #3's Nurse's Notes reflected: [DATE] at 2:30 p.m. Resident #3 was sitting in dining room, shivering with puffy eyes, inability to finish his sentences, and a temperature of 100.1 F. Resident was sent to the ER. [DATE] at 5:00 p.m. Resident #3 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. Resident #3's Physician order [REDACTED].>[DATE] Sent to emergency room for evaluation and treatment Resident #3's Hospital Records, dated [DATE], reflected the resident was admitted with Influenza and placed in droplet isolation. Resident was ordered to start [MEDICATION NAME]. Resident #3's Facility Medication Administration Record (MAR), dated February 2017, reflected the resident took [MEDICATION NAME] starting on [DATE] at 8:00 a.m. and ending on [DATE] at 8:00 a.m. An interview with Resident #3 on [DATE] at 9:15 a.m. revealed he had been sick with influenza and was hospitalized . He reported when he returned to the facility he was not placed in isolation. He reported his roommate, Resident #1, also had influenza before him and was placed in isolation. Resident #3 reported he thought he caught influenza from Resident #1 because he was removed from isolation too early. A subsequent interview with Resident #3 on [DATE] at 12:00 p.m. revealed when his roommate, Resident #1, returned to his room he still had a cough. Resident #3 stated he immediately got sick after Resident #1 returned to his room. Resident #3 reported he felt better after returning to the facility from the hospital, but still had respiratory symptoms when he returned. An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #3 returned from the hospital, but was not placed in isolation because she did not receive orders to do so. She reported Resident #3 was very active in the facility and rarely stayed in his room. An interview with the DON on [DATE] at 9:10 a.m. revealed Resident #3 was never placed in isolation at the facility and she was ok with that because he did not have any signs or symptoms of infection. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed she did not know why Resident #3 was never placed in isolation at the facility. The facility map, received on [DATE] from the DON reflected Resident #1 was transferred back to his regular room on [DATE] that he shared with Resident #3. The facility investigation report, dated [DATE], reflected Residents #1, #2, and #3 were all diagnosed with [REDACTED].#3 had completed his [MEDICATION NAME] dose at the hospital. The provider response interventions included: contacted the local health department, and assessed staff and residents for signs and symptoms of influenza daily and as needed. In-services were completed on [DATE] with staff including Relias Learning: H1N1 Influenza in Post-Acute Settings, The CDC recommends that isolation precautions be continued for 7 days from the time symptoms are first seen until they are no longer present. Resident #4's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was offered and declined the influenza vaccine. The resident's cognitive status was severely impaired. Resident #4's Influenza Declination form, dated [DATE], reflected the resident's family refused the influenza vaccine due to the resident's allergy to eggs. Resident #4's Nurse's Notes reflected: [DATE] at 10:30 a.m. Resident confused with occasional cough and emesis. 7:35 p.m. Resident transferred to hospital. [DATE] at 9:35 p.m. Resident #4 returned to the facility from the hospital with a [DIAGNOSES REDACTED]. [DATE] Isolation discontinued due to resident completing antibiotics [DATE] 2:00 p.m. Resident with hoarseness and occasional non-productive cough Resident #4's Hospital Records, dated [DATE], reflected the resident was admitted with sepsis secondary to influenza. Resident was ordered to start [MEDICATION NAME]. Resident #4's Physician order [REDACTED].>[DATE] [MEDICATION NAME] 75mg twice daily for 5 days [DATE] Transfer to emergency room for evaluation due to change in condition and elevated temperature [DATE] [MEDICATION NAME] 75mg twice daily for 1 day, droplet isolation precautions [DATE] Discontinue isolation due to completion of antibiotics Resident #4's February 2017 MAR reflected the resident took [MEDICATION NAME] starting on [DATE] at 7:00 a.m. and ending on [DATE] at 7:00 p.m. The facility investigation report, dated [DATE], reflected Resident #4 was diagnosed with [REDACTED]. Resident #4 was confirmed as positive with Influenza Type A and returned to the facility and was placed on droplet isolation precautions for one day. The provider response interventions included: contacted the local health department again and staff in-services completed. An observation of Resident #4 on [DATE] at 11:35 a.m. revealed she was in her room. There were no isolation signs on her door. There was no isolation equipment available. An interview with the DON on [DATE] at 11:45 a.m. revealed Resident #4 was placed in isolation, and then it was discontinued when the doctor said it was ok. An interview with the Nurse Practitioner on [DATE] at 12:15 p.m. revealed she remembered placing Resident #4 in isolation and discontinuing the isolation, but could not remember the dates. Resident #5's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was severely impaired. Resident #5's Influenza Consent form, dated [DATE], reflected the resident received the influenza vaccine on [DATE]. Resident #5's Nurse's Notes reflected: [DATE] Resident was very agitated, refused to sit down, and had elevated white blood cells. Nurse Practitioner notified and ordered resident to start [MEDICATION NAME]. Resident #5's Physician order [REDACTED].>[DATE] [MEDICATION NAME] 75mg twice daily for 5 days, Urine Analysis with culture and sensitivity, [MEDICATION NAME] twice daily x 3 days An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #5 had developed an URI and was on [MEDICATION NAME] also. Resident #5 was not placed in isolation. The facility map, received on [DATE] from the DON, reflected Residents #5 and #6 shared a room which was directly across the hall from Residents #1's and #3's room. Resident #6's MDS assessment, dated [DATE], reflected the resident was a [AGE] year-old male, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident received the influenza vaccine on [DATE]. The resident's cognitive status was moderately impaired. Resident #6's Influenza Consent form, dated [DATE], reflected the resident received the influenza vaccine on [DATE]. Resident #6's Nurse's Notes reflected: [DATE] Resident was very lethargic, physician notified and [MEDICATION NAME] ordered due to Resident #5's (roommate) possible [DIAGNOSES REDACTED]. [DATE] Resident #6's temperature was 98.9 degrees Fahrenheit and resident's cheeks were flushed. The resident had nasal stuffiness, congestion, and an occasional, dry, non-productive cough. Resident #6's Physician order [REDACTED].>[DATE] Z-Pak ([MEDICATION NAME]) as directed for Upper Respiratory Infection [DATE] [MEDICATION NAME] 75 mg twice daily for 5 days An interview with LVN B on [DATE] at 3:40 p.m. revealed Resident #6 was started on [MEDICATION NAME] because he was taking a Z-pak ([MEDICATION NAME]) for an infection, but was still declining. Resident #6 was not placed in isolation. The facility map, received on [DATE] from the DON, reflected Residents #5 and #6 shared a room which was directly across the hall from Residents #1's and #3's room. An interview with LVN A on [DATE] at 2:30 p.m. revealed there were no residents in the facility on isolation. An interview with the Administrator on [DATE] at 4:45 p.m. revealed she did not know when a resident's droplet isolation should be discontinued and she would have to find out. She reported she did not necessarily want to follow the CDC recommendations because they were just recommendations. She reported the facility was doing surveillance to ensure no one else had influenza. A subsequent interview with the Administrator on [DATE] at 2:15 p.m. the corporate email: Flu Outbreak 2017 were guidelines, and the facility followed the physician orders [REDACTED]. She reported she felt the facility policy was effective and the influenza cases were not related. Corporate email: Flu Outbreak 2017, 1. Droplet precautions for residents with confirmed flu with MD orders. Set up droplet precautions per Daybreak policy and procedure. 2. Droplet precautions for residents being treated [MEDICATION NAME] with MD orders. 3. Daily: assess residents for signs/symptoms of respiratory concerns. 4. Daily: assess staff for signs and symptoms of respiratory concerns, staff are not to work when ill. An interview with the Medical Director on [DATE] at 5:20 p.m. revealed he did not know what the facility isolation policy was for influenza. He reported he would contact the Administrator immediately and probably inform her to follow CDC recommendations regarding isolation for residents with influenza to immediately address the issue. An interview with the Corporate RN on [DATE] at 11:00 a.m. revealed a corporate email: Flu Outbreak 2017 was sent to the facility on [DATE] regarding placing residents with influenza in isolation. Additionally the facility received a monitoring tool for residents and staff to assess for signs and symptoms of influenza. Facility Policy and Procedure, Infection Control-Precautions-Initiating and Discontinuing, dated [DATE], reflected the following: .It is the policy of this home that isolation precautions will be initiated when there is reason to believe that a resident has an infectious of communicable disease. They will remain on isolation preventions until the attending physician orders [REDACTED]. Discontinuation .The nurse in charge of the section in which the resident resides shall be responsible for notifying the DON and other appropriate department heads of the decision to discontinue isolation. Facility Policy and Procedure, Infection Control-Precautions-Categories and Notices, dated [DATE], reflected the following: It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Droplet precautions must be implemented for a resident documented or suspected to be infected with influenza. The Centers for Disease Control and Prevention, www.cdc.gov, accessed on [DATE] reflected the following: Droplet precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. Because residents with influenza may continue to shed influenza virus while on antiviral treatment, infection control measures to reduce transmission, including following standard and droplet precautions should continue while the resident is taking antiviral therapy. Implement daily active surveillance for respiratory illness among ill residents, health care personnel, and visitors to the facility. An Immediate Jeopardy was identified on [DATE]. The Administrator and DON were notified of the Immediate Jeopardy on [DATE] at 2:10 p.m. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on [DATE] at 4:00 p.m. and reflected the following: Immediate Action for Identified Resident: Identified resident no longer has Influenza and is no longer a threat to other residents as of [DATE] per physician order. Resident was treated with [MEDICATION NAME] and signs and symptoms resolved. Who Has Potential to be affected: We identify that all residents had the potential to be affected by this resident's infection. Action Taken to Correct Alleged Deficient Practice: In-services start immediately- RN, Regional Nurse Consultant started in servicing nurse managers on the Daybreak Policy and Procedure for care of residents with Influenza utilizing the Policy and Procedure for: Influenza Outbreak Infection Control Precautions Initiating and Discontinuing Infection Control Categories and Notices Hand washing These policies and procedures follow the CDC guidelines and will be followed by the facility staff. These in-services will then be presented to the all staff by the DON, ADON or designees. Started-- [DATE] Completed-[DATE] No staff will be allowed to work until they have completed the above in-services. Monitoring-all residents and staff will be assessed, to include complete vital signs, for signs and symptoms of Influenza. Started [DATE] Completed [DATE] These assessments will be completed by the DON, ADON or designee. Residents suspected of having Influenza will be placed in Droplet Precautions and a Flu swab done to confirm infection or not; staff will not be allowed to return to work until they have been cleared by their physician if/when they have a positive Flu swab. Surveillance of the flu and other respiratory infections will be conducted on an ongoing basis. The surveillance will include assessing residents and staff for flu like symptoms, tracking the prevalence, monitoring staff absenteeism and trending to determine if the facility needs to implement measures to further control the spread of the infection. The surveillance tool (the line listing tool) will be utilized to monitor staff and/or residents. The Infection Control Committee will oversee the surveillance. Droplet precautions for residents with confirmed flu will remain on isolation x 7 days or until end of symptoms per Medical Director recommendation based on best practice per CDC guidelines. Droplet precautions for residents being treated [MEDICATION NAME] for the flu will remain on isolation x 7 days or until end of symptoms per Medical Director recommendation based on best practice per CDC guidelines. The Administrator will be responsible to monitor that all of the above actions are followed through and completed as noted. To verify the faciltiy implements their Plan of Removal interviews were conducted on [DATE] starting at 9:40 a.m. and continued through [DATE] at 4:00 p.m. Fourteen staff members from various shifts were interviewed, they were: LVN A, LVN B, LVN D, LVN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, Laundry M, Laundry N, and CNA O. Responses revealed the staff received in-services regarding resident influenza infection symptom identification, droplet isolation, isolation orders, influenza isolation timeframes, hand washing, and staff influenza illness. The staff members were able to: identify the signs and symptoms a resident with influenza might have, verbalize the action to take if they identified a resident with signs/symptoms of influenza, explain when droplet isolation was required and the equipment needed, identify persons responsible for obtaining isolation orders, explain the CDC recommended timeframe for influenza isolation, describe the hand washing process, and describe the actions they would take if they became sick with influenza symptoms. An interview with the Administrator and DON on [DATE] at 5:00 p.m. revealed going forward the facility would follow best practice guidelines including residents with signs/symptoms of influenza would be placed on droplet isolation immediately and would continue the isolation for 7 days or longer depending on the signs and symptoms of the resident and the physician orders. Additionally, surveillance would continue to monitor every resident and staff member for signs/symptoms of influenza. The Administrator and DON were notified on [DATE] at 5:45 p.m. the Immediate Jeopardy was removed. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. The facility's census, dated [DATE], reflected 40 residents resided in the facility.

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for one (Resident #5) of two residents reviewed for wound care. 1. The Wound Care Nurse failed to ensure Resident #5 received pain medication prior to treating a DTI on the resident's left heel, which resulted in the resident exhibiting signs of pain to include facial grimacing, crying, and moaning. The Wound Care Nurse and ADON D failed to stop Resident #5's wound care when the resident exhibited these signs and symptoms of pain. 2. The facility failed to develop a care plan to address Resident #5's pain related to wound care. The failures could affect the three residents with pressure ulcers by placing them at risk for discomfort, pain, and emotional distress. Findings included: Resident #5's admission care plan, dated 09/28/15, reflected a care plan for pain had been developed which reflected to monitor for pain and administer pain medications as ordered. The care plan did not address pain related to wounds or pre-medicating the resident with pain medication prior to wound care. Resident #5's MDS assessment, dated 11/12/15, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. The resident had severe cognitive impairment and [DIAGNOSES REDACTED]. The resident was totally dependent on staff for ADL care. Resident #5's December 2015 Physician order [REDACTED]. The orders reflected the resident had orders to receive the following pain medications: [REDACTED]. The Braden Scale completed for Resident #5 on 12/14/15 by the Wound Care Nurse reflected Resident #5 was not always able to communicate discomfort. Observation on 12/17/15 at 1:32 p.m. revealed Resident #5 had a DTI on her left heel that was covered with 100% black necrotic (dead) tissue, surrounded by skin redness. Wound care was provided by Wound Care Nurse assisted by ADON D. Resident #5 appeared thin, weak and frail, she exhibited facial grimacing, and she was moaning and crying out, mostly nonsensical speech, pulling her left leg away from Wound Care Nurse. When questioned by ADON D, regarding if Resident #5 had received pain medication prior to wound care, Wound Care Nurse revealed Resident #5 had received [MEDICATION NAME] 50 mg tablet at 9:30 a.m., and she thought she may have received [MEDICATION NAME] at 1:00 p.m. Resident #5 continued to cry out. During wound care, Wound Care Nurse remarked, I hate for her to be so uncomfortable, and I hate to touch it (left heel) because it hurts her so bad. Wound Care Nurse completed her wound care and Resident #5 stopped crying out. Following the wound care on 12/17/15, a review of Resident #5's December 2015 MAR indicated [REDACTED]. The December 2015 MAR indicated [REDACTED]. Interview on 12/17/15 at 3:20 p.m. with ADON D revealed she had previously been the Wound Care Nurse for the facility. ADON D stated she thought Resident #5 experienced a high level of pain during wound care as evidenced by the resident crying out, tensing up, and pulling her affected leg back. She stated DTIs were very painful, and residents should be pre-medicated one hour prior to wound care in her experience. ADON D stated she assisted with three previous wound care procedures on Resident #5, and the resident appeared to be in pain each time similar to the observation on 12/17/15. ADON D stated she may have stopped the care and medicated Resident #5 further if she had been the Wound Care Nurse during the care observed. Interview on 12/18/15 at 10:15 a.m. with the DON revealed the Wound Care Nurse was hired 10/14/15, and she had completed wound care and pain management training. She was trained in wound care by RN I (Regional Nurse Consultant). The DON stated she, ADON D, and RN I evaluated the Wound Care Nurse on a weekly basis to observe her wound care procedures. Interview on 12/18/15 at 10:25 a.m. with the Wound Care Nurse revealed she had been performing wound care at this facility for four to six months. She revealed Resident #5's heel wound was painful and the redness around the wound area had increased. She stated she never thought she needed to check to ensure Resident #5 had been pre-medicated prior to wound care. She revealed in hindsight, she should have stopped the wound care. She also stated she should have given Resident #5 pain medication one hour prior to wound care. Interview on 12/17/15 at 2:40 p.m. with the DON confirmed there was no order to pre-medicate Resident #5 prior to wound care. As of 12/17/15, the DON stated she obtained an order from Physician J to medicate Resident #5 with [MEDICATION NAME] 7.5/325 mg one hour prior to wound care, and the resident's care plan had been updated. The facility's current Pain Management Policy and Procedure, dated March 2012, reflected: .Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e. wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities. The facility's current Skin-Treatment Guidelines for Pressure Ulcers, Policy and Procedure, dated March 2012, reflected: Assess and manage pain associated with deep tissue injury. Retrieved website information on 12/22/15, Department of Health and Human Services <http://www.guideline.gov/content.aspx?id= > National Quality Measures Clearinghouse <http://qualitymeasures.ahrq.gov/> reflected: Guideline Title: Pain management in older adults. In: Evidence-based geriatric nursing protocols for best practice. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. Administer [MEDICATION NAME] 30 minutes prior to activities. Educate patients, families, and other clinicians to use [MEDICATION NAME] medications [MEDICATION NAME] prior to and after painful procedures. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 12/15/15, reflected three residents had pressure ulcers. --

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan, which included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one (Resident #5) of seven residents reviewed for care-plans. The facility failed to develop a care plan to address Resident #5's need for pain medication prior to daily wound care for an unstageable pressure ulcer on the resident's left heel. The failure could affect the three residents with pressure ulcers by placing them at risk for discomfort, pain, and emotional distress. Findings included: Resident #5's admission care plan, dated 09/28/15 reflected, to monitor pain and administer pain medications as ordered. Her care plan did not include to pre-medicate for pain prior to wound care or to assess her for pain during or after wound care. Resident #5's MDS assessment, dated 11/12/15, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with severe cognitive impairment and [DIAGNOSES REDACTED]. She was totally dependent on staff for ADL care. Pain management included PRN pain medication and non-medication intervention. Resident #5's December 2015 Physician order [REDACTED]. The order reflected to clean the pressure ulcer and apply Skin Prep once each day. The orders also reflected the resident had orders to receive PRN pain medication as follows: two tablets of Tylenol 325 mg every six hours as needed for pain; one tablet of [MEDICATION NAME] 600 mg every eight hours as needed for pain; and one tablet of [MEDICATION NAME] 50 mg every eight hours as needed for pain. There were no orders to pre-medicate Resident #5 prior to wound care. Review of Resident #5's December 2015 MAR indicated [REDACTED] Observation on 12/17/15 at 1:32 p.m. revealed Resident #5 had an unstageable pressure ulcer on her left heel that was 100% black necrotic (dead) tissue, surrounded by skin redness. At the time of this observation, the Wound Care Nurse provided Resident #5 with wound care, and she was assisted by ADON D. During the wound care, Resident #5 grimaced, moaned, cried out, and pulled her left leg away from the Wound Care Nurse. The Wound Care Nurse revealed Resident #5 had received [MEDICATION NAME] 50 mg tablet at 9:30 a.m. that morning, and she thought the resident may have also received [MEDICATION NAME] at 1:00 p.m. Resident #5 continued to cry out as the wound was treated. The Wound Care Nurse stated, I hate for her to be so uncomfortable. She also stated, I hate to touch it (left heel) because it hurts her so bad. After the Wound Care Nurse completed the wound care, Resident #5 stopped crying out. Retrieved website information 12/22/15 from the Department of Health and Human Services at http://www.guideline.gov/content.aspx?id= National Quality Measures Clearinghouse http://qualitymeasures.ahrq.gov Guideline Title: Pain management in older adults. In: Evidence-based geriatric nursing protocols for best practice. Anticipate and aggressively treat for pain before, during, and after painful diagnostic and/or therapeutic treatments. Administer [MEDICATION NAME] 30 minutes prior to activities. Educate patients, families, and other clinicians to use [MEDICATION NAME] medications [MEDICATION NAME] prior to and after painful procedures. The facility's current Care Plan policy and procedure, dated March 2012, reflected: It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. The Resident Census and Conditions of Residents Form CMS-672, signed and dated by the DON on 12/15/15, reflected three residents had pressure ulcers.

Based on observation, interview and record review, it was determined the facility failed to ensure nine (Residents #1, #3, #6, #8, #9, #11, #12, #14 and #15) of ten residents reviewed with Restorative Nursing Program orders or Restorative Nursing Care (RNC) Plans of Care received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. 1) Resident #12 had severe contractures of both arms and hands. The facility's only ADON, Corporate Nurse and three CNAs were instructed by OT on proper application/fitting of stabilizers/immobilizers for both elbows and instructed to have the resident wear them on each arm in the AM & PM. On 09/14/11, OT discharged the resident to RNS with a schedule for the use of the stabilizers/immobilizers to be worn on the resident's elbows. The stabilizers/immobilizers were left in the therapy room and the resident had not received any RNS. She was readmitted to OT on 11/04/11 because the resident's contractures had worsened. These failures resulted in Resident #12 developing contractures, along with decreased PROM, increased pain, and she required greater assistance with transfers and care. 2) Resident #1 was discharged from PT/OT on 10/11/11 without contractures. A Restorative Nursing Care Plan was written by therapy on 10/11/11 for orthotics, splinting, PROM and AROM for the resident, but Resident #1 never received any restorative nursing care. On 12/01/11 Resident #1 was readmitted to PT/OT and was evaluated with decreased PROM finger extension at DIP (distal interphalangeal joint) and PIP (proximal interphalangeal joint) joints with mild contractures beginning to develop. PT assessed Resident #1 to require greater assistance with transferring from supine to a sitting position. These failures resulted in Resident #1 having increased tone, pain, decreased ROM, skin breakdown/redness at elbow creases influencing the ability to receive care by staff without pain, poor skin integrity, and contractures worsening since orthotics had not been worn. 3) Resident #6 had a Nursing Restorative Care Program for Transfers and Ambulation dated November 2011, which was never initiated. 4) Resident #3 was discharged from OT on 11/03/11 and had orders for Restorative Nursing Care, but it was never initiated. 5) Resident #8 was discharged from PT on 10/27/11 and had two "Nursing Restorative Care Program" plans of care dated 11/04/11, which were never initiated. 6) Resident #9 was evaluated by OT on 11/02/11 and orders for the Restorative Nursing Program. The orders included PROM/AAROM, but were never initiated. 7) Resident #11 had two "Nursing Restorative Care Program" plans of care dated 10/12/11, which were never initiated. 8) Resident #14 had Nursing Restorative Care Plans dated from October 2011, which had a date for being initiated, but were not initiated. 9) Resident #15 had orders for the Nursing Restorative Care Program from September 2011, which were never initiated. These failures could affect Residents #3, #6, #8, #9, #11, #14 and #15 and the 15 residents identified with contractures, the three residents, who were bedfast, and the 17 residents, who were primarily chair fast, and placed them at risk for their contractures worsening, having increased pain with movement, skin breakdown and social isolation due to the potential of not being able to leave bed and sit in a chair comfortably. Findings included: 1) The most current MDS assessment dated [DATE] reflected Resident #12, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #12 was severely cognitively impaired, required extensive assistance of two staff members for bed mobility, transfers and toileting. The MDS assessment also reflected the resident's ROM was impaired with impairment of both legs, and the resident had not received any restorative therapy, including ROM, in the last seven calendar days. Resident #12's Record of admitted d 04/05/11 reflected a readmission date of [DATE] and [DIAGNOSES REDACTED]. At 9:44 AM on 11/29/11 during initial tour with the facility's only ADON, Resident #12 was observed sitting in a Geri Chair. Contractures to both of the resident's hands, arms and legs were observed. No hand rolls were observed in Resident #12's hands. The ADON stated Resident # 12 has contractures of both arms, hands and legs and was unable to straighten out one leg due to a previous fracture. The ADON added the resident was total care and required assistance of two people using a hoyer lift for transfers. Review of the Discharge Summary dated 09/14/11 by the Therapy Director revealed: Functional level: 1. Positioning - The resident exhibits less hyper tonicity and muscle shortening while lying in bed for 3 hours utilizing rolls at elbow creases and in right hand. Orthotics did arrive and resident able to be positioned with orthotics up to 1 hour 15 min. at a time with very mild redness. 2. Prosthetic/Orthotic Use - The resident has been fitted with extension orthosis for both elbows and is able to wear orthosis on each arm for up to 1 hour 15 minutes with very minimal redness and no significant pressure points. 3. ROM: Elbow/Forearm - The resident demonstrates PROM (passive range of motion) on both upper extremity elbow extensions of approximately -90 to -95 degrees with no demonstration of pain with slow static stretch prior to ROM measurement. Orthotics is the use of orthopedic appliances. Orthosis is any device added to the body to stabilize or immobilie a body part, prevent deformity, protect against injury, or assist with function. Caregiver Education: The ADON, nurse and 3 CNAs were instructed on proper application/fitting of orthoses to both elbows and instructed to have resident wear orthosis on each arm for no more than 1 hour at a time in the AM & PM. Discharge Summary: Resident has achieved maximum rehab potential at this time and is being discharged to Restorative Nursing Plan with bilateral elbow orthosis wear scheduled. Review of Resident #12's Nursing Restorative Care Program (for Orthotics) dated September 2011 revealed the following: Goal: Maintain bilateral upper extremity ROM elbow extension with elbow extension orthotic. Approaches: 1. Apply elbow orthotic to each arm for 1 hour maximum two times per day (AM & PM) No signatures or initials of completion were on the care plan. Review of Resident #12's Nursing Restorative Care Plan (PROM) dated September 2011 revealed the following: Goal: Maintain bilateral upper extremity elbow extension of equal or to 90 degree extension and maintain shoulder/hand ROM. Approaches: 1. Perform PROM shoulder flexion, elbow extension 10 repetitions each and hold for 1-3 seconds. 2. Perform wrist flexion/extension PROM 10 reps hold 3 seconds each. 3. PROM finger extension stretch and hold for 5 seconds times 5 repetitions each. No signatures or initials of completion were on the care plan. An interview with the Therapy Director on 12/01/11 at 03:40 PM, revealed she had started working at the facility on 06/12/11. The Therapy Director stated when OT discharged a resident from therapy, she would write a Nursing Restorative Care Plan and would give it to the DON, which should be signed and then the Care Plan should be initiated. The Therapy Director provided from her own Restorative Book a copy of Resident #12's Nursing Restorative Care Program, which she had written. The Therapy Director stated the goal for a Nursing Restorative Care Program was to maintain residents at the same level when they were discharged from therapy to prevent a resident's functional decline. The Therapy Director stated Resident # 12's orthotics were left in the therapy room, and she had not seen any staff use the orthotics on Resident # 12. Review of Resident #12's signed Physician's telephone order dated 11/03/11 revealed OT and PT were to evaluate the resident due to increased tightness at the elbows and increase in his contractures. Resident #12 was readmitted to OT on 11/03/11. The Therapy Director's OT evaluation assessment dated [DATE] revealed the following: Patient has elbow orthotics, but has not had them applied for an extended time by staff. Significant staff turnover and new staff require training on RNP for ROM and orthotics fitting and application. Assessment: Patient presents with increased tone, pain, decreased ROM, skin breakdown/redness at elbow creases influencing ability to receive care by staff without pain, poor skin integrity, and patient's contractures are worsening since orthotics have not been worn. Current Level of Function - 1. Positioning - The patient exhibits tone pain, and rigidity at both elbows when lying in bed or up in chair during staff care and/or movement/ROM of both arms. 2. Prosthetic/Orthotic Use - The patient is unable to fit in current elbows extension orthoses due to increased tone/worsening contractures since patient has not had orthoses applied consistently. 3. ROM: Arm - Elbow/Forearm - The patient demonstrates PROM elbow extension to -145 with significant tone and facial display of pain. Review of Resident #12's Nursing Restorative Care Plan Program dated 12/05/11, revealed the following: Goal: Resident's ROM of affected extremities will be maintained. Approaches: 1. Soft folded cloth in hands for hygiene and to prevent skin to skin contact. Keep hands clean. 2. PROM x 4 extremities daily, then to increase to three x a day when all aides certified. 3. Quarterly therapy screen. 2) The quarterly MDS assessment dated [DATE] reflected Resident #1, a [AGE] year-old female, was admitted to facility on 07/21/11 with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #1 was severely cognitively impaired, was totally dependent on two staff for physical assist for bed mobility, transfers, toileting and personal hygiene. Resident #1 was not receiving therapy or "Restorative Nursing Programs." Review of Resident #1's admission progress note dated 07/26/11 revealed, "...client (Resident #1) moving constantly in bed, flinging arms and legs about...." Resident #1's OT Daily Treatment Note for October 2011 reflected her start of care date for OT was 07/25/11. Review of Resident #1's Progress Notes dated 08/10/11 revealed, "client (Resident #1) ...will follow simple commands such as turning her head, straightening out her legs...." Review of Resident #1's History and Physical Exam dated 08/24/11 revealed, "moves all extremities ad lib but no meaning." Review of an undated PT note revealed, "...Bed Mobility - Supine _ (to) Sit - The patient is able to safely transition from supine _ (to) requiring maximum assistance x 2 (76-99%) with 2 people.... " Further review of this form revealed the service dates were from 09/24/11 through 10/07/11. Review of Resident #1's OT Daily Treatment Note dated 10/10/11 revealed "...Pt. (Patient) received sustained or prolonged stretch to improve ROM and decrease potential for contracture. Established restorative nursing program from PROM and AAROM. Completed AAROM to prevent weakness, contractures." Review of Resident #1's "Physician Telephone Orders" dated 10/11/11 revealed, "D/C from OT services to RNP." Resident #1 had two "Nursing Restorative Care Program" plans of care dated 10/19/11, which reflected: a. Goal: Prevent contractures and skin breakdown in hands. Approaches: 1. Apply bilateral hand orthoses (hand devices to prevent contractures) and monitor for redness/pressure spots every 2 hours. 2. Take orthoses off as needed per nursing. 6 x week/for 12 weeks. b. Goal: Prevent contractions and weakness to both arms and hands. Approaches: 1. Perform PROM+/or AAROM at shoulders, elbows, wrist fingers joints. 5 reps each and hold for 5 - 10 seconds. 6 x week/ for 12 weeks. The Restorative Plans of Care were never initiated. Review of Resident #1's "Progress Notes" dated 10/16/11 at 5:00 PM revealed, "...Extremities remain contracted...." Review of Resident #1's Progress Notes dated 10/25/11 revealed, "Resident in fetal position..." Review of Resident #1's Progress Notes dated 10/28/11 at 3:00 AM revealed, "Resting _ (symbol for with) knees drawn up to her chest...." Review of Resident #1's care plan dated 11/11/11 revealed under the column labeled "Problem or Need" was handwritten "Contracture to all 4 ext forming fetal position." Under the column labeled "Goal/Objective" reflected handwritten in "on PT/OT/ST therapy." Under the column labeled "Approach" reflected, "...Restorative as appropriate. Consider PT referral to evaluate for ability to increase skills as appropriate." The ADON signed this care plan. Review of Resident #1's Comprehensive Plan of Care dated 11/16/11 revealed under the column, "...Problem/Need" was handwritten "Contractures to bil ? and lower ext. On PT/OT/ST therapy for pain mgt contractures." Resident #1 was observed on 11/29/11 at 11:20 AM sitting in a recliner in her room. Her knees were drawn up to her chest. A piece of sheepskin was in her hand and nothing in her left hand. Both hands were clenched closed and touched her shoulders. During an interview on 11/29/11 at 11:48 AM, LVN A stated the sheepskin in Resident #1's right hand was "smelly." The LVN further stated, "The sheepskin gets used on occasion. We are supposed to use hand rolls the majority of the time. The hand rolls are supposed to come off every two hours and left off for 10 to 15 minutes. The left hand roll has been off all day today." Observation on 11/29/11 at 3:20 PM revealed Resident #1 did not have the left hand orthosis under contracted fingers. Observation on 11/30/11 at 9:05 AM revealed Resident #1 did not have the left hand orthosis under contracted fingers. During an interview on 12/01/11 at 9:00 AM, the surveyor queried LVN A if she was aware Resident #1 had an order for [REDACTED]." Review of Resident #1's "Physician's Telephone Order" dated 12/01/11 revealed, "OT to evaluate + Tx. PT to evaluate + Tx." During the medication pass on 11/30/11 at 2:00 PM, Resident #1 was observed lying in bed in a fetal position with her legs pulled up to her chest. LVN A accessed the resident's gastrostomy tube after struggling to lift the resident's left arm up, and pushing the resident's left leg down. The LVN was then asked if the resident was contractured, at which time she stated, "No." On 12/01/11 at 3:45 PM, Resident #1 was observed in her bed lying in a fetal position. Again, LVN A was asked if the resident was contractured. The LVN stated, "No. You can pull on her legs, and finally she will relax and you can pull them straight out." LVN A went to the foot of Resident #1's bed and grabbed her right foot and began pulling the right leg down into a straight position. The resident's right knee pulled away from her chest, as she moaned, shook, and her body tightened up. The surveyor requested that the LVN stop pulling on her right foot, at which time the right leg withdrew back up to the resident's chest. During an interview on 12/02/11 at 3:15 PM, the Therapy Director stated when Resident #1 was discharged from OT on 10/11/11, she (Resident #1) could open her hands but they were clenched, so orthoses were used. "She (Resident #1) had no hand contractures." The Therapy Director also stated Resident #1 could sit on the side of the bed with two-person moderate to maximum assist for 15 minutes. "Restorative should have been able to maintain them fairly well." Observation on 12/02/11 at 3:55 PM revealed the Therapy Director evaluated Resident #1 for readmission to OT. Resident #1 was grunting and yelling as the Therapy Director was attempting to straighten out her right arm. The Therapy Director could not straighten out Resident #1's right or left legs. The Therapy Director stated, "She (Resident #1) is so tight." Resident #1's assessment dated [DATE] reflected: Left hand "slight contractures to left fingers, right arm tight, right elbow tight." "Right fingers are better than the left, with mild contractures to fingers." Review of Resident #1's OT Plan of Treatment dated 12/02/11 revealed the Treatment [DIAGNOSES REDACTED]. Further review of the Plan of Treatment revealed the Current Level of Function at Start of Care: "...The patient demonstrates decreased PROM finger extension at DIP and PIP joints with mild contractures beginning to develop. Approximate finger extension is -45 deg at PIP joints and approx. -30 deg at DIP joints." Review of the PT Plan of Treatment dated 12/02/11 revealed Functional Level "...Bed Mobility - Supine _ (to) Sit - The patient is able to safely transition from supine _ (to) sitting position requiring total assistance (100% assist)." 3) An interview with the Therapy Director on 12/01/11 at 03:40 PM, revealed she had started working at the facility on 06/12/11. The Therapy Director stated when OT discharged a resident from therapy, she would write a Nursing Restorative Care Plan and would give it to the DON. She stated the RN should sign the Nursing Restorative Care Plan and initiate the Care Plan. The Therapy Director stated she had already trained a few CNAs, the Corporate Nurse and the ADON in regard to Restorative Nursing. The Therapy Director provided a copy of the Clinical Check Off list, which included the training for the Restorative Aide dated 11/23/11 and the Corporate Nurse and ADON training with no date when the training had occurred. Also provided by the Therapy Director from her own Restorative Book were copies of Nursing Restorative Care Programs for Residents #1, #8, #11, #12, #14 and #15, which she had written. The Therapy Director stated the goal for a Nursing Restorative Care Program was to maintain residents at the same level when they were discharged from therapy to prevent a resident's functional decline. The Therapy Director also stated she had never seen any of the staff she trained provide any restorative nursing care. 4) The MDS assessment dated [DATE] reflected Resident #6, a [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected the Functional Limitation in Range of Motion reflected impairment in both lower extremities. Review of Resident #6's Nursing Restorative Care Program dated November 2011 for Transfers and Ambulation had not been initiated. During a confidential interview, it was revealed Resident #6 had requested staff to work with him to walk. The interviewee was aware six weeks prior the Restorative Nursing Program had not been initiated for Resident #6. He/She stated he/she had brought this request from the resident to the Administrator's attention on several times. During an interview on 12/05/11 at 11:23 AM, the Restorative Aide revealed she had started a Nursing Restorative Care Program on two residents on 12/02/11. One of the residents was Resident #6. She told the surveyor she had not initialed his New Restorative Care Plan dated 12/01/11 to indicate she had implemented the Care Plan. Review of Resident #6's Nursing Restorative Care Program dated 12/01/11 revealed care was provided by CNA B on 12/03/11 and 12/04/11. 5) The MDS assessment dated [DATE] reflected Resident #3, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected the resident had no functional limitation in ROM, but was not steady with transfers, walking, and turning around. Resident #3 required limited assistance of one person with ADLs. Review of "physician's orders [REDACTED]. Restorative Nursing had not been initiated. During an interview with the Corporate Nurse on 11/30/11 at 2:27 PM, she stated the ADON was not aware there was an order for [REDACTED]. 6) The admission MDS assessment dated [DATE] reflected Resident #8, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #8 required limited physical assistance of one person to complete her ADLs. Resident #8 had no impairment in her functional ROM. Resident #8 was receiving OT and PT, which were initiated on 08/18/11. Review of Resident #8's "Physician's Telephone Orders" dated 11/01/11 revealed "Discharge from skilled PT effective 10/27/11." Resident #8 had two Nursing Restorative Care Program plans of care dated 11/04/11, which reflected: a. Goal: Maintain upper body strength of 4/5 to remain modified independence with ADLs and mobility. Approaches: 1. Arm bike - 10 minutes at medium resistance. 2. Bilateral upper extremities AROM exercises with 2-3 pound weights - bicep curls, triceps press and shoulder flexion. To be completed 6 times a week for 12 weeks. b. Goal: Maintain ability to transfer with modified independence. Approaches: 1. Sit to stand from wheelchair. 10 reps x 2-3 sets. 2. Perform 2-4 functional transfers. 3. Standing tolerance/activity for 3-5 minutes. To be completed 6 times a week for 12 weeks. There was no evidence the Restorative Plans of Care were ever implemented. 7) The MDS assessment dated [DATE] reflected Resident #9, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9 had no impairment in her functional ROM, but was not steady and only able to stabilize with human assistance in moving from a seated to standing position and when moving on and off the toilet. Further review of the MDS assessment revealed Resident #9 required two person physical assist with total care with ADLs. Resident #9 had Nursing Restorative Care Plans dated September 2011, which had never been implemented. 8) The MDS assessment dated [DATE] reflected Resident #11, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #11 required the extensive assistance of one person physical assist with bed mobility, transfers ad toilet use. Resident #11 had functional limitation in range of motion to one upper extremity and to both lower extremities. Resident #11 was receiving OT. Resident #11 had two Nursing Restorative Care Program plans of care dated 10/12/11, which reflected: a. Goal: Resident will maintain current level of upper extremity strength 4/5. Approaches: 1) Arm bike 10 min as tolerated. 2) Bilateral AROM exercises with 1-wrist weights (example - rings, pegboards, etc. b. Goal: Patient will perform transfers at current level of stand by assist with minimal intervention without falling/falls. Approaches: 1) Wheelchair to toilet and/or wheelchair to recliner transfers x 3. 2) Sit to stands for wheelchair and/or at hall rail 10 times. There was no evidence these Restorative Plans of Care were ever implemented. Review of Resident #11's Physician Telephone Orders dated 11/08/11 revealed: 1. OT clarification orders: Patient will receive OT treatment 3 x week/30 days to include therapeutic exercise and activities, self-care and training and wheelchair management. 2. Patient for skilled PT 3 x week for 4 weeks for therapeutic exercises, therapeutic activities, gait, group, manual and neuro...education. 9) The MDS assessment dated [DATE] reflected Resident #14, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of Resident #14's MDS assessment revealed the resident required the extensive physical assistance of two people with bed mobility and transfers and limited assistance with mobility, dressing, toileting and personal hygiene. The MDS assessment reflected Resident #14 has ROM impairment of both legs (hips, knees, ankles and feet). Resident #14 had a Nursing Restorative Care Program, which was dated as having been initiated in October 2011. However, other than a date written in as being initiated, there was no other evidence to indicate it had been implemented. Resident #14 was again evaluated for PT/OT according to physician orders [REDACTED]. 10) The MDS assessment dated [DATE] reflected Resident #15, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #15 required extensive assistance with the physical assist of one person to complete her ADLs. Further review of the MDS assessment revealed Resident #15 had functional limitation in range of motion to one lower extremity and was not receiving therapy or RNP. Resident #15 had four Nursing Restorative Care Program plans of care dated 09/21/11, which reflected: a. Goal: Maintain left upper extremity strength to propel self in wheelchair and perform sit to stand by self. Approaches: 1. AROM exercises with 2-3 pound weights and/or 1.5-pound wrist weights. 10 reps x 3 sets each exercise. 2. Green theraband exercises left upper extremity 10 reps x 3 sets each direction. b. Goal: Maintain and/or improve strength and activity tolerance. Approaches: 1. Restorative with assistance. 2. Sitting lower extremity exercises. c. Goal: Maintain and/or improve transfers. 1. Stand at bar. 2. Transfer bed to wheelchair. d. Goal: Maintain current level of assist with transfers and ability to stand up at bar. 2. Sit to stand and bar/rail. 3 sets of 5. There was no evidence to indicate these Restorative Plans of Care were ever implemented. 11) An interview with the ADON and Corporate Nurse on 11/30/11 at 12:45 PM revealed the Restorative Aide had been trained and the facility would start a Restorative Nursing Program effective 12/01/11. The ADON stated several CNAs had been trained before (to use the Restorative Nursing Program) but were no longer employed at the facility. Both the ADON and Corporate Nurse stated the facility's Restorative Nursing Program had not been started prior to the survey team's survey visit. At 2:13 PM, the ADON was requested to provide any notes from Restorative Nursing. The ADON had no notes from Restorative Nursing. The ADON stated they had no notes because they have never started their restorative program. The last person they trained left. 12) On 11/30/11 at 2:29 PM, the Corporate Nurse provided the surveyor with the facility's Nursing Restorative Care Plan Book. She said the ADON reconciled the orders for Restorative Nursing. At 2:47 PM, review of the Nursing Restorative Care Plan Book revealed Residents #3, #6, #8 and #9 were included in the Nursing Restorative Care Program for November 2011. They had been completed by the Therapy Director and had no initials or signatures of completion. 13) During an interview on 12/05/11 at 10:15 AM, the Interim DON stated, "I identified, when I started here (2 weeks ago) that there was no restorative program. So I started it and hired a Restorative CNA. She (Restorative Aide) started actual restorative care sometime last week. I can't fix the past." 14) The facility's current Policy & Procedure for Restorative Program Referral, effective date: January 2008 reflected: Referrals: Therapist or the Interdisciplinary team may make referrals to the restorative nursing program. Restorative Program Coordinator to evaluate for individualized program need. Staff notified of applicable program. Appropriate nursing staff to perform program. Duration: The resident is to remain in the Restorative Program until maximal potential is reached. Should a therapist not be available for consultation, the decision to discharge the resident from the Restorative Nursing Program is to be made by the Interdisciplinary Team. 15) The CMS-672, Resident Census and Conditions of Residents, dated 11/30/11 and signed by the Interim DON, reflected 15 residents had contractures, 5 residents had contractures on admission, 3 residents were bedfast and 17 residents were primarily chair-fast.

Based on interview and record review, the facility failed to notify and consult with the resident's physician when there was a significant change in the physical health for one closed clinical record (Resident #10) of 10 residents reviewed for a change in condition. Resident #10 was admitted to the facility on [DATE] with exacerbation [MEDICAL CONDITION], was on hospice and he wanted to be fully resuscitated. From [DATE] until [DATE], when he was transferred to the hospital and died , the resident experienced a continuous decline in his respiratory status. The facility failed to: 1. Consult with the resident's physician for guidance with the resident's plan of care when his breathing difficulty increased and secretions changed on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; staff would either call hospice or wait for hospice's scheduled visit; 2. Accurately assess the resident following a fall. 3. Follow the resident's physician's orders [REDACTED]. Resident #3 consistently was receiving 3 LPM of oxygen instead of the ordered 2 - 2.5 LPM; 4. Ensure the resident's physician had a complete and accurate report of the resident's status on [DATE] when the physician made rounds. These failures could affect the two residents receiving hospice services and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and painfree life they desired. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. 1) The "Admission/Readmission Data Summary" dated [DATE] reflected Resident #10, a [AGE] year-old male, was admitted from an area hospital with Exacerbation of [MEDICAL CONDITION]. The Summary reflected the resident was "Alert," his "Short and Long Term Memory were OK," he was able to "Understand, and able to be Understood" and exhibited "Verbal Expressions of distress and a Sad, anxious appearance." The Summary also reflected Resident #10 was "Independent" with "Eating and Toilet Use," was independent with an assistive device for mobility and he needed occasional physical assistance with transfers. Resident #10's Admission Care Plan dated [DATE] reflected the resident was alert and oriented. The care plan identified the problem of "URI/Pneumonia" with goals to monitor lung sounds and administer oxygen at 2.5 L/min per nasal cannula. Under the "Cardiac" identified problem, the care plan reflected in addition to oxygen therapy, the facility would monitor the resident' s oxygen saturation levels. The care plan did not address any problem with respiratory crisis associated with [MEDICAL CONDITION]. Resident #10's MDS assessment dated [DATE] reflected the resident had shortness of breath at rest, with exertion and when lying flat. Review of Resident #10's clinical record revealed a piece of paper in the front of Resident #10's chart indicating Resident #10 was a "Full Code." Resident #10's Progress Notes dated [DATE] at 9:00 AM reflected the resident had a productive cough with "thick yellow green sputum." Respirations were even and labored and he was using accessory muscles to breathe (which meant he was struggling to breathe). The resident had scattered wheezing in his lower lobes. Resident #10's Progress Notes dated [DATE] at 10:30 AM reflected the resident's oxygen saturation level was down to 86%-91% when he was off oxygen (normal ,[DATE]%; less than 90% is considered low). The notes reflected Resident #10 had wheezing audible in all lobes and his respirations were even and labored. The notes also reflected his cough was productive with thick sputum and his oxygen saturation level was 98% on oxygen. Resident #10's Progress Notes reflected his oxygen saturation level dropped to between 80% - 83% when he was off oxygen. Resident #10's Progress Notes dated [DATE] at 12:30 PM reflected the resident's oxygen saturation level dropped to below 85% on room air. The note also reflected, "Lung sounds observed to be scattered, wet productive cough. Respirations even and labored using all accessory muscles to breathe." Interview on [DATE] at 10:10 AM with LVN F revealed she took care of Resident #10 on [DATE] and [DATE]. LVN F stated Resident #10 was very alert. LVN F stated the resident's oxygen saturation level would drop a lot if the resident was not kept on oxygen. LVN F stated the resident would go on smoke breaks and would not have his oxygen on. When he returned, he would put his oxygen back on himself. He stayed stable on 3 liters of oxygen per minute. The surveyor asked the LVN if she knew what the resident's order for oxygen was. LVN F responded, "not really." The surveyor informed the LVN it was for ,[DATE].5 LPM. The LVN was then asked if she knew how high oxygen could be set for a resident with [MEDICAL CONDITION], LVN F answered, "No. Not really." and then told the surveyor the resident's oxygen saturation level dropped down to 86% the first weekend ([DATE] through [DATE]) he was in the facility. LVN F stated at 12:30 PM, Resident #10 began to have a deep, wet, productive cough and his oxygen was 85%. He had scattered wheezing. The surveyor then asked when LVN F would call the doctor. The LVN stated, "Right then." The surveyor then asked LVN F, "Did you call him?" LVN F said, "No." The surveyor asked, "You didn't call the doctor?" LVN F stated the hospice nurse was going to be in the facility on Sunday ([DATE]). The surveyor then asked LVN F when Resident #10's oxygen saturation level dropped below 92%, should she have called the physician. LVN F answered, "Yes." Review of Resident #10's admission physician orders [REDACTED]. Review of the hospice skilled nurse's notes had an entry dated [DATE], which revealed the nurse made a PRN visit for Resident #10 due to his increased shortness of breath. The hospice notes reflected the resident had inspiratory and expiratory wheezes. The nurse wrote orders for [MEDICATION NAME] (pain medication) as needed, [MEDICATION NAME] (narcotic [MEDICATION NAME]) to be administered via nebulizer every 4 hours and [MEDICATION NAME] (laxative) as needed. There was no documentation to indicate the hospice nurse notified the physician. Resident #10's Progress Notes dated [DATE] at 6:45 AM reflected the resident had a "resp (respiratory) event & labored accessory muscles being used ...Call cord in reach." The notes were unclear as to the time of the event and did not reflect any other nursing action taken at that time. An approximate blood oxygen level can also be determined using a pulse oximeter - a small device that clips on your finger. Though the pulse oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. <http://www.mayoclinic.com/health/hypoxemia/MY > Last updated [DATE] and Retrieved [DATE] [MEDICAL CONDITION] Managing exacerbationsEven with ongoing treatment, you may experience times when symptoms suddenly get worse. This is called an acute exacerbation, and it may cause lung failure if you don't receive prompt treatment. Exacerbations may be caused by a respiratory infection, a change in outdoor temperatures or high air pollution levels. Seek medical attention if you notice more coughing or a change in your mucus or if you have a harder time breathing. <http://www.mayoclinic.com/health/[MEDICAL CONDITION]/DS /METHOD=print> Last updated [DATE] and Retrieved [DATE] Resident #10's Progress Notes dated [DATE] at 11:00 AM reflected the resident had labored breathing using "all of his accessory muscles to breathe; diminished lung sounds to lower lobes with scattered wheezing to upper lobes. Resident had a productive cough with dark yellow sputum." During the interview on [DATE] at 10:10 AM with LVN F, the surveyor asked the LVN to review Resident #10's Progress Notes dated [DATE] at 11:00 AM. LVN F revealed she had written the notes. LVN F was asked if a resident was using all the accessory muscles to breathe, would that be an indication to call the physician. LVN F replied, "Yes." When asked if she had called Resident #10's physician, LVN F stated, "No." LVN F stated she called Hospice. The surveyor asked LVN F when would she call a doctor. LVN F stated when there was a change in condition. The surveyor asked her when would she send the resident to the hospital. LVN F did not reply. The surveyor asked LVN F if she should have sent Resident #10 to the hospital. LVN F stated, "Yes." LVN F told the surveyor she was focused on Resident #10 "being on Hospice." Resident #10's Progress Notes dated [DATE] at 11:35 AM reflected the resident had a fall and was found on his right side with the oxygen tubing and the cord from the remote wrapped around his feet. The nurse documented the resident was without injury. The physician was informed of the fall. Resident #10 was put on neurological assessments due to his fall and the potential for a head injury. Review of an Incident/Accident Report dated [DATE] at 11:35 AM revealed Resident #10 was found on the floor with his oxygen tubing and bed remote wrapped around his feet. The report reflected, "? (no) injuries reported." The report along with the Final Disposition Report reflected the resident was alert and oriented at that time and no x-rays or lab work were ordered. The resident's family and the Medical Director were notified, per the notes. The hospice nursing entry dated [DATE] reflected a prn visit was made to observe Resident #10. The resident's lungs were "very congested" and his oxygen was on at 3 liters. Resident #10 was complaining of a sore throat and his tongue and throat were red. The resident complained his [MEDICATION NAME] was not working and needed to be increased. His oxygen saturation level was 86% while he was on oxygen. The hospice nurse received an order from the Medical Director to increase his [MEDICATION NAME] to two tablets three times a day as needed for his headache and added [MEDICATION NAME] Spray, five sprays every two hours as needed for his sore throat. Review of Resident #10's Neurological assessment dated [DATE], [DATE] and [DATE] revealed, following the incident, the resident was checked on [DATE] at 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 1:15 PM, 1:45 PM, 2:15 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 7:00 PM. The assessments reflected the resident's BP remained consistent between ,[DATE] and ,[DATE]; the resident's respiratory rate remained between 22 and 26 per minutes; his heart rate fluctuated between 58 and 110 beats per minute and his temperatures were from 96.3 - 98.8 F. His pupils were always a "4" in size and reacted to light. Resident #4's speech was always clear and he never had a headache. The assessments were continued on [DATE] at 3:00 AM, 11:00 AM, 7:00 PM and on [DATE] at 3:00 AM. His heart rate fluctuated between 79 and 113 beats per minute and his blood pressure dropped to ,[DATE] on [DATE] at 7:00 PM. His Neurological Assessment reflected he never had a headache despite his request on [DATE], following his fall, for an increase in his medication, [MEDICATION NAME], because it was "not working." He was receiving [MEDICATION NAME] for his headaches. Resident #10's Progress Notes dated [DATE] at 11:15 AM reflected the resident had gurgles in his throat and mumbled speech. The Notes also reflected Resident #10 had "copious amounts of clear/yellow sputum. Respirations are labored using accessory muscles to breathe." The resident's sputum had changed to being copious and clear/yellow. The fact he had mumbled speech was not on his Neurological Assessment either. During the interview on [DATE] at 10:10 AM with LVN F, the LVN stated the Medical Director of the facility (also Resident #10's primary physician) came to the facility for a routine visit on [DATE], but the orders for Resident #10 did not change. The surveyor asked LVN F if she told the physician about Resident #10's current condition, and LVN F stated, "No," she just told the physician he, "needed to see the resident." LVN F stated she did not think the doctor saw him, because he did not document any visit in his notes. The surveyor asked LVN F who (the facility or hospice) should have called 911 when Resident #10's condition continued to deteriorate on [DATE], and LVN F stated, "We should have," meaning facility staff. Resident #10's Progress Notes dated [DATE] at 2:30 AM reflected the resident had a productive cough with thick yellow/green secretions. The Notes also reflected his respirations were labored and all his accessory muscles were being used. There was no evidence the physician was notified. The Notes reflected at 11:40 AM, Resident #10 was struggling to breathe and 911 was called. At 11:52 AM, he stopped breathing and there was no audible heart rate. The resident was moved to the floor and staff initiated CPR. Interview on [DATE] at 9:30 AM with LVN E revealed she worked a double the weekend of [DATE] through [DATE] and provided care to Resident #10. LVN E stated Resident #10 was having a difficult time breathing, using his accessory muscles, and his respirations were labored. LVN E stated the resident coughed a lot and most of the time the sputum was green in color. The surveyor asked LVN E when she would consider calling the resident's doctor. LVN E stated if his respirations "got over 25, I would probably call the MD." LVN E stated she would be worried if they were greater than 25. LVN E stated the last time his breathing was labored, they sent him to the hospital for assessment of [MEDICAL CONDITION] activity. LVN E stated they were also watching his oxygen saturation level, and if it fell below 90%, she would call the doctor. Resident #10's emergency room Notes dated [DATE] at 4:10 p.m. reflected Resident #10 was pronounced dead and the cause of death was "AMI" (Acute [MEDICAL CONDITION] Infarction ([MEDICAL CONDITION])). According to http:/chestjournal.chestpubs.org/content/,[DATE].abstract, retrieved on [DATE], "Conclusion: The results suggest that exacerbations of [MEDICAL CONDITION] increase the risk of MI...." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected the chest x-rays taken indicated the resident had "...some focal areas of pneumonitis within the upper right lobe and a small area within the left upper lobe...There appears to be some mucus within the right lower lobe of lung." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected a CT scan taken of Resident #10's brain indicated a suspicious subarachnoid bleed (bleeding in the brain). Further review of Resident #10's closed clinical record on [DATE], revealed there was no physician's progress note for the dates of [DATE] or [DATE]. A physician's progress note dated [DATE] for Resident #10 was provided to the surveyors on [DATE]. The resident's physician, the Medical Director, had documented on this progress note there were "no new problems." The surveyor interviewed the Medical Director on [DATE] at 11:58 AM. When the surveyor asked the Medical Director if he knew Resident #10 was a full code, he responded, "No. I don't think I did." The surveyor asked the Medical Director if he saw Resident #10 on [DATE]. The Medical Director stated he went to see the resident, but he saw from the doorway Resident #10 was sleeping. He said he did not want to wake him. The Medical Director stated the resident was on antibiotics. The Medical Director also stated usually the hospice staff take care of the residents. The surveyor asked the Medical Director how he perceived hospice was involved with residents' care. The Medical Director stated hospice was to keep the resident comfortable and assess the resident's needs. The Medical Director stated hospice staff were called most of the time for the resident's care. He stated hospice called him if the resident in the facility was his patient. The Medical Director then stated the facility gives the primary care and the facility always calls me. The Medical Director stated Resident #10 had a plethora of medical problems and he could have gone to the emergency room every day. The surveyor stated the facility still had to honor the resident's wishes. The Medical Director stated, "Yeah. That's right." An interview was conducted with RN G on [DATE] at 3:30 PM. During this conversation, the RN confirmed she remembered Resident #10. The RN stated on the night of [DATE] at 9:00 PM, the Medical Director came to the facility and made rounds on his residents. The Medical Director was informed he needed to see Resident #10, who needed to be assessed by the physician. During the physician's rounds, RN G stated he approached the door to Resident #10's room and looked inside at the resident, who was asleep in bed. The Medical Director told RN G Resident #10 was sleeping and he was not going to wake him up. RN G said the Medical Director knew "we" wanted him to see the resident, but he did not ask any questions about Resident #10's signs/symptoms. According to RN G, the Medical Director continued on down the hall and never returned to Resident #10 to assess him. During RN G's interview, she stated on two separate occasions, the Medical Director never wrote a progress note for Resident #10. RN G stated the Medical Director only looked at the resident from the hallway, he never entered the resident's room and he never assessed the resident. RN G stated specifically, "I can tell you there was not a progress note written (on [DATE]) on Resident ___ (#10) by the Medical Director." An interview on [DATE] at 1:00 PM with the Regional Manager Hospice RN C revealed the facility needed to do more than what they did because Resident #10 was a full code (to be administered cardiopulmonary resuscitation). RN C stated she thought the facility was just trying to let him go (die on his own). 2) The facility's current policy and procedure for Change of Condition - Observing, Reporting and Recording, revised [DATE] reflected: "It is the policy of this home to informs (sic) the resident, the residents (sic) physician and if indicted (sic) the residents (sic) responsible party of the following... 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications... 4. A need to alter treatment significantly... Procedure... 1. After resident changes in condition ...conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition. 3. The attending physician should be notified as soon as possible if immediate attention is required...If you are unable to reach the attending physician, call the alternate physician... 6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital...." 3) On [DATE] at 11:50 AM, the Administrator was interviewed and asked what type of procedure was in place to ensure the nursing needs of the residents were being met. The Administrator stated the facility had a standup meeting in the morning where the 24 hour report is reviewed. The 24 hour report is supposed to include the Nursing staff list, resident behaviors, resident changes in condition, new admits and discharges, and incidents. Nursing reviews and conducts the follow-up. All Department Heads are aware of what has occurred. The facility also has the Guardian Angel Program. Department Heads are assigned a room to visit each morning. They review the room and talk to the resident to ensure their needs are being met. This is being reinstituted today ([DATE]). The Administrator was then asked how he monitored staff (for example, the DON) to ensure they systems they monitor are being done sufficiently. The Administrator stated at the daily standup meeting, there is a form, which is to be completed, which includes changes, social services and staffing issues. The form is also used to make note of issues, which the Administrator said he personally follows up. 4) On [DATE] at approximately 11:45 AM, the newly-hired DON was interviewed and asked what training she is going to ensure the nursing staff have in order to care for a resident with a change in condition. She wants to be sure they know how to assist with documenting the change of condition. She wants the CNAs to note it on the skin assessment form for now. She would inservice the CNAs and the nurses on payday or to come in to the facility and do it face to face. When asked how she would ensure nursing staff were competent in their skills in caring for a resident with a change in condition, she referred to skills checks on hire and at least annually. The DON stated when a resident was admitted with special needs, the staff would be inserviced and there would be a check off to ensure competence. The DON was asked what plan the facility had in place for a change in condition. The DON stated she had now implemented a morning routine, which was not previously in place. There was now a five page form called "The Morning Routine," which had to be completed and followed up. When asked about inservices, the DON stated inservices have been given for change of condition and how to respond when hospice is involved. 5) Review of an Inservice Training Report dated [DATE] at 2:00 PM revealed the subject was Change of Condition and 11 nursing staff were provided the inservice one on one with written quizzes entitled "Change of Condition Verification." Review of an Inservice Training Report dated [DATE] at 10:00 AM revealed the subject was Change of Baseline - Resident and 14 nursing staff were provided the inservice one on one and was job specific. Review of an Inservice Training Report dated [DATE] at 3:30 PM revealed the subject was Change of Condition/Notification and the new DON was provided the inservice one on one. 6) Interviews were conducted with facility staff to determine whether they had been inserviced on a resident's change of condition, whether the resident receiving hospice services made a difference in facility staff's reactions and reporting and the facility's status as the resident's caregivers. On [DATE], the following staff were interviewed and able to respond appropriately in regard to the information provided at the facility's inservices: LVN K at 10:55 AM The Restorative Aide at approximately 2:00 pm CNA H at approximately 2:05 pm LVN I at approximately 2:10 pm RN J at 2:32 PM LVN F at 3:00 PM 7) The facility's CMS-802, Roster/Sample Matrix, provided to the survey team on [DATE] reflected there were two residents receiving hospice services.

Based on observation, interview and record review, the facility failed to implement facility policies and procedures to ensure one resident's closed clinical record (Resident #10) of 16 residents reviewed was free from neglect. Resident #10 was admitted to the facility on [DATE] with exacerbation [MEDICAL CONDITION], was on hospice and he wanted to be fully resuscitated. From [DATE] until [DATE], when he was transferred to the hospital and died , the resident experienced a continuous decline in his respiratory status. The facility failed to: 1. Consult with the resident's physician for guidance with the resident's plan of care when his breathing difficulty increased and secretions changed on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; staff would either call hospice or wait for hospice's scheduled visit; 2. Accurately assess the resident following a fall. 3. Follow the resident's physician's orders [REDACTED]. Resident #3 consistently was receiving 3 LPM of oxygen instead of the ordered 2 - 2.5 LPM; 4. Ensure the resident's physician had a complete and accurate report of the resident's status on [DATE] when the physician made rounds. These failures could affect the two residents receiving hospice services and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and painfree life they desired. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. 1) The "Admission/Readmission Data Summary" dated [DATE] reflected Resident #10, a [AGE] year-old male, was admitted from an area hospital with Exacerbation of [MEDICAL CONDITION]. The Summary reflected the resident was "Alert," his "Short and Long Term Memory were OK," he was able to "Understand, and able to be Understood" and exhibited "Verbal Expressions of distress and a Sad, anxious appearance." The Summary also reflected Resident #10 was "Independent" with "Eating and Toilet Use," was independent with an assistive device for mobility and he needed occasional physical assistance with transfers. Resident #10's Admission Care Plan dated [DATE] reflected the resident was alert and oriented. The care plan identified the problem of "URI/Pneumonia" with goals to monitor lung sounds and administer oxygen at 2.5 L/min per nasal cannula. Under the "Cardiac" identified problem, the care plan reflected in addition to oxygen therapy, the facility would monitor the resident' s oxygen saturation levels. The care plan did not address any problem with respiratory crisis associated with [MEDICAL CONDITION]. Resident #10's MDS assessment dated [DATE] reflected the resident had shortness of breath at rest, with exertion and when lying flat. Review of Resident #10's clinical record revealed a piece of paper in the front of Resident #10's chart indicating Resident #10 was a "Full Code." Resident #10's Progress Notes dated [DATE] at 9:00 AM reflected the resident had a productive cough with "thick yellow green sputum." Respirations were even and labored and he was using accessory muscles to breathe (which meant he was struggling to breathe). The resident had scattered wheezing in his lower lobes. Resident #10's Progress Notes dated [DATE] at 10:30 AM reflected the resident's oxygen saturation level was down to 86%-91% when he was off oxygen (normal ,[DATE]%; less than 90% is considered low). The notes reflected Resident #10 had wheezing audible in all lobes and his respirations were even and labored. The notes also reflected his cough was productive with thick sputum and his oxygen saturation level was 98% on oxygen. Resident #10's Progress Notes reflected his oxygen saturation level dropped to between 80% - 83% when he was off oxygen. Resident #10's Progress Notes dated [DATE] at 12:30 PM reflected the resident's oxygen saturation level dropped to below 85% on room air. The note also reflected, "Lung sounds observed to be scattered, wet productive cough. Respirations even and labored using all accessory muscles to breathe." Interview on [DATE] at 10:10 AM with LVN F revealed she took care of Resident #10 on [DATE] and [DATE]. LVN F stated Resident #10 was very alert. LVN F stated the resident's oxygen saturation level would drop a lot if the resident was not kept on oxygen. LVN F stated the resident would go on smoke breaks and would not have his oxygen on. When he returned, he would put his oxygen back on himself. He stayed stable on 3 liters of oxygen per minute. The surveyor asked the LVN if she knew what the resident's order for oxygen was. LVN F responded, "not really." The surveyor informed the LVN it was for ,[DATE].5 LPM. The LVN was then asked if she knew how high oxygen could be set for a resident with [MEDICAL CONDITION], LVN F answered, "No. Not really." and then told the surveyor the resident's oxygen saturation level dropped down to 86% the first weekend ([DATE] through [DATE]) he was in the facility. LVN F stated at 12:30 PM, Resident #10 began to have a deep, wet, productive cough and his oxygen was 85%. He had scattered wheezing. The surveyor then asked when LVN F would call the doctor. The LVN stated, "Right then." The surveyor then asked LVN F, "Did you call him?" LVN F said, "No." The surveyor asked, "You didn't call the doctor?" LVN F stated the hospice nurse was going to be in the facility on Sunday ([DATE]). The surveyor then asked LVN F when Resident #10's oxygen saturation level dropped below 92%, should she have called the physician. LVN F answered, "Yes." Review of Resident #10's admission physician orders [REDACTED]. Review of the hospice skilled nurse's notes had an entry dated [DATE], which revealed the nurse made a PRN visit for Resident #10 due to his increased shortness of breath. The hospice notes reflected the resident had inspiratory and expiratory wheezes. The nurse wrote orders for [MEDICATION NAME] (pain medication) as needed, [MEDICATION NAME] (narcotic [MEDICATION NAME]) to be administered via nebulizer every 4 hours and [MEDICATION NAME] (laxative) as needed. There was no documentation to indicate the hospice nurse notified the physician. Resident #10's Progress Notes dated [DATE] at 6:45 AM reflected the resident had a "resp (respiratory) event & labored accessory muscles being used ...Call cord in reach." The notes were unclear as to the time of the event and did not reflect any other nursing action taken at that time. An approximate blood oxygen level can also be determined using a pulse Oximeter - a small device that clips on your finger. Though the pulse Oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse Oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. <http://www.mayoclinic.com/health/hypoxemia/MY > Last updated [DATE] and Retrieved [DATE] [MEDICAL CONDITION] Managing exacerbationsEven with ongoing treatment, you may experience times when symptoms suddenly get worse. This is called an acute exacerbation, and it may cause lung failure if you don't receive prompt treatment. Exacerbations may be caused by a respiratory infection, a change in outdoor temperatures or high air pollution levels. Seek medical attention if you notice more coughing or a change in your mucus or if you have a harder time breathing. <http://www.mayoclinic.com/health/[MEDICAL CONDITION]/DS /METHOD=print> Last updated [DATE] and Retrieved [DATE] Resident #10's Progress Notes dated [DATE] at 11:00 AM reflected the resident had labored breathing using "all of his accessory muscles to breathe; diminished lung sounds to lower lobes with scattered wheezing to upper lobes. Resident had a productive cough with dark yellow sputum." During the interview on [DATE] at 10:10 AM with LVN F, the surveyor asked the LVN to review Resident #10's Progress Notes dated [DATE] at 11:00 AM. LVN F revealed she had written the notes. LVN F was asked if a resident was using all the accessory muscles to breathe, would that be an indication to call the physician. LVN F replied, "Yes." When asked if she had called Resident #10's physician, LVN F stated, "No." LVN F stated she called Hospice. The surveyor asked LVN F when would she call a doctor. LVN F stated when there was a change in condition. The surveyor asked her when would she send the resident to the hospital. LVN F did not reply. The surveyor asked LVN F if she should have sent Resident #10 to the hospital. LVN F stated, "Yes." LVN F told the surveyor she was focused on Resident #10 "being on Hospice." Resident #10's Progress Notes dated [DATE] at 11:35 AM reflected the resident had a fall and was found on his right side with the oxygen tubing and the cord from the remote wrapped around his feet. The nurse documented the resident was without injury. The physician was informed of the fall. Resident #10 was put on neurological assessments due to his fall and the potential for a head injury. Review of an Incident/Accident Report dated [DATE] at 11:35 AM revealed Resident #10 was found on the floor with his oxygen tubing and bed remote wrapped around his feet. The report reflected, "? (no) injuries reported." The report along with the Final Disposition Report reflected the resident was alert and oriented at that time and no x-rays or lab work were ordered. The resident's family and the Medical Director were notified, per the notes. The hospice nursing entry dated [DATE] reflected a prn visit was made to observe Resident #10. The resident's lungs were "very congested" and his oxygen was on at 3 liters. Resident #10 was complaining of a sore throat and his tongue and throat were red. The resident complained his [MEDICATION NAME] was not working and needed to be increased. His oxygen saturation level was 86% while he was on oxygen. The hospice nurse received an order from the Medical Director to increase his [MEDICATION NAME] to two tablets three times a day as needed for his headache and added [MEDICATION NAME] Spray, five sprays every two hours as needed for his sore throat. Review of Resident #10's Neurological assessment dated [DATE], [DATE] and [DATE] revealed, following the incident, the resident was checked on [DATE] at 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 1:15 PM, 1:45 PM, 2:15 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 7:00 PM. The assessments reelected the resident's BP remained consistent between ,[DATE] and ,[DATE]; the resident's respiratory rate remained between 22 and 26 per minutes; his heart rate fluctuated between 58 and 110 beats per minute and his temperatures were from 96.3 - 98.8 F. His pupils were always a "4" in size and reacted to light. Resident #4's speech was always clear and he never had a headache. The assessments were continued on [DATE] at 3:00 AM, 11:00 AM, 7:00 PM and on [DATE] at 3:00 AM. His heart rate fluctuated between 79 and 113 beats per minute and his blood pressure dropped to ,[DATE] on [DATE] at 7:00 PM. His Neurological Assessment reflected he never had a headache despite his request on [DATE], following his fall, for an increase in his medication, [MEDICATION NAME], because it was "not working." He was receiving [MEDICATION NAME] for his headaches. Resident #10's Progress Notes dated [DATE] at 11:15 AM reflected the resident had gurgles in his throat and mumbled speech. The Notes also reflected Resident #10 had "copious amounts of clear/yellow sputum. Respirations are labored using accessory muscles to breathe." The resident's sputum had changed to being copious and clear/yellow. The fact he had mumbled speech was not on his Neurological Assessment either. During the interview on [DATE] at 10:10 AM with LVN F, the LVN stated the Medical Director of the facility (also Resident #10's primary physician) came to the facility for a routine visit on [DATE], but the orders for Resident #10 did not change. The surveyor asked LVN F if she told the physician about Resident #10's current condition, and LVN F stated, "No," she just told the physician he, "needed to see the resident." LVN F stated she did not think the doctor saw him, because he did not document any visit in his notes. The surveyor asked LVN F who (the facility or hospice) should have called 911 when Resident #10's condition continued to deteriorate on [DATE], and LVN F stated, "We should have," meaning facility staff. Resident #10's Progress Notes dated [DATE] at 2:30 AM reflected the resident had a productive cough with thick yellow/green secretions. The Notes also reflected his respirations were labored and all his accessory muscles were being used. There was no evidence the physician was notified. The Notes reflected at 11:40 AM, Resident #10 was struggling to breathe and 911 was called. At 11:52 AM, he stopped breathing and there was no audible heart rate. The resident was moved to the floor and staff initiated CPR. Interview on [DATE] at 9:30 AM with LVN E revealed she worked a double the weekend of [DATE] through [DATE] and provided care to Resident #10. LVN E stated Resident #10 was having a difficult time breathing, using his accessory muscles, and his respirations were labored. LVN E stated the resident coughed a lot and most of the time the sputum was green in color. The surveyor asked LVN E when she would consider calling the resident's doctor. LVN E stated if his respirations "got over 25, I would probably call the MD." LVN E stated she would be worried if they were greater than 25. LVN E stated the last time his breathing was labored, they sent him to the hospital for assessment of [MEDICAL CONDITION] activity. LVN E stated they were also watching his oxygen saturation level, and if it fell below 90%, she would call the doctor. Resident #10's emergency room Notes dated [DATE] at 4:10 p.m. reflected Resident #10 was pronounced dead and the cause of death was "AMI" (Acute [MEDICAL CONDITION] Infarction ([MEDICAL CONDITION])). According to http:/chestjournal.chestpubs.org/content/,[DATE].abstract, retrieved on [DATE], "Conclusion: The results suggest that exacerbations of [MEDICAL CONDITION] increase the risk of MI...." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected the chest x-rays taken indicated the resident had "...some focal areas of pneumonitis within the upper right lobe and a small area within the left upper lobe...There appears to be some mucus within the right lower lobe of lung." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected a CT scan taken of Resident #10's brain indicated a suspicious subarachnoid bleed (bleeding in the brain). Further review of Resident #10's closed clinical record on [DATE], revealed there was no physician's progress note for the dates of [DATE] or [DATE]. A physician's progress note dated [DATE] for Resident #10 was provided to the surveyors on [DATE]. The resident's physician, the Medical Director, had documented on this progress note there were "no new problems." The surveyor interviewed the Medical Director on [DATE] at 11:58 AM. When the surveyor asked the Medical Director if he knew Resident #10 was a full code, he responded, "No. I don't think I did." The surveyor asked the Medical Director if he saw Resident #10 on [DATE]. The Medical Director stated he went to see the resident, but he saw from the doorway Resident #10 was sleeping. He said he did not want to wake him. The Medical Director stated the resident was on antibiotics. The Medical Director also stated usually the hospice staff take care of the residents. The surveyor asked the Medical Director how he perceived hospice was involved with residents' care. The Medical Director stated hospice was to keep the resident comfortable and assess the resident's needs. The Medical Director stated hospice staff were called most of the time for the resident's care. He stated hospice called him if the resident in the facility was his patient. The Medical Director then stated the facility gives the primary care and the facility always calls me. The Medical Director stated Resident #10 had a plethora of medical problems and he could have gone to the emergency room every day. The surveyor stated the facility still had to honor the resident's wishes. The Medical Director stated, "Yeah. That's right." An interview was conducted with RN G on [DATE] at 3:30 PM. During this conversation, the RN confirmed she remembered Resident #10. The RN stated on the night of [DATE] at 9:00 PM, the Medical Director came to the facility and made rounds on his residents. The Medical Director was informed he needed to see Resident #10, who needed to be assessed by the physician. During the physician's rounds, RN G stated he approached the door to Resident #10's room and looked inside at the resident, who was asleep in bed. The Medical Director told RN G Resident #10 was sleeping and he was not going to wake him up. RN G said the Medical Director knew "we" wanted him to see the resident, but he did not ask any questions about Resident #10's signs/symptoms. According to RN G, the Medical Director continued on down the hall and never returned to Resident #10 to assess him. During RN G's interview, she stated on two separate occasions, the Medical Director never wrote a progress note for Resident #10. RN G stated the Medical Director only looked at the resident from the hallway, he never entered the resident's room and he never assessed the resident. RN G stated specifically, "I can tell you there was not a progress note written (on [DATE]) on Resident ___ (#10) by the Medical Director." An interview on [DATE] at 1:00 PM with the Regional Manager Hospice RN C revealed the facility needed to do more than what they did because Resident #10 was a full code (to be administered cardiopulmonary resuscitation). RN C stated she thought the facility was just trying to let him go (die on his own). 2) The facility's current policy and procedures entitled Abuse Policy with a revised date of [DATE] reflected the following: "POLICY It is the policy of this facility to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident or event in which there was cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. DEFINITIONS ...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. ...The facility's administration will prohibit neglect... of residents caused by another person. The facility's administration will conduct and investigate allegations of suspected ...neglect...." "...IV. Identification: ...D. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident... immediately to their supervisor or Senior Staff Member...." The facility's current policy and procedure for Change of Condition - Observing, Reporting and Recording, revised [DATE] reflected: "It is the policy of this home to informs (sic) the resident, the residents (sic) physician and if indicted (sic) the residents (sic) responsible party of the following... 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications... 4. A need to alter treatment significantly... Procedure... 1. After resident changes in condition ...conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition. 3. The attending physician should be notified as soon as possible if immediate attention is required...If you are unable to reach the attending physician, call the alternate physician... 6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital...." 3) On [DATE] at 11:50 AM, the Administrator was interviewed and asked what type of procedure was in place to ensure the nursing needs of the residents were being met. The Administrator stated the facility had a standup meeting in the morning where the 24 hour report is reviewed. The 24 hour report is supposed to include the Nursing staff list, resident behaviors, resident changes in condition, new admits and discharges, and incidents. Nursing reviews and conducts the follow-up. All Department Heads are aware of what has occurred. The facility also has the Guardian Angel Program. Department Heads are assigned a room to visit each morning. They review the room and talk to the resident to ensure their needs are being met. This is being reinstituted today ([DATE]). The Administrator was then asked how he monitored staff (for example, the DON) to ensure they systems they monitor are being done sufficiently. The Administrator stated at the daily standup meeting, there is a form, which is to be completed, which includes changes, social services and staffing issues. The form is also used to make note of issues, which the Administrator said he personally follows up. 4) On [DATE] at approximately 11:45 AM, the newly-hired DON was interviewed and asked what training she is going to ensure the nursing staff have in order to care for a resident with a change in condition. She wants to be sure they know how to assist with documenting the change of condition. She wants the CNAs to note it on the skin assessment form for now. She would inservice the CNAs and the nurses on payday or to come in to the facility and do it face to face. When asked how she would ensure nursing staff were competent in their skills in caring for a resident with a change in condition, she referred to skills checks on hire and at least annually. The DON stated when a resident was admitted with special needs, the staff would be inserviced and there would be a check off to ensure competence. The DON was asked what plan the facility had in place for a change in condition. The DON stated she had now implemented a morning routine, which was not previously in place. There was now a five page form called "The Morning Routine," which had to be completed and followed up. When asked about inservices, the DON stated inservices have been given for change of condition and how to respond when hospice is involved. 5) Review of an Inservice Training Report dated [DATE] at 2:00 PM revealed the subject was Change of Condition and 11 nursing staff were provided the inservice one on one with written quizzes entitled "Change of Condition Verification." Review of an Inservice Training Report dated [DATE] at 10:00 AM revealed the subject was Change of Baseline - Resident and 14 nursing staff were provided the inservice one on one and was job specific. Review of an Inservice Training Report dated [DATE] at 3:30 PM revealed the subject was Change of Condition/Notification and the new DON was provided the inservice one on one. 6) Interviews were conducted with facility staff to determine whether they had been inserviced on a resident's change of condition, whether the resident receiving hospice services made a difference in facility staff's reactions and reporting and the facility's status as the resident's caregivers. On [DATE], the following staff were interviewed and able to respond appropriately in regard to the information provided at the facility's inservices: LVN K at 10:55 AM The Restorative Aide at approximately 2:00 pm CNA H at approximately 2:05 pm LVN I at approximately 2:10 pm RN J at 2:32 PM LVN F at 3:00 PM 7) The facility's CMS-802, Roster/Sample Matrix, provided to the survey team on [DATE] reflected there were two residents receiving hospice services.

Based on observation, interview and record review, the facility failed to implement the facility's written policies and procedures to ensure one resident's closed clinical record (Resident #10) of 16 residents reviewed was free from neglect. Resident #10 was admitted to the facility on [DATE] with exacerbation [MEDICAL CONDITION], was on hospice and he wanted to be fully resuscitated. From [DATE] until [DATE], when he was transferred to the hospital and died , the resident experienced a continuous decline in his respiratory status. The facility failed to: 1. Consult with the resident's physician for guidance with the resident's plan of care when his breathing difficulty increased and secretions changed on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; staff would either call hospice or wait for hospice's scheduled visit; 2. Accurately assess the resident following a fall. 3. Follow the resident's physician's orders [REDACTED]. Resident #3 consistently was receiving 3 LPM of oxygen instead of the ordered 2 - 2.5 LPM; 4. Ensure the resident's physician had a complete and accurate report of the resident's status on [DATE] when the physician made rounds. On [DATE] at 2:25 PM, an Immediate Jeopardy (IJ) was identified in the area of Resident Behavior/Facility Practice. While the IJ was lowered on [DATE] at 3:20 PM, the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "Pattern" due to the facility still implementing the Plan of Removal. These failures could affect the two residents receiving hospice services and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and painfree life they desired. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. The facility's current policy and procedures entitled Abuse Policy with a revised date of [DATE] reflected the following: "POLICY It is the policy of this facility to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident or event in which there was cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. DEFINITIONS ...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. ...The facility's administration will prohibit neglect... of residents caused by another person. The facility's administration will conduct and investigate allegations of suspected ...neglect...." "...IV. Identification: ...D. Employees are required to report all incidents of possible abuse, mistreatment, or neglect of any resident... immediately to their supervisor or Senior Staff Member...." 1) The "Admission/Readmission Data Summary" dated [DATE] reflected Resident #10, a [AGE] year-old male, was admitted from an area hospital with Exacerbation of [MEDICAL CONDITION]. The Summary reflected the resident was "Alert," his "Short and Long Term Memory were OK," he was able to "Understand, and able to be Understood" and exhibited "Verbal Expressions of distress and a Sad, anxious appearance." The Summary also reflected Resident #10 was "Independent" with "Eating and Toilet Use," was independent with an assistive device for mobility and he needed occasional physical assistance with transfers. Resident #10's Admission Care Plan dated [DATE] reflected the resident was alert and oriented. The care plan identified the problem of "URI/Pneumonia" with goals to monitor lung sounds and administer oxygen at 2.5 L/min per nasal cannula. Under the "Cardiac" identified problem, the care plan reflected in addition to oxygen therapy, the facility would monitor the resident' s oxygen saturation levels. The care plan did not address any problem with respiratory crisis associated with [MEDICAL CONDITION]. Resident #10's MDS assessment dated [DATE] reflected the resident had shortness of breath at rest, with exertion and when lying flat. Review of Resident #10's clinical record revealed a piece of paper in the front of Resident #10's chart indicating Resident #10 was a "Full Code." Resident #10's Progress Notes dated [DATE] at 9:00 AM reflected the resident had a productive cough with "thick yellow green sputum." Respirations were even and labored and he was using accessory muscles to breathe (which meant he was struggling to breathe). The resident had scattered wheezing in his lower lobes. Resident #10's Progress Notes dated [DATE] at 10:30 AM reflected the resident's oxygen saturation level was down to 86%-91% when he was off oxygen (normal ,[DATE]%; less than 90% is considered low). The notes reflected Resident #10 had wheezing audible in all lobes and his respirations were even and labored. The notes also reflected his cough was productive with thick sputum and his oxygen saturation level was 98% on oxygen. Resident #10's Progress Notes reflected his oxygen saturation level dropped to between 80% - 83% when he was off oxygen. Resident #10's Progress Notes dated [DATE] at 12:30 PM reflected the resident's oxygen saturation level dropped to below 85% on room air. The note also reflected, "Lung sounds observed to be scattered, wet productive cough. Respirations even and labored using all accessory muscles to breathe." Interview on [DATE] at 10:10 AM with LVN F revealed she took care of Resident #10 on [DATE] and [DATE]. LVN F stated Resident #10 was very alert. LVN F stated the resident's oxygen saturation level would drop a lot if the resident was not kept on oxygen. LVN F stated the resident would go on smoke breaks and would not have his oxygen on. When he returned, he would put his oxygen back on himself. He stayed stable on 3 liters of oxygen per minute. The surveyor asked the LVN if she knew what the resident's order for oxygen was. LVN F responded, "not really." The surveyor informed the LVN it was for ,[DATE].5 LPM. The LVN was then asked if she knew how high oxygen could be set for a resident with [MEDICAL CONDITION], LVN F answered, "No. Not really." and then told the surveyor the resident's oxygen saturation level dropped down to 86% the first weekend ([DATE] through [DATE]) he was in the facility. LVN F stated at 12:30 PM, Resident #10 began to have a deep, wet, productive cough and his oxygen was 85%. He had scattered wheezing. The surveyor then asked when LVN F would call the doctor. The LVN stated, "Right then." The surveyor then asked LVN F, "Did you call him?" LVN F said, "No." The surveyor asked, "You didn't call the doctor?" LVN F stated the hospice nurse was going to be in the facility on Sunday ([DATE]). The surveyor then asked LVN F when Resident #10's oxygen saturation level dropped below 92%, should she have called the physician. LVN F answered, "Yes." Review of Resident #10's admission physician orders [REDACTED]. Review of the hospice skilled nurse's notes had an entry dated [DATE], which revealed the nurse made a PRN visit for Resident #10 due to his increased shortness of breath. The hospice notes reflected the resident had inspiratory and expiratory wheezes. The nurse wrote orders for [MEDICATION NAME] (pain medication) as needed, [MEDICATION NAME] (narcotic [MEDICATION NAME]) to be administered via nebulizer every 4 hours and [MEDICATION NAME] (laxative) as needed. There was no documentation to indicate the hospice nurse notified the physician. Resident #10's Progress Notes dated [DATE] at 6:45 AM reflected the resident had a "resp (respiratory) event & labored accessory muscles being used ...Call cord in reach." The notes were unclear as to the time of the event and did not reflect any other nursing action taken at that time. An approximate blood oxygen level can also be determined using a pulse Oximeter - a small device that clips on your finger. Though the pulse Oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse Oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. <http://www.mayoclinic.com/health/hypoxemia/MY > Last updated [DATE] and Retrieved [DATE] [MEDICAL CONDITION] Managing exacerbationsEven with ongoing treatment, you may experience times when symptoms suddenly get worse. This is called an acute exacerbation, and it may cause lung failure if you don't receive prompt treatment. Exacerbations may be caused by a respiratory infection, a change in outdoor temperatures or high air pollution levels. Seek medical attention if you notice more coughing or a change in your mucus or if you have a harder time breathing. <http://www.mayoclinic.com/health/[MEDICAL CONDITION]/DS /METHOD=print> Last updated [DATE] and Retrieved [DATE] Resident #10's Progress Notes dated [DATE] at 11:00 AM reflected the resident had labored breathing using "all of his accessory muscles to breathe; diminished lung sounds to lower lobes with scattered wheezing to upper lobes. Resident had a productive cough with dark yellow sputum." During the interview on [DATE] at 10:10 AM with LVN F, the surveyor asked the LVN to review Resident #10's Progress Notes dated [DATE] at 11:00 AM. LVN F revealed she had written the notes. LVN F was asked if a resident was using all the accessory muscles to breathe, would that be an indication to call the physician. LVN F replied, "Yes." When asked if she had called Resident #10's physician, LVN F stated, "No." LVN F stated she called Hospice. The surveyor asked LVN F when would she call a doctor. LVN F stated when there was a change in condition. The surveyor asked her when would she send the resident to the hospital. LVN F did not reply. The surveyor asked LVN F if she should have sent Resident #10 to the hospital. LVN F stated, "Yes." LVN F told the surveyor she was focused on Resident #10 "being on Hospice." Resident #10's Progress Notes dated [DATE] at 11:35 AM reflected the resident had a fall and was found on his right side with the oxygen tubing and the cord from the remote wrapped around his feet. The nurse documented the resident was without injury. The physician was informed of the fall. Resident #10 was put on neurological assessments due to his fall and the potential for a head injury. Review of an Incident/Accident Report dated [DATE] at 11:35 AM revealed Resident #10 was found on the floor with his oxygen tubing and bed remote wrapped around his feet. The report reflected, "? (no) injuries reported." The report along with the Final Disposition Report reflected the resident was alert and oriented at that time and no x-rays or lab work were ordered. The resident's family and the Medical Director were notified, per the notes. The hospice nursing entry dated [DATE] reflected a prn visit was made to observe Resident #10. The resident's lungs were "very congested" and his oxygen was on at 3 liters. Resident #10 was complaining of a sore throat and his tongue and throat were red. The resident complained his [MEDICATION NAME] was not working and needed to be increased. His oxygen saturation level was 86% while he was on oxygen. The hospice nurse received an order from the Medical Director to increase his [MEDICATION NAME] to two tablets three times a day as needed for his headache and added [MEDICATION NAME] Spray, five sprays every two hours as needed for his sore throat. Review of Resident #10's Neurological assessment dated [DATE], [DATE] and [DATE] revealed, following the incident, the resident was checked on [DATE] at 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 1:15 PM, 1:45 PM, 2:15 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 7:00 PM. The assessments reelected the resident's BP remained consistent between ,[DATE] and ,[DATE]; the resident's respiratory rate remained between 22 and 26 per minutes; his heart rate fluctuated between 58 and 110 beats per minute and his temperatures were from 96.3 - 98.8 F. His pupils were always a "4" in size and reacted to light. Resident #4's speech was always clear and he never had a headache. The assessments were continued on [DATE] at 3:00 AM, 11:00 AM, 7:00 PM and on [DATE] at 3:00 AM. His heart rate fluctuated between 79 and 113 beats per minute and his blood pressure dropped to ,[DATE] on [DATE] at 7:00 PM. His Neurological Assessment reflected he never had a headache despite his request on [DATE], following his fall, for an increase in his medication, [MEDICATION NAME], because it was "not working." He was receiving [MEDICATION NAME] for his headaches. Resident #10's Progress Notes dated [DATE] at 11:15 AM reflected the resident had gurgles in his throat and mumbled speech. The Notes also reflected Resident #10 had "copious amounts of clear/yellow sputum. Respirations are labored using accessory muscles to breathe." The resident's sputum had changed to being copious and clear/yellow. The fact he had mumbled speech was not on his Neurological Assessment either. During the interview on [DATE] at 10:10 AM with LVN F, the LVN stated the Medical Director of the facility (also Resident #10's primary physician) came to the facility for a routine visit on [DATE], but the orders for Resident #10 did not change. The surveyor asked LVN F if she told the physician about Resident #10's current condition, and LVN F stated, "No," she just told the physician he, "needed to see the resident." LVN F stated she did not think the doctor saw him, because he did not document any visit in his notes. The surveyor asked LVN F who (the facility or hospice) should have called 911 when Resident #10's condition continued to deteriorate on [DATE], and LVN F stated, "We should have," meaning facility staff. Resident #10's Progress Notes dated [DATE] at 2:30 AM reflected the resident had a productive cough with thick yellow/green secretions. The Notes also reflected his respirations were labored and all his accessory muscles were being used. There was no evidence the physician was notified. The Notes reflected at 11:40 AM, Resident #10 was struggling to breathe and 911 was called. At 11:52 AM, he stopped breathing and there was no audible heart rate. The resident was moved to the floor and staff initiated CPR. Interview on [DATE] at 9:30 AM with LVN E revealed she worked a double the weekend of [DATE] through [DATE] and provided care to Resident #10. LVN E stated Resident #10 was having a difficult time breathing, using his accessory muscles, and his respirations were labored. LVN E stated the resident coughed a lot and most of the time the sputum was green in color. The surveyor asked LVN E when she would consider calling the resident's doctor. LVN E stated if his respirations "got over 25, I would probably call the MD." LVN E stated she would be worried if they were greater than 25. LVN E stated the last time his breathing was labored, they sent him to the hospital for assessment of [MEDICAL CONDITION] activity. LVN E stated they were also watching his oxygen saturation level, and if it fell below 90%, she would call the doctor. Resident #10's emergency room Notes dated [DATE] at 4:10 p.m. reflected Resident #10 was pronounced dead and the cause of death was "AMI" (Acute [MEDICAL CONDITION] Infarction ([MEDICAL CONDITION])). According to http:/chestjournal.chestpubs.org/content/,[DATE].abstract, retrieved on [DATE], "Conclusion: The results suggest that exacerbations of [MEDICAL CONDITION] increase the risk of MI...." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected the chest x-rays taken indicated the resident had "...some focal areas of pneumonitis within the upper right lobe and a small area within the left upper lobe...There appears to be some mucus within the right lower lobe of lung." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected a CT scan taken of Resident #10's brain indicated a suspicious subarachnoid bleed (bleeding in the brain). Further review of Resident #10's closed clinical record on [DATE], revealed there was no physician's progress note for the dates of [DATE] or [DATE]. A physician's progress note dated [DATE] for Resident #10 was provided to the surveyors on [DATE]. The resident's physician, the Medical Director, had documented on this progress note there were "no new problems." The surveyor interviewed the Medical Director on [DATE] at 11:58 AM. When the surveyor asked the Medical Director if he knew Resident #10 was a full code, he responded, "No. I don't think I did." The surveyor asked the Medical Director if he saw Resident #10 on [DATE]. The Medical Director stated he went to see the resident, but he saw from the doorway Resident #10 was sleeping. He said he did not want to wake him. The Medical Director stated the resident was on antibiotics. The Medical Director also stated usually the hospice staff take care of the residents. The surveyor asked the Medical Director how he perceived hospice was involved with residents' care. The Medical Director stated hospice was to keep the resident comfortable and assess the resident's needs. The Medical Director stated hospice staff were called most of the time for the resident's care. He stated hospice called him if the resident in the facility was his patient. The Medical Director then stated the facility gives the primary care and the facility always calls me. The Medical Director stated Resident #10 had a plethora of medical problems and he could have gone to the emergency room every day. The surveyor stated the facility still had to honor the resident's wishes. The Medical Director stated, "Yeah. That's right." An interview was conducted with RN G on [DATE] at 3:30 PM. During this conversation, the RN confirmed she remembered Resident #10. The RN stated on the night of [DATE] at 9:00 PM, the Medical Director came to the facility and made rounds on his residents. The Medical Director was informed he needed to see Resident #10, who needed to be assessed by the physician. During the physician's rounds, RN G stated he approached the door to Resident #10's room and looked inside at the resident, who was asleep in bed. The Medical Director told RN G Resident #10 was sleeping and he was not going to wake him up. RN G said the Medical Director knew "we" wanted him to see the resident, but he did not ask any questions about Resident #10's signs/symptoms. According to RN G, the Medical Director continued on down the hall and never returned to Resident #10 to assess him. During RN G's interview, she stated on two separate occasions, the Medical Director never wrote a progress note for Resident #10. RN G stated the Medical Director only looked at the resident from the hallway, he never entered the resident's room and he never assessed the resident. RN G stated specifically, "I can tell you there was not a progress note written (on [DATE]) on Resident ___ (#10) by the Medical Director." An interview on [DATE] at 1:00 PM with the Regional Manager Hospice RN C revealed the facility needed to do more than what they did because Resident #10 was a full code (to be administered cardiopulmonary resuscitation). RN C stated she thought the facility was just trying to let him go (die on his own). 2) On [DATE] at 11:50 AM, the Administrator was interviewed and asked what type of procedure was in place to ensure the nursing needs of the residents were being met. The Administrator stated the facility had a standup meeting in the morning where the 24 hour report is reviewed. The 24 hour report is supposed to include the Nursing staff list, resident behaviors, resident changes in condition, new admits and discharges, and incidents. Nursing reviews and conducts the follow-up. All Department Heads are aware of what has occurred. The facility also has the Guardian Angel Program. Department Heads are assigned a room to visit each morning. They review the room and talk to the resident to ensure their needs are being met. This is being reinstituted today ([DATE]). The Administrator was then asked how he monitored staff (for example, the DON) to ensure they systems they monitor are being done sufficiently. The Administrator stated at the daily standup meeting, there is a form, which is to be completed, which includes changes, social services and staffing issues. The form is also used to make note of issues, which the Administrator said he personally follows up. 3) On [DATE] at approximately 11:45 AM, the newly-hired DON was interviewed and asked what training she is going to ensure the nursing staff have in order to care for a resident with a change in condition. She wants to be sure they know how to assist with documenting the change of condition. She wants the CNAs to note it on the skin assessment form for now. She would inservice the CNAs and the nurses on payday or to come in to the facility and do it face to face. When asked how she would ensure nursing staff were competent in their skills in caring for a resident with a change in condition, she referred to skills checks on hire and at least annually. The DON stated when a resident was admitted with special needs, the staff would be inserviced and there would be a check off to ensure competence. The DON was asked what plan the facility had in place for a change in condition. The DON stated she had now implemented a morning routine, which was not previously in place. There was now a five page form called "The Morning Routine," which had to be completed and followed up. When asked about inservices, the DON stated inservices have been given for change of condition and how to respond when hospice is involved. 4) Review of an Inservice Training Report dated [DATE] at 2:00 PM revealed the subject was Change of Condition and 11 nursing staff were provided the inservice one on one with written quizzes entitled "Change of Condition Verification." Review of an Inservice Training Report dated [DATE] at 10:00 AM revealed the subject was Change of Baseline - Resident and 14 nursing staff were provided the inservice one on one and was job specific. Review of an Inservice Training Report dated [DATE] at 3:30 PM revealed the subject was Change of Condition/Notification and the new DON was provided the inservice one on one. 5) Interviews were conducted with facility staff to determine whether they had been inserviced on a resident's change of condition, whether the resident receiving hospice services made a difference in facility staff's reactions and reporting and the facility's status as the resident's caregivers. On [DATE], the following staff were interviewed and able to respond appropriately in regard to the information provided at the facility's inservices: LVN K at 10:55 AM The Restorative Aide at approximately 2:00 pm CNA H at approximately 2:05 pm LVN I at approximately 2:10 pm RN J at 2:32 PM LVN F at 3:00 PM 6) The facility's CMS-802, Roster/Sample Matrix, provided to the survey team on [DATE] reflected there were two residents receiving hospice services.

Based on interview and record review the facility failed to provide the necessary care and services to attain, or maintain the highest practicable physical, mental, and psychosocial well-being for one resident's closed clinical record (Resident #10) of 16 residents reviewed for quality of care. Resident #10 was admitted to the facility on [DATE] with exacerbation [MEDICAL CONDITION], was on hospice and he wanted to be fully resuscitated. From [DATE] until [DATE], when he was transferred to the hospital and died , the resident experienced a continuous decline in his respiratory status. The facility failed to: 1. Consult with the resident's physician for guidance with the resident's plan of care when his breathing difficulty increased and secretions changed on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]; staff would either call hospice or wait for hospice's scheduled visit; 2. Accurately assess the resident following a fall. 3. Follow the resident's physician's orders [REDACTED]. Resident #3 consistently was receiving 3 LPM of oxygen instead of the ordered 2 - 2.5 LPM; 4. Ensure the resident's physician had a complete and accurate report of the resident's status on [DATE] when the physician made rounds. These failures could affect the two residents receiving hospice services and placed them at risk for not receiving the care and services they needed to maintain their well-being, comfort and painfree life they desired. Findings included: Per Administrative Review of the CMS 2567, the facility's survey was reopened for further investigation on [DATE]. 1) The "Admission/Readmission Data Summary" dated [DATE] reflected Resident #10, a [AGE] year-old male, was admitted from an area hospital with Exacerbation of [MEDICAL CONDITION]. The Summary reflected the resident was "Alert," his "Short and Long Term Memory were OK," he was able to "Understand, and able to be Understood" and exhibited "Verbal Expressions of distress and a Sad, anxious appearance." The Summary also reflected Resident #10 was "Independent" with "Eating and Toilet Use," was independent with an assistive device for mobility and he needed occasional physical assistance with transfers. Resident #10's Admission Care Plan dated [DATE] reflected the resident was alert and oriented. The care plan identified the problem of "URI/Pneumonia" with goals to monitor lung sounds and administer oxygen at 2.5 L/min per nasal cannula. Under the "Cardiac" identified problem, the care plan reflected in addition to oxygen therapy, the facility would monitor the resident' s oxygen saturation levels. The care plan did not address any problem with respiratory crisis associated with [MEDICAL CONDITION]. Resident #10's MDS assessment dated [DATE] reflected the resident had shortness of breath at rest, with exertion and when lying flat. Review of Resident #10's clinical record revealed a piece of paper in the front of Resident #10's chart indicating Resident #10 was a "Full Code." Resident #10's Progress Notes dated [DATE] at 9:00 AM reflected the resident had a productive cough with "thick yellow green sputum." Respirations were even and labored and he was using accessory muscles to breathe (which meant he was struggling to breathe). The resident had scattered wheezing in his lower lobes. Resident #10's Progress Notes dated [DATE] at 10:30 AM reflected the resident's oxygen saturation level was down to 86%-91% when he was off oxygen (normal ,[DATE]%; less than 90% is considered low). The notes reflected Resident #10 had wheezing audible in all lobes and his respirations were even and labored. The notes also reflected his cough was productive with thick sputum and his oxygen saturation level was 98% on oxygen. Resident #10's Progress Notes reflected his oxygen saturation level dropped to between 80% - 83% when he was off oxygen. Resident #10's Progress Notes dated [DATE] at 12:30 PM reflected the resident's oxygen saturation level dropped to below 85% on room air. The note also reflected, "Lung sounds observed to be scattered, wet productive cough. Respirations even and labored using all accessory muscles to breathe." Interview on [DATE] at 10:10 AM with LVN F revealed she took care of Resident #10 on [DATE] and [DATE]. LVN F stated Resident #10 was very alert. LVN F stated the resident's oxygen saturation level would drop a lot if the resident was not kept on oxygen. LVN F stated the resident would go on smoke breaks and would not have his oxygen on. When he returned, he would put his oxygen back on himself. He stayed stable on 3 liters of oxygen per minute. The surveyor asked the LVN if she knew what the resident's order for oxygen was. LVN F responded, "not really." The surveyor informed the LVN it was for ,[DATE].5 LPM. The LVN was then asked if she knew how high oxygen could be set for a resident with [MEDICAL CONDITION], LVN F answered, "No. Not really." and then told the surveyor the resident's oxygen saturation level dropped down to 86% the first weekend ([DATE] through [DATE]) he was in the facility. LVN F stated at 12:30 PM, Resident #10 began to have a deep, wet, productive cough and his oxygen was 85%. He had scattered wheezing. The surveyor then asked when LVN F would call the doctor. The LVN stated, "Right then." The surveyor then asked LVN F, "Did you call him?" LVN F said, "No." The surveyor asked, "You didn't call the doctor?" LVN F stated the hospice nurse was going to be in the facility on Sunday ([DATE]). The surveyor then asked LVN F when Resident #10's oxygen saturation level dropped below 92%, should she have called the physician. LVN F answered, "Yes." Review of Resident #10's admission physician orders [REDACTED]. Review of the hospice skilled nurse's notes had an entry dated [DATE], which revealed the nurse made a PRN visit for Resident #10 due to his increased shortness of breath. The hospice notes reflected the resident had inspiratory and expiratory wheezes. The nurse wrote orders for [MEDICATION NAME] (pain medication) as needed, [MEDICATION NAME] (narcotic [MEDICATION NAME]) to be administered via nebulizer every 4 hours and [MEDICATION NAME] (laxative) as needed. There was no documentation to indicate the hospice nurse notified the physician. Resident #10's Progress Notes dated [DATE] at 6:45 AM reflected the resident had a "resp (respiratory) event & labored accessory muscles being used ...Call cord in reach." The notes were unclear as to the time of the event and did not reflect any other nursing action taken at that time. An approximate blood oxygen level can also be determined using a pulse Oximeter - a small device that clips on your finger. Though the pulse Oximeter actually measures the saturation of oxygen in your blood, the results are often used as an estimate of blood oxygen levels. Normal pulse Oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low. <http://www.mayoclinic.com/health/hypoxemia/MY > Last updated [DATE] and Retrieved [DATE] [MEDICAL CONDITION] Managing exacerbationsEven with ongoing treatment, you may experience times when symptoms suddenly get worse. This is called an acute exacerbation, and it may cause lung failure if you don't receive prompt treatment. Exacerbations may be caused by a respiratory infection, a change in outdoor temperatures or high air pollution levels. Seek medical attention if you notice more coughing or a change in your mucus or if you have a harder time breathing. <http://www.mayoclinic.com/health/[MEDICAL CONDITION]/DS /METHOD=print> Last updated [DATE] and Retrieved [DATE] Resident #10's Progress Notes dated [DATE] at 11:00 AM reflected the resident had labored breathing using "all of his accessory muscles to breathe; diminished lung sounds to lower lobes with scattered wheezing to upper lobes. Resident had a productive cough with dark yellow sputum." During the interview on [DATE] at 10:10 AM with LVN F, the surveyor asked the LVN to review Resident #10's Progress Notes dated [DATE] at 11:00 AM. LVN F revealed she had written the notes. LVN F was asked if a resident was using all the accessory muscles to breathe, would that be an indication to call the physician. LVN F replied, "Yes." When asked if she had called Resident #10's physician, LVN F stated, "No." LVN F stated she called Hospice. The surveyor asked LVN F when would she call a doctor. LVN F stated when there was a change in condition. The surveyor asked her when would she send the resident to the hospital. LVN F did not reply. The surveyor asked LVN F if she should have sent Resident #10 to the hospital. LVN F stated, "Yes." LVN F told the surveyor she was focused on Resident #10 "being on Hospice." Resident #10's Progress Notes dated [DATE] at 11:35 AM reflected the resident had a fall and was found on his right side with the oxygen tubing and the cord from the remote wrapped around his feet. The nurse documented the resident was without injury. The physician was informed of the fall. Resident #10 was put on neurological assessments due to his fall and the potential for a head injury. Review of an Incident/Accident Report dated [DATE] at 11:35 AM revealed Resident #10 was found on the floor with his oxygen tubing and bed remote wrapped around his feet. The report reflected, "? (no) injuries reported." The report along with the Final Disposition Report reflected the resident was alert and oriented at that time and no x-rays or lab work were ordered. The resident's family and the Medical Director were notified, per the notes. The hospice nursing entry dated [DATE] reflected a prn visit was made to observe Resident #10. The resident's lungs were "very congested" and his oxygen was on at 3 liters. Resident #10 was complaining of a sore throat and his tongue and throat were red. The resident complained his [MEDICATION NAME] was not working and needed to be increased. His oxygen saturation level was 86% while he was on oxygen. The hospice nurse received an order from the Medical Director to increase his [MEDICATION NAME] to two tablets three times a day as needed for his headache and added [MEDICATION NAME] Spray, five sprays every two hours as needed for his sore throat. Review of Resident #10's Neurological assessment dated [DATE], [DATE] and [DATE] revealed, following the incident, the resident was checked on [DATE] at 11:30 AM, 11:45 AM, 12:00 PM, 12:15 PM, 1:15 PM, 1:45 PM, 2:15 PM, 3:00 PM, 4:00 PM, 5:00 PM, and 7:00 PM. The assessments reelected the resident's BP remained consistent between ,[DATE] and ,[DATE]; the resident's respiratory rate remained between 22 and 26 per minutes; his heart rate fluctuated between 58 and 110 beats per minute and his temperatures were from 96.3 - 98.8 F. His pupils were always a "4" in size and reacted to light. Resident #4's speech was always clear and he never had a headache. The assessments were continued on [DATE] at 3:00 AM, 11:00 AM, 7:00 PM and on [DATE] at 3:00 AM. His heart rate fluctuated between 79 and 113 beats per minute and his blood pressure dropped to ,[DATE] on [DATE] at 7:00 PM. His Neurological Assessment reflected he never had a headache despite his request on [DATE], following his fall, for an increase in his medication, [MEDICATION NAME], because it was "not working." He was receiving [MEDICATION NAME] for his headaches. Resident #10's Progress Notes dated [DATE] at 11:15 AM reflected the resident had gurgles in his throat and mumbled speech. The Notes also reflected Resident #10 had "copious amounts of clear/yellow sputum. Respirations are labored using accessory muscles to breathe." The resident's sputum had changed to being copious and clear/yellow. The fact he had mumbled speech was not on his Neurological Assessment either. During the interview on [DATE] at 10:10 AM with LVN F, the LVN stated the Medical Director of the facility (also Resident #10's primary physician) came to the facility for a routine visit on [DATE], but the orders for Resident #10 did not change. The surveyor asked LVN F if she told the physician about Resident #10's current condition, and LVN F stated, "No," she just told the physician he, "needed to see the resident." LVN F stated she did not think the doctor saw him, because he did not document any visit in his notes. The surveyor asked LVN F who (the facility or hospice) should have called 911 when Resident #10's condition continued to deteriorate on [DATE], and LVN F stated, "We should have," meaning facility staff. Resident #10's Progress Notes dated [DATE] at 2:30 AM reflected the resident had a productive cough with thick yellow/green secretions. The Notes also reflected his respirations were labored and all his accessory muscles were being used. There was no evidence the physician was notified. The Notes reflected at 11:40 AM, Resident #10 was struggling to breathe and 911 was called. At 11:52 AM, he stopped breathing and there was no audible heart rate. The resident was moved to the floor and staff initiated CPR. Interview on [DATE] at 9:30 AM with LVN E revealed she worked a double the weekend of [DATE] through [DATE] and provided care to Resident #10. LVN E stated Resident #10 was having a difficult time breathing, using his accessory muscles, and his respirations were labored. LVN E stated the resident coughed a lot and most of the time the sputum was green in color. The surveyor asked LVN E when she would consider calling the resident's doctor. LVN E stated if his respirations "got over 25, I would probably call the MD." LVN E stated she would be worried if they were greater than 25. LVN E stated the last time his breathing was labored, they sent him to the hospital for assessment of [MEDICAL CONDITION] activity. LVN E stated they were also watching his oxygen saturation level, and if it fell below 90%, she would call the doctor. Resident #10's emergency room Notes dated [DATE] at 4:10 p.m. reflected Resident #10 was pronounced dead and the cause of death was "AMI" (Acute [MEDICAL CONDITION] Infarction ([MEDICAL CONDITION])). According to http:/chestjournal.chestpubs.org/content/,[DATE].abstract, retrieved on [DATE], "Conclusion: The results suggest that exacerbations of [MEDICAL CONDITION] increase the risk of MI...." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected the chest x-rays taken indicated the resident had "...some focal areas of pneumonitis within the upper right lobe and a small area within the left upper lobe...There appears to be some mucus within the right lower lobe of lung." The Department of Radiology Final Report from the hospital dated [DATE] for Resident #10 reflected a CT scan taken of Resident #10's brain indicated a suspicious subarachnoid bleed (bleeding in the brain). Further review of Resident #10's closed clinical record on [DATE], revealed there was no physician's progress note for the dates of [DATE] or [DATE]. A physician's progress note dated [DATE] for Resident #10 was provided to the surveyors on [DATE]. The resident's physician, the Medical Director, had documented on this progress note there were "no new problems." The surveyor interviewed the Medical Director on [DATE] at 11:58 AM. When the surveyor asked the Medical Director if he knew Resident #10 was a full code, he responded, "No. I don't think I did." The surveyor asked the Medical Director if he saw Resident #10 on [DATE]. The Medical Director stated he went to see the resident, but he saw from the doorway Resident #10 was sleeping. He said he did not want to wake him. The Medical Director stated the resident was on antibiotics. The Medical Director also stated usually the hospice staff take care of the residents. The surveyor asked the Medical Director how he perceived hospice was involved with residents' care. The Medical Director stated hospice was to keep the resident comfortable and assess the resident's needs. The Medical Director stated hospice staff were called most of the time for the resident's care. He stated hospice called him if the resident in the facility was his patient. The Medical Director then stated the facility gives the primary care and the facility always calls me. The Medical Director stated Resident #10 had a plethora of medical problems and he could have gone to the emergency room every day. The surveyor stated the facility still had to honor the resident's wishes. The Medical Director stated, "Yeah. That's right." An interview was conducted with RN G on [DATE] at 3:30 PM. During this conversation, the RN confirmed she remembered Resident #10. The RN stated on the night of [DATE] at 9:00 PM, the Medical Director came to the facility and made rounds on his residents. The Medical Director was informed he needed to see Resident #10, who needed to be assessed by the physician. During the physician's rounds, RN G stated he approached the door to Resident #10's room and looked inside at the resident, who was asleep in bed. The Medical Director told RN G Resident #10 was sleeping and he was not going to wake him up. RN G said the Medical Director knew "we" wanted him to see the resident, but he did not ask any questions about Resident #10's signs/symptoms. According to RN G, the Medical Director continued on down the hall and never returned to Resident #10 to assess him. During RN G's interview, she stated on two separate occasions, the Medical Director never wrote a progress note for Resident #10. RN G stated the Medical Director only looked at the resident from the hallway, he never entered the resident's room and he never assessed the resident. RN G stated specifically, "I can tell you there was not a progress note written (on [DATE]) on Resident ___ (#10) by the Medical Director." An interview on [DATE] at 1:00 PM with the Regional Manager Hospice RN C revealed the facility needed to do more than what they did because Resident #10 was a full code (to be administered cardiopulmonary resuscitation). RN C stated she thought the facility was just trying to let him go (die on his own). 2) The facility's current policy and procedure for Change of Condition - Observing, Reporting and Recording, revised [DATE] reflected: "It is the policy of this home to informs (sic) the resident, the residents (sic) physician and if indicted (sic) the residents (sic) responsible party of the following... 2. A significant change in the resident's physical, mental or psychosocial status, such as a deterioration in health, mental, or psychosocial status, in life-threatening conditions or clinical complications... 4. A need to alter treatment significantly... Procedure... 1. After resident changes in condition ...conduct a thorough assessment and compare against baseline. 2. Do not leave the resident alone when a change in condition is identified until the licensed nurse has determined that the resident is not in danger in any way related to their medical or mental changes in condition. 3. The attending physician should be notified as soon as possible if immediate attention is required...If you are unable to reach the attending physician, call the alternate physician... 6. If necessary due to the seriousness of the change in condition or as ordered by the physician, transfer the resident to the hospital...." 3) On [DATE] at 11:50 AM, the Administrator was interviewed and asked what type of procedure was in place to ensure the nursing needs of the residents were being met. The Administrator stated the facility had a standup meeting in the morning where the 24 hour report is reviewed. The 24 hour report is supposed to include the Nursing staff list, resident behaviors, resident changes in condition, new admits and discharges, and incidents. Nursing reviews and conducts the follow-up. All Department Heads are aware of what has occurred. The facility also has the Guardian Angel Program. Department Heads are assigned a room to visit each morning. They review the room and talk to the resident to ensure their needs are being met. This is being reinstituted today ([DATE]). The Administrator was then asked how he monitored staff (for example, the DON) to ensure they systems they monitor are being done sufficiently. The Administrator stated at the daily standup meeting, there is a form, which is to be completed, which includes changes, social services and staffing issues. The form is also used to make note of issues, which the Administrator said he personally follows up. 4) On [DATE] at approximately 11:45 AM, the newly-hired DON was interviewed and asked what training she is going to ensure the nursing staff have in order to care for a resident with a change in condition. She wants to be sure they know how to assist with documenting the change of condition. She wants the CNAs to note it on the skin assessment form for now. She would inservice the CNAs and the nurses on payday or to come in to the facility and do it face to face. When asked how she would ensure nursing staff were competent in their skills in caring for a resident with a change in condition, she referred to skills checks on hire and at least annually. The DON stated when a resident was admitted with special needs, the staff would be inserviced and there would be a check off to ensure competence. The DON was asked what plan the facility had in place for a change in condition. The DON stated she had now implemented a morning routine, which was not previously in place. There was now a five page form called "The Morning Routine," which had to be completed and followed up. When asked about inservices, the DON stated inservices have been given for change of condition and how to respond when hospice is involved. 5) Review of an Inservice Training Report dated [DATE] at 2:00 PM revealed the subject was Change of Condition and 11 nursing staff were provided the inservice one on one with written quizzes entitled "Change of Condition Verification." Review of an Inservice Training Report dated [DATE] at 10:00 AM revealed the subject was Change of Baseline - Resident and 14 nursing staff were provided the inservice one on one and was job specific. Review of an Inservice Training Report dated [DATE] at 3:30 PM revealed the subject was Change of Condition/Notification and the new DON was provided the inservice one on one. 6) Interviews were conducted with facility staff to determine whether they had been inserviced on a resident's change of condition, whether the resident receiving hospice services made a difference in facility staff's reactions and reporting and the facility's status as the resident's caregivers. On [DATE], the following staff were interviewed and able to respond appropriately in regard to the information provided at the facility's inservices: LVN K at 10:55 AM The Restorative Aide at approximately 2:00 pm CNA H at approximately 2:05 pm LVN I at approximately 2:10 pm RN J at 2:32 PM LVN F at 3:00 PM. 7) The facility's CMS-802, Roster/Sample Matrix, provided to the survey team on [DATE] reflected there were two residents receiving hospice services.

Based on observation, interview and record review, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one of (Resident #1) of three residents reviewed for care. 1. Resident #1 was admitted to the facility with a left leg ischemic ulcer but there was no admission nursing assessment or assessment of the ulcer to describe the ulcer and give measurements of the ulcer. Resident #1's attending physician wrote an order for [REDACTED]. The wound clinic changed the treatment orders, but the new orders were not implemented for two days. Resident #1 was showered early in the morning and his wound was undressed for the shower and then wrapped in a towel after the shower. His wound was wrapped in the towel for four and half hours, before LVN A provided wound care treatment to Resident #1. LVN A provided wound care to Resident #1 with poor lighting and he did not use a flashlight. LVN A did not clean the wound, according to the physician's orders. An Immediate Jeopardy (IJ) was identified on 06/09/11. While the IJ was removed on 06/13/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. These failures could affect the three residents, including Resident #1, who had skin problems, which were not pressure ulcers by placing them at risk of poor wound treatment, infections and delays in treatment. Findings included: 1) A review of the MDS assessment (Comprehensive Assessment) dated 05/17/11 revealed Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE]. The assessment reflected Resident #1 was cognitively intact and he did not have any behaviors. The assessment also reflected Resident #1 needed extensive assistance of two or more staff with bed mobility, transfers, dressing, and toilet use. He needed limited assistance with locomotion and personal hygiene. The assessment reflected he needed assistance with bathing and he was frequently incontinent of bladder and continent of bowel. The assessment also reflected he was on a scheduled pain medication regimen. The MDS assessment reflected Resident #1 had a venous/arterial ulcer. Resident #1's Admission Care Plan dated 05/10/11 reflected Pressure Sores/Skin Care was not marked. The Care Plan reflected Infection Control was marked due to Resident #1's [MEDICAL CONDITION]. Resident #1's Comprehensive Plan of Care dated 05/25/11 reflected he had a stasis ulcer on his left leg and the treatment. Review of Resident #1's entire clinical record revealed no admission nursing assessment identifying the ulcer's size, location, or condition. Physician's Telephone Order dated 05/26/11 reflected to refer Resident #1 to a wound care clinic. Nurse's Notes dated 05/31/11 timed at 10:20 a.m. reflected no one had scheduled an appointment for Resident #1 at the wound clinic. The notes reflected an appointment was made for 06/01/11 at 2:30 p.m. Physician's Telephone Order for Resident #1, dated 05/27/11, reflected to continue wound care, discuss with family more intense care and possible amputation, and obtain the hospital discharge summary. Nurse's Notes dated 05/31/11 and timed at 2:25 a.m. reflected Resident #1 had an ischemic wound to his left lower extremity, which had not improved. The notes also reflected Resident #1 was non-compliant with treatment for [REDACTED]. The notes reflected Resident #1 was also non-compliant with attempts of smoking cessation. Nurse's Notes dated 05/31/11 timed at 7:00 p.m. reflected Resident #1 was seen by the resident's physician, who asked when Resident #1 would be seen at the wound clinic. The notes also reflected the physician stated he hoped Resident #1's wound on his left foot could be healed or there would be a possibility of an amputation. Multiple requests on 06/09/11 and 06/10/11 for the skin assessment sheets for May 2011, when Resident #1 was admitted , revealed no May 2011 skin assessment sheets were presented. Nurse's Notes dated 06/01/11 timed at 10:25 a.m. reflected Resident #1 continued to be non-compliant with his treatment. The notes reflected he stated, "'I don't want that thing on ly (sic) leg." Physician's Orders dated 06/01/11 through 06/30/11 reflected the following Diagnoses: [REDACTED]. The orders also reflected apply 1/2 inch of [MEDICATION NAME] Ointment to Resident #1's left foot every 12 hours for 30 days; clean left lower extremity wound with normal saline or wound cleaner, pat dry, apply santyl to yellow slough and black eschar area, apply [MEDICATION NAME] to pink tissue area, cover with calcium alginate, wrap with Kerlix every 72 hours and as needed until healed; clean left foot wound with normal saline or wound cleaner, pat dry, apply santyl to yellow slough and black eschar areas, apply [MEDICATION NAME] to pink tissue areas, cover with calcium alginate wrap with Kerlix every 72 hours and as needed until healed. Review of the assessment notes obtained from the (local hospital) Wound Clinic, for Resident #1's 06/01/11 visit, revealed, "Previously documented wounds have now bridged together to form one wound. Wound extends proximally and distally from the ankle. Multiple satellite wounds of various sizes (but not over 1 cm x 1 cm) on the periwound tissue. Exudate: varies from serosanguinous to green tinted. Approximately 10 maggots (approx. (approximately) 0.3 cm long) were noted on the anterior/lateral aspect of the wound. An additional two maggots were crawling out from a 1.5 cm long area of detached tissue. Maggots removed with forceps and disposed of properly. Wound cleansed with [MEDICATION NAME] scrub and left to dry before applying dressing. Pressure relieving boot donned to left foot." Additionally, the local hospital Wound Clinic assessment identified Resident #1's left lower extremity wound measurements as "13.5 cm long x 21 cm wide x 1 cm deep with large serous exudate and a strong odor - slough 26-50%; eschar 51%-75% (Eschar (Necrotic (dead) tissue is usually yellow-gray and soft is called slough... Black-gray, hard leathery tissue is called eschar... Retrieved on 10/18/10 from <http://www.medscape.com/viewarticle/ 9>)." The Wound Clinic also changed the treatment orders for Resident #1's wound on his left ankle. The orders dated 06/01/11 reflected, "Dressing Changes qd (every day) and prn with strike thru exudate. Medicate patient (Resident #1) 30 minutes prior to dressing change with [MEDICATION NAME]. Remove old dressing... utilize saline to remove any adherent dressings. Monitor, assess and report maggots present on the wound. cleanse the wound with saline. Apply [MEDICATION NAME] to all wounds, allow to dry before covering with ABD's (abdominal pads), Secure with Kerlix and retention net... Physician Consults Vascular Consult- Refer to (physician's name) - Evaluate left lower extremity regarding level of amputation. ASAP (as soon as possible)." The physician at the Wound Clinic also [MEDICATION NAME] mg twice a day for 10 days for an infection. Resident #1's Treatment Sheets dated 06/01/11 through 06/30/11 reflected apply 1/2 inch of [MEDICATION NAME] Ointment to Resident #1's left foot every 12 hours for 30 days; clean left lower extremity wound with normal saline or wound cleaner, pat dry, apply santyl to yellow slough and black eschar area, apply [MEDICATION NAME] to pink tissue area, cover with calcium alginate, wrap with Kerlix every 72 hours and as needed until healed; clean left foot wound with normal saline or wound cleaner, pat dry, apply santyl to yellow slough and black eschar areas, apply [MEDICATION NAME] to pink tissue areas, cover with calcium alginate wrap with Kerlix every 72 hours and as needed until healed until 06/03/11. The previous treatment orders had "discontinued" written next to them with the date 06/03/11. A handwritten note dated 06/03/11 reflected, "Remove old drsg (dressing), cleanse c (with) NS (normal saline) or __ cleanse, pat dry. Apply [MEDICATION NAME] allow to dry then apply ABD, wrap c Kerlix." The Non-Pressure Sore Surveillance Form dated 06/02/11 reflected Resident #1 was admitted with a left lower extremity ulcer, the treatment for [REDACTED]." The form reflected a space for "Site & Description (Size, Depth, etc.)," but there were no measurements or descriptions of the wound. During observation on 06/09/11 at 10:18 a.m., a fly was noted on the ceiling at the nurses' station and flies were observed buzzing in Hall C. On 06/09/11 at 10:22 a.m. in an interview, LVN A (the treatment nurse) stated he had only been a nurse for three months and this was his first job as a nurse. Observation on 06/09/11 at 10:56 a.m. of Resident #1 revealed he was sitting in a wheelchair in his room. Resident #1 had his left foot wrapped in a towel and a protective boot over the towel-wrapped foot. LVN A stated, "They wrap it in a towel after his shower, then I come and change the dressing." LVN A further stated, Resident #1 was "incontinent of bladder;" was "assisted with his activities of daily living;" was "alert and oriented to person only, confused and forgetful with behavioral problems." LVN A said Resident #1's behaviors included "agitation, noncompliance with dressing changes, smokes heavily and had poor nutrition." LVN A identified the left lower extremity wound as an "arterial ulcer." Observation on 06/09/11 beginning at 10:58 a.m. revealed LVN A washed his hands and wiped the wound cleanser bottle and the [MEDICATION NAME] bottle with super sani wipes. LVN A placed waxed paper on the top of the treatment cart. With his bare hands, LVN A placed clean 4x4s and opened four sterile ABD pads onto the waxed paper. LVN A then adjusted his pants. LVN A placed several clean [MEDICATION NAME] Gloves on the waxed paper. LVN A then folded the waxed paper and supplies and carried them to Resident #1's overbed table. LVN A stated, "I forgot my Bio Hazard Bag. Can you watch that stuff?" as he left the room. He opened the door to the hall and went to the treatment cart outside of Resident #1's room. Upon return to the room, LVN A closed the door. During the same observation, the overall lighting in Resident #1's room was very dim. The window blinds were closed and down. The ceiling light was behind the pulled curtain. LVN A provided the treatment to Resident #1 with his (LVN A's) back to the light - further blocking any light the ceiling light provided and two flies were in Resident #1's room during the treatment. LVN A placed a disposable blue pad on a folding metal chair. LVN A removed the foot protector boot and towel from Resident #1's left foot. He then asked the surveyor to turn on the light (surveyor turned on the overbed light). At 11:06 a.m., the left lower extremity wound was exposed and Resident #1's foot was placed on a folding metal chair. Resident #1's tendons were exposed on the left lower extremity on the top of Resident #1's foot. LVN A washed his hands, opened the door to the hall, and went to the treatment cart outside of Resident #1's room to obtain a measuring device. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and measured the eschar edge to partial edge. LVN A reported the wound was 16 cm long by 18 cm wide. When it was pointed out to LVN A that the measuring device did not extend to the wound edges and was shorter than the width of the wound and the linear measurement of the wound did not include the curvature of the juncture of the lower leg and foot, LVN A said "it's close." There was a foul odor with some drainage observed during this measurement. After measuring the length and width of the wound, during the same observation on 06/09/11, LVN A removed his gloves, washed his hands, opened the door to the hall and went to the treatment cart outside of Resident #1's room for another measuring device to measure the depth of the wound. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and measured the depth of the wound at 0.5 cm. LVN A removed his gloves and washed his hands. When asked if he was going to measure the opened area of the wound, LVN A replied, "Yes ma'am." LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room for an additional measuring device. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and dropped the measuring device on the floor. LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room to obtain another measuring device. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and reported the opened wound area was 4 cm by 7 cm and was a Stage III. During the same observation on 06/09/11, LVN A removed his gloves, washed his hands, picked up the red bag, which had fallen on the floor, and placed it on the back of the metal chair. LVN A had disposed of his contaminated gloves and supplies in this red bag. LVN A regloved and sprayed the wound with wound cleanser holding 4x4s around the wound in a manner, which prevented over-spray. LVN A removed his gloves and washed his hands. When spraying the wound cleanser, LVN A did not wipe any part of the wound or skin edges. LVN A placed the wound cleanser bottle on the floor. Then LVN A removed his gloves and washed his hands. LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room and obtained additional gloves. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and patted the wound dry from the medial outer edge of the eschar and then patted the opened area of the wound on the left lower leg where the tendons were exposed. LVN A cleansed from the the "dirty" area to the "clean" area of the wound, which exposed the "clean" area to microorganisms. After wiping the opened area, LVN A then wiped the medial outer edge of the left foot again. LVN A then removed his gloves and washed his hands. The red bag fell on the floor again. LVN A regloved and attempted to pour Triadine ([MEDICATION NAME]) solution on the wound but stated, "That bottle's not open." LVN A replaced the red bag on the back of the metal chair, removed his gloves and washed his hands. LVN A opened the bottle of Triadine, regloved and squirted Triadine on the wound. LVN A then placed the bottle of Triadine on the floor next to the wound cleanser bottle, which had been knocked over. LVN A removed his gloves, washed his hands and said, "The order says to let the [MEDICATION NAME] (Triadine) dry. I forgot the Kerlix." Then LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room for Kerlix and came back in the room and said, "Would you mind standing here while I go to the supply room and get some Kerlix?" LVN A left Resident #1's room and was observed to go down the hall and around the corner at the nurse's station. A fly was buzzing in Resident #1's room. When LVN A returned, Resident #1 said he needed to use the urinal. LVN A said, "We are just waiting for that to dry. Let's finish the treatment." LVN A then opened the door to the hall and went to the treatment cart for scissors. A fly was observed to be sitting on the draw sheet of Resident #1's bed. A second fly was observed buzzing around Resident #1's foot protector boot and foot. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and applied two ABD dressings over the lower leg part of the wound at 11:34 a.m. on 06/09/11. While LVN A was opening the Kerlix, he acknowledged the facility had a problem with flies. LVN A said, "The Administrator has been working on it, but we do have a problem with flies." LVN A washed his hands, regloved, and wrapped the ABD dressing, which covered the lower leg part of the wound, with a Kerlix dressing. LVN A did not use all of the Kerlix and cut the dressing with the scissors. LVN A laid the scissors on the overbed table, removed his gloves, and washed his hands. LVN A regloved. The red bag containing contaminated supplies fell on the floor again. LVN A taped the upper Kerlix dressing. LVN A removed his gloves and started for the door. He then went to the bathroom and washed his hands. LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room for more gloves. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and applied an ABD dressing pad to the remaining open area on top of the left foot. LVN A removed his gloves, washed his hands, regloved and asked the resident to raise his leg up one more time. LVN A then wrapped the ABD dressing covered foot with Kerlix. He cut the Kerlix and taped the dressing. During the same observation on 06/09/11, LVN A gathered all of the leftover supplies with gloved hands and put them in the red bag. LVN A removed his gloves, tied the red bag and carried the red bag to the treatment cart, where he placed the red bag in a red bag draped trash receptacle on the cart. LVN A wiped the wound cleanser and Triadine bottles with sani wipes. LVN A gloved and removed the drainage-soiled towel from the protective boot and placed the towel (towel that had been wrapped around Resident #1's foot after his shower) in a soiled linen barrel in the hall. LVN A returned to Resident #1's room and applied the boot, folded the chair, and put paper trash in the treatment cart. He washed his hands and said, "I won't do any more treatments until after lunch." The treatment was completed at 11:55 a.m. During this observation in this low-level lighted room, LVN A did not use a flashlight to assess Resident #1's wound. Review of Resident #1's nurses notes dated 06/09/11 at 1405 (2:05 p.m.) revealed "Resident's nurse in contact with wound care at _____ (local hospital). Notified ____ (Resident #1's physician) of advice given to see surgeon. NO (new order) from ____ (Resident #1's physician). Refer to Dr. ____ (named surgeon) (surgeon) to determine surgical needs...." Review of Resident #1's nurses notes dated 06/09/11 at 1420 (2:20 p.m.) revealed, "Resident appt (appointment) made with _____ (named same surgeon) regarding LLE ischemic ulcer. Appt made for Tuesday June 14th at 2:45 p.m...." On 06/09/11 at 2:21 p.m. in an interview, CNA B said she bathed Resident #1 this morning (06/09/11) at "6:30" a.m. and "wrapped his foot (left) in a towel until he can get his treatment." CNA B said Resident #1 got his bath on Tuesday, Thursday and Saturday. In an interview on 06/09/11 at 2:30 p.m., LVN A stated he was aware Resident #1 had maggots in his wound. "The (local hospital) wound clinic staff told me when he went for his visit on June 1st." LVN A acknowledged informing the ADM of the maggots in Resident #1's wound. (Reference: The common house fly lays its eggs in rotting, moist material. The maggots emerge from the eggs in warm weather within 8 to 20 hours, and they immediately feed on, and grow in, the material where the eggs were laid. These larvae are 3 to 9 mm long and creamy white in color... Naturally occurring maggot infestations can of course be very harmful. In some fly species, the larval forms feed upon live tissue as well as decaying material, and the larvae can be a big problem. Obtained on 06/14/11 from <http://www.worsleyschool.net/science/files/maggot/info.html>.) (Reference: Flies pick up all manner of nasty bacteria, then transport the disease-causing organisms right to your food. A single house fly can carry over one million bacteria. No less than 60 different diseases can be transmitted by filth flies, from salmonella to dysentery. Obtained 06/14/11 from <http://insects.about.com/od/insectpests/a/control-filth-flies.htm>.) On 06/09/11, an IJ was identified at 5:00 p.m. and the ADM was informed of the IJ and that the survey would be extended. A Plan of Removal for the IJ was requested from the ADM at that time. The facility's Plan of Removal dated 06/09/11 reflected all nursing staff was being inserviced on the skin monitoring policy, which included the CNAs reporting any skin problems to the charge nurse immediately and informing the DON and physician. Any skin problems will have an order from the physician to ensure appropriate interventions were taken. To confirm understanding of the policy, the DON will randomly interview staff. The inservicing was initiated on 06/09/11 and will be completed by 06/10/11. In order to prevent a recurrence, all new nursing staff will be inserviced when hired. The DON and/or designee completed head-to-toe skin assessments on all residents to ensure skin issues were accurately identified. The residents' skin will be checked each time assistance was provided. The facility's contracted pest control company treated for [REDACTED]. 60-watt light bulbs will be replaced with 100-watt light bulbs in residents' rooms and it was initiated on 06/10/11 and will be ongoing. CNA care plans will reflect residents requiring interventions for the prevention of skin deficits or interventions in place to prevent further decline of skin deficits. A QA meeting was held on 06/10/11. For the staff, who were unable to come to the facility for training, an inservice will be conducted with the employee prior to the start of his or her next shift. The DON will continue to complete all treatments per policy and procedure. The DON was checked off on competency for wound treatments by the Assistant Director of Clinical Services. The ADM and DON will monitor the Plan of Removal during the week and on the weekends. If issues arise, they will address them at that time. Residents with significant skin deficits such as "stage IV ischemic ulcer" have been transferred to another level of care facility. There were no Stage III or Stage IV skin deficits in the facility. The Treatment Nurse was no longer employed at the facility and the DON was completing all skin deficit treatments. Nurse's Notes dated 06/09/11 and timed at 8:30 p.m. reflected Resident #1's physician gave an order for [REDACTED].#1 on 06/01/11. On 06/10/11 at 9:20 a.m. in an interview, the ADM stated Resident #1 was sent to the hospital. On 06/10/11 at 10:00 a.m. the foot candles were checked in Resident #1's room. (Note: The location where Resident #1 received his treatment on 06/09/11. There had been no changes to the lighting since 06/09/11). The overhead light was on, the curtain between bed A and bed B was pulled, and the window blind was closed and down, which reflected the same conditions of the room when Resident #1 received his treatment The light meter reading reflected 5 foot candles after three minutes. When the overbed light was turned on, the light meter reflected a reading of 5 foot candles (the light meter was held at the height of the metal chair on which Resident #1's foot was resting during his treatment on 06/09/11). In an interview on 06/10/11 at 12:30 p.m., the ADM confirmed she was aware the local hospital wound center had informed them about the maggots in Resident #1's wound. On 06/10/11 at 12:30 p.m., observation of the low-level lighting conditions in Resident #1's room with the ADM revealed the low-level lighting conditions were unchanged from 06/09/11. During this observation, the ADM said she wondered how a person could do a treatment and not see maggots in a wound. The ADM saw the blinking of the overbed light and said she would have the maintenance man replace the bulb. On 06/10/11 at 3:45 p.m. a message was left for Resident #1's physician, who was also the facility's Medical Director, requesting a return call. As of 06/13/11 exit at 12:30 p.m., Resident #1's physician had not returned the call. On 06/13/11 at 11:00 a.m. in an interview, the facility's ADON stated he could not find an admission nursing assessment for Resident #1. The ADON further stated there should be an admission nursing assessment; however, none was presented prior to exit. Review of the facility policy for Skin Integrity Monitoring System with a revised dated of May 2010 provided by the ADM as the current policy on 06/10/11 revealed, "It is the policy of this home that: (1) A system will be in place to assure that all residents will be assessed and monitored for any type of skin breakdown... (3) A system will be in place to assure any type of skin conditions that do not constitute pressure ulcers, will be monitored closely for any type of complications. . . Skin Integrity Management of Non-Pressure Ulcers - Definitions - Non-Pressure Ulcer - any skin integrity alteration not caused by pressure. May present as a surgical site, bruise, skin tear, tape burn, scratches, perineal [MEDICAL CONDITION], maceration, excoriation, rash, stasis ulcers or etc - Procedure (1) Assessment of the skin area is documented using 'Skin Assessment Flowsheet - Non-Pressure Ulcer' (3) Physician, interested party and resident are to be notified of alteration in skin. (4) Treatment orders are secured and noted on the Treatment Administration Record (TAR). (7) Skin alteration should be added to care plan. (8) Review the resident's skin-at-risk assessment (Braden Scale) and update if needed." Review of the Treatment Skills Checklist dated 05/19/11 from a different corporation than the current one that owned the facility revealed LVN A was "competent" as signed by the trainer - RN C. On 06/10/11 at 9:30 a.m. in an interview, when asked "How do you think this IJ came about?" The ADM replied, "Breakdown in Nursing - Poor leadership in this facility for years - Recognized problems and started making changes. The DON stepped down in March (2011) - No DON until now - so breakdown in leadership." Additional questions for the ADM revealed, "different Leadership and new tone in Corporate. Support from Corporate now 'anything you want.'" Regarding the Medical Director (residents stated they did not have the MD see them and the MD was not responsive), the ADM replied, "That is true. I could look for a new Medical Director." On 06/10/11 at 10:00 a.m. an interview with the DON, who started on 06/01/11, revealed, "Staffing - not adequate - Not adequately trained or orientation - such a need to get them on the floor - too high acuity for the staff they had. Staffing has been a problem since I got here - 2 new hires oriented last night - 2 new nurses M-F day next week - Hired one new CNA today." On 06/11/11 beginning at 9:00 a.m., five of the six staff on duty were interviewed regarding the inservices referred to in the facility's Plan of Removal. In interview at 9:30 a.m., RN D stated she had not been inserviced since Thursday 06/09/11. RN D stated the staff had mandatory inservices on paydays, which were the 14th and 29th of each month. RN D said she had not seen the DON, the ADM or Corporate staff today. In an interview at 9:45 a.m., LVN E stated she had not received any inservices since Thursday 06/09/11. She stated, "I haven't been here. I only work the weekend. I have not seen the DON or the ADM. I have not been inserviced on anything this week." In an interview at 9:55 a.m., CNA E said, "This is my second day. I haven't had any inservices here since I came. I haven't met the DON or the ADM yet...." On 06/12/11 beginning at 8:00 a.m., an observation revealed fly lights were installed by the front/lobby door and back porch side door. Interview at 8:25 a.m. with the DON revealed inservices on infection control, change of condition, skin prevention measures for pressure ulcers, skin treatment, behavior management, lighting, and abuse/neglect were being given to all staff. The DON stated, "Corporate has not been in the building since Friday (06/10/11)." In an interview on 06/12/11 at 9:10 a.m., LVN D stated she had been inserviced on 06/12/11 at the beginning of her shift. In an interview on 06/12/11 at 9:31 a.m., RN E stated she had been inserviced on 06/11/11. In an interview on 06/12/11 at 9:57 a.m., CNA F revealed she had been inserviced on 06/10/11. In an interview on 06/12/11 at 10:20 a.m., CNA G revealed her first day was "last Saturday" (06/ 04/11) and she had been inserviced on 06/11/11. Observation on 06/12/11 at 10:02 a.m. revealed light showing through cracks and no weather stripping in the door. Observations of the front/lobby door on 06/12/11 at 10:03 a.m. revealed no weather stripping had been installed and light was showing through the cracks in the door. Observation on 06/12/11 at 10:05 a.m. of the back porch side door revealed new weather stripping around the door; however, the door would not completely close, even when pulled shut. The IJ was removed on 06/13/11 and the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been inserviced on skin care, treatments and infection control, and the facility was still monitoring implementation of the Plan of Removal. The ADM, DON, and Assistant Director of Clinical Services were notified on 06/13/11 at 12:30 p.m. Review of the CMS form 672 (Resident Census and Conditions of Residents), dated and signed by MDS Nurse A on 06/09/11, revealed a total census of 36 residents and the Non-Pressure Sore Surveillance Form, dated 06/02/11, reflected three residents had non-pressure sores.

Based on observation, interview and record review, it was determined the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for two (Residents #1 and #2) of three residents observed for wound care. 1) Resident #1 had maggots in his ischemic wound. During wound care, two flies were flying around in his room and one was near exposed wound. LVN A did not wash his hands everytime he re-entered the room after beginning wound care. Resident #1 was seen at a wound clinic, where the maggots where discovered, and the physician at the clinic prescribed an antibiotic for Resident #1. 2) LVN A used Alcohol Based Hand Sanitizer (ABSH) during wound care for Resident #2 and did not wash his hands. There were no paper towels in Resident #2's bathroom, so LVN A could wash his hands. When CNA B and LVN A positioned Resident #2 for wound care on her coccyx, there was fecal matter on the pad underneath her, where her wound was located. They continued with the wound care, did not provide incontinent care, and then allowed the resident to lie down on the soiled pad after her wound had been cleaned. An Immediate Jeopardy (IJ) was identified on 06/09/11. While the IJ was removed on 06/13/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been trained and the facility was still monitoring the plan of removal. These failures could affect the four residents, including Residents #1 and #2, who received treatments to open wounds by placing them at risk for infection and maggots in open wounds. Findings included: 1) A review of the MDS assessment (Comprehensive Assessment) dated 05/17/11 revealed Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE]. The assessment reflected Resident #1 was cognitively intact and he did not have any behaviors. The assessment also reflected Resident #1 needed extensive assistance of two or more staff with bed mobility, transfers, dressing, and toilet use. He needed limited assistance with locomotion and personal hygiene. The assessment reflected he needed assistance with bathing and he was frequently incontinent of bladder and continent of bowel. The assessment also reflected he was on a scheduled pain medication regimen. The MDS assessment reflected Resident #1 had a venous/arterial ulcer. Resident #1's Admission Care Plan dated 05/10/11 reflected Pressure Sores/Skin Care was not marked. The Care Plan reflected Infection Control was marked due to Resident #1's Cellulitis. Resident #1's Comprehensive Plan of Care dated 05/25/11 reflected he had a stasis ulcer on his left leg and the treatment. physician's orders [REDACTED]. Physician's Telephone Order dated 05/26/11 reflected to refer Resident #1 to a wound care clinic. Physician's Telephone Order for Resident #1, dated 05/27/11, reflected to continue to wound care, discuss with family more intense care and possible amputation, and obtain the hospital discharge summary. Review of the assessment notes obtained from the (local hospital) Wound Clinic, for Resident #1's 06/01/11 visit, revealed, "Previously documented wounds have now bridged together to form one wound. Wound extends proximally and distally from the ankle. Multiple satellite wounds of various sizes (but not over 1 cm x 1 cm) on the periwound tissue. Exudate: varies from serosanguinous to green tinted. Approximately 10 maggots (approx. 0.3 cm long) were noted on the anterior/lateral aspect of the wound. An Additional two maggots were crawling out from a 1.5 cm long area of detached tissue. Maggots removed with forceps and disposed of properly. Wound cleansed with [MEDICATION NAME] scrub and left to dry before applying dressing. Pressure relieving boot donned to left foot." Additionally, the local hospital Wound Clinic assessment identified Resident #1's left lower extremity wound measurements as "13.5 cm long x 21 cm wide x 1 cm deep with large serous exudate and a strong odor - slough 26-50%; eschar 51%-75% (Eschar (Necrotic (dead) tissue is usually yellow-gray and soft is called slough... Black-gray, hard leathery tissue is called eschar... Retrieved on 10/18/10 from <http://www.medscape.com/viewarticle/ 9>." The Wound Clinic also changed the treatment orders for Resident #1's wound on his left ankle. The orders dated 06/01/11 reflected, "Dressing Changes qd (every day) and prn with strike thru exudate. Medicate patient (Resident #1) 30 minutes prior to dressing change with [MEDICATION NAME]. Remove old dressing...utilize saline to remove any adherent dressings. Monitor, assess and report maggots present on the wound. cleanse the wound with saline. Apply [MEDICATION NAME] to all wounds, allow to dry before covering with ABD's (abdominal pads), Secure with Kerlix and retention net... Physician Consults Vascular Consult- Refer to (physician's name) - Evaluate left lower extremity regarding level of amputation. ASAP (as soon as possible)." The physician at the Wound Clinic also [MEDICATION NAME] mg twice a day for 10 days for an infection. During observation on 06/09/11 at 10:18 a.m., a fly was noted on the ceiling at the nurses' station and flies were observed buzzing in Hall C. On 06/09/11 at 10:22 a.m. in an interview, LVN A (the treatment nurse) stated he had only been a nurse for three months and this was his first job as a nurse. Observation on 06/09/11 at 10:56 a.m. of Resident #1 revealed he was sitting in a wheelchair in his room. Resident #1 had his left foot wrapped in a towel and a protective boot over the towel-wrapped foot. LVN A stated, "They wrap it in a towel after his shower, then I come and change the dressing." LVN A further stated, Resident #1 was "incontinent of bladder;" was "assisted with his activities of daily living;" was "alert and oriented to person only, confused and forgetful with behavioral problems." LVN A said Resident #1's behaviors included "agitation, noncompliance with dressing changes, smokes heavily and had poor nutrition." LVN A identified the left lower extremity wound as an "arterial ulcer." Observation on 06/09/11 beginning at 10:58 a.m. revealed LVN A washed his hands and wiped the wound cleanser bottle and the [MEDICATION NAME] bottle with super sani wipes. LVN A placed waxed paper on the top of the treatment cart. With his bare hands, LVN A placed clean 4x4s and opened four sterile ABD pads onto the waxed paper. LVN A then adjusted his pants. LVN A placed several clean [MEDICATION NAME] Gloves on the waxed paper. LVN A then folded the waxed paper and supplies and carried them to Resident #1's overbed table. LVN A stated, "I forgot my Bio Hazard Bag. Can you watch that stuff?" as he left the room. He opened the door to the hall and went to the treatment cart outside of Resident #1's room. Upon return to the room, LVN A closed the door. LVN A placed a disposable blue pad on a folding metal chair. LVN A removed the foot protector boot and towel from Resident #1's left foot. He then asked the surveyor to turn on the light (surveyor turned on the overbed light). At 11:06 a.m., the left lower extremity wound was exposed and Resident #1's foot was placed on a folding metal chair. Resident #1's tendons were exposed on the left lower extremity on the top of Resident #1's foot. LVN A washed his hands, opened the door to the hall, and went to the treatment cart outside of Resident #1's room to obtain a measuring device. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and measured the eschar edge to partial edge. LVN A reported the wound was 16 cm long by 18 cm wide. When it was pointed out to LVN A that the measuring device did not extend to the wound edges, and was shorter than the width of the wound, and the linear measurement of the wound did not include the curvature of the juncture of the lower leg and foot, LVN A said "it's close." There was a foul odor with some drainage observed during this measurement. After measuring the length and width of the wound, during the same observation on 06/09/11, LVN A removed his gloves, washed his hands, opened the door to the hall and went to the treatment cart outside of Resident #1's room for another measuring device to measure the depth of the wound. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and measured the depth of the wound at 0.5 cm. LVN A removed his gloves and washed his hands. When asked if he was going to measure the opened area of the wound, LVN A replied, "Yes ma'am." LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room for an additional measuring device. LVN A returned to the room, closed the door, donned his gloves, without washing his hands and dropped the measuring device on the floor. LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room to obtain another measuring device. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and reported the opened wound area was 4 cm by 7 cm and was a Stage III. During the same observation on 06/09/11, LVN A removed his gloves, washed his hands, picked up the red bag, which had fallen on the floor and placed it on the back of the metal chair. LVN A had disposed of his contaminated gloves and supplies in this red bag. LVN A regloved and sprayed the wound with wound cleanser holding 4x4s around the wound in a manner, which prevented over-spray. LVN A removed his gloves and washed his hands. When spraying the wound cleanser, LVN A did not wipe any part of the wound or skin edges. LVN A placed the wound cleanser bottle on the floor. Then LVN A removed his gloves and washed his hands. LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room and obtained additional gloves. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and patted the wound dry from the medial outer edge of the eschar and then patted the opened area of the wound on the left lower leg where the tendons were exposed. LVN A cleansed from the the "dirty" area to the "clean" area of the wound, which exposed the "clean" area to microorganisms. After wiping the opened area, LVN A then wiped the medial outer edge of the left foot again. LVN A then removed his gloves and washed his hands. The red bag fell on the floor again. LVN A regloved and attempted to pour Triadine ([MEDICATION NAME]) solution on the wound but stated, "That bottle's not open." LVN A replaced the red bag on the back of the metal chair, removed his gloves and washed his hands. LVN A opened the bottle of Triadine, regloved and squirted Triadine on the wound. LVN A then placed the bottle of Triadine on the floor next to the wound cleanser bottle, which had been knocked over. LVN A removed his gloves, washed his hands and said, "The order says to let the [MEDICATION NAME] (Triadine) dry. I forgot the Kerlix." Then LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room for Kerlix and came back in the room and said, "Would you mind standing here while I go to the supply room and get some Kerlix?" LVN A left Resident #1's room and was observed to go down the hall and around the corner at the nurse's station. A fly was buzzing in Resident #1's room. When LVN A returned, Resident #1 said he needed to use the urinal. LVN A, said, "We are just waiting for that to dry. Let's finish the treatment." LVN A then opened the door to the hall and went to the treatment cart for scissors. A fly was observed to be sitting on the draw sheet of Resident #1's bed. A second fly was observed buzzing around Resident #1's foot protector boot and foot. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and applied two ABD dressings over the lower leg part of the wound at 11:34 a.m. on 06/09/11. While LVN A was opening the Kerlix, he acknowledged the facility had a problem with flies. LVN A said, "The Administrator has been working on it, but we do have a problem with flies." LVN A washed his hands, regloved, and wrapped the ABD dressing, which covered the lower leg part of the wound, with a Kerlix dressing. LVN A did not use all of the Kerlix and cut the dressing with the scissors. LVN A laid the scissors on the overbed table, removed his gloves, and washed his hands. LVN A regloved. The red bag containing contaminated supplies fell on the floor again. LVN A taped the upper Kerlix dressing. LVN A removed his gloves and started for the door. He then went to the bathroom and washed his hands. LVN A opened the door to the hall and went to the treatment cart outside of Resident #1's room for more gloves. LVN A returned to the room, closed the door, donned his gloves, without washing his hands, and applied an ABD dressing pad to the remaining open area on top of the left foot. LVN A removed his gloves, washed his hands, regloved and asked the resident to raise his leg up one more time. LVN A then wrapped the ABD dressing covered foot with Kerlix. He cut the Kerlix and taped the dressing. During the same observation on 06/09/11, LVN A gathered all of the leftover supplies with gloved hands and put them in the red bag. LVN A removed his gloves, tied the red bag and carried the red bag to the treatment cart, where he placed the red bag in a red bag draped trash receptacle on the cart. LVN A wiped the wound cleanser and Triadine bottles with sani wipes. LVN A gloved and removed the drainage-soiled towel from the protective boot and placed the towel (towel that had been wrapped around Resident #1's foot after his shower) in a soiled linen barrel in the hall . LVN A returned to Resident #1's room and applied the boot, folded the chair, and put paper trash in the treatment cart. He washed his hands and said, "I won't do any more treatments until after lunch." The treatment was completed at 11:55 a.m. Review of the Treatment Skills Checklist dated 05/19/11 from a different corporation than the current one who owned the facility revealed LVN A was "competent" as signed by the trainer - RN C. On 06/0911 at 2:21 p.m. in an interview, CNA B said she bathed Resident #1 this morning (06/09/11) at "6:30" a.m. and "wrapped his foot (left) in a towel until he can get his treatment." CNA B said Resident #1 got his bath on Tuesday, Thursday and Saturday. In an interview on 06/09/11 at 2:30 p.m. LVN A stated he was aware Resident #1 had maggots in his wound. "The (local hospital) wound clinic staff told me when he went for his visit on June 1st." LVN A acknowledged informing the ADM of the maggots in Resident #1's wound. Review of facility policy for Infection Control: Handwashing Policy and Procedure dated January 2008 provided by Clinical Consultant Nurse on 06/10/11 as the current policy revealed, "It is the policy of this Home that staff will perform proper handwashing technique to prevent the spread of infection and diseases within the facility (7)(f) After contact with blood, body secretions, excretions, mucous membranes, or non-intact skin; (7)(g) After handling items potentially contaminated with blood, body fluids, excretions, or secretions;(7)(o) Upon completion of duty." (Reference: The common house fly lays its eggs in rotting, moist material. The maggots emerge from the eggs in warm weather within 8 to 20 hours, and they immediately feed on, and grow in, the material where the eggs were laid. These larvae are 3 to 9 mm long and creamy white in color. . . Naturally occurring maggot infestations can of course be very harmful. In some fly species, the larval forms feed upon live tissue as well as decaying material, and the larvae can be a big problem. Obtained on 06/14/11 from <http://www.worsleyschool.net/science/files/maggot/info.html> ) (Reference: Flies pick up all manner of nasty bacteria, then transport the disease-causing organisms right to your food. A single house fly can carry over one million bacteria. No less than 60 different diseases can be transmitted by filth flies, from salmonella to dysentery. Obtained 06/14/11 from <http://insects.about.com/od/insectpests/a/control-filth-flies.htm> ) On 06/09/11, an IJ was identified at 5:00 p.m. and the ADM was informed of the IJ and that the survey would be extended. A Plan of Removal for the IJ was requested from the ADM at that time. The facility's Plan of Removal dated 06/09/11 reflected the facility's contracted pest control company treated for [REDACTED]. A QA meeting was held on 06/10/11. For the staff, who were unable to come to the facility for training, an inservice will be conducted with the employee prior to the start of his or her next shift. The DON will continue to complete all treatments per policy and procedure. The DON was checked off on competency for wound treatments by the Assistant Director of Clinical Services. The check off included infection control procedures. The DON will continue training existing and new nursing staff on wound care techniques including infection control. The ADM and DON will monitor the Plan of Removal during the week and on the weekends. If issues arise, they will address them at that time. Residents with significant skin deficits such as "stage IV ischemic ulcer" have been transferred to another level of care facility. There were no Stage III or Stage IV skin deficits in the facility. The Treatment Nurse was no longer employed at the facility and the DON was completing all skin deficit treatments. Nurse's Notes dated 06/09/11 and timed at 8:30 p.m. reflected Resident #1's physician gave an order for [REDACTED]. The hospital reflected was not the hospital, where the wound clinic was located that treated Resident #1 on 06/01/11. On 06/10/11 at 9:20 a.m. in an interview, the ADM stated Resident #1 was sent to the hospital. On 06/10/11 at 9:30 a.m. in an interview, when asked "How do you think this IJ came about?" The ADM replied, "Breakdown in Nursing - Poor leadership in this facility for years - Recognized problems and started making changes. The DON stepped down in March (2011) - No DON until now - so breakdown in leadership." Additional questions for the ADM revealed, "different Leadership and new tone in Corporate. Support from Corporate now "anything you want." Regarding the Medical Director (residents stated they did not have the MD see them and the MD was not responsive), the ADM replied, "That is true. I could look for a new Medical Director." On 06/10/11 at 10:00 a.m. an interview with the DON, who started on 06/01/11, revealed, "Staffing - not adequate - Not adequately trained or orientation - such a need to get them on the floor - too high acuity for the staff they had. Staffing has been a problem since I got here - 2 new hires oriented last night - 2 new nurses M-F day next week - Hired one new CNA today." In an interview on 06/10/11 at 12:30 p.m., the ADM confirmed she was aware the local hospital wound center had informed them about the maggots in Resident #1's wound. On 06/11/11 beginning at 9:00 a.m., five of the six staff on duty were interviewed regarding the inservice, referred to in the Plan of Removal. At 9:30 a.m., RN D stated she had not been inserviced since Thursday 06/09/11. RN D stated the staff had mandatory inservices on paydays, which were the 14th and 29th of each month. RN D said she had not seen the DON, the ADM or Corporate staff today. At 9:45 a.m., LVN E stated she had not received any inservices since Thursday 06/09/11. She stated, "I haven't been here. I only work the weekend. I have not seen the DON or the ADM. I have not been inserviced on anything this week." At 9:55 a.m., CNA E said, "This is my second day. I haven't had any inservices here since I came. I haven't met the DON or the ADM yet...." On 06/12/11 beginning at 8:00 a.m., an observation revealed fly lights were installed by the front/lobby door and back porch side door. Interview at 8:25 a.m. with the DON revealed inservices on infection control, change of condition, skin prevention measures for pressure ulcers, skin treatment, behavior management, lighting, and abuse/neglect were being given to all staff. The DON stated, "Corporate has not been in the building since Friday (06/10/11)." In an interview on 06/12/11 at 9:10 a.m., LVN D stated she had been inserviced on 06/12/11 at the beginning of her shift. In an interview on 06/12/11 at 9:31 a.m., RN E stated she had been inserviced on 06/11/11. In an interview on 06/12/11 at 9:57 a.m., CNA F revealed she had been inserviced on 06/10/11. In an interview on 06/12/11 at 10:20 a.m., CNA G revealed her first day was "last Saturday" (06/ 04/11) and she had been inserviced on 06/11/11. Observation on 06/12/11 at 10:02 a.m. revealed light showing through cracks and no weather stripping in the door. Observations of the front/lobby door on 06/12/11 at 10:03 a.m. revealed no weather stripping had been installed and light was showing through the cracks in the door. Observation on 06/12/11 at 10:05 a.m. of the back porch side door revealed new weather stripping around the door, however the door would not completely close, even when pulled shut. The IJ was removed on 06/13/11 and the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because all staff had not been inserviced on skin care, treatments and infection control, and the facility was still monitoring implementation of the Plan of Removal. The ADM, DON, and Assistant Director of Clinical Services were notified on 06/13/11 at 12:30 p.m. 2) Review of Resident #2's MDS assessment dated [DATE] revealed Resident #2, a [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS assessment reflected Resident #2 was able to complete the interview; she was dependent on staff for bed mobility, transfers, locomotion, dressing, eating, toileting, personal hygiene and bathing; she had an indwelling urinary catheter; she was incontinent; she was on a scheduled pain regimen; and she had two Stage II pressure ulcers and one Stage IV pressure ulcer. Review of Resident #2's care plan revealed no care plan for pressure ulcers since her undated admission care plan. Review of the unsigned consolidated physician's orders [REDACTED].#2 was admitted to hospice on 04/15/11. Review of Resident #2's hospice care plan dated 05/11/11 revealed there was no care plan for pressure ulcers. Observation on 06/09/11 at 10:38 a.m. revealed Resident #2 was sitting up in a Geri chair. In an interview during this initial round, LVN A said Resident #2 was incontinent of bowel and had an indwelling Foley catheter; was alert and oriented to person, confused and forgetful with behavior problems, which included refusing treatments every once in a while. LVN A stated Resident #2 had pressure ulcers on her coccyx and right heel. LVN A asked Resident #2 if she was in pain. Resident #2 responded "Yes, my butt" at a "10." LVN A said Resident #2 was on hospice for adult failure to thrive and acknowledged Resident #2 had sustained a weight loss. On 06/09/11 at 12:25 p.m., an interview was conducted with Resident #2. When asked if there were flies in the building, Resident #2 replied "Yes." When asked how often flies were seen Resident #2 replied "Everyday." When asked if there were flies in Resident #2's room, the resident replied "Sometimes." During observation on 06/09/11 at 12:43 p.m., multiple flies were buzzing down Hall C beside the treatment cart as LVN A was pushing it to Resident #2's room. On 06/09/11 at 12:45 p.m., an observation of the treatment provided by LVN A for Resident #2 revealed CNA B assisted him. LVN A cleaned the overbed table with sani wipes and then returned the sani wipes to the cart and adjusted his pants. LVN A draped the top of the treatment cart with waxed paper and cleaned the wound cleanser bottle with sani wipes. LVN A placed gloves, 4x4s and a cotton-tipped applicator on the waxed paper. LVN A left the wound supplies exposed on top of the treatment cart unattended to get a medication (med) cup from a med cart at the end of the hall. LVN A then put Santyl in the med cup. LVN A placed a measuring device and an unopened sterile dry island dressing on the waxed paper. LVN A folded the waxed paper containing the supplies and moved them to the overbed table in Resident #2's room. During the same observation, LVN A washed his hands, opened the door to the hall, left the room, and went to the treatment cart outside of Resident #2's room for a red biohazard bag. LVN A returned to the room, closed the door and opened the red bag and draped it over the foot of the bed. CNA B, who had washed her hands at the beginning of this treatment and was now wearing gloves, attempted to turn Resident #2 with the foot elevator pillow beneath her legs. When CNA B turned Resident #2, a blue disposable pad was noted under the resident. On the blue pad was a small amount of fecal matter at the level of Resident #2's pressure ulcer. Resident #2 had fecal matter around her anus and buttocks. LVN A assisted in removal of the positioning pillow. LVN A washed his hands and gloved. LVN A measured the coccyx wound as a "2.5 cm x 3 cm Stage II with tunneling at 6:00 o'clock." LVN A removed his gloves, washed his hands, regloved and measured the tunneling with the cotton-tipped applicator. LVN A broke off the applicator and laid the tip of the applicator, which had been in Resident #2's wound, on the bare area of the overbed table. LVN A removed his gloves, washed his hands and regloved. LVN A then sprayed wound cleanser on the open wound and held 4 x 4s beneath the wound. LVN A removed his gloves after disposing of the wet 4x4s in the red bag. LVN A waited on a resident from the adjoining room to leave the bathroom, so he could wash his hands. CNA B said there were no paper towels available at the sink in Resident #2's room. After a few minutes, LVN A asked CNA B to "run get some paper towels." CNA B released her hold on Resident #2, who rolled back on the clean pressure ulcer and on the pad, where the fecal matter had gotten on the blue pad. CNA B opened the door and left the room. During this same observation, CNA B returned with a bottle of ABHS. Both LVN A and CNA B used the ABHS, instead of washing their hands. LVN A then asked CNA B to get his box of gloves from the treatment cart. CNA B removed her gloves, opened the door, left the room and returned with the box of gloves. CNA B used the ABHS, instead of washing her hands and regloved. LVN A regloved and applied a large glob of Santyl to the open wound. The dry island dressing was applied. LVN A removed his gloves, cleaned up the remaining supplies on the waxed paper and disposed of them in the red bag. LVN A opened the door and went to the treatment cart for sani wipes and wiped the table and wound cleanser bottle. LVN A used the ABHS, instead of washing his hands, and told Resident #2 he was going to treat her heel. LVN A asked Resident #2 about her pain. Resident #2 replied, "It's Ok right now." LVN A opened the door to the hall, left the room, and went to the treatment cart outside of Resident #2's room for a red biohazard bag and placed the red bag on the foot of Resident #2's bed and placed a blue pad beneath Resident #2's right foot. LVN A returned to the treatment cart where he placed waxed paper on top of the treatment cart. LVN A placed 4x4s, [MEDICATION NAME], a measuring device and an island dressing on the waxed paper. LVN A folded the waxed paper with the supplies, entered Resident #2's room and placed the supplies folded in the waxed paper on the overbed table. LVN A placed gloves on the waxed paper. LVN A used the ABHS, instead of washing his hands, and gloved. LVN A measured the right heel wound at 2 cm x 3 cm eschar that was "loose" to the right heel. LVN A removed his gloves and used the ABHS, instead of washing his hands. LVN A sprayed the heel wound with wound cleanser. LVN A did not touch the wound with the 4x4s; but held the 4x4s beneath the wound to catch the wound cleanser runoff. LVN A removed his gloves and placed them in the red bag. LVN A used the ABHS, instead of washing his hands, regloved and sprayed a copious amount of [MEDICATION NAME] on the right heel eschar. The runoff of the [MEDICATION NAME] was caught in the 4x4s. LVN A removed his gloves and placed them in the red bag. LVN A used the ABHS, instead of washing his hands, and said his hands were sticky. LVN A opened the sterile dry island dressing and dated it. LVN A regloved and applied the dry island dressing to Resident #2's right heel. LVN A removed the blue pad from beneath Resident #2's foot. LVN A removed his gloves, disposed of the blue pad, gathered the waxed paper and placed the used supplies in the red bag. LVN A tied the red bag, which contained wound cleanser and [MEDICATION NAME]-wet 4x4s and contaminated gloves, and went to the treatment cart, where he placed the tied red bag in the red-bag-lined container on the treatment cart. LVN A obtained sani wipes from the cart and cleaned the wound cleanser bottle and the [MEDICATION NAME] spray container with sani wipes and returned them to the treatment cart. LVN A placed the ABHS in the cart. LVN A documented the treatment and Resident #2's pain assessment. LVN A pushed the treatment cart down the hall and said there were "no other residents with pressure sores." LVN A pushed the treatment cart to the employee lounge room and then left that room and pushed the cart to room [ROOM NUMBER] where oxygen and central supplies were stored. LVN A stood in room [ROOM NUMBER] and discussed the treatment cart storage with the DON. LVN A tied the red bag lining the cart and took it to the trash area. LVN A did not wash his hands following Resident #2's treatment. The treatment was completed at 1:35 p.m. Review of Resident #2's nurses notes dated 06/10/11 at 1:30 a.m. revealed "Wheel chair transport here to transfer this resident (#2) to (name of sister facility)." 3) Review of the CMS form 672 (Resident Census and Conditions of Residents) dated and signed by Corporate MDS Nurse A on 06/09/11 revealed a total census of 36 residents. The Pressure Sore Surveillance Form and Non-Pressure Sore Surveillance Form dated 06/02/11 reflected four residents with wounds.

Based on observation, interview and record review, it was determined the facility failed to maintain an effective pest control program so that the facility was free of flies for one (Resident #1) of three residents reviewed for care. 1. Resident #1 had an ischemic leg wound, which was infected and had maggots in it. 2. Flies were in the dining room, multiple residents' rooms, the kitchen, hallways, nursing stations and front lobby of the facility. 3. There were cracks in the exterior doors with visible daylight showing through on the outside front lobby door, the outside dining room door, the outside door exiting to the smoking area and the outside east exit door, which created entry points for flies. An Immediate Jeopardy (IJ) was identified on 06/09/11. While the IJ was removed on 06/13/11, the facility remained out of compliance at a scope of "patterned" and a severity of "actual harm that is not immediate jeoapardy." These failures caused Resident #1 to develop maggots in his wound and had the potential to affect all 36 residents as they could be exposed to flies landing on wounds or food and suffer from maggots, Dysentery, Gastroenteritis or Respiratory infections. Findings included: 1) A review of the MDS assessment dated [DATE] revealed Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE]. The assessment reflected Resident #1 had a venous/arterial ulcer. Review of the assessment notes obtained from the _____ (local hospital) Wound Clinic, for Resident #1's 06/01/11 visit to the wound care clinic revealed, "...Approximately 10 maggots (approx. 0.3 cm long) were noted on the anterior/lateral aspect of the wound. An additional two maggots were crawling out from a 1.5 cm long area of detached tissue. Maggots removed with forceps and disposed of properly...." Observation on 06/09/11 beginning at 10:58 a.m. revealed LVN A performed wound care to Resident #1's left lower extremity wound. During the treatment, a fly was sitting on the draw sheet of Resident #1's bed. A second fly was flying around Resident #1's foot protector boot and foot, when the wound exposed. At 11:34 a.m., during the observation, LVN A acknowledged the facility had a problem with flies. LVN A said, "The Administrator has been working on it, but we do have a problem with flies." (Reference: The common house fly lays its eggs in rotting, moist material, The maggots emerge from the eggs in warm weather within 8 to 20 hours, and they immediately feed on, and grow in the material where the eggs were laid. These larvae are 3 to 9 mm long and creamy white in color . . . Naturally occurring maggot infestations can of course be very harmful. In some fly species, the larval forms feed upon live tissue as well as decaying material, and the larvae can be a big problem. Obtained on 06/14/11 from <http://worsleyschool.net/science/flies/maggot/info.html>) (Reference: Flies pick up all manner of nasty bacteria, and then transport the disease-causing organisms right to your food. A single house fly can carry over one million bacteria. No less than 60 different diseases can be transmitted by filth flies, from salmonella to dysentery. Obtained 06/14/11 from <http://insects.about.com/od/insectpests/a/control-filth-flies.html> ) 2) During an observation on 06/09/11 at 10:18 a.m. a fly was on the ceiling at the nurses' station and flies were observed flying in Hall C. 3) During an observation on 06/09/11 at 12:15 p.m., three flies were in the dining room. Two flies were flying around Resident #5 and one fly was flying around the lunch tray of Resident #6. 4) During an observation on 06/09/11 at 12:27 p.m., a fly was flying at the entrance to the dining room across from Hall A. 5) During an observation on 06/09/11 at 1:56 p.m., two flies were flying at the nurses' station. 6) On 06/09/11, at 12:07 p.m., one fly was observed in the dining room by the window flying over an unidentified sleeping resident's lunch and the resident. 7) On 06/09/11, at 12:11 p.m., while in the kitchen, after the lunch trays had been served to the residents, one fly was observed flying by the wash sink. 8) On 06/09/11, at 12:14 p.m., while in the kitchen, one fly was observed flying by the refrigerator, which was adjacent to the steam table, with uncovered pans containing food left over from the lunch service. 9) On 06/09/11, at 12:17 p.m., one fly was observed in the window in the front lobby area. 10) On 06/09/11, at 12:25 p.m., one fly was observed in Resident #2's room flying around the room. Resident #2 was lying in the bed in the room. On 06/09/11, at 12:25 p.m., an interview was conducted with Resident #2. When asked if there were flies in the building, Resident #2 replied, "Yes." When asked how often flies were seen, Resident #2 replied "everyday." When asked if the flies were in Resident #2's room, the reply was "sometimes." 11) On 06/09/11, at 12:28 p.m., five flies were observed in, housing Resident #6's room. One fly was on the television screen, two flies were flying in the room, and two flies were on Resident #6. One fly was on his arm and one was on his hand. A fly swatter was on a nail on the wall of the room. 12) On 06/09/11, at 12:30 p.m., four flies were observed in the room of which housed Residents #3 and #4. Two flies were flying by Resident #3 in the "A" bed, and two flies were flying around Resident #4 in the "B" bed. Resident #4 had a fly swatter in his hand and was swatting flies on his bedside table. 13) On 06/09/11, at 12:30 p.m., an interview with Resident #3 revealed "I see flies every two seconds. We try to kill them but it don't do no good (sic). Everyone has them." 14) Observation of the exterior doors of the facility on 06/09/11, from 12:04 p.m. to 12:44 p.m., revealed daylight visible through four of the five exterior doors: exterior front door/lobby, exterior back porch side door, exterior kitchen door, and east exit exterior door. 15) Review of an entry dated 05/08/11 on a form titled ____ (Pest Control Company) Service Request Log under a column labeled "request/problem" revealed "flies." On this same form under a column labeled "Exact Location and Description" revealed "Dining room Area - In entire facility - please place bait." Review of an ___ (Pest Control Company) Customer Service Report dated 06/06/11 revealed facility was treated for [REDACTED]. This same form reflected "Ordered fly lights 06/06/11 should be in 06/15/11 and will install ASAP when they come in the warehouse." Even though the facility had been treated for [REDACTED]. Review of a form titled Product and Services Supply Agreement with ___ (Pest Control Company) dated 01/03/08 provided by the ADM and identified as the current contract revealed the facility had "Stealth Flying Insect Defense Program," which was to consist of "multiple strategies on both the exterior and interior of the facility to minimize house fly and other large fly activity. ___ (Pest Control Company) will install and maintain this program 8 months each year while flies are active. Service of this program will begin in the month of April and will continue through the end of November." The program was to include exterior application of "fast acting, long-[MEDICATION NAME] residual products to fly resting surfaces such as garbage storage areas and building entryways." The contract further reflected that in the interior of the facility they would "strategically place and service Stealth Fly traps on a monthly basis" and will replace "glue boards each active month of the program and bulbs as needed. Residual products will be applied to interior fly resting surfaces." The contract reflected the fly program was to include "Stealth Maxima Fly Traps, Stealth Decora Fly traps, and Air Defense Units." 16) Review of a policy titled Preventive Maintenance Program for Physical Plant, provided by the ADM and identified as current environmental policy, on page 69, in section titled, "Maintaining, Doors, Closers, Locks, Hinges and Panic Hardware", revealed the facility was to "check weather stripping on exterior doors for leaks and drags, repair and replace as necessary." The policy on page 65, reflected, "in your nursing home you will be looking to achieve a better, safer and fresher environment for your residents and staff." The policy did not address pest control directly. 17) An IJ was identified on 06/09/11. The ADM was informed on 06/09/11 at 5:00 p.m. of the IJ and a Plan of Removal was requested at that time. 18) The Plan of Removal dated 06/09/11 reflected the facility's pest control company treated for [REDACTED]. Weather stripping was installed around the front and back exit doors to aid in preventing flies from entering the facility. Fly traps were installed on the back patio area. New batteries were placed in the automatic insect canisters at the front and back doors. Fly traps will be installed. A diffuser will be installed on the fan on the back door to better redirect the air to the outside in order to repel flies. Flies will be monitored daily by the ADM/designee with communication made to the pest control company. The pest control company will service the facility at least monthly. The facility was also add to the pest control company's fly program. 19) On 06/10/11 at 9:30 a.m. in an interview, when asked "How do you think this IJ came about?" the ADM replied, "Breakdown in Nursing - Poor leadership in this facility for years - Recognized problems and started making changes. The DON stepped down in March (2011) - No DON until now - so breakdown in leadership." Additional questions for the ADM revealed "different Leadership and new tone in Corporate. Support from Corporate now 'anything you want.'" 20) On 06/10/11 at 10:00 a.m. in an interview, when asked, "How do you think this IJ occurred?" the DON, who started on 06/01/11 stated, "Staffing - not adequate - Not adequately trained or orientation - such a need to get them on the floor - too high acuity for the staff they had. Staffing has been a problem since I got here - 2 new hires oriented last night - 2 new nurses M-F day next week - Hired one new CNA today." 21) On 06/10/11, at 10:00 a.m., one fly was flying around Resident #6 in the resident's room. 22) On 06/10/11, at 10:22 a.m., one fly was flying around the med cart in the hallway outside Room 111. 23) On 06/10/11 at 10:30 a.m., an interview with the ADM revealed the facility's pest control company was called and would be in the building on 06/10/11 to spray repellant in the facility. The ADM stated fly lights were ordered and would be installed on 06/10/11, seals on the exterior doors would be replaced and the air curtains on the exterior front/lobby door and the back porch side door were being adjusted. The ADM revealed "all these things are being done to fix the fly problem." 24) On 06/10/11, at 11:10 a.m., one fly was observed flying around the nurses' station. 25) On 06/10/11, at 11:49 a.m., one fly was observed on the ceiling pipe in Resident #6's room. 26) On 06/10/11, at 12:06 p.m., an interview with the facility's pest control company technician, revealed when he/she was wiping down the window sills in the facility for flies on 06/10/11 he/she found a concentration of dead flies in the front lobby, in the room "with the plants" and in the Room 113. He/she stated the facility had ordered fly lights recently and had never been on a fly program with the pest control company previously. 27) In an interview on 06/10/11 at 12:30 p.m. the ADM confirmed she was aware the wound center had informed them about the maggots in Resident #1's wound. 28) On 06/10/11 at 12:30 p.m. observation of the low level lighting conditions in Resident #31's room with the ADM revealed the low-level lighting conditions were unchanged from 06/09/11. During this observation, the ADM said she wondered how a person could do a treatment and not see maggots in a wound. The ADM saw the blinking of the overbed light and said she would have the maintenance man replace the bulb. 29) Fly lights were observed on 06/12/11, at 8:00 a.m., by the exterior front/lobby door and the exterior back porch/side door. 30) On 06/12/11, at 8:12 a.m., observation was made of fly lights installed inside the facility by the back porch exterior door and the front/lobby door. 31) On 06/12/11, at 8:20 a.m., one fly was observed flying and landing on an unidentified resident in the doorway of the dining room. 32) On 06/12/11, at 9:40 a.m., one fly was observed flying in Room 111. 33) Observation at 10:02 a.m. on 06/12/11 revealed light showing through cracks and no weather stripping in the door. Observations of the front/lobby door at 10:03 a.m. revealed no weather stripping had been installed and light was showing through the cracks in the door. Observation at 10:05 a.m. of the back porch side door revealed door with new weather stripping around door, however door would not completely close, even when pulled shut. 34) On 06/13/11 at 11:48 a.m., the pest control company technician was observed installing a fly light in the dining room. 35) On 06/13/11, at 11:50 a.m., one fly was observed flying by the nurses' station. 36) While the IJ was removed on 06/13/11, the facility remained out of compliance at a scope of "pattern" and a severity level of "actual harm that is not immediate jeopardy" because the facility was still monitoring the implementation of the Plan of Removal. The facility was informed of the IJ removal on 06/13/11 at 12:30 p.m. 37) Review of the CMS form 672 (Resident Census and Conditions of Residents) dated and signed by the Corporate MDS Nurse A on 06/09/11 revealed a total census of 36 residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure one (Resident# 8) of ten residents reviewed for abuse was free from verbal, mental, and emotional abuse. The surveyor witnessed LVN B loudly telling Resident #8 his physician would not talk with him, she spoke with his physician, and she knew what the physician wanted. LVN B told Resident #8 he had to take the medication the physician ordered and he needed "to let it go." She also told Resident #8 he could not talk to his physician. LVN B then escorted Resident #8 to his room and closed the door. This loud verbal confrontation occurred in the hall of the facility exposing residents, staff and visitors to the exchange. This failure affected Resident #8 as evidenced by his expressions of feeling like he was "nothin," he did not matter, he was ignored, he was lower than the staff and fear of being "kicked out" of the facility. This failure could affect all 43 residents, who resided in the facility, by placing them at risk of abuse, feelings of hopelessness, worthlessness, fear, and retaliation. Findings included: 1) A review of the undated "Admission and Discharge Summary" for Resident #8 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An observation at 9:15 am on 3/09/11, during the medication pass, revealed Resident #8 approached LVN A and asked her if the Doctor was coming to the facility that day, because he wanted to talk with him since he did not get to see his doctor or talk to him the previous day. Before LVN A could complete a response, LVN B interrupted stating she would handle the situation. LVN B then stated in a loud stern voice with hand gestures, "No. Listen, you have to take what is ordered...I talked to the doctor...you have to take what he ordered...you're not going to talk to the doctor. He has ordered what he wants you to have...that is what he wants you to take...that is want you'll take ...That is it...Let it go...he is not talking to you ... He talked to me ... I know what he wants..., that's it let it go... You will take what he wants you to take." LVN B then escorted Resident #8 to his room and closed the door behind them. At 9:25 am LVN B came out of Resident 8's room and interrupted the medication pass stating, "Just so you know (to LVN A)... All he wants is drugs... that's all he cares about... he is not to get anymore...That's just how he is, I know him he's always like that..." When questioned by the surveyor as to how long she had known this resident , LVN B stated, "Well, since he's been here...2-3 days." The ADM, DON, and Corporate Nurse were informed of this observation on 3/09/11 at approximately 4:00 PM. The concerns regarding the potential effect of the interaction on Resident #8, other residents, staff and visitors who witnessed or overheard were also discussed. The ADM and the Corporate Nurse commented that such behavior was " certainly inappropriate and unprofessional." The ADM stated, " We'll take care of it." An observation at 9:15 am on 3/10/11 revealed LVN B working as the charge nurse/treatment nurse. An interview with Resident #8 and his roommate/spouse on 3/10/11 at 10:45 am regarding the altercation with LVN B, revealed, "I felt like I was being ignored...like I was nothin'...they just want the money...I'm afraid if my wife dies they will kick me out...made me feel low... lower than them...like I didn't count. One nurse said 'I've got other patients.. listen you're not the only patient'... took me three days to get my wife a [MEDICATION NAME] for her itching rash... Now, I'm tryin' not to talk too much just try to get along...they already kicked out two people....I'm just not wanting to cause trouble." 2) A review of the facility Provider Investigation Report on 3/11/11 revealed no date or time of reporting the incident to DADS (State survey and certification agency). A Notice of Disciplinary Action for LVN B was attached to the Report. The Notice reflected, "allegation of verbal/emotional abuse" with suspension of LVN B starting on 3/09/11 and returned to work on 3/09/11. A review of the Inservice Report dated 3/09/11 reflected the length of the inservice for LVN B was 10 minutes long and the topic was "Sensitivity and Appropriate Communication." A written statement dated 3/10/11 by LVN A reflected, "....I cannot remember word for word, but she ( LVN B) was somewhat stern and argumentative" The Satisfaction rounds documented by the Social Worker did not have a date, time or identifying signature and were attached to the Provider Investigation Report. 3) Review of the facility Policies on Abuse/Neglect and Exploitation revealed, " Suspected or substantiated cases of Resident Abuse, neglect misappropriation...or mistreatment shall be thoroughly investigated and documented by the Administrator/designee and reported to the appropriate state agencies. The Administrator is assigned as the abuse coordinator and shall report findings of the investigation to the party/parties that reported the alleged abuse....or mistreatment..." 1. Any alleged violation involving mistreatment, misappropriation..., abuse exploitation or neglect of a resident shall be reported to the administrator immediately. 2. The administrator shall thoroughly investigate all allegations. 4. The administrator will take steps to ensure and prevent further potential abuse while investigation is in process. a) If a direct care giver is observed, suspected, or alleged to have engaged in abuse, neglect,,,,,the care giver will be relieved of duty and placed under investigative suspension by the administrator...until the investigation is completed." 4) The CMS Form 672 (Resident Census and Condition of Residents) signed by the ADON and dated 03/08/11 reflected a census of 42 residents.

Based on observation, interview and record review, it was determined the facility failed to ensure one (Resident #1) of eight residents reviewed for abuse was free from from verbal/mental abuse. Resident #1 was verbally/mentally abused by LVN A for a period of approximately six months. Housekeeper B, CNA D, CNA E and the DM stated they knew they should have reported the abuse, but were afraid of LVN A and administration and did not know who to report abuse to or who could be trusted. CNA D had never had any inservices in the six months she had been working at the facility. On 09/17/10, Resident #2 stated he would not tell who "yells" at specific residents, because "If you tell, it gets really bad for you here." The ADM, the DON and the facility's only ADON denied they had knowledge of any verbal/mental abuse involving LVN A verbally/mentally abusing Resident #1. On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the areas of Resident Behavior/Facility Practice with Substandard Quality of Care (SQC) affecting Resident #1 and the rest of the facility's 41 residents. On 09/20/10 at 2:55 p.m., the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. These failures could affect the facility's 42 residents, including Resident #1, placing them at risk for being fearful of staff and resulted in an atmosphere where verbal/mental abuse was allowed to continue and flourish, placing residents at risk for becoming objects of abuse themselves, which could have resulted in injury, psychological harm, a decline in the residents' physical and mental well-being, all having a negative impact on the residents' quality of life. Findings included: 1) The face sheet dated 01/22/10 reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] (most recent MDS on the clinical record) reflected Resident #1's cognition as moderately impaired (decisions poor, cues/supervision required). It further reflected Resident #1 only had "Periods of restlessness" and had a behavior of "wandering." The ADL section of the MDS reflected Resident #1 was a one-person physical assist with setup help only. On 09/14/10 Resident #1 was sent to the emergency room (ER) for a laceration to his scalp. While at the ER, Resident #1 stated to the ER nurse, "_____ (LVN A), yanks me around like a rag doll and is verbally abuse to me." The allegation of abuse was called to DADS, and a complaint investigation was initiated on 09/17/10. Observation on 09/17/10 at 9:30 a.m. of Resident #1 revealed he was sitting in a wheelchair and watching TV in his room. He was alert and oriented X 2 and was verbally responsive when asked about any problems he had been having in the facility. Resident #1's room was the far end of the hall. From the nurse's station, one walked by two offices to get to the resident's room. An interview at that time with Resident #1 revealed on several (undated) occasions LVN A "Throws me around like a rag doll," and "Yells at me for everything." He further stated LVN A "Gets in my face and tells me, 'I hate you!'" Resident #1 stated he was very scared of LVN A and she "curses" at him frequently. Resident #1 asked, "Why does she yell at me?" 2) During an interview on 09/17/10 at 9:50 a.m., Housekeeper B stated LVN A "yells" very loud at Resident #1. During an interview on 09/17/10 at 1:00 p.m. with CNA D, she stated LVN A was very "verbally abusive" to Resident #1. CNA D stated LVN A cursed him and threatened him by telling him she would tell her husband to come to the facility (to beat him up). CNA D stated over the last six months, every time LVN A worked, she threatened Resident #1. CNA D stated on several occasions, LVN A came to the nurse's station yelling, "I just want to kill him. I just want to choke him," referring to Resident #1. The CNA stated when Resident #1 tried to get out of his wheelchair in the dining room, LVN A would get in his face and yell at him to "Sit your ass in your wheelchair, and wheel yourself." She stated LVN A was very rough with him whenever she had to assist Resident #1 with anything. CNA D stated LVN A was only this way with Resident #1. CNA D stated she knew she should have reported the abuse but did not, because she was scared of retaliation from both LVN A and administration. CNA D stated she had worked at the facility for six months and had not had any inservices since she had been there. On 09/18/10, the surveyor received a handwritten statement from CNA D, which confirmed the interview given on 09/17/10. In CNA D's written statement, she wrote: "...There are so many times ____ (LVN A) has acted out in a tacky and unprofessional manner. but anyhow everyone in the building knows what has been going on everyone!! (underlined four times) They all are as guilty as myself for not doing anything. ...I'm so serious when I say everyone (underlined three times) knew. Further included in the written statement, "...he (Resident #1) was always depressed and it never mattered to her (LVN A), she made it worse even when he had a good day or excited about something she would make it bad for him...." During an interview on 09/17/10 at 1:25 p.m., CNA E stated LVN A was very rude and verbally abusive to Resident #1. CNA E stated when Resident #1 did something that "pisses off" LVN A, LVN A would tell Resident #1 to "keep his ass" in his room, and has told him, "You aren't going to Bingo," which was Resident #1's favorite activity. The CNA stated the LVN would also take the resident's personal belongings, like his markers away from him. CNA E stated on 09/14/10, when Resident #1 was on the floor, LVN A told him to "get your m_____-f______ ass off the floor. I'm sick of this bullshit." CNA E stated this (abuse) had been going on every day for months. CNA E stated the reason she did not report the abuse was because she was scared of LVN A and was also afraid to report it to administration because of retaliation. LVN A would threaten Resident #1 by telling him she would "bring ____ (her husband) up here, and he'll whoop your ass." CNA E stated she believed the facility's only ADON knew about LVN A yelling at Resident #1, because LVN A would yell and scream about Resident #1 while at the nurse's station. On 09/18/10, the surveyor received a handwritten statement from CNA E, which confirmed the interview given on 09/17/10. Note: This facility is built in an L-shape. The nurse's station is located at the corner of the L where the two halls meet. Administrative offices are located in the same area, with offices located within ten to twenty feet of the nurse's station. According to the facility's floor plan, there were four offices in the facility. 3) An interview on 09/17/10 at 11:30 a.m. with Resident #2, who was alert and oriented X 3, revealed he had been in the facility four years. Resident #2 stated he would not tell who "yells" at specific residents because, "If you tell, it gets really bad for you here." Resident #2 stated he was "done talking." 4) During an interview on 09/17/10 at 12:30 p.m. via phone with LVN A, she denied ever having been rough with a resident or having yelled at a resident. An interview on 09/17/10 at 1:45 p.m. with the DON revealed she had no knowledge of any LVN verbally abusing any residents in the facility. An interview on 09/17/10 at 2:05 p.m. with the facility's only ADON revealed she had no knowledge of any LVN verbally abusing any residents in the facility. During an interview on 09/17/10 at 2:10 p.m., the ADM stated a "few days" days ago a CNA came to her and reported LVN A had yelled at her in front of the residents. The ADM stated the CNA had subsequently quit. The ADM stated she had no knowledge of any incidents involving LVN A being verbally abusive to any of the residents. The ADM added, if she had ever had any knowledge regarding that, she would have suspended LVN A immediately pending the outcome of the facility investigation. 5) During an interview on 09/17/10 at 10:00 a.m. with the ADM, she stated on 09/16/10 she self-reported an incident of a night nurse "punching" an unidentified resident. The ADM stated she was going to start the investigation, but the surveyor entered the facility. The ADM stated there were no suspects named in the alleged incident, and no resident was identified. The ADM was asked for the information in reference to the alleged physical abuse allegations. The ADM stated she did not have any information ready yet. 6) The facility's current policy and procedure on Abuse dated January 2005 and provided on 09/17/10 by the ADM reflected the following: Policy: 1. The resident has the right to be free from abuse: verbal, mental, physical, or sexual... Procedure: 1. The facility will... inform the resident of the definitions of: a. Verbal abuse is the use of oral, written or gestured language which could be viewed as or understood to have disparaging or derogatory intent which is directed toward the resident... which is in hearing or visual distance regardless of age, disability or ability to understand. Example: Threats of harm, instilling of fear, verbal slander, etc. ...d. Mental abuse includes harassment, humiliation, demoralization, threats of punishment or deprivation... Abuse Guidelines (Abuse Definitions) "Mental Abuse-defined as, but not limited, humiliation, harassment, threats, of punishment, or withholding of treatment or services." Abuse Guideline (Abuse, prevention) "Our abuse prevention/intervention program includes, but is not limited to, the following: Encouraging all personnel, residents, family members, visitors, etc., to report any signs of suspected incidents of abuse to facility management immediately." Federal Regulation F-223 (Abuse) Policy- "The resident has the right to be free from abuse: verbal, mental, physical, or sexual." In the Abuse Guidelines Section regarding Incident/Accident Reporting reflected the following definitions: 1. Any event, accident or incident, which results in an injury or has the potential for injury, ...any allegations of mistreatment of [REDACTED]. ...4. Complaint of mental or physical abuse or neglect, or actual abuse or neglect. Abuse and/or neglect may be inflicted by... staff... Guidelines ...5. The Administrator will coordinate an investigation of the event, as needed, within 24 hours of the event. The investigation would be separate from the incident/accident report investigation. 6. ...Any incident or accident that requires reporting will be completed according to state standards. Resident Incident/Accident ...14. The DON, or designee, or Administrator, or Safety Committee Chairperson (facility must designate which one) will complete an investigation of the incident/accident within 24 hours of the event. This investigation, at minimum, must attempt to identify any trends that may indicate resident abuse.... 7) On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the areas of Resident Behavior/Facility Practice with Substandard Quality of Care (SQC) affecting Resident #1 and the rest of the facility's 41 residents. The ADM, the DON, and the facility's only ADON were informed at that time. They were further informed of the alleged perpetrator, LVN A, and the alleged victim, Resident #1. 8) An interview was conducted on 09/18/10 at 11:20 a.m. with Resident #1. Resident #1 stated the Administrator came to him "last night" and talked to him about LVN A yelling at him. Resident #1 then asked the surveyor, "Am I going to get yelled at again?" 9) An interview was conducted on 09/18/10 at 11:33 a.m. with Resident #3, who was alert and oriented X 3. Resident #3 stated "some nurse," who he was unable to identify, had told him to "Get yourself up," and "Clean yourself." 10) During an interview on 09/18/10 at 11:40 a.m. with CNA E, the CNA stated after the surveyor left on 09/17/10, she was called into the Administrator's office by the ADM and asked if she had ever witnessed any verbal abuse by LVN A. CNA E stated she admitted she had and wrote a statement for the ADM. CNA E stated she only told the ADM about the most recent occurrence of abuse by LVN A, which happened on 09/14/10. CNA E again told the surveyor she did not report the abuse, because she was scared of retaliation from the administration and from LVN A. 11) On 09/20/10 at 9:30 a.m., a copy of the investigation involving LVN A and Resident #1 was requested from the Administrator. At 11:00 a.m., the Administrator, RDO and the facility's only ADON informed the survey team they had not conducted a separate investigation for the allegation of abuse involving LVN A and Resident #1. They had included it with the already self-reported incident of the allegation of physical abuse perpetrated by an unknown person against an unknown resident. The RDO at that time agreed with the ADM the two allegations were the same incident. The ADM, the RDO and the DON were then advised by the survey team the two incidents were not one and the same. They were informed an allegation of physical abuse, which occurred at night by an unidentified staff against an unidentified resident, was not the same as an allegation of verbal/mental abuse perpetrated by LVN A against Resident #1 during the daytime. 12) In an interview with the DON on 09/20/10 at 12:35 p.m., the DON stated LVN A was always loud. She did not think the LVN was abusive or inappropriate. The DON stated she was not scared of LVN A and did not hear the LVN complain about the residents. 13) An interview on 09/20/10 at 2:10 p.m. with the DM revealed on 07/04/10, LVN A was at the nurse's station yelling, "This f______ place," and cursing very loudly in front of several residents and staff members. The DM stated the language was very offensive to her. On one occasion, a resident was on the floor and LVN A "grabbed" the resident off the floor in a forceful manner and carried her in a "bear hug" style to her room, and then shut the door. On a separate occasion, the DM witnessed LVN A "yelling" at a CNA in front of the residents and staff members. She overheard LVN A say, "I'm gonna have my husband come kick his ass," while at the nurses station. The DM stated she did not know who the comment was in reference to, but she assumed it was toward a male resident since there were no male CNAs. The DM stated on an almost daily basis, Resident #1 would knock on the kitchen door. When LVN A saw this, she would yell at him, "What do you want?" The DM stated she did not report these occurrences, because she did not know who to go to or who she could trust. She stated the management staff was not very friendly when you reported things to them. After the inservice per the Plan of Removal, she stated she felt much better going to the ADM, but before she did not trust her (the ADM) and was not comfortable going to her. The DM added she was very intimidated by LVN A, and the work environment was very hostile when the LVN was in the building. The DM admitted she never reported LVN A to the ADM and should have, but she would from now on. 14) The facility's Plan of Removal (POR) with an origination date of 09/18/10 and accepted on 09/20/10 reflected: All facility staff (all staff/all departments: licensed nurses certified nursing assistants, dietary, housekeeping, laundry, office manager, activity director, social worker, maintenance) are being in-serviced on reporting of any allegation of abuse and/or neglect of residents. In-services have been initiated by the ADM. These in-services will continue each shift to ensure all staff have the training. In-services were initiated on 09/17/10, projected completion date of 09/18/10 and then monthly over the next three months. LVN A was immediately suspended pending investigation related to allegations brought to the ADM by the surveyor. The ADM immediately initiated a full investigation into the allegations. This investigation included individual staff interviews and resident interviews. LVN A was terminated on 09/18/10 based on findings of the facility investigation, which was initiated 09/17/10 and completed on 09/18/10. A resident group meeting was held on 09/17/10 by the Abuse Coordinator (the ADM) on the topic of Abuse and Neglect, including reporting procedures. The Abuse Coordinator will hold resident group meetings monthly over the next three months on the same topic. Residents who do not attend the group meetings will be seen individually by the Abuse Coordinator. The ADM has been in-serviced on the Abuse Guidelines by the Regional Nurse Consultant on 09/17/10. The facility's only ADON has been designated as the alternate Abuse Coordinator effective 09/17/10 and has been trained by the Regional Nurse Consultant on 09/17/10. Resident #1 has been physically assessed by a licensed nurse on 09/18/10 related to the allegations. The outcome of the physical assessment indicated no injuries that had not been previously identified by the facility. The Abuse Coordinator (ADM) completed an emotional assessment on Resident #1 on 09/17/10. No psychological or emotional distress related to the allegations was evident at that time. The Facility Social Worker will also visit Resident #1 weekly over the next four weeks. These actions were initiated 09/17/10 and completed on 09/18/10. Monitoring to prevent reoccurrence: All new staff (licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, Office Manager, Activity Director, Social Worker, Maintenance) upon hire, will be in-serviced by the Abuse Coordinator regarding the facility abuse guidelines. The Abuse Coordinator and Alternate Abuse Coordinator will make random facility rounds. A QA meeting was held on 09/17/10 with members of the QA team, including the facility Medical Director. The QA committee, which included the Medical Director, will monitor for the next 90 days to ensure systems are effective. The QA Committee meeting will include review of complaints and will monitor future complaints. 15) On 09/20/10, from 2:05 to 2:55 p.m., a total of nine staff interviews were conducted after the plan of removal was accepted. Interviews were conducted with CNA F, Housekeeper C, LVN G, CNA H, LVN I, CNA D, CNA E, CNA J, and Dietary Aide K. All staff interviewed were able to verbalize an understanding of: the definition of abuse, different types of abuse, the signs and symptoms of abuse, how and to whom to report and were able to identify the Abuse Coordinator. CNA E stated she felt more comfortable now about reporting to the ADM. CNA D stated she did not report the abuse because she was scared, but knows now that she has to (report the abuse). On 09/20/10, the DON provided two in-service training reports signed by all employees in the facility. The in-services were entitled "Abuse" and "Employee Burn-Out." 16) On 09/20/10 at 2:55 PM, the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. The ADM, the DON, the facility's only ADON, the RDO and the Regional Nurse Consultant were informed at that time. 17) The facility's CMS 672 (Resident Census and Conditions of Residents) dated 09/17/10 and signed by the facility's only ADON reflected a census of 42 residents.

Based on observation, interview and record review, it was determined the facility failed to ensure all alleged violations involving mistreatment and abuse were reported immediately to the administrator and the State agency to ensure all alleged violations were thoroughly investigated and prevent further potential abuse during the investigation for one (Resident #1) of eight residents reviewed for abuse/neglect. Resident #1 was verbally/mentally abused by LVN A for a period of approximately six months. Housekeeper B, CNA D, CNA E and the DM stated they knew they should have reported the abuse, but were afraid of LVN A and administration and did not know who to report abuse to or who could be trusted. CNA D had never had any inservices in the six months she had been working at the facility. On 09/17/10, Resident #2 stated he would not tell who "yells" at specific residents, because "If you tell, it gets really bad for you here." The ADM, the DON and the facility's only ADON denied they had knowledge of any verbal/mental abuse involving LVN A verbally/mentally abusing Resident #1. On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the areas of Resident Behavior/Facility Practice with Substandard Quality of Care (SQC) affecting Resident #1 and the rest of the facility's 41 residents. On 09/20/10 at 2:55 p.m., the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. These failures could affect the facility's 42 residents, including Resident #1, placing them at risk for being fearful of staff and resulted in an atmosphere where verbal/mental abuse was allowed to continue and flourish, placing residents at risk for becoming objects of abuse themselves, which could have resulted in injury, psychological harm, a decline in the residents' physical and mental well-being, all having a negative impact on the residents' quality of life. Findings included: 1) The face sheet dated 01/22/10 reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] (most recent MDS on the clinical record) reflected Resident #1's cognition as moderately impaired (decisions poor, cues/supervision required). It further reflected Resident #1 only had "Periods of restlessness" and had a behavior of "wandering." The ADL section of the MDS reflected Resident #1 was a one-person physical assist with setup help only. On 09/14/10 Resident #1 was sent to the emergency room (ER) for a laceration to his scalp. While at the ER, Resident #1 stated to the ER nurse, "_____ (LVN A), yanks me around like a rag doll and is verbally abuse to me." The allegation of abuse was called to DADS, and a complaint investigation was initiated on 09/17/10. Observation on 09/17/10 at 9:30 a.m. of Resident #1 revealed he was sitting in a wheelchair and watching TV in his room. He was alert and oriented X 2 and was verbally responsive when asked about any problems he had been having in the facility. Resident #1's room was the far end of the hall. From the nurse's station, one walked by two offices to get to the resident's room. An interview at that time with Resident #1 revealed on several (undated) occasions LVN A "Throws me around like a rag doll," and "Yells at me for everything." He further stated LVN A "Gets in my face and tells me, 'I hate you!' " Resident #1 stated he was very scared of LVN A and she "curses" at him frequently. Resident #1 asked, "Why does she yell at me?" 2) During an interview on 09/17/10 at 9:50 a.m., Housekeeper B stated LVN A "yells" very loud at Resident #1. During an interview on 09/17/10 at 1:00 p.m. with CNA D, she stated LVN A was very "verbally abusive" to Resident #1. CNA D stated LVN A cursed him and threatened him by telling him she would tell her husband to come to the facility (to beat him up). CNA D stated over the last six months, every time LVN A worked, she threatened Resident #1. CNA D stated on several occasions, LVN A came to the nurse's station yelling, "I just want to kill him. I just want to choke him," referring to Resident #1. The CNA stated when Resident #1 tried to get out of his wheelchair in the dining room, LVN A would get in his face and yell at him to "Sit your ass in your wheelchair, and wheel yourself." She stated LVN A was very rough with him whenever she had to assist Resident #1 with anything. CNA D stated LVN A was only this way with Resident #1. CNA D stated she knew she should have reported the abuse but did not, because she was scared of retaliation from both LVN A and administration. CNA D stated she had worked at the facility for six months and had not had any inservices since she had been there. On 09/18/10, the surveyor received a handwritten statement from CNA D, which confirmed the interview given on 09/17/10. In CNA D's written statement, she wrote: "...There are so many times ____ (LVN A) has acted out in a tacky and unprofessional manner. but anyhow everyone in the building knows what has been going on everyone!! (underlined four times) They all are as guilty as myself for not doing anything. ...I'm so serious when I say everyone (underlined three times) knew. Further included in the written statement, "...he (Resident #1) was always depressed and it never mattered to her (LVN A), she made it worse even when he had a good day or excited about something she would make it bad for him...." During an interview on 09/17/10 at 1:25 p.m., CNA E stated LVN A was very rude and verbally abusive to Resident #1. CNA E stated when Resident #1 did something that "pisses off" LVN A, LVN A would tell Resident #1 to "keep his ass" in his room, and has told him, "You aren't going to Bingo," which was Resident #1's favorite activity. The CNA stated the LVN would also take the resident's personal belongings, like his markers away from him. CNA E stated on 09/14/10, when Resident #1 was on the floor, LVN A told him to "get your m_____-f______ ass off the floor. I'm sick of this bullshit." CNA E stated this (abuse) had been going on every day for months. CNA E stated the reason she did not report the abuse was because she was scared of LVN A and was also afraid to report it to administration because of retaliation. LVN A would threaten Resident #1 by telling him she would "bring ____ (her husband) up here, and he'll whoop your ass." CNA E stated she believed the facility's only ADON knew about LVN A yelling at Resident #1, because LVN A would yell and scream about Resident #1 while at the nurse's station. On 09/18/10, the surveyor received a handwritten statement from CNA E, which confirmed the interview given on 09/17/10. Note: This facility is built in an L-shape. The nurse's station is located at the corner of the L where the two halls meet. Administrative offices are located in the same area, with offices located within ten to twenty feet of the nurse's station. According to the facility's floor plan, there were four offices in the facility. 3) An interview on 09/17/10 at 11:30 a.m. with Resident #2, who was alert and oriented X 3, revealed he had been in the facility four years. Resident #2 stated he would not tell who "yells" at specific residents because, "If you tell, it gets really bad for you here." Resident #2 stated he was "done talking." 4) During an interview on 09/17/10 at 12:30 p.m. via phone with LVN A, she denied ever having been rough with a resident or having yelled at a resident. An interview on 09/17/10 at 1:45 p.m. with the DON revealed she had no knowledge of any LVN verbally abusing any residents in the facility. An interview on 09/17/10 at 2:05 p.m. with the facility's only ADON, revealed she had no knowledge of any LVN verbally abusing any residents in the facility. During an interview on 09/17/10 at 2:10 p.m., the ADM stated a "few days" days ago a CNA came to her and reported LVN A had yelled at her in front of the residents. The ADM stated the CNA had subsequently quit. The ADM stated she had no knowledge of any incidents involving LVN A being verbally abusive to any of the residents. The ADM added, if she had ever had any knowledge regarding that, she would have suspended LVN A immediately pending the outcome of the facility investigation. 5) During an interview on 09/17/10 at 10:00 a.m. with the ADM, she stated on 09/16/10 she self-reported an incident of a night nurse "punching" an unidentified resident. The ADM stated she was going to start the investigation, but the surveyor entered the facility. The ADM stated there were no suspects named in the alleged incident, and no resident was identified. The ADM was asked for the information in reference to the alleged physical abuse allegations. The ADM stated she did not have any information ready yet. 6) The facility's current policy and procedure on Abuse dated January 2005 and provided on 09/17/10 by the ADM reflected the following: Policy: 1. The resident has the right to be free from abuse: verbal, mental, physical, or sexual... Procedure: 1. The facility will... inform the resident of the definitions of: a. Verbal abuse is the use of oral, written or gestured language which could be viewed as or understood to have disparaging or derogatory intent which is directed toward the resident... which is in hearing or visual distance regardless of age, disability or ability to understand. Example: Threats of harm, instilling of fear, verbal slander, etc. ...d. Mental abuse includes harassment, humiliation, demoralization, threats of punishment or deprivation... Abuse Guidelines (Abuse Definitions) "Mental Abuse-defined as, but not limited, humiliation, harassment, threats, of punishment, or withholding of treatment or services." Abuse Guideline (Abuse, prevention) "Our abuse prevention/intervention program includes, but is not limited to, the following: Encouraging all personnel, residents, family members, visitors, etc., to report any signs of suspected incidents of abuse to facility management immediately." Federal Regulation F-223 (Abuse) Policy- "The resident has the right to be free from abuse: verbal, mental, physical, or sexual." In the Abuse Guidelines Section regarding Incident/Accident Reporting reflected the following definitions: 1. Any event, accident or incident, which results in an injury or has the potential for injury, ...any allegations of mistreatment of [REDACTED]. ...4. Complaint of mental or physical abuse or neglect, or actual abuse or neglect. Abuse and/or neglect may be inflicted by... staff... Guidelines ...5. The Administrator will coordinate an investigation of the event, as needed, within 24 hours of the event. The investigation would be separate from the incident/accident report investigation. 6. ...Any incident or accident that requires reporting will be completed according to state standards. Resident Incident/Accident ...14. The DON, or designee, or Administrator, or Safety Committee Chairperson (facility must designate which one) will complete an investigation of the incident/accident within 24 hours of the event. This investigation, at minimum, must attempt to identify any trends that may indicate resident abuse.... 7) On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the areas of Resident Behavior/Facility Practice with Substandard Quality of Care (SQC) affecting Resident #1 and the rest of the facility's 41 residents. The ADM, the DON, and the facility's only ADON were informed at that time. They were further informed of the alleged perpetrator, LVN A, and the alleged victim, Resident #1. 8) An interview was conducted on 09/18/10 at 11:20 a.m. with Resident #1. Resident #1 stated the Administrator came to him "last night" and talked to him about LVN A yelling at him. Resident #1 then asked the surveyor, "Am I going to get yelled at again?" 9) An interview was conducted on 09/18/10 at 11:33 a.m. with Resident #3, who was alert and oriented X 3. Resident #3 stated "some nurse," who he was unable to identify, had told him to "Get yourself up," and "Clean yourself." 10) During an interview on 09/18/10 at 11:40 a.m. with CNA E, the CNA stated after the surveyor left on 09/17/10, she was called into the Administrator's office by the ADM and asked if she had ever witnessed any verbal abuse by LVN A. CNA E stated she admitted she had and wrote a statement for the ADM. CNA E stated she only told the ADM about the most recent occurrence of abuse by LVN A, which happened on 09/14/10. CNA E again told the surveyor she did not report the abuse, because she was scared of retaliation from the administration and from LVN A. 11) On 09/20/10 at 9:30 a.m., a copy of the investigation involving LVN A and Resident #1 was requested from the Administrator. At 11:00 a.m., the Administrator, RDO and the facility's only ADON informed the survey team they had not conducted a separate investigation for the allegation of abuse involving LVN A and Resident #1. They had included it with the already self-reported incident of the allegation of physical abuse perpetrated by an unknown person against an unknown resident. The RDO at that time agreed with the ADM, the two allegations were the same incident. The ADM, the RDO and the DON were then advised by the survey team the two incidents were not one and the same. They were informed an allegation of physical abuse, which occurred at night by an unidentified staff against an unidentified resident, was not the same as an allegation of verbal/mental abuse perpetrated by LVN A against Resident #1 during the daytime. 12) In an interview with the DON on 09/20/10 at 12:35 p.m., the DON stated LVN A was always loud. She did not think the LVN was abusive or inappropriate. The DON stated she was not scared of LVN A and did not hear the LVN complain about the residents. 13) An interview on 09/20/10 at 2:10 p.m. with the DM revealed on 07/04/10, LVN A was at the nurse's station yelling, "This f______ place," and cursing very loudly in front of several residents and staff members. The DM stated the language was very offensive to her. On one occasion, a resident was on the floor and LVN A "grabbed" the resident off the floor in a forceful manner and carried her in a "bear hug" style to her room, and then shut the door. On a separate occasion, the DM witnessed LVN A "yelling" at a CNA in front of the residents and staff members. She overheard LVN A say, "I'm gonna have my husband come kick his ass," while at the nurses station. The DM stated she did not know who the comment was in reference to, but she assumed it was toward a male resident since there were no male CNAs. The DM stated on an almost daily basis, Resident #1 would knock on the kitchen door. When LVN A saw this, she would yell at him, "What do you want?" The DM stated she did not report these occurrences, because she did not know who to go to or who she could trust. She stated the management staff was not very friendly when you reported things to them. After the inservice per the Plan of Removal, she stated she felt much better going to the ADM, but before she did not trust her (the ADM) and was not comfortable going to her. The DM added she was very intimidated by LVN A, and the work environment was very hostile when the LVN was in the building. The DM admitted she never reported LVN A to the ADM and should have, but she would from now on. 14) The facility's Plan of Removal (POR) with an origination date of 09/18/10 and accepted on 09/20/10 reflected: All facility staff (all staff/all departments: licensed nurses certified nursing assistants, dietary, housekeeping, laundry, office manager, activity director, social worker, maintenance) are being in-serviced on reporting of any allegation of abuse and/or neglect of residents. In-services have been initiated by the ADM. These in-services will continue each shift to ensure all staff have the training. In-services were initiated on 09/17/10, projected completion date of 09/18/10 and then monthly over the next three months. LVN A was immediately suspended pending investigation related to allegations brought to the ADM by the surveyor. The ADM immediately initiated a full investigation into the allegations. This investigation included individual staff interviews and resident interviews. LVN A was terminated on 09/18/10 based on findings of the facility investigation, which was initiated 09/17/10 and completed on 09/18/10. A resident group meeting was held on 09/17/10 by the Abuse Coordinator (the ADM) on the topic of Abuse and Neglect, including reporting procedures. The Abuse Coordinator will hold resident group meetings monthly over the next three months on the same topic. Residents who do not attend the group meetings will be seen individually by the Abuse Coordinator. The ADM has been in-serviced on the Abuse Guidelines by the Regional Nurse Consultant on 09/17/10. The facility's only ADON has been designated as the alternate Abuse Coordinator effective 09/17/10 and has been trained by the Regional Nurse Consultant on 09/17/10. Resident #1 has been physically assessed by a licensed nurse on 09/18/10 related to the allegations. The outcome of the physical assessment indicated no injuries that had not been previously identified by the facility. The Abuse Coordinator (ADM) completed an emotional assessment on Resident #1 on 09/17/10. No psychological or emotional distress related to the allegations was evident at that time. The Facility Social Worker will also visit Resident #1 weekly over the next four weeks. These actions were initiated 09/17/10 and completed on 09/18/10. Monitoring to prevent reoccurrence: All new staff (licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, Office Manager, Activity Director, Social Worker, Maintenance) upon hire, will be in-serviced by the Abuse Coordinator regarding the facility abuse guidelines. The Abuse Coordinator and Alternate Abuse Coordinator will make random facility rounds. A QA meeting was held on 09/17/10 with members of the QA team, including the facility Medical Director. The QA committee, which included the Medical Director, will monitor for the next 90 days to ensure systems are effective. The QA Committee meeting will include review of complaints and will monitor future complaints. 15) On 09/20/10, from 2:05 to 2:55 p.m., a total of nine staff interviews were conducted after the plan of removal was accepted. Interviews were conducted with CNA F, Housekeeper C, LVN G, CNA H, LVN I, CNA D, CNA E, CNA J, and Dietary Aide K. All staff interviewed were able to verbalize an understanding of: the definition of abuse, different types of abuse, the signs and symptoms of abuse, how and to whom to report and were able to identify the Abuse Coordinator. CNA E stated she felt more comfortable now about reporting to the ADM. CNA D stated she did not report the abuse because she was scared, but knows now that she has to (report the abuse). On 09/20/10, the DON provided two in-service training reports signed by all employees in the facility. The in-services were entitled "Abuse" and "Employee Burn-Out." 16) On 09/20/10 at 2:55 PM, the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. The ADM, the DON, the facility's only ADON, the RDO and the Regional Nurse Consultant were informed at that time. 17) The facility's CMS 672 (Resident Census and Conditions of Residents) dated 09/17/10 and signed by the facility's only ADON reflected a census of 42 residents.

Based on observation, interview and record review, it was determined the facility failed to ensure its written policies and procedures, which prohibit mistreatment, neglect and abuse of residents, were implemented for one (Resident #1) of eight residents reviewed for abuse/neglect. Resident #1 was verbally/mentally abused by LVN A for a period of approximately six months. Housekeeper B, CNA D, CNA E and the DM stated they knew they should have reported the abuse, but were afraid of LVN A and administration and/or did not know who to report the abuse to or who could be trusted. CNA D had never had any inservices in the six months she had been working at the facility. Resident #2 stated he would not tell who "yells" at specific residents, because "If you tell, it gets really bad for you here." The ADM, the DON and the facility's only ADON denied having knowledge of any allegation of verbal/mental abuse involving LVN A verbally/mentally abusing Resident #1. On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the areas of Resident Behavior/Facility Practice with Substandard Quality of Care (SQC) affecting Resident #1 and the rest of the facility's 41 residents. On 09/20/10 at 2:55 p.m., the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. These failures could affect the facility's 42 residents, including Resident #1, placing them at risk for being fearful of staff and resulted in an atmosphere where verbal/mental abuse was allowed to continue and flourish, placing residents at risk for becoming objects of abuse themselves, which could have resulted in injury, psychological harm, a decline in the residents' physical and mental well-being, all having a negative impact on the residents' quality of life. Findings included: The facility's current policy and procedure on Abuse dated January 2005 and provided on 09/17/10 by the ADM reflected the following: Policy: 1. The resident has the right to be free from abuse: verbal, mental, physical, or sexual... Procedure: 1. The facility will... inform the resident of the definitions of: a. Verbal abuse is the use of oral, written or gestured language which could be viewed as or understood to have disparaging or derogatory intent which is directed toward the resident... which is in hearing or visual distance regardless of age, disability or ability to understand. Example: Threats of harm, instilling of fear, verbal slander, etc. ...d. Mental abuse includes harassment, humiliation, demoralization, threats of punishment or deprivation... Abuse Guidelines (Abuse Definitions) "Mental Abuse-defined as, but not limited, humiliation, harassment, threats, of punishment, or withholding of treatment or services." Abuse Guideline (Abuse, prevention) "Our abuse prevention/intervention program includes, but is not limited to, the following: Encouraging all personnel, residents, family members, visitors, etc., to report any signs of suspected incidents of abuse to facility management immediately." Federal Regulation F-223 (Abuse) Policy- "The resident has the right to be free from abuse: verbal, mental, physical, or sexual." In the Abuse Guidelines Section regarding Incident/Accident Reporting reflected the following definitions: 1. Any event, accident or incident, which results in an injury or has the potential for injury, ...any allegations of mistreatment of [REDACTED]. ...4. Complaint of mental or physical abuse or neglect, or actual abuse or neglect. Abuse and/or neglect may be inflicted by... staff... Guidelines ...5. The Administrator will coordinate an investigation of the event, as needed, within 24 hours of the event. The investigation would be separate from the incident/accident report investigation. 6. ...Any incident or accident that requires reporting will be completed according to state standards. Resident Incident/Accident ...14. The DON, or designee, or Administrator, or Safety Committee Chairperson (facility must designate which one) will complete an investigation of the incident/accident within 24 hours of the event. This investigation, at minimum, must attempt to identify any trends that may indicate resident abuse.... 1) The face sheet dated 01/22/10 reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] (most recent MDS on the clinical record) reflected Resident #1's cognition as moderately impaired (decisions poor, cues/supervision required). It further reflected Resident #1 only had "Periods of restlessness" and had a behavior of "wandering." The ADL section of the MDS reflected Resident #1 was a one-person physical assist with setup help only. On 09/14/10, Resident #1 was sent to the emergency room (ER) for a laceration to his scalp. While at the ER, Resident #1 stated to the ER nurse, "_____ (LVN A), yanks me around like a rag doll and is verbally abuse to me." The allegation of abuse was called to DADS, and a complaint investigation was initiated on 09/17/10. Observation on 09/17/10 at 9:30 a.m. of Resident #1 revealed he was sitting in a wheelchair and watching TV in his room. He was alert and oriented X 2 and was verbally responsive when asked about any problems he had been having in the facility. Resident #1's room was the far end of the hall. From the nurse's station, one walked by two offices to get to the resident's room. An interview at that time with Resident #1 revealed on several (undated) occasions LVN A "Throws me around like a rag doll," and "Yells at me for everything." He further stated LVN A "Gets in my face and tells me, 'I hate you!' " Resident #1 stated he was very scared of LVN A and she "curses" at him frequently. Resident #1 asked, "Why does she yell at me?" 2) During an interview on 09/17/10 at 9:50 a.m., Housekeeper B stated LVN A "yells" very loud at Resident #1. During an interview on 09/17/10 at 1:00 p.m. with CNA D, she stated LVN A was very "verbally abusive" to Resident #1. CNA D stated LVN A cursed him and threatened him by telling him she would tell her husband to come to the facility (to beat him up). CNA D stated over the last six months, every time LVN A worked, she threatened Resident #1. CNA D stated on several occasions, LVN A came to the nurse's station yelling, "I just want to kill him. I just want to choke him," referring to Resident #1. The CNA stated when Resident #1 tried to get out of his wheelchair in the dining room, LVN A would get in his face and yell at him to "Sit your ass in your wheelchair, and wheel yourself." She stated LVN A was very rough with him whenever she had to assist Resident #1 with anything. CNA D stated LVN A was only this way with Resident #1. CNA D stated she knew she should have reported the abuse but did not, because she was scared of retaliation from both LVN A and administration. CNA D stated she had worked at the facility for six months and had not had any inservices since she had been there. On 09/18/10, the surveyor received a handwritten statement from CNA D, which confirmed the interview given on 09/17/10. In CNA D's written statement, she wrote: "...There are so many times ____ (LVN A) has acted out in a tacky and unprofessional manner. but anyhow everyone in the building knows what has been going on everyone!! (underlined four times) They all are as guilty as myself for not doing anything. ...I'm so serious when I say everyone (underlined three times) knew. Further included in the written statement, "...he (Resident #1) was always depressed and it never mattered to her (LVN A), she made it worse even when he had a good day or excited about something she would make it bad for him...." During an interview on 09/17/10 at 1:25 p.m., CNA E stated LVN A was very rude and verbally abusive to Resident #1. CNA E stated when Resident #1 did something that "pisses off" LVN A, LVN A would tell Resident #1 to "keep his ass" in his room, and has told him, "You aren't going to Bingo," which was Resident #1's favorite activity. The CNA stated the LVN would also take the resident's personal belongings, like his markers away from him. CNA E stated on 09/14/10, when Resident #1 was on the floor, LVN A told him to "get your m_____-f______ ass off the floor. I'm sick of this bullshit." CNA E stated this (abuse) had been going on every day for months. CNA E stated the reason she did not report the abuse was because she was scared of LVN A and was also afraid to report it to administration because of retaliation. LVN A would threaten Resident #1 by telling him she would "bring ____ (her husband) up here, and he'll whoop your ass." CNA E stated she believed the facility's only ADON knew about LVN A yelling at Resident #1, because LVN A would yell and scream about Resident #1 while at the nurse's station. On 09/18/10, the surveyor received a handwritten statement from CNA E, which confirmed the interview given on 09/17/10. Note: This facility is built in an L-shape. The nurse's station is located at the corner of the L where the two halls meet. Administrative offices are located in the same area, with offices located within ten to twenty feet of the nurse's station. According to the facility's floor plan, there were four offices in the facility. 3) An interview on 09/17/10 at 11:30 a.m. with Resident #2, who was alert and oriented X 3, revealed he had been in the facility four years. Resident #2 stated he would not tell who "yells" at specific residents because, "If you tell, it gets really bad for you here." Resident #2 stated he was "done talking." 4) During an interview on 09/17/10 at 12:30 p.m. via phone with LVN A, she denied ever having been rough with a resident or having yelled at a resident. An interview on 09/17/10 at 1:45 p.m. with the DON revealed she had no knowledge of any LVN verbally abusing any residents in the facility. An interview on 09/17/10 at 2:05 p.m. with the facility's only ADON revealed she had no knowledge of any LVN verbally abusing any residents in the facility. During an interview on 09/17/10 at 2:10 p.m., the ADM stated a "few days" days ago a CNA came to her and reported LVN A had yelled at her in front of the residents. The ADM stated the CNA had subsequently quit. The ADM stated she had no knowledge of any incidents involving LVN A being verbally abusive to any of the residents. The ADM added, if she had ever had any knowledge regarding that, she would have suspended LVN A immediately pending the outcome of the facility investigation. 5) During an interview on 09/17/10 at 10:00 a.m. with the ADM, she stated on 09/16/10 she self-reported an incident of a night nurse "punching" an unidentified resident. The ADM stated she was going to start the investigation, but the surveyor entered the facility. The ADM stated there were no suspects named in the alleged incident, and no resident was identified. The ADM was asked for the information in reference to the alleged physical abuse allegations. The ADM stated she did not have any information ready yet. 6) On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the areas of Resident Behavior/Facility Practice with Substandard Quality of Care (SQC) affecting Resident #1 and the rest of the facility's 41 residents. The ADM, the DON, and the facility's only ADON were informed at that time. They were further informed of the alleged perpetrator, LVN A, and the alleged victim, Resident #1. 7) An interview was conducted on 09/18/10 at 11:20 a.m. with Resident #1. Resident #1 stated the Administrator came to him "last night" and talked to him about LVN A yelling at him. Resident #1 then asked the surveyor, "Am I going to get yelled at again?" 8) An interview was conducted on 09/18/10 at 11:33 a.m. with Resident #3, who was alert and oriented X 3. Resident #3 stated "some nurse," who he was unable to identify, had told him to "Get yourself up," and "Clean yourself." 9) During an interview on 09/18/10 at 11:40 a.m. with CNA E, the CNA stated after the surveyor left on 09/17/10, she was called into the Administrator's office by the ADM and asked if she had ever witnessed any verbal abuse by LVN A. CNA E stated she admitted she had and wrote a statement for the ADM. CNA E stated she only told the ADM about the most recent occurrence of abuse by LVN A, which happened on 09/14/10. CNA E again told the surveyor she did not report the abuse, because she was scared of retaliation from the administration and from LVN A. 10) On 09/20/10 at 9:30 a.m., a copy of the investigation involving LVN A and Resident #1 was requested from the Administrator. At 11:00 a.m., the Administrator, RDO and the facility's only ADON informed the survey team they had not conducted a separate investigation for the allegation of abuse involving LVN A and Resident #1. They had included it with the already self-reported incident of the allegation of physical abuse perpetrated by an unknown person against an unknown resident. The RDO at that time agreed with the ADM the two allegations were the same incident. The ADM, the RDO and the DON were then advised by the survey team the two incidents were not one and the same. They were informed an allegation of physical abuse, which occurred at night by an unidentified staff against an unidentified resident, was not the same as an allegation of verbal/mental abuse perpetrated by LVN A against Resident #1 during the daytime. 11) In an interview with the DON on 09/20/10 at 12:35 p.m., the DON stated LVN A was always loud. She did not think the LVN was abusive or inappropriate. The DON stated she was not scared of LVN A and did not hear the LVN complain about the residents. 12) An interview on 09/20/10 at 2:10 p.m. with the DM revealed on 07/04/10, LVN A was at the nurse's station yelling, "This f______ place," and cursing very loudly in front of several residents and staff members. The DM stated the language was very offensive to her. On one occasion, a resident was on the floor and LVN A "grabbed" the resident off the floor in a forceful manner and carried her in a "bear hug" style to her room, and then shut the door. On a separate occasion, the DM witnessed LVN A "yelling" at a CNA in front of the residents and staff members. She overheard LVN A say, "I'm gonna have my husband come kick his ass," while at the nurses station. The DM stated she did not know who the comment was in reference to, but she assumed it was toward a male resident since there were no male CNAs. The DM stated on an almost daily basis, Resident #1 would knock on the kitchen door. When LVN A saw this, she would yell at him, "What do you want?" The DM stated she did not report these occurrences, because she did not know who to go to or who she could trust. She stated the management staff was not very friendly when you reported things to them. After the inservice per the Plan of Removal, she stated she felt much better going to the ADM, but before she did not trust her (the ADM) and was not comfortable going to her. The DM added she was very intimidated by LVN A, and the work environment was very hostile when the LVN was in the building. The DM admitted she never reported LVN A to the ADM and should have, but she would from now on. 13) The facility's Plan of Removal (POR) with an origination date of 09/18/10 and accepted on 09/20/10 reflected: All facility staff (all staff/all departments: licensed nurses certified nursing assistants, dietary, housekeeping, laundry, office manager, activity director, social worker, maintenance) are being in-serviced on reporting of any allegation of abuse and/or neglect of residents. In-services have been initiated by the ADM. These in-services will continue each shift to ensure all staff have the training. In-services were initiated on 09/17/10, projected completion date of 09/18/10 and then monthly over the next three months. LVN A was immediately suspended pending investigation related to allegations brought to the ADM by the surveyor. The ADM immediately initiated a full investigation into the allegations. This investigation included individual staff interviews and resident interviews. LVN A was terminated on 09/18/10 based on findings of the facility investigation, which was initiated 09/17/10 and completed on 09/18/10. A resident group meeting was held on 09/17/10 by the Abuse Coordinator (the ADM) on the topic of Abuse and Neglect, including reporting procedures. The Abuse Coordinator will hold resident group meetings monthly over the next three months on the same topic. Residents who do not attend the group meetings will be seen individually by the Abuse Coordinator. The ADM has been in-serviced on the Abuse Guidelines by the Regional Nurse Consultant on 09/17/10. The facility's only ADON has been designated as the alternate Abuse Coordinator effective 09/17/10 and has been trained by the Regional Nurse Consultant on 09/17/10. Resident #1 has been physically assessed by a licensed nurse on 09/18/10 related to the allegations. The outcome of the physical assessment indicated no injuries that had not been previously identified by the facility. The Abuse Coordinator (ADM) completed an emotional assessment on Resident #1 on 09/17/10. No psychological or emotional distress related to the allegations was evident at that time. The Facility Social Worker will also visit Resident #1 weekly over the next four weeks. These actions were initiated 09/17/10 and completed on 09/18/10. Monitoring to prevent reoccurrence: All new staff (licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, Office Manager, Activity Director, Social Worker, Maintenance) upon hire, will be in-serviced by the Abuse Coordinator regarding the facility abuse guidelines. The Abuse Coordinator and Alternate Abuse Coordinator will make random facility rounds. A QA meeting was held on 09/17/10 with members of the QA team, including the facility Medical Director. The QA committee, which included the Medical Director, will monitor for the next 90 days to ensure systems are effective. The QA Committee meeting will include review of complaints and will monitor future complaints. 14) On 09/20/10, from 2:05 to 2:55 p.m., a total of nine staff interviews were conducted after the plan of removal was accepted. Interviews were conducted with CNA F, Housekeeper C, LVN G, CNA H, LVN I, CNA D, CNA E, CNA J, and Dietary Aide K. All staff interviewed were able to verbalize an understanding of: the definition of abuse, different types of abuse, the signs and symptoms of abuse, how and to whom to report and were able to identify the Abuse Coordinator. CNA E stated she felt more comfortable now about reporting to the ADM. CNA D stated she did not report the abuse because she was scared, but knows now that she has to (report the abuse). On 09/20/10, the DON provided two in-service training reports signed by all employees in the facility. The in-services were entitled "Abuse" and "Employee Burn-Out." 15) On 09/20/10 at 2:55 PM, the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. The ADM, the DON, the facility's only ADON, the RDO and the Regional Nurse Consultant were informed at that time. 16) The facility's CMS 672 (Resident Census and Conditions of Residents) dated 09/17/10 and signed by the facility's only ADON reflected a census of 42 residents.

Based on observation, interview, and record review, it was determined the Administrator and the DON failed to effectively and efficiently manage its resources to attain or maintain the facility's highest practicable physical, mental, and psychosocial well-being of each resident by ensuring they were protected from staff-to-resident verbal abuse and an allegation of staff-to-resident verbal/mental abuse was reported to the Abuse Coordinator, investigated, and reported to the State agency for one (Resident #1) of eight residents. The Administrator and the DON failed to monitor and apprise LVN A when she was "loud" in the facility and determine whether the LVN was appropriate with residents and staff. The Administrator and the DON failed to monitor and apprise staff to ensure incidents of verbal/mental abuse perpetrated by LVN A against Resident #1 were reported to the Administrator and/or the DON. The Administrator and the DON failed to monitor and apprise staff to ensure they knew who to report allegations of abuse and were provided different avenues of approach to report allegations of abuse. The Administrator and the DON failed to monitor and apprise staff to ensure the facility's atmosphere was one in which facility staff were not afraid of retribution if they reported an allegation of abuse. Resident #1 was being verbally/mentally abused by LVN A. Several staff members had witnessed the verbal abuse; however, no staff members had ever reported the verbal abuse to the Abuse Coordinator or administrative staff. The ADM and the DON denied being aware of LVN A abusing Resident #1. On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the area of Administration affecting affecting Resident #1 and the rest of the facility's 41 residents. On 09/20/10 at 2:55 p.m., the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. These failures could affect the facility's 42 residents, including Resident #1, and placed them at risk for verbal/mental abuse, resulting in feelings of self worthlessness, loss of self-esteem, self-isolation, loss of dignity and a decreased quality of life. Findings included: 1) The face sheet dated 01/22/10 reflected Resident #1 was a [AGE] year-old male, who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] (most recent MDS on the clinical record) reflected Resident #1's cognition as moderately impaired (decisions poor, cues/supervision required). It further reflected Resident #1 only had "Periods of restlessness" and had a behavior of "wandering." The ADL section of the MDS reflected Resident #1 was a one-person physical assist with setup help only. On 09/14/10 Resident #1 was sent to the emergency room (ER) for a laceration to his scalp. While at the ER, Resident #1 stated to the ER nurse, "_____ (LVN A), yanks me around like a rag doll and is verbally abuse to me." The allegation of abuse was called to DADS, and a complaint investigation was initiated on 09/17/10. Observation on 09/17/10 at 9:30 a.m. of Resident #1 revealed he was sitting in a wheelchair and watching TV in his room. He was alert and oriented X 2 and was verbally responsive when asked about any problems he had been having in the facility. Resident #1's room was the far end of the hall. From the nurse's station, one walked by two offices to get to the resident's room. An interview at that time with Resident #1 revealed on several (undated) occasions LVN A "Throws me around like a rag doll," and "Yells at me for everything." He further stated LVN A "Gets in my face and tells me, 'I hate you!' " Resident #1 stated he was very scared of LVN A and she "curses" at him frequently. Resident #1 asked, "Why does she yell at me?" 2) During an interview on 09/17/10 at 9:50 a.m., Housekeeper B stated LVN A "yells" very loud at Resident #1. During an interview on 09/17/10 at 1:00 p.m. with CNA D, she stated LVN A was very "verbally abusive" to Resident #1. CNA D stated LVN A cursed him and threatened him by telling him she would tell her husband to come to the facility (to beat him up). CNA D stated over the last six months, every time LVN A worked, she threatened Resident #1. CNA D stated on several occasions, LVN A came to the nurse's station yelling, "I just want to kill him. I just want to choke him," referring to Resident #1. The CNA stated when Resident #1 tried to get out of his wheelchair in the dining room, LVN A would get in his face and yell at him to "Sit your ass in your wheelchair, and wheel yourself." She stated LVN A was very rough with him whenever she had to assist Resident #1 with anything. CNA D stated LVN A was only this way with Resident #1. CNA D stated she knew she should have reported the abuse but did not, because she was scared of retaliation from both LVN A and administration. CNA D stated she had worked at the facility for six months and had not had any inservices since she had been there. On 09/18/10, the surveyor received a handwritten statement from CNA D, which confirmed the interview given on 09/17/10. In CNA D's written statement, she wrote: "...There are so many times ____ (LVN A) has acted out in a tacky and unprofessional manner. but anyhow everyone in the building knows what has been going on everyone!! (underlined four times) They all are as guilty as myself for not doing anything. ...I'm so serious when I say everyone (underlined three times) knew. Further included in the written statement, "...he (Resident #1) was always depressed and it never mattered to her (LVN A), she made it worse even when he had a good day or excited about something she would make it bad for him...." During an interview on 09/17/10 at 1:25 p.m., CNA E stated LVN A was very rude and verbally abusive to Resident #1. CNA E stated when Resident #1 did something that "pisses off" LVN A, LVN A would tell Resident #1 to "keep his ass" in his room, and has told him, "You aren't going to Bingo," which was Resident #1's favorite activity. The CNA stated the LVN would also take the resident's personal belongings, like his markers away from him. CNA E stated on 09/14/10, when Resident #1 was on the floor, LVN A told him to "get your m_____-f______ ass off the floor. I'm sick of this bullshit." CNA E stated this (abuse) had been going on every day for months. CNA E stated the reason she did not report the abuse was because she was scared of LVN A and was also afraid to report it to administration because of retaliation. LVN A would threaten Resident #1 by telling him she would "bring ____ (her husband) up here, and he'll whoop your ass." CNA E stated she believed the facility's only ADON knew about LVN A yelling at Resident #1, because LVN A would yell and scream about Resident #1 while at the nurse's station. On 09/18/10, the surveyor received a handwritten statement from CNA E, which confirmed the interview given on 09/17/10. Note: This facility is built in an L-shape. The nurse's station is located at the corner of the L where the two halls meet. Administrative offices are located in the same area, with offices located within ten to twenty feet of the nurse's station. According to the facility's floor plan, there were four offices in the facility. 3) An interview on 09/17/10 at 11:30 a.m. with Resident #2, who was alert and oriented X 3, revealed he had been in the facility four years. Resident #2 stated he would not tell who "yells" at specific residents because, "If you tell, it gets really bad for you here." Resident #2 stated he was "done talking." 4) During an interview on 09/17/10 at 12:30 p.m. via phone with LVN A, she denied ever having been rough with a resident or having yelled at a resident. An interview on 09/17/10 at 1:45 p.m. with the DON revealed she had no knowledge of any LVN verbally abusing any residents in the facility. An interview on 09/17/10 at 2:05 p.m. with the facility's only ADON revealed she had no knowledge of any LVN verbally abusing any residents in the facility. During an interview on 09/17/10 at 2:10 p.m., the ADM stated a "few days" days ago a CNA came to her and reported LVN A had yelled at her in front of the residents. The ADM stated the CNA had subsequently quit. The ADM stated she had no knowledge of any incidents involving LVN A being verbally abusive to any of the residents. The ADM added, if she had ever had any knowledge regarding that, she would have suspended LVN A immediately pending the outcome of the facility investigation. 5) During an interview on 09/17/10 at 10:00 a.m. with the ADM, she stated on 09/16/10 she self-reported an incident of a night nurse "punching" an unidentified resident. The ADM stated she was going to start the investigation, but the surveyor entered the facility. The ADM stated there were no suspects named in the alleged incident, and no resident was identified. The ADM was asked for the information in reference to the alleged physical abuse allegations. The ADM stated she did not have any information ready yet. 6) The facility's current policy and procedure on Abuse dated January 2005 and provided on 09/17/10 by the ADM reflected the following: Policy: 1. The resident has the right to be free from abuse: verbal, mental, physical, or sexual... Procedure: 1. The facility will... inform the resident of the definitions of: a. Verbal abuse is the use of oral, written or gestured language which could be viewed as or understood to have disparaging or derogatory intent which is directed toward the resident... which is in hearing or visual distance regardless of age, disability or ability to understand. Example: Threats of harm, instilling of fear, verbal slander, etc. ...d. Mental abuse includes harassment, humiliation, demoralization, threats of punishment or deprivation... Abuse Guidelines (Abuse Definitions) "Mental Abuse-defined as, but not limited, humiliation, harassment, threats, of punishment, or withholding of treatment or services." Abuse Guideline (Abuse, prevention) "Our abuse prevention/intervention program includes, but is not limited to, the following: Encouraging all personnel, residents, family members, visitors, etc., to report any signs of suspected incidents of abuse to facility management immediately." Federal Regulation F-223 (Abuse) Policy- "The resident has the right to be free from abuse: verbal, mental, physical, or sexual." In the Abuse Guidelines Section regarding Incident/Accident Reporting reflected the following definitions: 1. Any event, accident or incident, which results in an injury or has the potential for injury, ...any allegations of mistreatment of [REDACTED]. ...4. Complaint of mental or physical abuse or neglect, or actual abuse or neglect. Abuse and/or neglect may be inflicted by... staff... Guidelines ...5. The Administrator will coordinate an investigation of the event, as needed, within 24 hours of the event. The investigation would be separate from the incident/accident report investigation. 6. ...Any incident or accident that requires reporting will be completed according to state standards. Resident Incident/Accident ...14. The DON, or designee, or Administrator, or Safety Committee Chairperson (facility must designate which one) will complete an investigation of the incident/accident within 24 hours of the event. This investigation, at minimum, must attempt to identify any trends that may indicate resident abuse.... 7) On 09/17/10 at 2:30 p.m., an Immediate Jeopardy (IJ) situation was identified in the area of Administration affecting affecting Resident #1 and the rest of the facility's 41 residents. The ADM, the DON, and the facility's only ADON were informed at that time. They were further informed of the alleged perpetrator, LVN A, and the alleged victim, Resident #1. 8) An interview was conducted on 09/18/10 at 11:20 a.m. with Resident #1. Resident #1 stated the Administrator came to him "last night" and talked to him about LVN A yelling at him. Resident #1 then asked the surveyor, "Am I going to get yelled at again?" 9) An interview was conducted on 09/18/10 at 11:33 a.m. with Resident #3, who was alert and oriented X 3. Resident #3 stated "some nurse," who he was unable to identify, had told him to "Get yourself up," and "Clean yourself." 10) During an interview on 09/18/10 at 11:40 a.m. with CNA E, the CNA stated after the surveyor left on 09/17/10, she was called into the Administrator's office by the ADM and asked if she had ever witnessed any verbal abuse by LVN A. CNA E stated she admitted she had and wrote a statement for the ADM. CNA E stated she only told the ADM about the most recent occurrence of abuse by LVN A, which happened on 09/14/10. CNA E again told the surveyor she did not report the abuse, because she was scared of retaliation from the administration and from LVN A. 11) On 09/20/10 at 9:30 a.m., a copy of the investigation involving LVN A and Resident #1 was requested from the Administrator. At 11:00 a.m., the Administrator, RDO and the facility's only ADON informed the survey team they had not conducted a separate investigation for the allegation of abuse involving LVN A and Resident #1. They had included it with the already self-reported incident of the allegation of physical abuse perpetrated by an unknown person against an unknown resident. The RDO at that time agreed the two allegations were the same incident. The ADM, the RDO and the DON were then advised by the survey team the two incidents were not one and the same. They were informed an allegation of physical abuse, which occurred at night by an unidentified staff against an unidentified resident, was not the same as an allegation of verbal/mental abuse perpetrated by LVN A against Resident #1 during the daytime. 12) In an interview with the DON on 09/20/10 at 12:35 p.m., the DON stated LVN A was always loud. She did not think the LVN was abusive or inappropriate. The DON stated she was not scared of LVN A and did not hear the LVN complain about the residents. 13) An interview on 09/20/10 at 2:10 p.m. with the DM revealed on 07/04/10, LVN A was at the nurse's station yelling, "This f______ place," and cursing very loudly in front of several residents and staff members. The DM stated the language was very offensive to her. On one occasion, a resident was on the floor and LVN A "grabbed" the resident off the floor in a forceful manner and carried her in a "bear hug" style to her room, and then shut the door. On a separate occasion, the DM witnessed LVN A "yelling" at a CNA in front of the residents and staff members. She overheard LVN A say, "I'm gonna have my husband come kick his ass," while at the nurses station. The DM stated she did not know who the comment was in reference to, but she assumed it was toward a male resident since there were no male CNAs. The DM stated on an almost daily basis, Resident #1 would knock on the kitchen door. When LVN A saw this, she would yell at him, "What do you want?" The DM stated she did not report these occurrences, because she did not know who to go to or who she could trust. She stated the management staff was not very friendly when you reported things to them. After the inservice, she stated she felt much better going to the ADM, but before she did not trust her (the ADM) and was not comfortable going to her. The DM added she was very intimidated by LVN A, and the work environment was very hostile when the LVN was in the building. The DM admitted she never reported LVN A to the ADM and should have, but she would from now on. 14) The facility's Plan of Removal (POR) with an origination date of 09/18/10 and accepted on 09/20/10 reflected: All facility staff (all staff/all departments: licensed nurses certified nursing assistants, dietary, housekeeping, laundry, office manager, activity director, social worker, maintenance) are being in-serviced on reporting of any allegation of abuse and/or neglect of residents. In-services have been initiated by the ADM. These in-services will continue each shift to ensure all staff have the training. In-services were initiated on 09/17/10, projected completion date of 09/18/10 and then monthly over the next three months. LVN A was immediately suspended pending investigation related to allegations brought to the ADM by the surveyor. The ADM immediately initiated a full investigation into the allegations. This investigation included individual staff interviews and resident interviews. LVN A was terminated on 09/18/10 based on findings of the facility investigation, which was initiated 09/17/10 and completed on 09/18/10. A resident group meeting was held on 09/17/10 by the Abuse Coordinator (the ADM) on the topic of Abuse and Neglect, including reporting procedures. The Abuse Coordinator will hold resident group meetings monthly over the next three months on the same topic. Residents who do not attend the group meetings will be seen individually by the Abuse Coordinator. The ADM has been in-serviced on the Abuse Guidelines by the Regional Nurse Consultant on 09/17/10. The facility's only ADON has been designated as the alternate Abuse Coordinator effective 09/17/10 and has been trained by the Regional Nurse Consultant on 09/17/10. Resident #1 has been physically assessed by a licensed nurse on 09/18/10 related to the allegations. The outcome of the physical assessment indicated no injuries that had not been previously identified by the facility. The Abuse Coordinator (ADM) completed an emotional assessment on Resident #1 on 09/17/10. No psychological or emotional distress related to the allegations was evident at that time. The Facility Social Worker will also visit Resident #1 weekly over the next four weeks. These actions were initiated 09/17/10 and completed on 09/18/10. Monitoring to prevent reoccurrence: All new staff (licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, Office Manager, Activity Director, Social Worker, Maintenance) upon hire, will be in-serviced by the Abuse Coordinator regarding the facility abuse guidelines. The Abuse Coordinator and Alternate Abuse Coordinator will make random facility rounds. A QA meeting was held on 09/17/10 with members of the QA team, including the facility Medical Director. The QA committee, which included the Medical Director, will monitor for the next 90 days to ensure systems are effective. The QA Committee meeting will include review of complaints and will monitor future complaints. 15) In an interview with the DON on 09/20/10 at 12:35 p.m., the following questions were asked and included his response: 1. What type of training did you conduct regarding abuse and neglect since the incident? Response: "In-services, individual and per shift. We conducted a resident meeting with the residents. We discussed abuse and neglect and signs and symptoms of burnout with staff." 2. How do you think the IJ came about? Response: "I don't know how. The staff should have brought the issues to someone." 3. What type of procedure is there to ensure staff feels comfortable reporting abuse? Response: "Visit with staff. Talk to them about reporting. Talk to the residents and staff and make more daily rounds." 4. What have you done differently since the IJ was called? Response: "Started doing in-services. The staff already seem more comfortable reporting and they are talking more to the admin staff." 5. Had you heard any verbal abuse by LVN A toward a resident? Response: "____ (LVN A) was always loud, but I didn't think it was abusive or inappropriate. I wasn't scared of her, and I didn't hear ____ (LVN A) complain about any residents." 16) In an interview with the Administrator on 09/20/10 at 1:05 p.m., the following questions were asked and included his response: 1. What type of procedure is in place to make sure that abuse does not occur again? Response: "Increasing in-services, do a role play on what abuse is. Do rounds daily with staff and residents and conduct sensitivity trainings." 2. How do you think the IJ came about? Response: "I don't know." 3. What type of procedure is there to ensure staff feels comfortable reporting abuse? Response: "Visit with staff, talk to them about reporting. Reiterating that it's confidential. Monitor behaviors of staff and suspend alleged perpetrators." 4. What have you done differently since the IJ was called? Response: "In-servicing staff on reporting, how to report, types of abuse and burn out." 5. How often were ins-services provided before this incident? Response: "Annual in-service prior to the incident that has now been increased to quarterly." 17) On 09/20/10, from 2:05 to 2:55 p.m., a total of nine staff interviews were conducted after the plan of removal was accepted. Interviews were conducted with CNA F, Housekeeper C, LVN G, CNA H, LVN I, CNA D, CNA E, CNA J, and Dietary Aide K. All staff interviewed were able to verbalize an understanding of: the definition of abuse, different types of abuse, the signs and symptoms of abuse, how and to whom to report and were able to identify the Abuse Coordinator. CNA E stated she felt more comfortable now about reporting to the ADM. CNA D stated she did not report the abuse because she was scared, but knows now that she has to (report the abuse). On 09/20/10, the DON provided two in-service training reports signed by all employees in the facility. The in-services were entitled "Abuse" and "Employee Burn-Out." 18) On 09/20/10 at 2:55 p.m., the IJ was lowered, but the facility remained out of compliance at a severity level of "Actual harm that is not immediate jeopardy" and a scope of "pattern." The facility was continuing to in-service staff and monitor for implementation of the plan of removal. The ADM, the DON, the facility's only ADON, the RDO and the Regional Nurse Consultant were informed at that time. 19) The facility's CMS 672 (Resident Census and Conditions of Residents) dated 09/17/10 and signed by the facility's only ADON reflected a census of 42 residents.