Every finding on record at Hillcrest Nursing Center

Based on observation, interview, record review, and facility policy review, the facility failed to store food in accordance with professional standards by not removing expired food product, and not labeling or dating opened or prepared food items for one (1) of two (2) kitchen observations.Findings include:A review of the facility's policy, Food Storage Labeling, revised 8/12, revealed, Policy: The facility will ensure the safety and quality of food by adhering to proper storage and labeling procedures. Procedure: 1. Labeling a. All temperature-controlled foods and ready-to-eat foods that are prepared in the facility and held for longer than twenty-four hours will be labeled. Information included on the label: Name of the Food.Date of storage.3. Rotation.b. Foods stored in storage units will be surveyed routinely to identify and discard foods that have passed its manufacturer use-by date or expiration date. On 7/13/2026 at 10:30 AM, during an observation and interview with the Dietary Manager (DM) in the kitchen, there was one (1) opened bag of breaded okra stored in the freezer that was not labeled. The milk refrigerator contained one (1) pitcher of tea without a preparation or discard date, (1) one covered plastic glass containing milk without a date, and two (2) half-pint cartons of milk with an expiration date of 7/12/2026. The DM explained the milk vendor instructed the facility to keep the expired milk in the refrigerator until the facility received credit for the products. The walk-in freezer had one (1) opened bag of breaded chicken patties that was not labeled with the date it was opened. On 7/14/2026 at 11:00 AM, the DM stated all opened food items should be properly closed and dated when opened to ensure they remained within safe-use periods. She stated expired food items should be discarded because spoiled food could cause residents to become ill. She confirmed pitchers of tea should be dated to prevent spoilageDuring an interview on 7/15/2026 at 11:15 AM, the Nursing Home Administrator (NHA) stated that improperly labeled or expired foods presented a health hazard and could cause residents to become ill. He confirmed he discussed the expired milk with the DM and the milk vendor. He explained expired products must be removed immediately and should not be stored with food available for resident use. The NHA stated the DM and dietary staff were responsible for ensuring foods were properly labeled, dated, monitored, and stored.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to comfortable hot water temperatures for one (1) of three (3) resident rooms reviewed, (Resident #53).Findings include:A review of the facility's document entitled Water Temperature revised 08/00, revealed, Procedure: The temperature of hot water at plumbing fixtures used by residents shall not exceed 115 degrees Fahrenheit and no less than 100 degrees Fahrenheit.On 7/13/2026 at 12:30 PM, during an interview and observation, Resident #53 was seated in a wheelchair. Resident #53 explained the hot water at the bathroom sink did not get hot. The resident stated the Maintenance Director had been informed of the problem, but it had been corrected. The hot water was turned on for two (2) minutes and was lukewarm. Resident #53 stated the water always had to run for a long time before it became slightly warm or at a comfortable temperature.On 7/14/2026 at 9:27 AM, during an observation and interview, with the Maintenance Director, the water temperature was measured with a thermometer at 98.2 degrees after running for two (2) minutes, which was below 100 degrees Fahrenheit. The Maintenance Director explained he believed the thermostat on the water heater was causing low water temperatures. He reported a plumber had been contacted to evaluate the system and acknowledged the facility had experienced previous problems with the water heaters.During an interview on 7/15/2026 at 11:30 AM, the Nursing Home Administrator stated the Maintenance Director informed him of the out-of-range temperatures identified on 7/14/2026. The Administrator stated he instructed the Maintenance Director to increase the thermostat setting on the water heater. The Administrator acknowledged that water temperatures outside the facility's acceptable range could cause resident discomfort and stated the facility would continue monitoring water temperatures.A record review of the Face Sheet revealed Resident #53 was admitted by the facility on 1/7/2026 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 6/5/2026, revealed Resident #53 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to dignity by entering the residents' room without knocking for one (1) of eighteen (18) residents sampled. Resident #20.Findings include:A review of the facility's policy, Dignity and Respect, revised 07/22, revealed A facility must treat each resident with respect and dignity.The facility shall protect the rights of the resident.6. All staff, regardless of department, should knock and wait for a response before entering any resident's room.On 07/13/2026 at 2:08 PM, during an observation of the residents' halls, Certified Nursing Assistant (CNA) #1 entered Resident #20's room twice without knocking on her door. On 07/13/2026 at 2:15 PM, during an interview with CNA #1, she confirmed that she entered Resident #20's room twice without knocking. CNA #1 stated the facility's protocol for entering residents' rooms is to knock, announce self, and explain the care to be administered. CNA #1 reported the purpose of knocking is to announce oneself before entering.On 07/15/2026 at 8:46 AM, during an interview with the Director of Nursing (DON) she was made aware of CNA #1 entering Resident #20s room twice without knocking on her door. The DON confirmed that the facility's protocol for entering a resident's room is for the staff to knock before entering, introduce themself, announce the care to be performed. The DON added that the staff are to further ensure privacy by pulling the curtain and closing the door. The DON reported that the purpose of knocking on a resident's door prior to entering is to respect the residents' privacy. The DON affirmed that her expectation for the staff is that they will honor the residents' privacy and knock before entering their rooms.A record review of the Face Sheet revealed the facility admitted Resident #20 on 05/28/2002 with diagnoses including Cerebral Infarction.A record review Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/02/2026 revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 03 indicating severe cognitive impairment.

Based on interview, record review, and facility policy review, the facility failed to comply with state nursing facility staffing requirements by failing to ensure the nursing staff had a ratio of 2.8 hours of direct nursing care per resident per twenty-four (24) hours for two (2) of 13 days reviewed in the Second Quarter (January, February, and March) of 2026).Findings include:A record review of the facility's policy, Nursing Services - Staffing, with a revision date of 02/2026, revealed, .The facility will comply with established staffing requirements by the individual state governing agencies. A record review of the Minimum Standards for Institutions for the Aged or Infirm for Rule 45.4.1 Nursing Facility, revealed, .To be classified as a facility, the institution shall comply with the following staffing requirements. 1. Minimum requirements for nursing staff shall be based on the ratio of two and eight-tenths (2.80) hours of direct nursing care per resident per twenty-four (24) hours. Staffing requirements are based upon resident census.A record review of the PBJ (Payroll Based Journal) Data Report for the Fiscal Year Quarter 2 2026 (January - March 31) revealed the facility's Metric for Excessively Low Weekend Staffing resulted in Triggered which indicated the submitted weekend staffing data submitted by the facility was excessively low.A record review of the Staffing Grid completed by the facility revealed that on 2/7/26, the staffing ratio was 2.63 and on 3/21/26 the staffing ratio was 2.7 which were below the state requirement of 2.8.During an interview on 7/15/26 at 1:50 PM, the Administrator stated reports for 2/7/26 and 3/21/26 failed to generate email notifications to alert him that the facility fell below the 2.8 staffing ratio. He confirmed the facility did not meet its established staffing level of 2.8 nursing hours per resident day on those dates.

Based on observation, interview, facility policy review, and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP) were implemented in accordance with facility policy and current infection control standards during percutaneous endoscopic gastrostomy (PEG) tube care for (1) one of (3) three care observations. (Resident #1) Findings Include:A review of the facility's policy Enhanced Barrier Precautions with a revision date of 03/24 revealed Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and gloves use during high-contact residents care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices) .On 12/22/25 at 12:22 PM during an observation of Registered Nurse #1(RN)/ Nurse Supervisor performing PEG tube care she did not apply a gown during care. On 12/22/25 at 1:15 PM in an interview with RN #1 stated she uses a gown when resident has a PEG tube and care is prolonged or heavy drainage at the site. She stated the gown is used to protect the residents from the staff. She stated by her not wearing a gown the resident has an increased risk of getting an infection.On 12/22/25 at 2:44 PM an interview with Licensed Practical Nurse #1(LPN)/ Infection Preventionist nurse stated that EBP consists of a gown and gloves and should be used when a resident has colonized wounds, indwelling catheter and PEG tube. She stated EBP is used to protect the residents from the staff. She stated it also protects the staff from any organism the resident may have. She stated RN #1 could have transferred something from her uniform to the resident. She stated there could be a possibility the resident could get sick.On 12/23/25 at 10:57 AM an interview with Director of Nursing (DON) confirmed that RN #1 should have had a gown on while doing PEG tube care. She stated that Resident #1 is at high risk for infection due to PEG tube. She stated the gown protects the resident from getting something the nurse may have on her uniform. She stated there is a chance of spreading infection when a nurse does not wear a gown while doing high contact care. A record review of Resident #1's admission Record revealed an admission date of 12/12/24 with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction affecting right dominant side and Dysphagia, Oropharyngeal Phase.A record review of Resident #1's Physician orders revealed clean 18FR(french)/20 ml(milliliter) PEG tube site with normal saline, pat dry with 4x4 gauze, apply split sponge daily.A record review of the Minimum Data Set (MDS) with Assessment Reference Date (ARD) 10/28/25 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicates moderate cognitive impairment.A record review of the EBP signage on the door revealed everyone must wear gown and gloves for the following high-contact care activities. Device care or use: feeding tube.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were not left unattended at the bedside or on the medication cart for two (2) of four (4) residents observed during medication administration. Residents #19 and #79. Findings Included: A review of the facility's policy, Drug Administration and Documentation, revised 3/25, revealed, .Under no circumstance is medication to be left at the bedside or given to the resident without him/her swallowing it in your presence . Do not leave any medication on top of the medication cart unattended . Resident #19 A record review of the Order Listing Report revealed Resident #19 had a Physician's Order, revised 9/3/2024, for Polyethylene Glycol 3350 Oral Powder 17 gram/scoop, one (1) scoop orally two (2) times daily, mix in juice or water. On 4/16/25 at 8:00 AM, during an observation of medication administration, Licensed Practical Nurse (LPN) #2 administered Polyethylene Glycol 3350 Oral Powder 17 gram/scoop in water to Resident #19. She left the medication at the bedside and informed the resident she was going to leave it for her to finish drinking. On 4/16/25 at 10:46 AM, during an interview with LPN #2, she stated that some days she leaves Polyethylene Glycol 3350 at the bedside and that the amount left varies. She stated the resident takes a while to drink it and she does not want to rush her. She confirmed that Polyethylene Glycol 3350 is a medication and should not be left at the bedside. She acknowledged that if the medication is left unattended, there is no way to confirm whether the resident consumed the full dose, and that physician orders required a full dose to be taken. A record review of the Admission Record revealed the facility admitted Resident #19 on 9/6/19 with diagnoses including Constipation. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/14/25 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of ten (10), which indicated her cognition was moderately impaired. Resident #79 On 4/16/25 at 9:22 AM, during an observation of medication preparation for Resident #79, LPN #1 was observed placing a vial of Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG (milligrams)/3ML (milliliters) on top of the medication cart and leaving the medication unattended while she left to retrieve supplies. The medication cart was unattended for two (2) to three (3) minutes. On 4/17/25 at 10:15 AM, during an interview with LPN #1, she acknowledged that she should not have left Resident #79 medication on the cart and stated she was not thinking. She admitted that she knew better and that leaving medication unattended on the cart could result in another resident taking it. On 4/17/25 at 10:33 AM, during an interview with the Director of Nursing (DON), she confirmed that no medications should be left unattended on the cart or in residents' rooms. She stated that leaving medications unattended could result in uncertainty about whether the resident took, discarded, or pocketed the medication. She stated that staff are expected to always follow medication administration policy. A record review of the Order Listing Report revealed Resident #79 had a Physician's Order, revised 4/15/25, for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (a type of nebulizer medication) every 12 hours as needed for wheezing and cough. A record review of the Admission Record revealed the facility admitted Resident #79 on 3/10/2025 with current diagnoses including Cough and Wheezing. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated his cognition was moderately impaired.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the oxygen flow rate was consistent with the physician's order for one (1) of one (1) resident reviewed for oxygen administration. (Resident #79) Findings included: A record review of the facility's policy Drug Administration and Documentation, revised 3/25 revealed, .The complete act of administration entails .verifying it with the physician's orders . A record review of the Order Listing Report revealed Resident #79 had a Physician's Order, revised 4/15/25, for oxygen via nasal cannula at two (2) liters per minute for shortness of breath or oxygen saturation of 93% (per cent) or below every 24 hours as needed. During an observation on 4/16/25 at 8:40 AM, Resident #79 was observed receiving oxygen via nasal cannula at a flow rate above three (3) liters per minute. During an observation and interview with Licensed Practical Nurse (LPN) #1 on 4/16/25 at 9:22 AM, Resident #79's oxygen flow was observed at 3.4 liters per minute. LPN #1 stated the resident's oxygen typically runs at three (3) liters per minute. During an observation and follow up interview with LPN #1 on 4/16/25 at 11:08 AM, LPN #1 confirmed the oxygen flow was above 3 liters per minute. She stated she had checked the oxygen flow that morning and she had not changed the setting. She confirmed the physician's order was for 2 liters per minute as needed and acknowledged the oxygen should never be adjusted without a new physician order. She explained that receiving oxygen at a higher rate than ordered could lead to adverse effects and make it harder for the resident to breathe. During an interview on 4/17/25 at 10:37 AM, the Director of Nursing (DON) stated when a resident receives more oxygen than ordered, their lungs may have to work harder to exhale. She stated the nurse should check the order and ensure it is followed every shift. A record review of the Admission Record revealed the facility admitted Resident #79 on 3/10/2025 with current diagnoses including Cough and Wheezing. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated his cognition was moderately impaired. Further review revealed he was receiving oxygen therapy.

Based on observation, staff interview, record review, and facility policy review, the facility failed to revise a comprehensive care plan for a resident with an indwelling catheter for one (1) of 19 care plans reviewed. Resident #79 Findings include: A review of the facility' policy, Care Plan Process dated 12/2024 revealed . The care plan must be reviewed and revised periodically, on an ongoing basis to reflect the services provided . On 04/14/25 at 12:29 PM, during an observation, Resident #79 was sitting in a wheelchair in his room and catheter tubing was observed near his leg. A record review of the Care Plan Report revealed Resident #79 had a care plan focus of The resident has a .Catheter. There was no intervention related to how often catheter care should be performed or the position responsible for providing the care. A record review of the Task List Report, initiated on 3/10/25, revealed Certified Nurse Aides (CNAs) documented the task of Bladder Voiding and Toilet Use, Cath Use every shift for Resident #79. A record review of theFollow Up Question Report for 04/01/25 through 04/16/2025 revealed catheter care was provided by CNAs for Resident #79. On 04/15/2025 at 10:05 AM, in an interview with CNA #1, she explained that the CNAs are responsible for catheter care and documenting in the Electronic Health Record (EHR). She stated that catheter care is displayed on the computer for them to document the task every shift. On 04/16/2025 at 11:16 AM, in an interview with Registered Nurse (RN) #1 she confirmed that the care plan for Resident #79 did not include an intervention for routine catheter care. She stated that a physician's order is not required for catheter care and they had not added it to the care plan. She agreed that routine catheter care should have been included as an intervention and the care plan revised to reflect the frequency and discipline responsible for the care. On 04/17/2025 at 08:59 AM, during an interview with the Director of Nursing (DON), she stated that she was made aware that the care plan related to catheter care for Resident #79 had not been revised to include an intervention for routine catheter care. She reported that the care plan team had already begun to correct this issue. A record review of the Admission Record revealed the facility admitted Resident #79 on 03/10/2025 with diagnoses including Acute Kidney Failure. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated his cognition was moderately impaired. Further review revealed he had an indwelling catheter.

Based on observation, interview, facility policy review, and record review, the facility failed to implement the care plan interventions related to oxygen administered for one (1) of 19 care plans reviewed. Resident #79. Findings Included: A record review of the facility's policy, Care Plan Process revised 12/24, revealed, .The overall care plan should be oriented towards .10. Assessing and planning for care to meet the resident's medical, nursing, mental, and psychosocial needs .The Care Plan Format includes .the interventions, the staff responsible to carry out the interventions . A record review of the Comprehensive Care Plan revealed Resident #79 had a care plan Focus The resident has a hx (history) of Asthma .Interventions .Oxygen at 2L/MIN (Liters per minute) per NC (Nasal Cannula) as needed for SOB (Shortness of Breath). On 4/16/25 at 9:15 AM, during an observation of Resident #79 in bed, the oxygen concentrator at the bedside was observed to be running at a flow rate of three (3) liters per minute. A record review of the Order Listing Report revealed Resident #79 had a Physician's Order, revised 4/15/25, for oxygen via nasal cannula at 2 liters per minute for shortness of breath or oxygen saturation of 93% or below every 24 hours as needed. On 4/17/25 at 9:10 AM, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that the physician order and care plan for Resident #79 indicated that the resident should be receiving oxygen at two (2) liters per minute via nasal cannula. LPN #1 confirmed that the oxygen should not have been set at three (3) liters and acknowledged that staff are expected to follow the resident's physician orders and care plan interventions as written. On 4/17/25 at 9:40 AM, during an interview with the Director of Nursing (DON), she confirmed that care plan interventions must be implemented as written. She acknowledged that a discrepancy between the oxygen flow rate provided, and the resident's physician order and care plan represent a failure to follow the individualized plan of care. She stated that if the resident requires an adjustment to the oxygen level, the nurse must obtain a physician's order and update the care plan accordingly. A record review of the Admission Record revealed the facility admitted Resident #79 on 3/10/2025 with current diagnoses including Cough and Wheezing. A record review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/17/25 revealed Resident #79 had a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated his cognition was moderately impaired. Further review revealed under Section O that he was receiving oxygen therapy.

Based on interviews, record review and facility policy review, the facility failed to provide the Resident and/or the Resident's Representative with written notification for the reason the residents were transferred to local hospital for two (2) of three (3) residents reviewed for hospitalization s. Residents #36 and # 56. Findings Include: A review of the facility's policy titled, Discharge Transfer and Planning, revised 9/23, revealed, Before a facility transfers or discharges a resident, the facility must .Notify the resident and the resident's representative(s) of the transfer or discharge and the reason for the move in writing and in a language and manner they understand . Resident #36 A record review of the Transfer notices dated 8/13/23, 9 /9/23 and 11/15/23 revealed, the facility failed to provide the resident and the resident's representative with written notification of the reason for transfer from the facility. The form, utilized at that time, only stated that the facility was no longer able to meet the resident's needs in the facility and the transfer was necessary for their welfare. A record review, of the facility's Face Sheet, revealed the facility admitted the Resident #36 on 2/18/22, with diagnoses that included Acute on Chronic Congestive Heart Failure and Unspecified Dementia. A record review of the Quarterly Minimum Data Set (MDS) for Resident #36, with an Assessment Reference Date (ARD) of 10/9/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #56 A record review of the Departmental Notes, Category: Nurses Notes for Resident #56 dated 2/13/23, 5/30/23, and 8/4/23, revealed the resident was transferred to a local Behavior Health Unit due to increased behavior. A record review of Resident #56's MDS with an ARD of 2/13/23, MDS with an ARD of 5/30/23, and MDS with an ARD of 8/4/23, revealed the resident was discharged to a Psychiatric hospital. A record review of the facility hospitalization letters dated 2/13/23, 5/30/23 and 8/4/23,revealed the letters did not provide written notification as to the reason Resident #56 was sent to the local Behavior Health Unit. During an interview on 12/13/23 at 3:37 PM, the Director of Nursing (DON) confirmed the facility failed to provide a written explanation to the resident and Resident Representative (RR) with the reason the resident was transferred to another facility. The DON said the nurses normally call the families and notify them of the hospital transfer and the reason. During an interview on 12/13/23 at 3:50 PM, the Accounts Manager (AM) revealed she is responsible for sending out the hospitalization letters. The AM also stated that she just answers the questions after each resident is transferred to the local hospital. The AM stated that she does not know the specific reason why the resident is sent out, however, she will start putting the specific reasons on the notices prior to sending them out to the resident or RR. During an interview on 12/13/23 at 4:00 PM, the Administrator confirmed the facility had failed to inform residents and RR with the specific reasons why the residents were transferred out of the facility. The Administrator stated that writing we are no longer able to meet your needs in the facility and the transfer is necessary for your welfare, was insufficient. The Administrator stated the facility policy states the facility is responsible for providing written notification to the resident and resident's representative for the reason for the transfer in a language that they can understand. 48181

Based on observation, interview, record review and facility policy review the facility failed to prevent the possible spread of foodborne illness for 83 of 89 residents residing in the facility. Findings Include: A review of the facility's policy, Food Storage Labeling, revision date 5/2018, the facility will ensure the safety and quality of food by following good storage and labeling procedures. The facility's, policy, Recommended Food Storage Chart, dated 9/2012, condiments open 6 months in cooler and salad dressing open 3 months in cooler. On 08/24/21 at 10:33 AM, an initial tour of the kitchen with the Interim Dietary Manager (IDM) revealed the following: The walk in cooler contained a one (1) gallon sweet pickle relish, 1/3 full, with an opened date of 6/30 with no year indicated. There was black mold on the outside and rim of the container. There was a one (1) gallon container of barbeque sauce, 1/4 full, not labeled with the date opened, that had black and green mold at the top of the container and around the rim. There was a one (1) gallon container of Italian Dressing, 1/3 full, with an opened date of 5/21 with no year indicated. The expiration date on this container was illegible. There was black mold on the outside of the container and around the rim. There was an one (1) gallon container of dill pickle chips 2/3 full with an opened date of 8/12 with no year recorded that had an expiration date of 4/12/20. This container had black mold at the top of the container. In an interview on 8/25/21 at 10:55 AM with the IDM, she stated food containers with mold had the possibility of causing foodborne illness. She further stated mold could affect a lot of things for the residents. The IDM state the residents already had compromised immune systems. The IDM stated the items should have been discarded and staff should date all items before placing them in the cooler. She agreed the barbeque sauce container was not dated. On 8/26/21 at 11:08 AM in an interview with Dietary Cook #2, she stated the containers with mold should have been thrown away and it coud have made the residents sick. She stated the mold could possibly get in the food. She stated anyone in the kitchen might check the food in the cooler. On 8/26/21 at 2:42 PM in an interview with IDM #1 she stated it was the responsibility of the cook to check and dispose of the molded food items. On 8/26/21 at 4:10 PM in an interview with Administrator, he stated the molded containers should have been pulled and discarded. He stated it was the cook and dietary staff's responsibility to check the food items. He stated there was currently an interim dietary manager and it was currently the administrator's responsibility to oversee the dietary staff. The administrator stated he had been in the kitchen frequently to check on dietary staff and expected them to discard foods when needed. An interview on 08/27/21 at 01:50 PM with Licensed Practical Nurse #1, the Infection Preventionist, she stated residents could get upset stomachs and mold could cause foodborne illness. She stated if the date revealed the item was good but it had mold on it, the dietary staff needed to throw it away.

Based on observation, staff interviews, record reviews and facility policy review, the facility failed to follow the COVID-19 Infection Control Guidance to prevent the spread of the COVID-19 virus, as evidenced by, the facility ' s failure to change disposable gowns when going between COVID-19 positive residents' room, to residents' rooms who were pending and/or negative for COVID-19, failure to remove gloves and wash hands before exiting resident rooms, and failure to separate COVID-19 positive residents from COVID-19 pending residents and COVID-19 negative residents, which potentially affected all residents in the facility and likely led to the death of 18 of 91 residents, who had not been outside the facility, Resident #9, #12, #13, # 14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25, #26, # 27 and #28. The State Agency (SA) identified an Immediate Jeopardy (IJ) on [DATE], and determined the IJ existed on [DATE], when the facility had eight (8) deaths related to COVID-19 and 74 positive residents for COVID-19. The facility had a total of 18 deaths related to COVID-19 and a total of 91 residents positive for COVID-19 on [DATE]. Prior to all the residents' deaths, none had been hospitalized or left the facility prior to their [DIAGNOSES REDACTED]. The facility's Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 4:55 PM and the IJ template was provided to the Administrator. The IJ existed at: 42 CFR(s): 483.80(a)(1)(2)(4)(f)-Infection Prevention and Control (F880) The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed and the IJ removed on [DATE]. The State Agency (SA) validated the facility's Removal Plan and the IJ was determined to be removed on [DATE] prior to exit. Therefore, the scope and severity for 42 CFR(s): 483.80(a)(1)(2)(4)(a)(f)-Infection Prevention and Control (F880), was lowered from a L to a scope and severity of a F while the facility develops and implements a plan of correction and monitors the effectiveness of the systematic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: A review of the facility's, Infection Prevention and Control Program policy, dated ,[DATE], revealed, the facility had developed and maintained an infection prevention and control program that provided a safe, sanitary and comfortable environment to help prevent the development and transmission of infection. Review of the facility's, Emergency Preparedness-Emerging Infectious Disease or Infectious Disease policy, with a revision date of ,[DATE], revealed, the facility would implement appropriate infection control policies and procedures in order to protect the health and safety of residents and staff. A review of the facility's, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) policy, with a revision date of ,[DATE], revealed: It is the policy of the facility to minimize exposures to respiratory pathogens and promptly identify residents with Clinical Features and an Epidemiologic Risk for the COVID-19 and to adhere to Transmission-Based Precautions, including the use of eye protection. Note: All healthcare personnel will be correctly trained and capable of implementing infection control procedures and to adhere to requirements. The policy further revealed, if co-horting must occur, co-hort positive with positive, and co-hort pending with pending. Review of the facility's Removing Personal Protective Equipment PPE policy, dated ,[DATE], revealed, disposable gowns, mask, gloves etc., should be used and discarded in either the trash or used linen receptacle before you are leaving the resident's room. A record review of the COVID-19 testing census, dated [DATE], revealed Resident # 1 was negative for COVID-19, and she was in the room with Resident #2 whose was positive for COVID -19. On [DATE] at 11:30 AM, in an interview with Registered Nurse (RN) #1/Nurse Case Manager, revealed, she stated, in the beginning they tried to group all positive residents together. RN #1 stated they now have some positive and negative residents in the same room. She stated they were told to treat everybody as if they were positive. RN #1 revealed management told them to treat everybody as if they were positive. On [DATE] at approximately 11:35 AM, in an interview with the Administrator, he revealed the facility had 74 residents positive for COVID-19, and they did not have a separate COVID-19 unit. On [DATE], at approximately 11:45 AM, the State Agency (SA) made observations of the West Hall with Registered Nurse (RN) #1/Nurse Case Manager, which revealed, Certified Nursing Assistant (CNA) #1, exited Resident #1's room with gloves on to get a black bag. Wearing the same gloves, she went back into the room to get the resident's lunch tray. CNA #1 put the lunch tray in the bag, took the gloves off, washed her hands and exited the room with the bag. On [DATE] at 1:24 PM, during an interview with CNA #1, she revealed, that she came out of the room into the hallway to get a bag for the lunch tray. She stated, she had just put the gloves on, went to get the bag so that she could put the tray in it. CNA #1 stated when she put the gloves on, she walked right back out to get the garbage bag for the trays. she stated when she got back in the room, she took them off and put them in the garbage bag. CNA #1 stated she forgot to take gloves off. She stated she haven't had an in-service since COVID-19 has been going on. CNA #1 revealed, she knew that they are supposed to follow infection control rules. A review of the facility's sign sheets for in-services on Infection Control, revealed, CNA #1 was in attendance on [DATE], [DATE] and [DATE]. During an interview, on [DATE] at 1:40 PM, with Licensed Practical Nurse (LPN) #1, Infection Control Nurse (ICN), with CNA #1 present, LPN #1 stated, staff was not supposed to wear gloves in the hall and that it was an infection control issue. She stated that she does in-services on Infection Control weekly. LPN #1 stated they have not had an in-service in the last week, due to she had to work on the floor. She stated that she stays over to in-service all shifts. On [DATE] at 3:45 PM, in an interview with the Administrator, he revealed Resident #1's pending results came in Sunday night ([DATE]). The Administrator stated he was just reviewing them when he was told the Mississippi State Department of Health (MSDH) was at the facility for an Infection Control Survey. He stated he was looking at them (results) to see where they were going to move Resident #1. The Administrator stated he was going to move Resident #1 today. He stated Resident #1 not being moved and not being moved quickly, could cause her to get COVID-19. He stated the facility had 74 positive residents in the building and had five (5) residents in the hospital with COVID-19, and one resident hospitalized for [REDACTED]. On [DATE] at 4:00 PM, during an interview with CNA #2, she revealed that they were told to treat all residents as if they were positive. She stated that she didn't know which resident rooms were positive, negative or pending. She stated, I guess I should change gowns when I go from a positive room to a negative or pending room. I do not have a list to know who is positive or negative. I have not been told who is positive, negative or pending. There is nothing on the door telling me who is positive, negative or pending. During an interview, on [DATE] at 4:30 PM, with CNA #3, revealed, she was told to treat everybody as if they were positive. She stated she changed her gown, but sometimes she would forget. CNA #3 stated that she did not know which residents were positive, negative or pending for COVID-19. She stated there was nothing on the door to tell them if the residents were positive, negative or pending. On [DATE] at 5:00 PM, an interview with the Administrator, revealed, Resident #1 had been moved to another room. Review of the facility's in-service sign sheets revealed CNA #2, CNA #3 and RN #5 were in attendance on [DATE] for an in-service related to staff wearing PPE. A review of the facility's sign sheet, for an in-service on Infection Control practices, dated [DATE], revealed CNA #2 was in attendance. Review of the facility's sign sheet, for an in-service on Infection Control, dated [DATE], revealed, the Administrator and DON was in attendance. On [DATE] at 9:45 AM, during an observation, Housekeeping Staff (HS) #1 was observed in the doorway of Resident #34's room. HS #1 went back into Resident #34's room and started cleaning and mopping. She placed a wet floor sign in Resident #34's room, left out and went into Resident #31's room and begin cleaning, HS #1 did not change gowns between the two rooms. On [DATE] at 10:48 AM, during an interview with HS #1, she revealed, that she was not told to change disposable gowns between rooms. She revealed of not being told which residents were positive, negative or pending for COVID-19. She stated there was not anything on the residents' door to tell her the resident's status. During an observation, on [DATE] at 10:05 AM, LPN #2 went into Resident #9's room and administered medications. While in the room, she assisted the resident and leaned over to fix the covers on the bed. LPN #2 took her gloves off and sanitized her hands at the medication cart. Upon hearing a beeping noise in the hallway, she went into the room occupied by Resident #3 and #4 room, then into the room occupied by Resident #5 and #6, then into Residents #1 and #2's room, and finally into Residents #7 and #8's room, where she discovered a feeding pump beeping. She stopped the pump from beeping, washed her hands and returned to the cart. LPN #2 did not change gowns between any of the rooms she entered and exited. On [DATE] at 10:15 AM, in an interview with LPN #1 Infection Control Nurse, she revealed, that she tries to in-service all newly hired staff prior to them working the floor. She stated they also must watch an 8-hour video in-service on policy and rules. On [DATE] at 10:57 AM, in an interview LPN #2, she revealed, that she didn't know who was positive, negative or pending. LPN #2 stated she was not told to change gowns when entering positive, negative and pending rooms. She stated she was told if she left the unit, take off PPE and put clean PPE on when returning. LPN #2 revealed, today was literally her first day back working at the facility. She stated she used to work there before and have not had any in-service prior to starting today. LPN #2 stated they told her to treat everybody as if they were positive. During an interview, on [DATE] at 11:22 AM, RN #3 stated, the last in-service on Infection Control was done last week. She stated they have in-services weekly. On [DATE] at 9:51 AM, during a phone interview with the Medical Director (MD), he revealed that he attended all Quality Assurance (QA) meetings. The MD revealed he had no concerns related to residents and COVID-19. The MD stated he was diagnosed with [REDACTED]. He stated he did not remember any Infection Control issues. The MD stated he communicated with the facility by phone in most of July, when he tested COVID-19 positive. During an interview, on [DATE] at 11:30 AM, the DON revealed, she did not have all death certificates at this time. She stated the eighteen resident deaths had been due toCOVID-19. A review of the COVID-19 death report from the facility revealed they had eighteen (18) related to COVID-19. A review of the COVID-19 lab results for Residents #9, Residents #12, and Resident # 28 revealed they tested positive for COVID-19, while not leaving the facility and residing at the facility. A review of the death certificates for Residents #9, Resident #12, Resident #13, Resident #14, Resident #15 and Resident #16 revealed their deaths were caused by COVID-19. Resident #18, Resident #21 and Resident #26's death certificates revealed the cause of death was COVID-19. A review of the Quality Assurance (QA) meeting, dated [DATE], revealed, Infection Control was discussed. A review of the QA meeting, dated [DATE], revealed, COVID-19 was discussed. Review of the QA meeting dated [DATE] revealed, Infection Control and COVID-19 was discussed. A review of the QA meeting notes, dated [DATE], revealed, COVID-19 was discussed. Review of the QA meeting notes, dated [DATE], revealed, the QAA Committee discussed Infection Control, Co-horting, Use of PPE for COVID-19, and Infection Control transmitting. A review of the facility's census, dated [DATE], revealed, Resident #30 was co-horting with Resident #31. Resident #30 was positive for COVID-19 on [DATE]. On [DATE], Resident #31 tested negative for COVID-19. Review of the facility's census and laboratory results, dated [DATE], revealed Resident #29 was positive for COVID-19 on [DATE], and was co-horting with Resident #10, whose results were negative on [DATE]. A review of the facility's census, dated [DATE], and laboratory results, revealed, Resident #2's COVID-19 test was not detected on [DATE]. Resident #2 was co-horting with Resident #1, who was COVID-19 positive on [DATE]. Review of the facility's census, dated [DATE], and laboratory results, revealed Resident #32 was positive for COVID-19 on [DATE]. Resident #32 was co-horting with Resident #33, who was COVID-19 positive on [DATE]. Resident #9 tested positive for COVID-19 on [DATE] and expired on [DATE]. A review of Resident #9's death certificate, revealed, the cause of death was COVID-19. A review of Resident #12's death certificate, revealed, the cause of death as COVID-19. Resident #13 tested positive for COVID-19 on [DATE] and expired on [DATE]. A review of Resident #13's death certificate, revealed, the cause of death as COVID-19. Resident #14 tested positive for COVID-19 on [DATE] and expired on [DATE]. A review of Resident #14's death certificate, revealed, the cause of death as COVID-19. Resident #15 tested positive for COVID-19 on [DATE] and expired on [DATE]. A review of Resident #15's death certificate, revealed the cause of death as being COVID-19. Resident #16 tested positive for COVID-19 on [DATE] and expired on [DATE]. A review of Resident #16's death certificate, revealed, COVID-19 as the cause of death. Resident #17 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #18 tested positive for COVID-19 on [DATE] and expired on [DATE]. A review of Resident #18's death certificate, revealed, the cause of death as COVID-19. Resident #19 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #20 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #21 tested positive for COVID-19 on [DATE] and expired on [DATE]. Review of Resident #21's death certificate, revealed, COVID-19 as the cause of death. Resident #22 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #23 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #24 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #25 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #26 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #27 tested positive for COVID-19 on [DATE] and expired on [DATE]. Resident #28 tested positive for COVID-19 on [DATE] and expired on [DATE]. The facility submitted an acceptable Removal Plan on [DATE], in which the facility alleged all corrective actions were completed and the IJ removed on [DATE]. 1. On [DATE] and [DATE], an immediate jeopardy and substandard quality of care was identified during observations on the day shift, facility failed to follow infection control guidelines by not co-horting known Covid-19 positive residents, pending with pending, and negative with negative residents. On [DATE] Resident #1 was symptomatic pending Covid-19 test results co-horted with Resident #2 a known Covid-19 positive. On [DATE], Resident #3 had a negative Covid-19 test co-horted with Resident #4 an asymptomatic resident pending Covid-19 test result. On [DATE], Resident #5 had a negative Covid-19 test co-horting with Resident #6 a known Covid-19 positive. As of [DATE], sixty active residents were positive for COVID-19. All sixty active resident care plans were updated as of [DATE] by facility Registered Nurse Case Manager. Facility failed to change Personal Protective Equipment between resident care from a positive Covid-19 resident to a pending Covid-19 resident. On [DATE] Housekeeper #1, Licensed Practical Nurse #1 and Certified Nursing Assistant #1 failed to change personal protective equipment when entering room of Resident #1 and Resident #2. On [DATE] state agency notified Nursing Facility Administrator at 4:55 p.m. of immediate jeopardy due to facility failure to follow Center for Disease Control and Center for Medicare and Medicaid Services guidelines of infection control practices during the COVID-19 pandemic. 2. Facility Quality Assurance Committee Meeting was held on Tuesday, [DATE] at 12:59 pm, with the committee consisting of facility Medical Director, Nursing Facility Administrator., Director of Nursing, Staff Development Coordinator/ Infection Control Preventionist, Facility Nurse Practitioner, Registered Nurse Case Manager, Registered Nurse Supervisor, Licensed Practical Nurse Assessment Nurse and Assistant Director of Nursing. Topics discussed: Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) and procedures and Infection Control Program and practices. Quality Assurance Committee also reviewed and approved current co-horting/zoning areas and corrective action plan. Tracking and Trending of COVID positive with positive, pending with pending and negative with negative will be reviewed in daily stand-up meeting. Director of Nursing, Assistant Director of Nursing and Infection Preventionist began observing donning/doffing of personal protective equipment at least five times weekly. Quality Assurance Committee reviewed current infection control policy and procedures with no recommended changes. 3. Facility Staff Development Coordinator (SDC)/Infection Preventionist #1 immediately initiated in-services on [DATE], on policies for Infection Control latest revision ,[DATE], Gloves latest revision ,[DATE], Removing Personal Protective Equipment per Center for Disease Control guidelines, Donning Personal Protective Equipment per Center for Disease Control guidelines and Interim Policy for suspected or Confirmed Coronavirus (COVID-19) latest revision ,[DATE] with emphasis on setting up zone for patient placement. In-service initiated on [DATE] to include all staff consisting of nine of nine Registered Nurses, twenty-one of twenty-one Licensed Practical Nurses, thirty-six of thirty-six Certified Nursing Assistants, eleven of eleven Dietary staff, six of six Housekeeping staff, six of six Laundry staff, four of four Therapy staff and one of one Maintenance staff. No staff will be allowed to work until participation of the in-services for Infection Control latest revision ,[DATE] and Interim Policy for suspected or Confirmed Coronavirus (COVID-19) latest revision ,[DATE]. 4. Resident #1 COVID-19 testing results were received as COVID negative on [DATE]. Resident #1 was moved to room [ROOM NUMBER]B on [DATE] by the facility Maintenance Supervisor #1. Resident #4 COVID-19 testing results were received as COVID-19 positive on [DATE]. Resident #3 was the room mate of Resident #4 therefore, Resident #3 was moved to room [ROOM NUMBER]B on [DATE] by the facility Maintenance Supervisor #1. Resident #6 COVID-19 testing results were received on [DATE] which were COVID-19 positive. Resident #5 was the room mate of Resident #6. Resident #5 was offered a room change on [DATE] and exercised her Resident Right to remain with a Covid-19 positive resident. Resident #5 has a BIMS score of 15 and is her own responsible representative. Eighty of Eighty in house residents were monitored by Nursing Facility Administrator on [DATE] for appropriate co-horting/zoning. All known Covid-19 positive residents, pending with pending, and negative with negative residents were co-horted/zoned appropriately. Resident #1, Resident #3 and Resident #5 were monitored daily by facility assigned medication licensed practical nurses for signs and symptoms of COVID-19. 5. Facility Administrator #1 was in-serviced by Regional Director #1 on [DATE] on Interim Policy for suspected or Confirmed Coronavirus (COVID-19) latest revision ,[DATE] with emphasis on Set-up Zone for Patient Placement (page 2 of 10 and page 3 of 10.) 6. Facility Quality Assurance Committee Meeting was held on Thursday, [DATE] at 1:00 pm, with the committee consisting of facility Medical Director, Nursing Facility Administrator, Director of Nursing, Staff Development Coordinator/ Infection Control Preventionist and Assistant Director of Nursing. Topics discussed: Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) and procedures and Infection Control Program and practices and recent exit of facility survey. Facility updated Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) on [DATE]th to comply with current Centers for Disease Control guidance. 7. An additional Quality Assurance Committee Meeting was held on Wednesday, [DATE] at 5:57 pm, with the committee consisting of facility Medical Director, Nursing Facility Administrator, Director of Nursing, Licensed Practical Assessment Nurse, Medical Records and Assistant Director of Nursing. Topics discussed: Infection Control Co-horting, Use of Personal Protective Equipment per Center for Disease Control guidelines and Infection Control. Policies and Procedures including Interim Policy for Suspected or Confirmed Coronavirus (COVID-19) and Infection Control Program were reviewed with no recommended changes. 8. Facility staff will not be allowed to work until in-serviced. An additional in-service for all staff was initiated on [DATE] by facility Staff Development Nurse /Infection Preventionist on Interim Guidance for Suspected or Confirmed Coronavirus specifically on co-horting/zoning, Donning/Doffing Personal Protective Equipment, Gloves and Infection Control prevention. 9. Facility alleges that the Immediate Jeopardy was removed on [DATE]. The SA validated the facility's Removal Plan and determined the facility took the corrective actions to correct the IJ through observation, interview, record review and in-service sign in sheets. 1. The SA validated through observations that no further issues noted with staff not wearing PPE (gloves) in the hall. 2. The SA validated through record review and observation that all residents were co-horting as follows COVID-19 positive with positive, negative with negative and pending with pending. 3. The SA validated a Quality Assessment and Assurance Committee meeting was held on [DATE], [DATE], and [DATE] was held by interview and sign in sheets. 4. The SA validated through interviews, observation and sign in sheets that in service was done in reference to wearing gloves in the hall and hand washing. 5. The SA validated through interviews, observation and sign in sheets that in-service was done in reference to changing disposable gowns from COVID-19 positive, negative and pending residents. 6. The SA validated through interviews, and sign in sheets that in service was done on [DATE] in reference to Infection Control and COVID-19 by Corporate. 7. The SA validated that all corrective actions listed were accomplished by [DATE]. 8. The SA validated through interviews and record reviews that staff were not allowed to work until in serviced. 9. The SA validated that all corrective actions were completed as of [DATE], and the IJ was removed prior to exit.

Based on observations, staff interviews, record reviews, and the facility policy review, the facility failed to follow the diet orders for chopped meats, choice of milk, and/or double portions on the meal trays for five (5) of 13 residents' meals observed, Resident #2, #5, #14, #16, #17. Findings Include: Review of the facility's policy, Liberalized Geriatric Diets, with a revision date of 10/08, and 08/12, revealed , b. Mechanical Soft Diet provides a regular diet of soft foods and finely chopped meats. The diet is indicated for residents with chewing difficulties. A mechanical soft diet with pureed meats may be ordered if the resident cannot chew chopped meats. If a soft diet is ordered, a mechanical soft diet will be served. The policy also revealed diet orders that are different from the liberalized geriatric diets will be changed to the appropriate diet order. A review of the facility's policy titled Physician Orders, revised date 11/2015; revealed it is the policy of this facility that all physicians' orders will be implemented timely and carried out in a professional manner. Resident #16: Observation on 06/15/2017 at 6:05 PM, of the supper meal tray for Resident #16, revealed no chopped meats were served. The meat portion of the meal consisted of a sandwich made of two (2) slices of white bread included whole thin portions of roast beef and a slice of yellow cheese. Resident #16 picked up a half of the roast beef sandwich and stated, I can't chew this, and asked about an alternate. Interview on 06/15/2017 at 6:10 PM, with Licensed Practical Nurse (LPN) #4, as she observed the meal tray revealed that's not chopped and offered Resident #16 the alternate. Review of a physician's orders [REDACTED].#16. Interview on 06/16/2017 at 9:50 AM, with LPN #4 revealed the original diet order for Resident #16 was dated 12/20/16, for the dental soft diet because Resident #16 had a [DIAGNOSES REDACTED]. Interview on 06/16/2017 at 10:20 AM, with Dietary Department Aide #3, revealed the statement, No, a roast beef sandwich is not a chopped meat. Review of the facility's face sheet revealed the facility admitted Resident #16 on 03/31/2016. Her [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 02/28/2017, revealed Resident #16 had a BIMS score of 11, which indicated moderately impaired cognitive status. Section K for Swallowing/Nutritional Status revealed a mechanically altered diet. Resident #17: Observation on 06/15/2017 at 6:10 PM, in the dining room revealed the following items on the supper meal tray for Resident #17: roast beef sandwich, potatoes, cake, lettuce leaves, water, juice, and a carton of 2 percent (%)white milk. The Registered Nurse (RN #4) served and set up the meal tray. Review of the meal ticket from Resident #17's diet tray listed eight (8) ounces of water, eight (8) ounces of cranberry juice, and chocolate milk. Chocolate milk eight (8) ounces was listed under resident Likes. Interview on 06/15/2017 at 6:15 PM, with the Registered Nurse (RN) #4, revealed, That's 2% white milk on the meal tray for Resident #17. Interview on 06/16/2017 at 10:20 AM, with Dietary Aide #3, revealed if liquids were listed on the meal ticket, each liquid had to be on the tray. Record review of Resident #17's cumulative physician's orders [REDACTED]. Review of the facility's face sheet revealed, the facility admitted the resident on 09/28/2004. Resident #17's [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/05/2017, revealed Resident #17 had a Brief Interview of Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Section G for Functional Status revealed Resident #17's eating skills required the assistance of one (1) staff person. Resident #2: Observation of the lunch meal tray on 06/14/2017 at 12:05 PM, revealed the tray items were four (4) ounces of cranberry juice, eight (8) ounces of water, 12 ounces of sweet tea, two (2) slices of bread, one (1) hamburger meat patty, baked beans, lettuce leaves, and a small bowl of gelatin. Observation of the meal tray ticket included Feeding Assistance Devices: Deep Divided Plate, Built-up Fork, Built-up spoon, and Kennedy Cup. The observed meal tray did not include the built-up fork, spoon, or Kennedy cup. The food items served did not include a double meat portion. ( In an interview on 06/14/2017 at 12:05 PM, during the lunch meal tray observation, Certified Nursing Assistant #2 confirmed the built-up spoon, fork, Kennedy cup and double meat portion were not on Resident #2's tray. Observation of Resident #2's breakfast meal tray on 06/15/2017 at 8:10 AM, revealed the meal items included one (1) sausage patty, one (1) scoop of scrambled eggs, one (1) slice of toast, and a large portion of grits. The meal was served on a divided plate but the tray did not include the built-up spoon or double portions of meat and eggs. Interview on 06/15/2017 at 8:10 AM, with Certified Nursing Assistant (CNA) #2 revealed there were no double portions of scrambled eggs and meat on the breakfast tray. Interview on 06/15/2017 at 8:10 AM, with Resident #2, revealed she could feed herself breakfast and lunch but by supper time she was too tired and needed to be fed. She stated she liked to use the Kennedy cup but the other utensils were heavy. Interview on 06/15/2017 at 3:10 PM, with CNA #2, revealed when she sets up the meal trays she checks the items on the tray against the meal ticket. She further stated she would report to the nurse if there was a difference. She stated she did not report the difference in Resident #2's tray items to the nurse yesterday because she was nervous. Record review of Resident #2's Meal Ticket included feeding assistance devices of a deep divided plate, built-up fork, built-up spoon and a Kennedy cup. Review of the Registered Dietitian Nutrition Assessment, for 5/19/2017, included the nutrition prescription for double meat/eggs at all meals for Resident #2. It further included the use of built-up fork, built-up spoon, deep divided plate and the Kennedy cup. Review of Resident #2's June 2017 cumulative physician's orders [REDACTED]. Review of the facility's face sheet revealed the facility admitted the resident on 12/31/2007. Resident #2's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 04/03/2017, revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated cognitively intact. Section G for functional status revealed Resident #2 required extensive assistance of one (1) staff member for eating. Resident #14: During observation with License Practical Nurse (LPN) #4, on 6/15/2017 at 6:20 PM, revealed Resident #14 did not receive chopped meat on her dinner tray. Resident #14 received a whole roast beef sandwich, pear salad, Potatoes, and cake. A review of the Physician order [REDACTED].#14's diet: chopped meats, no added salt and buttermilk at supper every day. During an interview on 6/16/2017 at 9:00 AM, LPN #4 confirmed the facility failed to follow the diet order for chopped meat on Resident #14's supper tray (for 6/15/17). During an interview on 6/16/2017 at 10:00 AM, the Dietary Manager confirmed the facility failed to follow the diet order for chopped meat on Resident 14's supper tray (for 6/15/17). A review of the facility's face sheet revealed the facility admitted Resident #14 on 3/09/2010, with diagnoses, which included Hypertension, Dementia, Depression, [MEDICAL CONDITION] Fibrillation and [MEDICAL CONDITION]. A review of Resident #14's Quarterly MDS, with an ARD of 04/6/2017, revealed Resident #14 had a BIMS score of 7, which indicated the resident was mildly cognitively impaired. Resident #5: An observation on 06/14.2017 at 8:05 AM, of Resident #5's breakfast tray revealed one (1) serving of eggs, grits and two (2) pieces of bacon. An observation on 06/14/2017 at 12:05 PM, of Resident #5's lunch tray revealed a one (1) hamburger patty on a bun, baked beans, salad, and dessert. A review of Resident's #5's diet slip for 06/14/2017, for the lunch tray, revealed a diet order for a regular diet. An observation on 06/15/2017 at 7:50 AM, and interview with Resident #5 revealed the breakfast tray with one (1) serving of eggs, two (2) pieces of bacon, one (1) serving of grits and juice. Resident #5 stated she had never received extra meat or eggs on her tray for any of the three (3) meals served. A review of Resident's #5's diet slip for 06/15/2017, for the breakfast tray revealed a diet order for a regular diet. A review of Resident #5's medical record revealed an order dated 5/23/17, for a Regular diet with double portions of meats and eggs until wound is healed. An interview on 06/15/2017 at 8:35 AM, with the Dietary Manger (DM), revealed that a regular serving of bacon is two (2) slices. An interview on 06/15/2017 at 9:35 AM, with Registered Nurse (RN) #1, Minimum Data Nurse (MDS), revealed they have 24 hour stand up meetings for new concerns. MDS RN #1 revealed if any diets have changed they are brought up in this meeting. MDS RN #1 revealed that the DM is a member of these team meetings. An interview on 06/15/17 at 9:55 AM, with the DM, revealed she receives the diet forms from the MDS office. The DM revealed she had only been working at this facility since the end of April 2017. The DM revealed she had not been to the stand-up meeting and unless she pulled the diets every single day she would not be aware of diet changes. The DM revealed she had not received any changes in Resident's #5's diet plan. The DM revealed the only training that she had received at this facility was on fire drills, neglect and abuse, and scheduling. An interview on 0 6/15/2107 at 10:05 AM, with the Director of Nursing (DON), revealed diet changes should be brought up in the 24 hour stand-up meetings and slips given to the dietary department. She stated all supervisors attend these meetings, including the DM. An interview on 06/15/2017 at 10:48 AM, with the Administrator, revealed the DM had orientation at this facility with a check off sheet to confirm completion of each field of training covered. The Administrator revealed one (1) of their sister facilities had sent their DM down two (2) times a week for four (4) weeks to train the DM in house. The DM was then sent to their facility to follow their DM for further training. A review of the Dietary Manger Orientation checklist, dated and signed by the DM on 05/02/2017, revealed all areas check for order of servings, use of computer and tray cards were completed. A review of the Facility's Admission Record revealed the facility admitted Resident #5 on 03/17/2017, with a [DIAGNOSES REDACTED]. A review of Resident's #5's MDS with an ARD of 3/23/17, revealed a score of 15 on the BIMS, which indicated no deficit in cognitive abilities.

Based on record review, staff interview, and facility policy review, the facility failed to accurately document medication on the Medication Administration Record (MAR) for one (1) of 18 resident records reviewed, Resident #10. Findings include: A review of facility's policy titled Medical Records, revised date 04/2017; revealed the purpose of the clinical record is to provide communication among health care professionals and interdisciplinary team members involved in the plan of care. A review of the facility's policy titled Monitoring Medication Pass revised on 07/2015, revealed, 6.) Be sure the nurse checks the medication against the MAR. A review of the facility's policy titled Oral Medication, Preparation and Administration revised 06/2016 revealed, 7.) Read medication order from MAR. Compare with label on medication container and 11.) Document all appropriate information in medical record. A review of Electronic MAR for Resident #10 revealed two (2) separate entries for [MEDICATION NAME], one (1) which read [MEDICATION NAME] 20 mg (milligrams) one (1) tablet by mouth (po) at hours sleep (HS) and the other entry read [MEDICATION NAME] 40 mg one (1) tablet by mouth at HS. The medications [MEDICATION NAME] 40 mg and [MEDICATION NAME] 20 mg had been both been signed off/documented as administered per a LPN (who was not available for an interview), for the days 06/10/ 2017-06/13/2017 at 9:00 PM. A review of the cumulative physician's orders [REDACTED].#10, revealed an order for [REDACTED]. A review of Physician order [REDACTED].#10, dated 6/10/17, revealed an order for [REDACTED]. Review of Departmental Notes, dated 05/24/2017 at 6:25 PM, for Resident #10, revealed a new order received to discontinue (D/C) [MEDICATION NAME] 40 mg at HS upon completion of medication on card. Order to be d/c'd on 06/09/2017, and new order for [MEDICATION NAME] 20 mg HS to start on 06/10/2017. RN Supervisor entered orders. A review of the [MEDICATION NAME] 20 mg Medication Card for Resident #10, revealed five (5) pills had been pulled from the card dated 06/05/2017. An interview with Licensed Practical Nurse (LPN) #3, on 06/15/2017 at 2:00 PM, revealed all of the nurses were responsible for taking the orders off the chart. The orders are flagged and then the nurses take the orders off and put them in the computer. After the completion of putting the orders in the computer, the slips are sent to Medical Records then they flag them to go to Minimum Data Set (MDS) staff. It is the responsibility of the nurse giving the medicine to check the orders on the chart prior to giving medications. Then the nurse needs to check the medication card against the medication given prior to documenting the medication was given. She stated if you don't give it, you don't document, if you give it then you document. An interview with Registered Nurse (RN) #3, on 06/16/17 at 2:05 PM, revealed all nurses are responsible for taking orders off of the chart and putting them in the computer and flagging them to go to medical records so medical records can make changes to the MAR and then to send to MDS staff if necessary. RN #3 revealed it is the responsibility of the nurse giving the medication to check the medication against the chart prior to giving medication. She also stated before documenting medication on the EMAR it is the responsibility of the nurse giving medication to document medication given or not given. Review of the of the facility's face sheet revealed the facility admitted Resident #10 on 11/4/16, with re-admission on 12/6/16, with [DIAGNOSES REDACTED]. A review of the MDS, with an Assessment Reference Date (ARD) of 04/27/2017, revealed Resident's #10 Brief Interview for Mental Status (BIMS) score was 9, which indicated moderate cognitive impairment.

Based on observation, staff interview, record review and the facility policy review, the facility failed to clean a glucometer per the manufacturer's guidelines for one (1) of 10 residents who received fingerstick glucose testing; Unsampled Resident A. Findings Include: Review of the facility's policy, Blood Glucose Quality Control originally dated 11/15, revealed,Always clean the meter after each use. Gently wipe and clean surface of the meter with a disinfectant wipe per facility policy. Review of the Infection Control Policy for General Cleaning and Maintenance of Equipment originally dated 06/14, revealed, It is the policy of this facility that all resident care equipment will be cleaned and decontaminated after use and will be prepared for reuse by the same or another resident. Equipment will be cleaned and decontaminated according to manufacturer's recommendation. Review of the Manufacturer's Guidelines for the blood glucose monitoring system being used by the facility revealed in the User Guide under, Cleaning and Disinfection: To mitigate the risk of blood borne pathogen transmission, the meter must be properly cleaned and disinfected after each patient. Put on protective gloves. Take a piece of moistened wipe out of canister. Remember to recap the canister. Wipe the device until visibly clean. Any disinfectant product with the EPA (Environmental Protection Agency) registration number of -12 may be used per recommendations. Observation on 6/13/2017 at 4:00 PM, of a fingerstick by Licensed Practical Nurse (LPN) #5, revealed she removed the glucometer from the medication cart and wiped the front and sides of the meter using alcohol prep pads. She performed the fingerstick on Unsampled Resident A and cleaned the glucometer again with alcohol pads. There was no visible blood on the glucometer. Interview on 6/14/2017 at 12:15 PM, with LPN #5, revealed she had cleaned the glucometer with the alcohol pads because she was nervous. She further stated, I knew better. She stated it was an infection control issue as the consequences of improperly cleaning the glucometer and knew to use the purple top wipes. Interview on 6/14/2017 at 2:20 PM, with LPN #6, who was the Staff Development nurse, stated the glucometers were cleaned with the purple top wipes. She stated they had just had an in-service on the cleaning and storage of the new glucometers. Interview on 6/14/2017 at 2:30 PM, with the Director of Nursing, revealed she educated the educators to make sure they were trained properly. Consequences of not cleaning the glucometer properly could result in infectious diseases. Record review of the In-service Training for LPN #5 revealed she had training on 8/13/2016, for blood glucose fingersticks, glucometer usage, and Infection Control. Review of Unsampled Resident A's face sheet revealed the facility admitted him on 2/06/2017. His [DIAGNOSES REDACTED].

Based on observations, interviews, record reviews, and the facility policy review, the facility failed to provide special eating equipment on meal trays for one (1) of 13 meals observed, for Resident #2. Findings Include: There was no available policy for adaptive equipment for meals. A review of the facility's policy titled Physician Orders, revised date 11/2015; revealed it is the policy of this facility that all physicians' orders will be implemented timely and carried out in a professional manner. Observation of the lunch meal tray on 06/14/2017 at 12:05 PM, revealed the meal tray did not include a built-up fork, spoon, or Kennedy cup. The meal ticket on the lunch tray included Feeding Assistance Devices: Deep Divided Plate, Built-up Fork, Built-up spoon, and Kennedy Cup. In an interview on 06/14/2017 at 12:05 PM, during the lunch meal tray observation, Certified Nursing Assistant #2 confirmed the built-up spoon, fork, and Kennedy cup were not included on the meal tray for Resident #2. Interview on 06/15/2017 at 8:10 AM, with Resident #2 revealed she could feed herself breakfast and lunch but by supper time she was too tired and needed to be fed. She stated she liked to use the Kennedy cup. Review of the June 2017 cumulative physician's orders [REDACTED]. Review of the Registered Dietitian Nutrition Assessment for 5/19/2017, included the use of a built-up fork, a built-up spoon, a deep divided plate and the Kennedy cup. Interview on 06/15/2017 at 9:35 AM, with the care plan assessment nurses Licensed Practical Nurse #2 and Registered Nurse (RN) #1 stated when they are doing the assessments they will visibly go and check to see if interventions were being implemented. They stated the orders come from the 24 hour reports and the department heads were responsible for their areas. Interview on 06/15/2017 at 3:10 PM, with CNA #2, revealed when she sets up the meal trays she checks the items on the tray against the meal ticket. She further stated she would report to the nurse if there was a difference. She stated she did not report that all of the items weren't on the meal tray to the nurse yesterday because she was nervous. Review of the facility's face sheet revealed the facility admitted the resident on 12/31/2007. Resident #2's [DIAGNOSES REDACTED]. Review of the Minimum Data Set with an Assessment Reference Date of 04/03/2017 revealed Resident #2 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated cognitively intact. Section G for functional status revealed Resident #2 required extensive assistance of one (1) staff member for eating.

Based on observations, staff interview, record review, and facility policy review the facility failed to follow the care plan and notify a change in resident's condition related to a wound for one (1) of 11 resident care observations, Resident #12. Findings include: A facility policy titled Care Plan Process, with a revised date of 12/2016, revealed the facility staff shall follow the care plan. A facility policy titled Prevention and treatment of [REDACTED]. A review of Resident #12's care plan, initiated 9/11/06, revealed a problem of a high risk for skin impairment with an approach for the CNA to inspect the skin every shift during routine care and to report any problems to the nurses. An observation during incontinent care, on 06/14/17 at 10:35 AM, revealed Resident #12 had a red, open area on the coccyx. The area was about the size of a dime, or approximately two (2) centimeters, in the center of old pink scar tissue. An interview on 06/14/17 at 10:55 AM, revealed Certified Nursing Assistant (CNA) #1 said the red area had been on Resident #12's sacrum, and she had been applying [MEDICATION NAME] cream. CNA #1 was not observed notifying Resident #12's nurse or the treatment nurse after providing the care. An interview on 06/14/17 at 1:00 PM, revealed Registered Nurse (RN) #2, Treatment Nurse, said she was not notified of any skin redness on resident #12. RN #2 said there had been no recent treatment orders for Resident #12. RN #2 said she had completed a skin assessment for Resident #12 on 06/14/17, and had identified a Stage II pressure area on the sacrum. RN #2 said CNA #1 had an in-service on notifying the nurse for any skin breaks. An interview on 06/16/17 at 9:45 AM, revealed RN #1 confirmed CNA's were responsible for notifying nurses of skin changes according to Resident #12's care plan. An interview on 06/16/17 at 10:15 AM revealed the Director of Nursing (DON) said CNA #1 did not notify the nurse of the skin break on Resident #12. DON said the CNA just asked for cream to use on residents. A review of the facility's face sheet revealed the facility admitted Resident #12 on 09/11/06. Resident #12's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/11/17, revealed Resident 12's Brief Interview for Mental Status (BIMS) was coded 0, which indicated severe cognitive impairment.

Based on observation, staff interview, record review, and facility policy review the facility failed to develop a comprehensive care plan related to range of motion for one (1) of 18 care plans reviewed, Resident #8. Findings included: A facility policy titled Care Plan Process, with a revised date of 12/2016, revealed the facility would use the results of the standardized assessment to develop, review, and revise each resident's comprehensive person-centered plan of care. The policy also revealed the care plan should be oriented towards preventing avoidable declines in functioning or functional levels. A review of Resident #8's care plan revealed an achieved care plan on 05/18/17, for limited ROM. The care plan also had an achieved care plan on 05/18/17 for contracture to left hand. The current care plan did not address the limited ROM for Resident #8. Review of a Nurse Data Collection and Screening form, dated 05/24/17, revealed Resident #8 was assessed to have Range of Motion (ROM) impairment on one (1) side of the upper and lower extremities. A review of Resident #8's current Care Area Assessment (CAA's), on the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/07/16, revealed Activities of Daily Living (ADL) functional rehab was triggered and the area to proceed to care plan was checked. An observation on 06/14/17 at 12:20 PM, revealed Resident #8 was unable to move the left arm or leg when positioned in bed. An interview on 06/16/17 at 10:00 AM, with Licensed Practical Nurse (LPN) #2, confirmed the ROM was not on the current care plan for Resident #8. LPN #2 said when physical therapy refused to work with Resident #8 after he finished Nursing Rehab, she did not address the ROM in the care plan. LPN #2 confirmed the assessment for the MDS, Section G, on 05/24/17 was completed by her and was correct for limited ROM on one (1) side of the upper and lower extremity. A review of the facility's face sheet revealed the facility admitted Resident #8 on 7/6/16, and readmitted the Resident on 11/30/16. Resident #8's [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/17, revealed Resident 8's Brief Interview for Mental Status (BIMS) was 14, which indicated intact cognition. The MDS also documented impairment of one (1) side of the upper and lower extremity.

Based on observation, staff interview, record review and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by: (a) storing an ice scoop in the ice chest on one (1) of six (6) halls observed, West Wing Rooms 1-12; (b) failing to clean the blood pressure cuff before and after use on a resident for three (3) of seven (7) residents observed during medication pass, Unsampled Resident A, B, and D; (c) using contaminated gloves to administer eye drops for one (1) of seven (7) residents observed during medication pass, Unsampled Resident B; (d) failing to perform hand hygiene before measuring a wound for one (1) of four (4) wound care observations, Resident #4; and (e) failing to wash hands before and after administration of peg feeding for one (1) of two (2) residents observed with peg tubes; Unsampled Resident D. Findings include: A review of the facility's policy entitled, Drinking Water, Serving of, revised 06/94, revealed the scoop is to be placed in receptacle and not in ice bin. Review of the facility's policy entitled General Infection Prevention and Control Nursing Policies, dated 06/14, revealed it is the facility's policy that all nursing activities will be performed in a manner to minimize the potential for infection in residents, staff and visitors. All items used for resident care will be cleaned and disinfected between uses or will be designated for that resident's use only. A review of the facility's policy entitled Standard Precautions, revised 11/14, revealed standard precautions should be employed by all personnel for all residents at all times. All employees are to wash hands after every unprotected contact with blood or other potentially infectious materials and after removing gloves. Review of the facility's policy Infection Control Inservice, revised 07/15, revealed: Hands are to be washed with soap and water between all resident contacts. Keep clean and soiled items from touching each other and from touching your clothing. Review of the facility's policy on dressing change, dated 3/14, revealed: Wash your hands thoroughly before beginning the procedure. Perform hand hygiene and apply gloves. Perform weekly wound measurements per the policy and procedure. Perform hand hygiene and apply gloves. Discard all disposable items in the appropriate container. Remove gloves and discard of the soiled supplies. Wash hands. Review of the facility's policy on hand hygiene, with a revision date of 6/14, revealed: clean hands to prevent the transmission of infection and other diseases. Handwashing provides a clean and healthy environment for the residents. Hand hygiene is the most important process for preventing the spread of infections. Gloves are not a replacement for handwashing. Review of the facility's policy on general infection prevention and control nursing policies, dated 6/14, revealed: All nursing activities will be performed in a manner to minimize the potential for infection for residents, staff, and visitors. All items for resident care will be cleaned and disinfected between uses. Items such as thermometers, and other commonly used items will be cleaned and disinfected according to the manufacturer's recommendations. Observation on 08/22/16 at approximately 11:20 AM, during the initial tour of the facility revealed Certified Nursing Assistant (CNA) #1 filling resident water pitchers on West Wing (Rooms 1-12). CNA #1 was observed coming out of a resident's rooms, filling the water pitcher with ice, placing the ice scoop into the ice chest and closing the lid. In an interview on 8/22/16 at 11:25 AM, CNA #1 confirmed the scoop was not placed in the holder and should not have been left in the ice chest. CNA #1 stated I don't know referring to why the ice scoop was left inside the chest. An interview on 08/25/16 at 1:35 PM, with CNA #1, revealed the ice scoop holder was new and they have to get into the habit of using it. CNA #1 revealed they had been inserviced on using the new ice scoop holders. Interview on 08/25/16 at 3:40 PM, with Licensed Practical Nurse (LPN) #2, confirmed that she observed the ice scoop left inside the ice chest by CNA #1. LPN #2 revealed the facility had recently bought the new ice coolers but the staff was using a plastic bag to store the ice scoop before they got the new coolers. An interview on 08/25/16 at 4:05 PM, with LPN #4, revealed the facility purchased the new ice coolers a few months ago. LPN #4 further revealed the staff has received in-services on Infection Control. A review of an Inservice Training sign in sheet revealed CNA #1 attended training in 2/2016 and 7/16 for Prevention and Control of Infections/Standard Precautions. Unsampled Resident A Observation on 08/23/16 at 8:00 AM, revealed Licensed Practical Nurse (LPN) #6 administered medications and obtained a blood pressure for Unsampled Resident A . Prior to entering the room, LPN #6 was observed retrieving a wrist blood pressure cuff from the top of medication cart. LPN #6 obtained the blood pressure on Unsampled Resident A and placed the wrist blood pressure cuff back on top of medication cart after exiting the room. LPN #6 did not clean the blood pressure cuff before or after using it on Unsampled Resident A. Interview on 08/23/16 at approximately 08:10 AM, with LPN #6, revealed that she did not clean the wrist blood pressure cuff before or after using it on Unsampled Resident A. LPN #6 further revealed they are supposed to clean the blood pressure cuff with the disinfectant wipes. Review of the Face Sheet revealed the facility readmitted Unsampled Resident A on 08/18/11, with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/29/16, revealed Unsampled Resident A scored 15 on the Brief Interview for Mental Status (BIMS) which indicated no cognitive impairment. Unsampled Resident B Observation on 08/23/16 at 08:30 AM, revealed LPN #5 administered medication pass to Unsampled Resident B. Prior to entering room, LPN #5 was observed placing a pair of gloves into her uniform pocket. LPN #5 was also observed taking the wrist blood pressure cuff from the top of the medication cart into the room of Unsampled Resident B. LPN #5 obtained a blood pressure on Unsampled Resident B and placed the wrist cuff on the bedside table. LPN #5 administered the oral medications for Unsampled Resident B and then reached into her pocket and applied gloves stored there to administer eye drops. LPN #5 applied one (1) drop to the left eye, removed her gloves, washed her hands and then donned clean gloves to apply a drop to the right eye. Upon exiting the room, LPN #5 placed the wrist blood pressure cuff back on top of the medication cart without cleaning it. In an interview on 08/23/16 at 8:50 AM, LPN #5 stated I wasn't thinking. LPN #5 stated that she knew not to place gloves in her pocket, but she was nervous. LPN #5 was aware that the gloves in her pocket were contaminated and placed the resident at risk for infection. Interview on 08/25/16 at 2:15 PM, with LPN #5, revealed that she did not clean the blood pressure cuff before or after using it on Unsampled Resident B. LPN #5 revealed, We are supposed to clean it with the sani-wipes before and after using it and between each resident. Review of the Face Sheet revealed the facility admitted Unsampled Resident B on 11/20/14, with [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment with an ARD of 07/06/16, revealed Unsampled Resident B scored seven (7) on the BIMS which indicated severe cognitive impairment. Resident #4 Observation of wound care on Resident #4, on 8/24/16, at 10:10 AM, with (RN) Registered Nurse #1, revealed, RN #1 did not wash her hands when she entered Resident #4's room with supplies to measure the resident's wound. She donned gloves and began measuring the resident's wound. She performed wound care then, took the biohazard bag which contained soiled supplies to the treatment cart in the hallway, and disposed of it in the biohazard bag on her treatment cart, then touched the computer key pad, which was sitting on top of the treatment cart. Staff interview with RN #1, on 8/25/16, at 10:20 AM, confirmed she did not wash her hands when entering Resident #4's room and when she measured his Stage 4 pressure wound. She confirmed not washing her hands after she left the resident's room with a biohazard bag which contained soiled supplies used during wound care. She said she disposed of the biohazard bag on her treatment cart then, touched the computer key pad, which was sitting on top of the treatment cart. Staff interview with the Director of Nursing (DON) on 8/25/16, at 10:30 AM, confirmed that RN #1 had a break in infection control when she did not wash her hands when entering Resident #4's room without washing her hands before donning gloves to measure the resident's wound, and when disposing of the biohazard bag with soiled supplies used during wound care. Review of the facility's face sheet revealed the facility admitted Resident #4, on 6/20/16, with [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 7/18/16, revealed Resident #4 had a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #4 was cognitively intact. Unsampled Resident C: Observation of Medication Pass, on 8/23/16, at 8:58 A-9:15 AM, revealed LPN (Licensed Practical Nurse) #1 left her medication cart, which was located in the hallway, and entered the medication room on two (2) occasions, using the phone at the nurses' station and returning to the medication cart to continue setting up medications for Unsampled Resident C, without performing hand hygiene. LPN #1 entered the resident's room, placed a blood pressure cuff on the resident, then placed it on the bedside table next to the barrier. She administered Unsampled Resident C's medication, and returned to the hallway and placed the blood pressure cuff on top of the medication cart, then placed it in the drawer of the medication cart without cleaning it. Staff interview with LPN #1, on 8/25/16, at 11:25 AM, confirmed she had several breaks in infection control while setting up Unsampled Resident C's medication by going back and forth to the medication room, touching the phone, and placing the blood pressure cuff on the bedside table, placing it on top of the medication cart, and not disinfecting the blood pressure cuff before placing it in the drawer of the medication cart. Staff interview with the Infection Control (IC) nurse on 8/25/16, at 3:55 PM, revealed the staff had a break in infection control during medication pass by not washing her hands or cleaning the blood pressure cuff before placing it in the medication cart drawer. Review of the facility's face sheet revealed the facility admitted Unsampled Resident C on 3/01/11. The resident's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 8/04/2016, revealed the resident's BIMS score was 10, indicating Unsampled Resident C had moderate cognitive impairment. Unsampled Resident D: Observation during medication pass on 8/23/16, at 8:58 AM, revealed LPN #3 entered Unsampled Resident D's room and administered the tube feeding Fibersource without washing her hands prior to or after the feeding was administered. Staff interview with LPN #3 on 8/25/16, confirmed she did not wash her hands prior to, or after administering the tube feeding to Unsampled Resident D during medication pass. Review of Unsampled Resident D's physician's orders [REDACTED]. Review of the facility's face sheet revealed the facility admitted Unsampled Resident D on 4/11/16. The resident's [DIAGNOSES REDACTED]. Review of the MDS with an ARD of 7/14/16, revealed the resident's BIMS score was 10, indicating Unsampled Resident D had moderate cognitive impairment.

Based on observation, staff interview, record review, and facility policy, review, the facility failed to properly store vegetables and failed to clean serving tray liners on the serving line for one (1) of two (2) dietary tours. Findings include: Review of the facility's policy on cleaning instructions for food bins, with a review date of 9/12, revealed equipment shall be kept in a clean and sanitary manner. Clean bins thoroughly with hot water detergent. Review of the facility's policy on storage of refrigerated and frozen foods, with a revision date of 9/12, revealed the facility ensures the quality and safety of refrigerated foods through accepted storage practices. No food is to be left uncovered. Observation of the dietary department on 8/22/16, at 10:15 AM, revealed a large build-up of ice to the walls of the chest freezer, and milk refrigerator. The walk-in freezer contained an opened five (5) pound bag of tater tots, an opened 20 pound box of mixed vegetables, a 20 pound box of speckled butter beans, a two (2) pound bag of bacon bits, half of a three (3) pound bag of purple cabbage and carrots, and half of a three (3) pound bag of chopped broccoli were all left open to air. There were three (3) large bins of sugar, flour, and corn meal containers with grease build-up and food residue to the tops of each container. Observation of the dietary department on 8/23/16, at 11:33 AM, during tray line temperatures and tray line service, revealed a large build-up of brownish-gold greasy residue to five (5) of the table inserts which held the stainless steel pans of food on the tray line. Staff interview with the DM on 8/23/16, at 11:33 AM, revealed problems with food storage in the walk-in refrigerator and walk-in freezer. She said the milk refrigerator and chest freezer needed to be defrosted, and the sugar, flour and cornmeal containers needed to be cleaned, and the inserts on the serving line were dirty and should be cleaned.

Based on the survey results dated 7/18/14, the facility failed to develop care plan interventions to address and manage disruptive and aggressive behavior for three (3) of 14 residents reviewed for care planning (Resident #1, Resident #2, and Resident #4). This was identified as an Immediate Jeopardy (IJ) on 7/10/14. A revisit was conducted from 8/5/14 through 8/7/14 to validate the Allegation of Compliance (AoC). The Immediate Jeopardy, which began 7/8/14, was determined to be removed on 7/24/14. The facility provided an Allegation of Compliance, which was accepted by the Centers for Medicare and Medicaid Services (CMS) on 8/5/14. CMS authorized the State Survey Agency (SSA) to conduct a revisit in order to determine if corrective actions implemented by the facility were able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible AoC from 8/5/14 through 8/7/14 was accomplished through staff interview, record review, and in-service review. The facility provided evidence the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 7/24/14. The facility will remain out of compliance at Scope and Severity of "D", isolated deficiencies, that constitute no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/5/14. CM'S authorized the SSA to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. Residents #1 and #2 were not included in the validation/revisit sample of 8/5/14-8/7/14 due to Resident #1 expiring on 7/8/14, and due to Resident #2's discharge from the facility. Resident #2 had been discharged from the facility on 7/8/14, when he was taken into police custody, where he remained as of the date of the revisit of 8/5/14 through 8/7/14. Information contained in the Credible AoC submitted by the facility, alleged removal as of 7/24/14, and the State Survey Agency (SSA) validated the facility implemented corrective actions as follows: The SSA Surveyor validated that a care plan was developed to address Resident #4's aggressive behavior on 07/23/14. The SSA Surveyor validated that 104 resident care plans were audited by the facility for individualized behavior interventions. The tools utilized by the facility to conduct this audit were reviewed and validated by the SSA Surveyor and were the facility's census list from 7/11/14 and the Physician order [REDACTED]. Review of seven (7) sampled resident care plans (Residents #1 - #7) during the revisit of 8/5/14-8/7/14 revealed care plans were developed and individualized to meet the residents needs. In addition to the sampled Residents , 13 additional unsampled resident care plans (Residents #D- #P) were reviewed and revealed the care plan interventions were developed to reflect the resident's individual choice of code status -- completion date 7/23/14. Review of training records revealed in-service training was provided on developing care plans for resident behaviors and resident code status for the Director of Nursing #1, Assistant Director of Nursing, Assessment Nurse, Nurse Case Manager and Social Services Staff #1 on 7/23/14. Interviews by the SSA Surveyor from 8/5/14 through 8/7/14, with the Director of Nursing #2, Assistant Director of Nursing, Assessment Nurse, Nurse Case Manager and Social Services Staff #2 confirmed each staff person understood the process of developing a care plan for the residents code status and resident behaviors. The facility will remain out of compliance at Scope and Severity of "D", isolated deficiencies, that constitute no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.

Based on the survey results dated 7/18/14, the facility failed to honor Resident #1's advance directive of Full Code status, one (1) of seven (7) residents reviewed for Advanced Directives. This was identified to be an Immediate Jeopardy (IJ) on 7/10/14. A revisit was conducted from 8/5/14 through 8/7/14 to validate the Allegation of Compliance (AoC). The Immediate Jeopardy, which began 7/8/14, was determined to be removed on 7/24/14. The facility provided an Allegation of Compliance, which was accepted by the Centers for Medicare and Medicaid Services (CMS) on 8/5/14. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible AoC from 8/5/14 through 8/7/14 was accomplished through staff interview, record review, policy review, and in-service review. The facility provided evidence the facility had implemented corrective actions listed in the AoC. The Immediate Jeopardy was determined to be removed on 7/24/14. The facility will remain out of compliance at Scope and Severity of "D", isolated deficiencies, that constitute no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/5/14. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. Information contained in the Credible AoC submitted by the facility, alleged removal as of 7/24/14. Resident #1 was not included in the validation/revisit sample of 8/5/14-8/7/14 due to Resident #1 expiring on 7/8/14. The following corrective actions were validated: The State Survey Agency Surveyor (SSA) reviewed the audit reports and validated 103 resident records were audited to ensure accurate reflection of each resident's code status in the clinical record, and 101 resident identification bands were audited to ensure the correct identification band was in place. These facility audits were completed as of 07/10/14. Two (2) residents were out of the facility on bed hold. Sign in sheets and in-service content related to Cardiopulmonary Resuscitation for staff in-services provided from 7/9/14 through 7/13/14 with the Administrator #1, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Dietary Staff, Social Service Staff #1, Activity Staff, Maintenance Staff, Laundry Staff, Housekeeping Staff, Agency Nursing Staff, and Office Personnel (e.g. Business Office staff, Receptionist) were reviewed by the SSA Surveyor. Documentation related to code drills, completed 7/12/14, 7/14/14, and 7/15/14, conducted by Director of Nursing and/or the Facility Administrator were reviewed by the SSA Surveyor during the revisit of 8/5/14 through 8/7/14. An interview with Social Services Staff #2 on 8/6/14 at 10:50 AM confirmed that she completed the monthly audit of identification bands, which confirmed the correct code status of each resident of the facility on 8/5/14. This audit was validated by the SSA surveyor through review of the audit report for identification bands. Interviews with 72 facility employees from 8/5/14 through 8/7/14, across all disciplines and shifts, confirmed the in-services on Cardiopulmonary Resuscitation and code drills, were conducted. Employees interviewed included facility staff as follows: Assistant Director of Nursing, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Dietary Staff, Activity Staff, Maintenance Staff, Laundry Staff, Housekeeping Staff, Agency Nursing Staff, and Facility Office Personnel (Business Office Manager and Receptionist). Based on verification of the facility's corrective actions validated by staff interview, record review, and in-service review, the Immediate Jeopardy, which began 7/8/14 , was removed. The State Agency Surveyor validated the facility's AoC, and the IJ was determined to be removed on 7/24/14. The facility will remain out of compliance at Scope and Severity of "D", an isolated deficiency, that constitutes no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.

A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions MS CI # Based on record review, interview, and policy review the facility failed to develop and implement appropriate plans of action to identify and correct quality deficiencies regarding (A) identifying residents with aggressive behaviors, (B) developing and implementing plans of care related to behaviors, and (C) monitoring residents with disruptive or aggressive behaviors and the failure to implement consultant recommendations for treatment and services and to honor Advance Directives. (Resident #1 and Resident #2) The facility's failure to identify, track, and trend issues for residents with behaviors, failure to follow through with treatment and services recommended by contracted consultants, and failure to honor the Full Code status resulted in an Immediate Jeopardy which was determined to begin on [DATE] Resident #2 became agitated and complained about his roommate's behaviors and placed a sandwich wrapped in plastic in the mouth of Resident #1 who was unable to physically remove it. Resident #1 asphyxiated (choked) and expired in the facility. This failure contributed to Resident #1's death in the facility and had the likelihood of resulting in serious injury, harm, impairment, or death to other residents. Findings Include: Review of the facility's policy entitled, "Procedure for Quality Assessment (QA) and Improvement Program", Latest Revision: ,[DATE] revealed, "The committee will establish the QA&I (Quality Assessment and Improvement) review each quarter using the outcome of the internal and external QA&I's, Regional's, Consultant's reports, accident/incident reports and complaints from families and/or residents. Each department must identify the problem areas, investigate and determine the probable cause, establish a plan of correction, and evaluate the outcomes". Review of the facility's policy entitled, "Planning and conducting the Quality Assessment and Improvement Meeting" Latest Revision: ,[DATE] revealed, "Before the quarterly meeting, the chairperson shall. B. Identify any other appropriate issues to be addressed. C. Each Department head is a part of the QA&I committee and should pull together information on problem area identified and prepare for QA&I meeting. The following sequence is recommended for each discipline in planning the meeting: 1. Identify the problems *Discuss and Gain input from Medical Director *Review reports/results of internal audit *Review report/results of external audit *Review applicable portion of Committee reports and prior identified problems". Interview, on [DATE] at 11:45 AM with the Director of Nurses (DON), the DON explained the tracking of identified QA concerns was done by the Management Company's Quality Improvement (QI) nurse. This QI nurse was not in the facility on a routine basis. The DON stated the process of identifying concerns consisted of: If there were any staff reported concerns, she (DON) would take them to the Administrator. The concerns were brought to the QA meeting by the Administrator. The DON confirmed Certified Nursing Assistants (CNAs) were not involved in the QA meeting. The DON reported the QA committee failed to identify any concerns related to behavior monitoring or care planning for residents with aggressive/disruptive behaviors (Resident #1 and Resident #2) and they failed to address recommendations from contracted consultants (Licensed Certified Social Worker (LCSW)and Psychological Services). The DON confirmed behaviors exhibited by Resident #1, Resident #2 and Resident #4 had not been brought to the QA committee prior to this survey beginning on [DATE]. During an Interview on [DATE] at 3:40 PM, the Management Company's Quality Improvement (QI) nurse produced a resident specific behavior monitoring report. The QI nurse explained the report was specific for each resident (including Resident #1 and Resident #2). During an interview on [DATE] at 4:45 PM, the DON and the Assistant Director of Nursing (ADON) confirmed neither of them knew how to obtain the behavior report and had never seen one printed. During an interview on [DATE] at 4:40 PM, Social Services Designee confirmed she was not aware of the existence of the behavior monitoring report and did not know how to print it. Interview with the Administrator, on [DATE] at 12:10 PM, confirmed he had no documentation to support the reports had been used for QA purposes or any other behavior monitoring had been addressed by the QA Committee related to resident behaviors affecting others (including Resident #1 and Resident #2). The facility also failed to provide evidence addressing follow up of contract consultants recommendations including LCSW and contract psychologist services. Review of a statement on facility letterhead provided by the Administrator, dated [DATE] (unsigned), revealed the facility held an emergency Quality Assurance and Improvement Committee (QAPI) meeting on [DATE] (survey team entered on [DATE]). The documentation read topics included: Cardiopulmonary Resuscitation, Abuse Neglect, Behavior Monitoring, Resident Room Compatibility and [MEDICAL CONDITION] devices. The Quality Assurance and Improvement Committee also reviewed the functions of the Quality Assurance and Improvement Committee meeting process. A review of Resident #1's Face Sheet revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had problems with long and short term memory and was moderately impaired for making decisions. Resident #2's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses, which included [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Symbolic Disorder, Anxiety, [MEDICAL CONDITION], and Diabetes. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #2 experienced other behavioral symptoms not directed toward others on four (4) to six (6) days during the assessment period.

The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. MS CI # Based on record review, policy review, incident report review, consent review, and staff interviews for one (1) of seven (7) residents reviewed, with Advanced Directives who had expired in the facility. The facility failed to honor Resident #1's rights as requested in his Advanced Directive, for a Full Code status. The facility failed to administer Cardiopulmonary Resuscitation (CPR) when Resident #1 was found unresponsive by Licensed Practical Nurse (LPN) #1. The facility's failure to honor Resident #1's Advanced Directive of Full Code status and to initiate CPR, places residents with Advance Directives of Full Code status in a situation that is likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy on [DATE], and was determined to exist on [DATE]. The IJ was not removed prior to exit on [DATE] and is Findings Include: A review of the facility's policy entitled, "Cardiac Resuscitation (CPR) Policy", Latest Revision: ,[DATE], revealed CPR will be performed unless the resident or resident's appropriate representative has made a valid written request in advance not to initiate basic CPR. A review of the facility's document entitled "Resident/Family Consent for Cardiopulmonary Resuscitation" signed [DATE] stated "I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in case of extreme emergency" Resident #1's Responsible Party had signed and initialed the consent form for Resident #1. A review of the facility's document entitled, "Resident Incident Report", dated [DATE], revealed the time of the incident was 8:55 PM and that Resident #1 was found unresponsive in his room. Licensed Practical Nurse (LPN) #1 noted food in the resident's mouth. LPN #1 performed finger sweeps and cleared a sandwich and the plastic wrap from Resident #1's airway. There was no documented evidence on this report to confirm that CPR was initiated. On [DATE] at 12:00 PM, an interview with LPN #1 confirmed she was summoned to Resident #1's room on [DATE] and Resident #1 was upright in the bed but slumped over. LPN #1 stated she cleared a sandwich still wrapped in plastic from Resident #1's throat. LPN #1 stated she noted the resident to have a white bracelet on which indicated Resident #1 was a full code. LPN #1 stated she did not know why she didn't start CPR. The LPN stated she understood the facility's system for code status identification, but as she believed the resident was already dead, she did not initiate CPR. On [DATE] at 6:50 PM, an interview with Certified Nurse Assistant (CNA) #1 confirmed she was working when Resident #1 expired ([DATE]). CNA #1 stated Resident #1 did not respond to his name or touch. CNA #1 stated she turned on the room light and noticed the resident to be very pale. CNA #1 confirmed the nurse did not administer CPR to Resident #1. On [DATE] at 7:30 PM, an interview with CNA #4 revealed she was with CNA #1 when Resident #1 was found unresponsive. CNA #4 stated Resident #1 was pale in color but was still very warm. CNA #4 also confirmed CPR was not administered to Resident #1. On [DATE] at 10:45 AM, an interview with Agency Nurse #1 revealed she was the nurse assigned to Resident #1 on [DATE]. Agency Nurse #1 confirmed Resident #1 was not responsive but upon touching him, he was still warm. Agency Nurse #1 confirmed CPR was not provided. Agency Nurse #1 stated during the [DATE] incident, she was administering medications to other residents when a nurse or nurse aide asked "Is he a code?" (referring to Resident #1). Agency Nurse #1 stated she looked at the Electronic Medication Administration Record [REDACTED]. Review of the facility's EMAR for Resident #1 revealed the code status was listed as "Full Code". On [DATE] at 11:00 AM, an interview with Resident #1's attending physician confirmed the resident was a Full Code. The attending physician stated the facility had notified him on [DATE] that Resident #1 had expired and the facility failed to render CPR. The physician stated he could not defend the nurses who failed to provide CPR. Review of Resident #1's EMAR revealed the facility admitted the resident on [DATE] with diagnoses, which included, Alzheimer's Dementia with Behaviors, Dysphagia, [MEDICAL CONDITIONS], and Muscle Weakness, and from the most recent Minimum Data Set of [DATE], was coded with long and short term memory loss, and was coded as moderately impaired for decision making.

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. by: MS CI # Based on record review, policy review, consent review, job description review, and staff interviews, the facility's Administration failed to ensure the facility used its resources effectively,to implement it abuse policies and procedures by recognizing escalating behaviors for prevention of resident to resident abuse; and subsequent protection of residents from residents who exhibit behaviors for two (2) of 19 residents (Residents #1 and Resident #2). The facility's failure to have effective Administrative oversight, implementation, and monitoring of its resources resulted in a situation that is likely to cause serious injury, impairment, harm, or death to residents. This situation resulted in an Immediate Jeopardy, and the State Agency identified the Immediate Jeopardy (IJ) on 7/10/14. The IJ was determined to exist on 07/08/14, and the IJ was not removed prior to exit on 7/18/14, and is considered ongoing. Findings Include: A review of the job description entitled "Administrator" documented, "The administrator directs and coordinates all activities of the nursing home, in carrying out its objectives of providing the best possible care for each resident, in striving to create a sense of security and usefulness for the residents". The job description further read under "Responsibilities" the Administrator "Evaluates, implements, and documents disposition of recommendations from the facility's committees and consultants. Reviews and reports to appropriate parties Policy and Procedures adopted by operating company." Interview, on 7/10/14 at 6:45 PM, with the Administrator confirmed his knowledge of Resident #2's room change "about a week and a half ago" due to Resident #2's "attention seeking" behaviors. The Administrator explained, "He (Resident #2) would deficate on the floor, and his room mate objected to the hygiene practice." The Administrator also confirmed knowledge of Resident #2's admission to a behavioral unit "last year" for "inappropriate touching of a female". The Administrator failed to provide any evidence of his monitoring of Resident #2's behavior or room change. The Administrator stated Resident #1 would "call out 'I'm hungry' at times, repeatedly, when he had just ate". The Administrator confirmed the staff interventions for monitoring these behaviors was to "just watch them". The Administrator stated "They (staff) really don't know what behaviors are". The Administrator again failed to provide any evidence of his monitoring of Resident #1's behaviors.

Each resident must receive and the facility must 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. MS CI # Based on staff interviews, record reviews, policy reviews, and consent review, the facility failed to provide care in a manner that promoted the highest physical well-being for two (2) of 18 residents (Residents #1 and #2). The facility failed to provide the appropriate treatment and services as evidenced by the facility's failure to initiate Cardiopulmonary Resuscitation (CPR) on Resident #1, who was designated as a Full Code status , was found unresponsive in his room on [DATE] at 8:55 PM (Resident #1), and required CPR. In addition, the facility failed to provide Resident #2, psychology recommended physician ordered medications and Bi-Level Positive Air Pressure (Bi-Pap) Therapy. The facility's failure to provide CPR to Resident #1, who required CPR, placed other residents in need of CPR, in a situation that is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was determined to exist on [DATE] when Resident #2 placed a sandwich wrapped in plastic in the mouth of Resident #1, causing Resident #1 to asphyxiate (choke), subsequently requiring Resident 1's need for CPR. The facility's nursing staff failed to initiate CPR for Resident #1, and Resident #1 expired in the facility [DATE] at 8:55 PM. The State Agency identified the Immediate Jeopardy on [DATE]. The IJ was not removed prior to exit on [DATE] and is considered ongoing. Findings Include: Resident #1 A review of the facility's policy entitled "Cardiac Resuscitation Policy (DNR or No Code)" Latest Revision: ,[DATE] revealed; "In the event of a cardiopulmonary arrest, basic CPR will be performed, unless, a Do Not Resuscitate Order has been made by the resident's physician and the resident or resident's appropriate representative has made a valid written request in advance not to initiate basic CPR". A review of the facility's document entitled "Resident/Family Consent for Cardiopulmonary Resuscitation" revealed "I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in case of extreme emergency" Resident #1's Responsible Party had signed and initialed the form. A review of the facility's policy entitled "Cardiac Resuscitation Policy" stated "A red identification bracelet will be placed on a resident with a DNR (No Code) indication and a DNR sticker will be placed on the alert sheet in the front of the chart so staff can easily identify the code status of resident. Staff will be in-serviced in the policy regarding DNR and trained to identify status per facility policy". A review of the facility's document entitled "Resident Incident Report", dated [DATE], revealed facility staff found Resident #1 unresponsive in his room at 8:55 PM. When Licensed Practical Nurse (LPN) #1 noted food in the resident's mouth, LPN #1 performed finger sweeps and cleared a sandwich and the plastic wrap from Resident #1's airway. There was no documented evidence for initiation of CPR. On [DATE] at 12:00 PM, an interview with LPN #1 confirmed staff called her to Resident #1's room on [DATE] , and when she arrived in the room, Resident #1 was upright in the bed but slumped over. LPN #1 stated she noted bits of food on Resident #1's gown and immediately performed a finger sweep in the resident's mouth and retrieved part of a sandwich from the resident's mouth. LPN #1 stated she performed a second finger sweep and she retrieved the rest of the sandwich still wrapped in plastic from Resident #1's throat. LPN#1 confirmed she noted the resident to have a white bracelet on which indicated Resident #1 was a full code and did not know why she did not start CPR. The LPN stated she understood the system, but as she believed the resident was already dead, she did not initiate CPR. On [DATE] at 6:50 PM, an interview with CNA #1 confirmed the nurse did not administer CPR to Resident # 1. An interview on [DATE] at 7:30 PM, CNA #4 confirmed Resident #1 did not receive CPR. On [DATE] at 10:45 AM, an interview with Agency Nurse #1 confirmed Resident #1 was not responsive, was warm to the touch, but no staff initiated CPR. Review of Resident #1's record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 AM, an interview with Resident #1's attending physician confirmed the resident was a full code. The attending physician stated the facility had notified him on [DATE] that Resident #1 had expired and the facility failed to render CPR. The physician stated he could not defend the nurses who failed to provide CPR. Resident #2 (Psychological Consult Example) A review of the facility's document with a revision date of ,[DATE] and entitled "Consultant Reports" stated, "The written report should contain documentation that indicates recommendations or specific plans. Facility staff shall act on recommendations or plans to correct, improve, or initiate action in a timely manner." A review of the contracted psychological services document entitled "Note to Attending Physician", dated [DATE], indicated, "Unless medically contraindicated, please: 1) Consider the addition of [MEDICATION NAME] or the [MEDICATION NAME] Patch to support cognitive functioning." Resident #2's attending physician checked he agreed and signed the recommendation on [DATE]. There was no documented evidence facility staff clarified or implemented the recommendation for Resident #2. An interview with the Director of Nursing (DON) on [DATE] at 4:30 PM revealed the recommendations by the contracted psychological services dated [DATE] were prior to her accepting the DON position. The DON stated staff now put all consultant recommendations in each physician's folder and hand deliver to each physician for review and signing. The DON confirmed there was no documentation facility staff implemented the recommendations dated and signed on [DATE] by the attending physician for Resident #2. Resident #2 (Bi-Pap Example) Resident #2 is no longer in the facility therefore observation of the resident was not possible. A review of Electronic Medication Administration Record (E-MAR) dated for June and [DATE] revealed the [MEDICAL CONDITION] had not been administered on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. Interview on [DATE] at 10:45 AM with Agency Nurse #1 revealed she said she applied a regular oxygen mask to deliver the [MEDICAL CONDITION] therapy because she "couldn't find a mask" but it "didn't work right". A review of the current revised printed Physicians Orders, dated [DATE], revealed Resident #2 had an order which read, "Resident to have [MEDICAL CONDITION] (Bi-Level Positive Air Pressure) @ ,[DATE]/cm H2O (centimeters of water), full face mask, chin strap, heated humidifier, continuous O2 (oxygen) @ (at) 2L PM Q HS (2 liters per minute every hour of sleep)". The revision date on the order was [DATE]. A review of a "Monthly Recertification Note", dated [DATE], by Resident #2's attending physician stated that the resident "has been in and out of the hospital in the emergency room with episodes of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Vitals look okay today although his O2 sats (saturations) are borderline most of the time. He has had quite a bit of work up recently but I think his main problem is something has happened to his C-PAP. I think he is getting hypoxic and this is causing other problems (no specific problems were specified in this note)". A review of a delivery slip from the local medical supply company revealed a [MEDICAL CONDITION] machine was delivered to the facility on [DATE] for Resident #2's use. A compliance report from the medical supply company obtained from the memory chip in the [MEDICAL CONDITION] machine revealed the resident had not used the machine since [DATE] (approximately a year). A resident interview was not possible since Resident #2 was no longer in the facility; however, an observation made of Resident #2's room on [DATE] at 8:30 PM, revealed a [MEDICAL CONDITION] machine on Resident #2's bedside table. The tubing was connected to the machine; however, no mask was observed. CNA #5 stated when Resident #2 moved to the present room (approximately a week ago), there was not a mask with his belongings and confirmed it had been a long time since she had seen Resident #2 using a [MEDICAL CONDITION]. On [DATE] at 6:50 PM, an interview with CNA #1 confirmed she had never seen Resident #2 using the [MEDICAL CONDITION] after he moved into his current room. On [DATE] at 7:00 PM, CNA #5 confirmed she took care of Resident #2 every time she worked and had never witnessed the use of a [MEDICAL CONDITION]. An interview on [DATE] at 3:00 PM, with LPN #4 confirmed when the nurse initialed and checked the EMAR (Electronic Medication Administration Record), it meant the nurse had administered the treatment or medication. She stated if a resident refused, the nurse should indicate that on the EMAR and inform the Physician of the refusal. On [DATE] at 3:45 PM, LPN #7 revealed a check mark on the E-MAR indicated administration of a medication or treatment. LPN # 7 stated if a resident refused the medication or treatment, the nurse documented "N" on the E-MAR and the physician notified. On [DATE] at 4:00 PM, an interview with LPN # 8 confirmed a check mark on the E-MAR means administration of the medication or treatment. An "N" indicated refusal and reason to report to the physician. On [DATE] at 3:20 PM, an interview with LPN #3 revealed Resident #2 would always refuse use of the [MEDICAL CONDITION]. LPN #3 stated when a resident refused a treatment, the nurse was required to document in the Nurse ' s Notes and the physician notified. Resident #2's EMAR revealed no evidence of documentation of refusal of the [MEDICAL CONDITION].

A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.25; and any services that would otherwise be required under ?483.25 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(b)(4). MS CI # Based on observation, interview, record review, and policy review the facility failed to develop care plan interventions to address and manage disruptive and aggressive behaviors for three (3) of 14 residents reviewed for care planning. The facility failed to develop interventions for Resident #1's Code status and disruptive yelling out and crys of hunger Resident #2's aggressive verbalizations; and Resident 4's aggressive behaviors toward other residents. The facility's failure to develop a comprehensive plan of care with specific interventions and approaches for managing behaviors exhibited by Resident #1 and Resident #2 created a situation that is likely to cause serious injury, harm death, or impairment to other residents. Resident #2's escalating agitation towards Resident #1 resulted in Resident #2 putting a sandwich wrapped in plastic into Resident #1's mouth to "shut him the (F) up", which led to Resident #1's death in the facility on [DATE], was determined an Immediate Jeopardy (IJ). The IJ was identified by the State Agency on [DATE] and was determined to exist on [DATE]. The IJ was not removed prior to exit on [DATE] and is considered ongoing. Findings Include: Review of the facility's policy entitled, "Care Plans-Comprehensive Assessment", Latest Revision: ,[DATE] revealed, "The interdisciplinary team will develop a comprehensive care plan for resident that includes measurable objectives and timetables to meet a resident's optimal medical, nursing, dietary, and psychosocial needs and maximize the resident's level of functioning". Review of the facility's policy entitled, "Care Plan Procedure", latest revision date ,[DATE], revealed, "As new problems are identified they are added to the resident's care plan by the different disciplines". Resident #1 Review of Resident #1's Electronic Medication Administration Record [REDACTED]. Review of Resident #1's "RESIDENT/FAMILY CONSENT FOR [MEDICAL CONDITION] RESUSCITATION" indicated Resident #1 as having a Full Code Status and CPR should be performed on the resident in the case of emergency. Review of Resident #1's careplans revealed a care plan had not been developed for Resident #1's Full code status. Review of the Incident Report dated [DATE] at 8:55 PM revealed Resident #1 was found unresponsive with a sandwich wrapped in plastic lodged in his throat. This report indicated Resident #1 expired [DATE]. There was no documented evidence CPR was initiated. Interview with LPN #1 on [DATE] at 12:00 PM revealed on [DATE] she (LPN #1) responded to Resident #1's room and found him to be unresponsive. She stated Resident #1 was wearing a white bracelet which indicated the resident's Full Code status. LPN #1 confirmed CPR was not initiated per the plan of care. Review of Resident #1's nurse notes revealed on the night of [DATE] Resident #1 exhibited disruptive behavior by hollering out and moaning. Resident #1's physician was called and a one time order was given for [MEDICATION NAME] (anti-anxiety) medication, 1.0 milligram IM (intramuscular) injection. Review of Resident #1's care plans revealed no documented evidence a care plan had been developed with interventions to address the behavior of hollering out and moaning which was disturbing the resident's roommate (Resident #2). A review of Resident #1's Face Sheet revealed the facility admitted him on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #1 was moderately impaired for making decisions. The MDS also indicated Resident #1 required a mechanically altered diet and required one person physical assist with eating. Resident #2 Review of Resident #1's Nurses Notes (Resident #2's roommate) revealed on the night of [DATE] Resident #2 was agitated and complaining about Resident #1's disruptive behavior. Interview with the Social Services Designee (SSD) on [DATE] at 7:25 PM confirmed Resident #2 had a history of [REDACTED]. Review the Resident #2's current care plans revealed no documented evidence a care plan had been developed to address Resident #2's history of aggressive behaviors and Resident #2's escalating agitation towards Resident #1. Further review revealed no documented evidence a care plan had been developed for the areas identified on Minimum (MDS) data set [DATE] under behaviors. A review of Resident #2's Face Sheet revealed the facility admitted him on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #2 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Upon further review, the MDS showed Resident #2 experienced the following: "C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) ". Section C was coded with a "2" which indicated the behaviors occurred on 4 to 6 days during the assessment period. Resident #4 Review of the Nurses Notes for Resident #4 revealed the facility transferred the resident to the local Behavior Health Unit for admission due to aggressive behavior on [DATE] and again on [DATE]. Review of the Nurse Notes from [DATE] through [DATE] revealed aggressive behaviors were documented four (4) times in February 2014, two (2) times in [DATE], two (2) times in [DATE], and one (1) time in [DATE]. Review of Resident #4's current care plans revealed no care plan had been developed to address the behaviors exhibited by Resident #4. These aggressive behaviors included biting. hitting, scratching, and cursing. In an interview, on [DATE] at 3:55 PM, the Social Services Designee (SSD) confirmed Resident #4 had exhibited aggressive behaviors and no care plan was developed for the resident's aggressive behaviors. Review of Resident #4's Comprehensive Care Plan (CP), dated [DATE], revealed a CP to address side effects of antipsychotic medications documented approaches to monitor and document behaviors and side effects every shift and report to the MD (Medical Doctor). The care plan did not address behaviors associated with aggression toward other residents. Review of Resident #4's Electronic Medication Administration Record [REDACTED]. Review of the EMAR revealed the EMAR listed target behavior as depression and paranoia. The EMAR did not address monitoring for aggressive behaviors. Review of FAce Sheet revealed the facility admitted Resident #4 on [DATE] with diagnoses, which included [MEDICAL CONDITION]. Review of the current physician orders, dated [DATE], revealed an additional [DIAGNOSES REDACTED].

Based on the survey results dated 7/18/14, the facility failed to ensure Social Services implemented goals, developed appropriate plans of care and monitored residents to meet the mental and psychosocial needs of three (3) of 13 residents reviewed for behaviors (Resident #1, Resident #2, and Resident #4). This was identified as an Immediate Jeopardy (IJ) on 7/10/14. A revisit was conducted from 8/5/14 through 8/7/14 to validate the Allegation of Compliance (AoC). The Immediate Jeopardy, which began 7/8/14, was determined to be removed on 7/24/14. The facility provided an Allegation of Compliance which was accepted by the Centers for Medicare and Medicaid Services (CMS) on 8/5/14. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility were able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible AoC from 8/5/14 through 8/7/14 was accomplished through staff interview, record review, policy review, in-service review and observation. The facility provided evidence the facility had implemented corrective actions listed in the AoC. The IJ was determined to be removed on 7/24/14. The facility will remain out of compliance at Scope and Severity of "D", isolated deficiencies, that constitute no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/5/14. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. Residents #1 and #2 were not included in the validation/revisit sample of 8/5/14-8/7/14 due to Resident #1 expiring on 7/8/14, and due to Resident #2's discharge from the facility. Resident #2 had been discharged from the facility on 7/8/14, when he was taken into police custody, where he remained as of the date of the revisit of 8/5/14 through 8/7/14. Information contained in the Credible AoC submitted by the facility, alleged removal as of 7/24/14, and the State Survey Agency (SSA) validated the facility implemented corrective actions as follows: The SSA Surveyor validated that a care plan was developed on 7/23/14 to address psychosocial needs for Resident #4. The SSA Surveyor reviewed sign in sheets and content for in-services provided on 7/13/14 for Administrator #1, Director of Nursing #1, Assistant Director of Nursing, Social Services #1 related to the process for monitoring residents for room compatability based on documented behaviors and resident council concerns, and the new process for monitoring of resident behaviors was implemented 7/13/14. The SSA Surveyor reviewed the new policy entitled, "Mood and Behavior Monitoring Documentation" latest revision 7/14 and validated by interview with CNAs across all three (3) shifts, and with Administrator #3, that they understood the new procedure for monitoring resident behaviors. Social Services Staff #1 terminated her employment with the facility on 8/1/14. An interview on 8/5/14 at 12:00 PM with Social Services Staff #2 revealed she began working in the facility the week of 7/28/14. She confirmed orientation to the facility was completed on 7/30/14. Social Services Staff #2 confirmed her training included behavior monitoring, care planning, resident rights, resident code status, and abuse/neglect. Social Services Staff #2 confirmed that she reviews the behavior monitoring report as part of the new procedure implemented 7/13/14 and compares it to the nurses notes to ensure that residents' behaviors are monitored and that interventions are developed and care planned as needed to meet the individual needs of the residents. She stated she had personally met with all "residents in the building " to determine room compatibility. Observations were made of nine (9) CNAs on all three (3) shifts to validate knowledge and demonstration of the new procedure for documenting resident behaviors. The SSA Surveyor observed the facility's management company's Registered Nurse and Facility Quality Improvement (QI) Nurse providing oversight and assistance to the facility's staff regarding the psychosocial needs of the residents during the 8/5/14 thru 8/7/14 revisit as outlined in the AoC. The SSA Surveyor validated that the facility had created a new position for a Social Services Assistant thru interview with Administrator #3 on 8/7/14 at 10:45 AM, and the job description for the new Social Services Assistant position was reviewed. Interview with Administrator #3 revealed that candidates were being screened, but a selection had not been finalized as of the date of the revisit. During the revisit of 08/5/14 - 8/7/14, the SSA Surveyor reviewed the contract with the new Licensed Certified Social Worker (LCSW), dated 8/1/14, and also reviewed progress notes in the medical record written by the LCSW for Resident #3 and Unsampled Residents #A, #B and #C. Review of the contract indicated the LCSW would be at the facility at least monthly and responsibilities included overseeing the social services department, providing necessary services to individual residents, and documenting in the individual residents medical record. The facility will remain out of compliance at Scope and Severity of "D", isolated deficiencies, that constitute no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.

The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. MS CI # Based on record review, interview and job description review, the facility failed to ensure Social Services implemented goals, developed appropriate plans of care, and monitored residents to meet the mental and psychosocial needs of three (3) of 13 residents reviewed for behaviors. (Resident #1, Resident #2 and Resident #4) The facility failed to identify and address Resident #2's escalating agitation towards Resident #1 and failed to identify and address Resident #1's disruptive behaviors resulting in Resident #2 putting a sandwich wrapped in plastic in the mouth of Resident #1, who required a pureed diet, leading to the resident's asphyxiation (choking). The facility's failure to provide for the mental and psychosocial needs of these residents placed these residents in a situation that is likely to cause serious injury, impairment, or death to other residents. An Immediate Jeopardy (IJ) was determined to begin on 7/8/14 when Resident #2 became agitated and complained to the facility staff about his roommate's (Resident #1) behaviors of yelling out, moaning, and making noises. The State Agency identified the IJ on 7/10/14. The IJ was not removed prior to exit on 7/18/14 and is considered ongoing. Findings Include: Interview on 7/10/14 at 7:05 PM with the SSD revealed she had been employed at the facility since 1995. The SSD signed the job description for Social Service Director in 2011. Review of the Job Description signed by the Social Services Designee (SSD) entitled, "Social Services Director", signed by the SSD and dated 6/17/11, revealed under, "Job Summary: Directs and supervises social service program. Evaluates the social needs of each patient admitted and formulates a written plan of care." Responsibilities included: "reviews and updates plan of care according to established policies; records continuing progress notes on the patient's social needs and response of the patient to delivered social services". Qualifications for the position included: "A college degree is mandated in Sociology or another related field approved by State representatives". Additionally, the qualifications listed that the Social Service Director would be "able to recognize and identify situations in which problems are such that referral is indicated". Interview on 7/16/14 at 11:09 AM with the SSD confirmed signing the facility Social Service Job Description and stated, "I didn't have the qualifications and they changed it to Social Service Designee". The SSD was unable to recall signing a new job description. Interview on 7/12/14 at 10:30 AM with the SSD confirmed the facility had a contracted Licensed Clinical Social Worker (LCSW) on staff; however, the LCSW did not see residents routinely and did not document in the residents' medical records. The SSD stated the LCSW's responsibility was to "check up on" the SSD, look at care plans, and Social Service's assessments. She reported the LCSW came to the facility quarterly and would send a report to the administrator. Review of recommendations from the contracted LCSW, dated 12/6/13, revealed a resident (the LCSW failed to identify what resident) was "combative with bath" and there was no care plan that identified care needs. Recommendations from the LCSW, dated 3/5/14, documented the need to update care on several residents. LCSW failed to identify which residents. Interview with the SSD on 7/10/14 revealed when problems were reported to her she would investigate and document in the Social Notes. However, there was no documentation in the Social Notes to corroborate She stated, "CNA (Certified Nurse Assistants) might document on the Jot Sheet" which she confirmed was not part of the medical record. In a later interview on 7/15/14 at 11:35 AM, the SSD reported she did not routinely review the "Jot Sheet" nor the Nurse Notes. She confirmed she relied on verbal reports from staff and residents to obtain information on the residents. Review of the facility's policy entitled, "Social Services Program", Latest Revision: 01/12, revealed the purpose of the facility's Social Service Program was to assure that sufficient and appropriate social services were provided to meet the resident's needs. Review of the facility's policy entitled, "Room Changes", Revised 01/12, documented,"The Social Service Designee/Social Worker, in conjunction with the DON, will assure that each resident is assigned a room suited to his/her needs. 2. Room changes are made for the following reasons: Incompatibility with roommates 3. All needs and requests for room changes will be handled by Social Services and/or the DON and supporting documentation will be maintained in the resident's medical record." Resident #1 Review of Resident #1's Nurse Notes revealed on the night of 7/6/14, Resident #1 was yelling out and moaning and the resident's roommate (Resident #2) was agitated and complaining about the yelling. The Nurses Notes showed the nurse on duty on 7/6/14 called Resident #1's physician and received an order for [REDACTED].#1. Review of Resident #1's Interdisciplinary Progress Notes revealed no documented evidence of monitoring or interventions implemented by the Social Services Designee (SSD) to address the behavior of hollering out and moaning which was disturbing the resident's roommate (Resident #2). A review of Resident #1's record revealed the facility admitted him on 2/3/14 with [DIAGNOSES REDACTED]. Muscle Weakness. Resident #2 Interview with the Social Services Designee (SSD) on 7/10/14 at 7:25 PM confirmed Resident #2 had a history of [REDACTED]. She stated Resident #2 "had problems in the past". Interview on 7/14/14 at 12:00 (noon), the SSD stated Resident #2 was going to an outpatient psychiatric program in the past; however, due to medical problems, Resident #2 was unable to continue. Interview, on 7/10 /14 at 7:05 PM, confirmed Resident #2 was not attending any outpatient programs at the time of the incident (7/8/14). Review of Resident #2's nurse notes, provided by SSD, revealed the last entry for Resident #2 attending a "day program" was dated 3/29/12. Interview on 7/10/14 at 6:45 PM revealed the Administrator reported the facility moved Resident #2 to Resident #1's room approximately a week prior to the incident of 7/8/14. According to the Administrator, Resident #2 was moved due to his prior roommate complaining about Resident #2's behavior of defecating on the floor. The Administrator did not reveal any evaluations done after the room change. Review of Resident #2's Interdisciplinary Progress Notes revealed no documented evidence of monitoring or inventions implemented by SSD for these behaviors. A review of Resident #2's Face Sheet revealed the facility admitted him on 12/30/10 with [DIAGNOSES REDACTED]. Review of Resident #2's Department of Mental Health Pre-Admission Screening and Resident Review (PASRR) Determination, dated 3/29/11, revealed admission was approved with the following Recommendations: Specialized Services by Counseling and Mental Health; and Mental Health Rehabilitation Services provided by the Nursing Facility. Treatment recommendations consisted of medication monitoring, individual/family/group therapy, elderly psychosocial rehabilitation, and nursing assessment. Interview with SSD on 7/14/14 at 12:00 (noon) revealed Resident #2 attended a Intensive Outpatient Program (IOP) but had started having medical problems and had stopped. The SSD provided nurse notes which revealed the last time Resident #2 attended the IOP was dated 3/29/12. The SSD was unable to provide information of any attempts to resume treatment at IOP. Resident #4 Review of Resident #4's Nurse Notes for January 2014 through present revealed aggressive behaviors were documented four (4) times in February 2014, two (2) times in May 2014, two (2) times in June 2014, and one (1) time in July 2014. Review of the medical record for Resident #4 revealed the facility transferred Resident #4 to a behavior health unit for aggressive behavior on 5/21/14 and 6/16/14 and the notes indicated Social Services was notified. Review of Resident #4's progress notes and care plans revealed a lack of social services monitoring and interventions to address agitated/ aggressive behavior. Interview with the Social Services Designee (SSD) on 7/10/14 at 7:25 PM revealed the Social Service department was not monitoring any residents with identified behavioral problems. Interview on 7/12/14 at 3:55 PM with Social Services Designee (SSD) confirmed no interventions were developed to address the resident's aggressive behaviors. Review of the Face Sheet revealed the facility admitted Resident #4 on 6/4/13 with diagnoses, which included Alzheimer's disease. Review of the current Physician Orders, dated July 2014, revealed a [DIAGNOSES REDACTED].

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. MS CI # Based on incident reports, staff written statements, staff interviews, and abuse policy review, the facility failed to: (A) assess residents, develop and implement care plans, and monitor residents with behaviors that could possibly lead to resident on resident conflict; (B) identify events and patterns that constituted abuse; (C) examine incidents to determine if policies and procedure revisions were needed; (D) protect residents for two (2) of eight (8) residents reviewed for abuse as evidenced by Resident #1 yelling out and moaning which caused increased anxiety for Resident #2. Resident #2 became agitated, asked staff to do something to stop his roommate's yelling, then placed a sandwich wrapped in plastic into Resident #1's mouth "to shut him the 'F' up". (Resident #1 and Resident #2) The facility's failure to develop and utilize components of the abuse/neglect policy related to Resident #1's disruptive behaviors and Resident #2's escalating agitation and aggressive statements towards Resident #1 resulted in Resident #2 putting a sandwich wrapped in plastic in the mouth of Resident #1 leading to Resident #1's asphyxiation (choking) and death. The facility's failure to intervene in the residents' known behaviors contributed to the death of Resident #1 and has the likelihood of resulting in serious injury, harm, impairment, or death to other residents. The State Agency identified this Immediate Jeopardy (IJ) on 7/10/14. The IJ was determined to exist on 7/08/14, was not removed prior to exit on 7/18/14, and is considered ongoing. Findings Include: A review of the facility's document entitled "Seven Components of Abuse and Neglect Regulations", with a revision date of 07/13, disclosed Screening of Employees, Training of Employees, Prevention of Abuse, Identification, Investigation of Abuse, Protection of the Resident, and Reporting Abuse were addressed in the facility's abuse policy. A Nurses Note dated 7/7/14 at 1:17 AM by Agency Nurse #1, revealed documentation of escalating behaviors between Resident #1 and Resident #2 in Resident #1's record. According to Resident #1's record documentation, Resident #1 was in his room screaming and restless and his roommate (Resident #2) stated he could not sleep. The Agency Nurse documented she called Resident #1's Physician at midnight, and received an order for [REDACTED].#1 documented when she made rounds after administering the [MEDICATION NAME], Resident #1 was asleep and resting quietly. Review of Resident #2's nurse notes for 7/6/14 revealed no documentation addressing the incident on 7/6/14, and Resident #2 remained in the room with Resident #1. The facility failed to provide any documentation of a room change assessment in order to remove Resident #2 from Resident #1's behaviors to protect both residents. During an interview on 7/12/14 at 10:45 AM, Agency Nurse #1 revealed on the night of 7/6/14, Resident #1 was restless and was moaning and barking like a dog. The LPN stated Resident #2 was hollering, "Shut him the 'F' up". She stated she made a call to Resident #1's physician on 7/6/14 and got an order for [REDACTED]. She stated she saw Resident #1 unresponsive and Licensed Practical Nurse (LPN) #1 doing a finger sweep in Resident #1's mouth. When Resident #2 was asked if he had given Resident #1 the sandwich, Agency Nurse #1 said Resident #2 stated, "I put it in his 'F-ing' mouth to shut him the 'F' up because he was hungry". The facility failed to provide evidence of the 7/6/14 behaviors being identified by staff as a possible pattern of behaviors leading to the harm of other residents, and provided no evidence the incident was reviewed to determine if policies and procedure revisions needed revision. On 7/10/14 at 6:50 PM, an interview with Certified Nurses Assistant (CNA) #1 revealed on 7/8/14, Resident #2 told her, "Ya'll are gonna have to do something to him (roommate). He's kept me awake for two nights". Review of Resident #1's and Resident #2's medical records revealed no documentation behaviors were reported to the multidisciplinary team, appropriate interventions were initiated, care plans were revised or initiated, or monitoring of Resident #1 or Resident #2 was increased. Review of facility documents revealed no evidence of resident behavior assessments, care plan development/implementation, or resident monitoring after the 7/6/14 behaviors and before the 7/8/14 behaviors. Review also revealed no documented evidence of communication and implementation of interventions by the interdisciplinary team. Interviews with the facility staff revealed resident behaviors were exhibited by Resident #1 and Resident #2. The facility failed to document appropriate interventions for these known behaviors in the resident records. There was no evidence the charge nurse or social services was notified when behaviors were exhibited. A review of Resident #1's Face Sheet revealed the facility admitted him on 2/3/14 with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of 6/24/14 revealed Resident #1 had problems with long and short term memory and was moderately impaired for making decisions. The MDS also indicated Resident #1 required a mechanically altered diet and required a one person physical assist with eating. MDS also documented Resident #2 required two(2) person assist with bed mobility. A review of Resident #2's Face Sheet revealed the facility admitted him on 12/30/10 with diagnoses, which included [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Symbolic Disorder, Anxiety, [MEDICAL CONDITION], and Diabetes. The most current Minimum Data Set (MDS) with an Assessment Reference Date of 6/30/14 revealed Resident #2 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact. Further review of the MDS showed Resident #2 experienced other behavioral symptoms not directed toward others on four (4) to six (6) days during the assessment period.

Based on the survey results dated 7/18/14, the facility failed to protect residents from resident on resident abuse and aggressive resident behaviors for two (2) of eight (8) residents reviewed for abuse (Resident #1 and Resident #2). This was identified as an Immediate Jeopardy (IJ) on 7/10/14. A revisit was conducted from 8/5/14 through 8/7/14 to validate the Allegation of Compliance (AoC). The Immediate Jeopardy, which began 7/8/14, was determined to be removed on 7/24/14. The facility provided an Allegation of Compliance, which was accepted by the Centers for Medicare and Medicaid Services (CMS) on 8/5/14. CMS authorized the State Agency to conduct a revisit in order to determine if corrective actions implemented by the facility were able to demonstrate removal of the Immediate Jeopardy. The validation of the Credible AoC from 8/5/14 through 8/7/14 was accomplished through staff interview, record review, contract review, in-service review, and observation. The facility provided evidence of implementation of corrective actions listed in the AoC. The IJ was determined to be removed on 7/24/14. The facility will remain out of compliance at Scope and Severity of "D", isolated deficiencies, that constitute no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility provided an Allegation of Compliance (AoC) that was accepted by CMS on 8/5/14. CMS authorized the State Survey Agency (SSA) to conduct a revisit in order to determine if corrective actions implemented by the facility have been able to demonstrate removal of the Immediate Jeopardy. Information contained in the Credible AoC submitted by the facility, alleged removal of the IJ as of 7/24/14. Resident #1 and #2 were not included in the validation/revisit sample of 8/5/14-8/7/14 due to Resident #1 expiring on 7/8/14, and due to Resident #2's discharge from the facility. Resident #2 had been discharged from the facility on 7/8/14, when he was taken into police custody, where he remained as of the date of the revisit of 8/5/14 through 8/7/14. The SSA Surveyor validated the following corrective actions: The SSA Surveyor reviewed a statement signed by Social Services Staff #1 which confirmed she had interviewed 90 residents related to roommate compatibility, completed on 7/9/14, with no concerns identified. Social Services Staff #1 resigned from the facility effective 8/1/14. The SSA Surveyor validated in-service sign in sheets and content related to resident room compatibility and reporting of resident behaviors dated 7/9/14 through 7/13/14. Attendance of facility staff included: Administrator #1, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Dietary Staff, Social Services Staff #1, Activity Staff, Maintenance Staff, Laundry Staff, Housekeeping Staff, Agency Nursing Staff, and Office Personnel (e.g. Business Office Staff and Receptionist). The SSA Surveyor validated the in-service was conducted through review of sign in sheets and in-service content, dated 7/23/14, on resident rights and abuse/neglect to include protection of residents from aggression, and the reporting of resident behaviors and complaints. A Registered Nurse, who was part of the Management Support Company, provided the in-service as indicated in the acceptable Allegation of Compliance. Staff interviews were conducted from 8/5/14 through 8/7/14. A total of 72 employees were interviewed which included staff across all disciplines and shifts. Staff interviews included the Administrator #3, Director of Nurses #2, Assistant Director of Nursing, Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Social Services Staff #2, Dietary Staff, current Social Service Staff, Activity Staff, Maintenance Staff, Laundry Staff, Housekeeping Staff, Agency Staff, and Business Office Personnel and the Receptionist staff. The interviews validated that staff were knowledgeable of the content regarding resident room compatibility, reporting of resident behaviors and complaints, Resident Rights and abuse/neglect to include protection of residents from aggressive behavior. Interviews with CNAs on all shifts and observation confirmed room [ROOM NUMBER] was the designated room used for residents with roommate compatibility problems as a temporary intervention. The SSA surveyor validated that in-servicing was provided on 7/13/14 for Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, across all shifts on the new policy and procedure for " Behavior Monitoring " through review of the sign-in sheets for this in-service. The SSA observed documentation of resident behaviors using the newly implemented behavior monitoring tool, with nine (9) Certified Nursing Assistants (CNA), across all shifts. The newly implemented behavior monitoring tool (electronic prompt on the kiosk) included documentation of exhibited resident behaviors by the CNAs. This tool generates a report that is printed and compared to the nurses notes for each resident by the Director of Nurses, the Administrator, and the Social Services Staff. The data (report) is then used to identify behaviors and assist in the development of care plan interventions for the resident exhibiting behaviors. Staff interviews with 70 employees across all disciplines and shifts validated the Hand in Hand Module training had been initiated and the facility had completed in-services using Modules One (1) and Two (2). Interview with Administrator #3 revealed that the facility had a contract with Simpson General Hospital to provide an intensive outpatient program (IOP) for their facility's residents. Interview with Administrator #3 also confirmed the facility did not have a contractual agreement with Patients' Choice Hospital but did have a referral process in place for inpatient behavioral health services. It was also confirmed through interview with Administrator #3 that Psychological Care Services provided in facility psychological services by a Psychologist for their residents requiring mental health services. Region 8 Mental Health Services also provided in facility mental health services through a referral process. Contractual agreements for Simpson General Hospital and Psychological Care Services as well as the referral process for Patients Choice Hospital and Region 8 Mental Health Services were validated by the surveyor during the revisit. Administrator #3 assumed the role of Administrator on 8/01/14. The facility will remain out of compliance at Scope and Severity of "D", isolated deficiencies, that constitute no actual harm with potential for more than minimal harm that is not an Immediate Jeopardy. The facility will remain out of compliance while the facility develops and implements the Plan of Correction (PoC); and while the facility's Quality Assessment and Assurance Committee monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.

The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. MS CI # Based on incident reports, staff written statements, staff interviews and policy review, the facility failed to protect residents from resident on resident abuse and aggressive resident behaviors for two (2) of eight (8) residents reviewed for abuse as evidenced by Resident #2 stated he placed a sandwich wrapped in plastic into Resident #1's mouth "to shut him the 'F' up because he was hungry" which caused Resident #1 to asphyxiate (choke) and expire at the facility. (Resident #1 and Resident #2) The facility's failure to monitor and intervene with Resident #1's disruptive behaviors and failure to monitor and intervene with Resident #2's escalating agitation and aggressive statements towards Resident #1 resulted in Resident #2 putting a sandwich wrapped in plastic in the mouth of Resident #1 leading to Resident #1's asphyxiation (choking)and death. Resident #1 was prescribed a pureed diet order and was unable to feed himself. The facility's failure to intervene in the residents' known behaviors resulted in harm for Resident #1 and has the likelihood of resulting in serious injury, harm, impairment, or death to other residents. The State Agency identified this Immediate Jeopardy (IJ) on [DATE]. The IJ was not removed prior to exit on [DATE] and is considered ongoing. Findings Include: A review of the facility's document entitled "Unmanageable Resident", with a revision date of ,[DATE], disclosed the following: "1. The facility will provide each resident with a safe/secure place of residence. 2. Should a resident become hostile or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Staff/Charge Nurse must be notified immediately and must: a. Provide for the safety of all residents in the facility; b. Notify the resident's attending physician for instructions; c. Notify the Director of Nursing and Administrator; d. Notify the resident's responsible party as soon as possible. 3. Every effort must be made to calm the resident by using creative alternative intervention. However, personal safety must always be considered and local law enforcement may be called for assistance. 4. The facility must demonstrate that appropriate multi-disciplinary interventions have been tried and failed before discharging a resident because of violent behavior. 5. Complete documentation of the incident must be recorded in the resident's medical record, as well as the filing of an incident report with the administrator. 6. Be aware that medical situations (i.e., urinary infection, medication reaction) may result in a sudden change in behavior." Upon review of a Nurses Note entered by Agency Nurse #1 dated [DATE] at 1:17 AM, revealed behavior problems between Resident #1 and Resident #2. The Nurses Note read, "Received resident (Resident #1) down in room screaming and restless, roommate (Resident #2) states he could not sleep. (Resident #1's Physician) was called at 2400 (midnight), and he gave order for a one time dose of [MEDICATION NAME] 1 mg (milligram), IM (intramuscular) for agitation." Agency Nurse #1 documented when she made rounds after administering the one time dose of [MEDICATION NAME], Resident #1 was asleep and resting quietly. Record review revealed there was no documented evidence of communication and implementation of interventions by the interdisciplinary team. Interviews with the facility staff revealed resident behaviors were exhibited by Resident #1 and Resident #2. The facility failed to document interventions for these known behaviors in the resident records. No evidence was provided of charge/staff nurse notification when behaviors were exhibited. Resident #1 A review of the facility's document entitled "Resident Incident Report" report completed by LPN #1 revealed on [DATE] at 8:55 PM, Certified Nursing Assistant (CNA) #2 called Licensed Practical Nurse (LPN) #1 to Resident #1's room. When LPN #1 noted Resident #1 was without a blood pressure, pulse or respirations. LPN #1 observed small pieces of a sandwich on the resident's chest. A finger sweep was performed and a silver dollar sized piece of sandwich was removed from Resident #1's mouth. The Incident Report further documented, "Resident deceased " (this report failed to document what qualified discipline pronounced death, LPN #1 prepared the report). The report confirmed the attending physician, the family, local law enforcement, and were notified The report revealed "Immediate action taken: CORONER CALLED and family notified". Resident #1's body was released to the state crime lab for an autopsy. An Interview on [DATE] at 11:30 AM with an Investigator from the State Attorney General's office revealed Resident #2 had stated in an interview that he had put the sandwich in Resident #1's mouth "to shut him up". During investigation, a review of the Nurses Notes written by LPN #1, dated [DATE] at 2:19 AM revealed, "AT APPROXIMATELY 8:55 PM ON [DATE], I WAS SUMMONED TO RESIDENT ROOM WEST 6A PER CNA (#2) STATING SOMETHING WAS WRONG WITH THE RESIDENT OCCUPYING THE ROOM, RESIDENT #1 UPON ARRIVAL TO THE ROOM I NOTED THAT RESIDENT WAS deceased ". LPN #1 documented performing a finger sweep and retrieving the sandwich wrapped in plastic from Resident #1's throat. LPN #1 also documented in the nurses notes she had pulled back the curtain and asked the roommate (Resident #2) if he had given Resident #1 a sandwich. Resident #2 responded, "Yes, I did a few minutes ago. I gave it to him because he wouldn't shut up". On [DATE] at 6:42 PM, an interview with the Assistant Director of Nursing revealed she saw Resident #1 being fed by staff at mealtime. She confirmed resident was unable to feed himself. On [DATE] at 12:00 PM, an interview with LPN #1 confirmed she was working the evening of [DATE]. She stated she worked the 7 PM-7 AM shift. LPN #1 stated staff called her to Resident #1's room on [DATE] at approximately 8:55 PM. She stated the resident was in an upright position but slumped over. She stated she noted bits of bread crust and pimento cheese on the front of the resident's gown. LPN #1 confirmed Resident #1 had minimal upper body movements and was unable to feed himself. LPN #1 stated she immediately performed a finger sweep of Resident #1's mouth. She stated she retrieved a part of a sandwich but could still feel something a little further down. She performed another finger sweep, was able to grab the plastic wrap in which the sandwich had been wrapped, and pulled the rest of the sandwich out. LPN stated after removing the sandwich, she noted frothy secretions and stomach contents in the resident's throat and mouth. A review of the facility's document entitled, "Brief Statement of Facts" and signed by CNA #2 on [DATE] at 10:55 PM stated, "(Resident #2) came up the hallway and he said 'I'm sick of all this[***] and I asked him what's wrong and he said, 'that damn man with all that hollering' and I asked him who and he said 'my roommate' ". The document also noted CNA #2 stated she went to the room to check on Resident #1 and to ask him what was wrong and Resident #1 answered he was hungry. A review of the "Brief Statement of Facts" written by CNA #1 revealed she had been passing out snacks and as she got to Resident #1's and Resident #2's room, (Resident #2) stated he didn't want a snack. CNA #1 wrote that Resident #2 stated, "Y'all need to give that (MF) something for he (direct quote) can shut the hell up all he's doing is groaning and hollering that he was hungry." The CNA stated she gave Resident #1 some "Grape juice" and left the resident sitting up in the bed. She stated as she was leaving, Resident #2 was still saying to do something with Resident #1's hollering. CNA #1 stated she left the room but returned a while later and Resident #1 was noted still sitting up in the bed but was slumped over. She stated she began calling his name and shaking him, but he did not respond. She called for the nurse. On [DATE] at 6:50 PM, an interview with CNA #1 confirmed she worked on [DATE] when Resident #1 expired. She stated she gave Resident #1 some juice during snack service. While she was in the residents' room, Resident #2 was complaining about Resident #1's hollering. The CNA stated Resident #2 had told her, "Y'all are going to have to do something to him. He's kept me awake for two nights." The CNA stated when she went back to the room a little later, Resident #1 did not respond to verbal or shaking him. CNA #1 stated she then turned on the room light and saw Resident #1 was very pale. She stated she yelled for the nurse. She stated when LPN #1 removed the sandwich and plastic wrap from Resident #1 she noted the wrapper had Resident #2's name on it and was dated as the 2:00 PM snack. On [DATE] at 7:00 PM, an interview with CNA #5 revealed Resident #1 was often awake during the night time hours. CNA #5 confirmed Resident #1 was not able to feed himself. She stated staff fed Resident #1 all meals and snacks. Review of Resident #1's Physician order [REDACTED]. There was no documented order for thickened liquids. On [DATE] at 10:45 AM, an interview with Agency Nurse #1 revealed at approximately 8:00 PM, she had heard Resident #1 stating "I'm hungry, I'm hungry." The Agency Nurse stated on the night of [DATE], Resident #1 was restless and was moaning and barking like a dog. The LPN stated Resident #2 was hollering, "Shut him the 'F' up". She stated she had made a call to Resident #1's physician and got an order for [REDACTED]. intramuscular. Agency Nurse #1 stated later when she was passing pills on [DATE] at approximately 8:45 PM, she was alerted that Resident #1 was found unresponsive. She stated when she got to the resident's room, LPN # 1 was removing food from Resident #1's mouth. Agency Nurse #1 said when Resident #2 was asked if he had given Resident #1 the sandwich, Resident #2 stated, "I put it in his 'F-ing' mouth to shut him the 'F' up because he was hungry". A review of Resident #1's Face Sheet revealed the facility admitted him on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #1 had problems with long and short term memory and was moderately impaired for making decisions. The MDS also indicated Resident #1 required a mechanically altered diet and required a one person physical assist with eating. MDS also documented Resident #2 required two(2) person assist with bed mobility. Resident #2 On [DATE] at 10:45 AM, an interview with Agency Nurse #1 revealed on the night of [DATE] Resident #2 was agitated and hollering about Resident #1's disruptive behavior. Review of Resident #2's nurse notes for [DATE] failed to address the incident and Resident #2 remained in the room with Resident #1. The facility failed to provide any documentation of attempting to remove Resident #2 from the situation. Review of the facility's policy entitled, "Room Changes", Revised ,[DATE], documented to assure the resident's appropriateness of placement within the facility, room changes are made for incompatibility with roommates. Interview, on [DATE] at 6:50 PM, with CNA #1 revealed on [DATE], she entered Resident #2's room and Resident #2 told her, "Ya'll are gonna have to do something to him. He's kept me awake for two nights". Review of Resident #2's nurse notes and care plan revealed no documented evidence of any staff intervention. Review of an Incident Report and Police Report, both dated [DATE], revealed on [DATE], Resident #2 confessed to trying to stop Resident #1's yelling and hollering that he was hungry by putting a sandwich wrapped in plastic wrap in Resident #1's mouth. Resident #1 choked on the wrapped sandwich and expired. Resident #2 was no longer in the facility, and an interview was not possible due to his arrest. Interview and review of Resident #2's nurses notes revealed the facility failed to address Resident #2's verbalized needs and/or assess Resident #2 for a possible room change. Resident #2 continued to complain and request staff assistance in relieving Resident #1's yelling and disruptive behavior. The facility staff failed to intervene and address these continued verbalized complaints by Resident #2 regarding Resident #1 which, Resident #1's nurse notes revealed began the night of [DATE]. A review of Resident #2's Face Sheet revealed the facility admitted him on [DATE] with diagnoses, which included [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Symbolic Disorder, Anxiety, [MEDICAL CONDITION], and Diabetes. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #2 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact. Further review of the MDS showed Resident #2 experienced other behavioral symptoms not directed toward others on four (4) to six (6) days during the assessment period.

2 The resident has the right to refuse treatment, to refuse to participate in experimental research, and to formulate an advance directive as specified in paragraph (8) of this section. The facility must comply with the requirements specified in subpart I of part 489 of this chapter related to maintaining written policies and procedures regarding advance directives. These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive. This includes a written description of the facility's policies to implement advance directives and applicable State law. MS CI # Based on record review, policy review, incident report review, consent review, and staff interviews for one (1) of seven (7) residents reviewed, with Advanced Directives who had expired in the facility. The facility failed to honor Resident #1's rights as requested in his Advanced Directive, for a Full Code status. The facility failed to administer Cardiopulmonary Resuscitation (CPR) when Resident #1 was found unresponsive by Licensed Practical Nurse (LPN) #1. The facility's failure to honor Resident #1's Advanced Directive of Full Code status and to initiate CPR, places residents with Advance Directives of Full Code status in a situation that is likely to cause serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy on [DATE], and was determined to exist on [DATE]. The IJ was not removed prior to exit on [DATE] and is Findings Include: A review of the facility's policy entitled, Cardiac Resuscitation (CPR) Policy, Latest Revision: ,[DATE], revealed CPR will be performed unless the resident or resident's appropriate representative has made a valid written request in advance not to initiate basic CPR. A review of the facility's document entitled Resident/Family Consent for Cardiopulmonary Resuscitation signed [DATE] stated I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in case of extreme emergency Resident #1's Responsible Party had signed and initialed the consent form for Resident #1. A review of the facility's document entitled, Resident Incident Report, dated [DATE], revealed the time of the incident was 8:55 PM and that Resident #1 was found unresponsive in his room. Licensed Practical Nurse (LPN) #1 noted food in the resident's mouth. LPN #1 performed finger sweeps and cleared a sandwich and the plastic wrap from Resident #1's airway. There was no documented evidence on this report to confirm that CPR was initiated. On [DATE] at 12:00 PM, an interview with LPN #1 confirmed she was summoned to Resident #1's room on [DATE] and Resident #1 was upright in the bed but slumped over. LPN #1 stated she cleared a sandwich still wrapped in plastic from Resident #1's throat. LPN #1 stated she noted the resident to have a white bracelet on which indicated Resident #1 was a full code. LPN #1 stated she did not know why she didn't start CPR. The LPN stated she understood the facility's system for code status identification, but as she believed the resident was already dead, she did not initiate CPR. On [DATE] at 6:50 PM, an interview with Certified Nurse Assistant (CNA) #1 confirmed she was working when Resident #1 expired ([DATE]). CNA #1 stated Resident #1 did not respond to his name or touch. CNA #1 stated she turned on the room light and noticed the resident to be very pale. CNA #1 confirmed the nurse did not administer CPR to Resident #1. On [DATE] at 7:30 PM, an interview with CNA #4 revealed she was with CNA #1 when Resident #1 was found unresponsive. CNA #4 stated Resident #1 was pale in color but was still very warm. CNA #4 also confirmed CPR was not administered to Resident #1. On [DATE] at 10:45 AM, an interview with Agency Nurse #1 revealed she was the nurse assigned to Resident #1 on [DATE]. Agency Nurse #1 confirmed Resident #1 was not responsive but upon touching him, he was still warm. Agency Nurse #1 confirmed CPR was not provided. Agency Nurse #1 stated during the [DATE] incident, she was administering medications to other residents when a nurse or nurse aide asked Is he a code? (referring to Resident #1). Agency Nurse #1 stated she looked at the Electronic Medication Administration Record [REDACTED]. Review of the facility's EMAR for Resident #1 revealed the code status was listed as Full Code. On [DATE] at 11:00 AM, an interview with Resident #1's attending physician confirmed the resident was a Full Code. The attending physician stated the facility had notified him on [DATE] that Resident #1 had expired and the facility failed to render CPR. The physician stated he could not defend the nurses who failed to provide CPR. Review of Resident #1's EMAR revealed the facility admitted the resident on [DATE] with diagnoses, which included, Alzheimer's Dementia with Behaviors, Dysphagia, [MEDICAL CONDITIONS], and Muscle Weakness, and from the most recent Minimum Data Set of [DATE], was coded with long and short term memory loss, and was coded as moderately impaired for decision making.

2 The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility must not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. MS CI # Based on incident reports, staff written statements, staff interviews and policy review, the facility failed to protect residents from resident on resident abuse and aggressive resident behaviors for two (2) of eight (8) residents reviewed for abuse as evidenced by Resident #2 stated he placed a sandwich wrapped in plastic into Resident #1's mouth to shut him the 'F' up because he was hungry which caused Resident #1 to asphyxiate (choke) and expire at the facility. (Resident #1 and Resident #2) The facility's failure to monitor and intervene with Resident #1's disruptive behaviors and failure to monitor and intervene with Resident #2's escalating agitation and aggressive statements towards Resident #1 resulted in Resident #2 putting a sandwich wrapped in plastic in the mouth of Resident #1 leading to Resident #1's asphyxiation (choking)and death. Resident #1 was prescribed a pureed diet order and was unable to feed himself. The facility's failure to intervene in the residents' known behaviors resulted in harm for Resident #1 and has the likelihood of resulting in serious injury, harm, impairment, or death to other residents. The State Agency identified this Immediate Jeopardy (IJ) on [DATE]. The IJ was not removed prior to exit on [DATE] and is considered ongoing. Findings Include: A review of the facility's document entitled Unmanageable Resident, with a revision date of ,[DATE], disclosed the following: 1. The facility will provide each resident with a safe/secure place of residence. 2. Should a resident become hostile or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Staff/Charge Nurse must be notified immediately and must: a. Provide for the safety of all residents in the facility; b. Notify the resident's attending physician for instructions; c. Notify the Director of Nursing and Administrator; d. Notify the resident's responsible party as soon as possible. 3. Every effort must be made to calm the resident by using creative alternative intervention. However, personal safety must always be considered and local law enforcement may be called for assistance. 4. The facility must demonstrate that appropriate multi-disciplinary interventions have been tried and failed before discharging a resident because of violent behavior. 5. Complete documentation of the incident must be recorded in the resident's medical record, as well as the filing of an incident report with the administrator. 6. Be aware that medical situations (i.e., urinary infection, medication reaction) may result in a sudden change in behavior. Upon review of a Nurses Note entered by Agency Nurse #1 dated [DATE] at 1:17 AM, revealed behavior problems between Resident #1 and Resident #2. The Nurses Note read, Received resident (Resident #1) down in room screaming and restless, roommate (Resident #2) states he could not sleep. (Resident #1's Physician) was called at 2400 (midnight), and he gave order for a one time dose of [MEDICATION NAME] 1 mg (milligram), IM (intramuscular) for agitation. Agency Nurse #1 documented when she made rounds after administering the one time dose of [MEDICATION NAME], Resident #1 was asleep and resting quietly. Record review revealed there was no documented evidence of communication and implementation of interventions by the interdisciplinary team. Interviews with the facility staff revealed resident behaviors were exhibited by Resident #1 and Resident #2. The facility failed to document interventions for these known behaviors in the resident records. No evidence was provided of charge/staff nurse notification when behaviors were exhibited. Resident #1 A review of the facility's document entitled Resident Incident Report report completed by LPN #1 revealed on [DATE] at 8:55 PM, Certified Nursing Assistant (CNA) #2 called Licensed Practical Nurse (LPN) #1 to Resident #1's room. When LPN #1 noted Resident #1 was without a blood pressure, pulse or respirations. LPN #1 observed small pieces of a sandwich on the resident's chest. A finger sweep was performed and a silver dollar sized piece of sandwich was removed from Resident #1's mouth. The Incident Report further documented, Resident deceased (this report failed to document what qualified discipline pronounced death, LPN #1 prepared the report). The report confirmed the attending physician, the family, local law enforcement, and were notified The report revealed Immediate action taken: CORONER CALLED and family notified. Resident #1's body was released to the state crime lab for an autopsy. An Interview on [DATE] at 11:30 AM with an Investigator from the State Attorney General's office revealed Resident #2 had stated in an interview that he had put the sandwich in Resident #1's mouth to shut him up. During investigation, a review of the Nurses Notes written by LPN #1, dated [DATE] at 2:19 AM revealed, AT APPROXIMATELY 8:55 PM ON [DATE], I WAS SUMMONED TO RESIDENT ROOM WEST 6A PER CNA (#2) STATING SOMETHING WAS WRONG WITH THE RESIDENT OCCUPYING THE ROOM, RESIDENT #1 UPON ARRIVAL TO THE ROOM I NOTED THAT RESIDENT WAS deceased . LPN #1 documented performing a finger sweep and retrieving the sandwich wrapped in plastic from Resident #1's throat. LPN #1 also documented in the nurses notes she had pulled back the curtain and asked the roommate (Resident #2) if he had given Resident #1 a sandwich. Resident #2 responded, Yes, I did a few minutes ago. I gave it to him because he wouldn't shut up. On [DATE] at 6:42 PM, an interview with the Assistant Director of Nursing revealed she saw Resident #1 being fed by staff at mealtime. She confirmed resident was unable to feed himself. On [DATE] at 12:00 PM, an interview with LPN #1 confirmed she was working the evening of [DATE]. She stated she worked the 7 PM-7 AM shift. LPN #1 stated staff called her to Resident #1's room on [DATE] at approximately 8:55 PM. She stated the resident was in an upright position but slumped over. She stated she noted bits of bread crust and pimento cheese on the front of the resident's gown. LPN #1 confirmed Resident #1 had minimal upper body movements and was unable to feed himself. LPN #1 stated she immediately performed a finger sweep of Resident #1's mouth. She stated she retrieved a part of a sandwich but could still feel something a little further down. She performed another finger sweep, was able to grab the plastic wrap in which the sandwich had been wrapped, and pulled the rest of the sandwich out. LPN stated after removing the sandwich, she noted frothy secretions and stomach contents in the resident's throat and mouth. A review of the facility's document entitled, Brief Statement of Facts and signed by CNA #2 on [DATE] at 10:55 PM stated, (Resident #2) came up the hallway and he said 'I'm sick of all this[***] and I asked him what's wrong and he said, 'that damn man with all that hollering' and I asked him who and he said 'my roommate' . The document also noted CNA #2 stated she went to the room to check on Resident #1 and to ask him what was wrong and Resident #1 answered he was hungry. A review of the Brief Statement of Facts written by CNA #1 revealed she had been passing out snacks and as she got to Resident #1's and Resident #2's room, (Resident #2) stated he didn't want a snack. CNA #1 wrote that Resident #2 stated, Y'all need to give that (MF) something for he (direct quote) can shut the hell up all he's doing is groaning and hollering that he was hungry. The CNA stated she gave Resident #1 some Grape juice and left the resident sitting up in the bed. She stated as she was leaving, Resident #2 was still saying to do something with Resident #1's hollering. CNA #1 stated she left the room but returned a while later and Resident #1 was noted still sitting up in the bed but was slumped over. She stated she began calling his name and shaking him, but he did not respond. She called for the nurse. On [DATE] at 6:50 PM, an interview with CNA #1 confirmed she worked on [DATE] when Resident #1 expired. She stated she gave Resident #1 some juice during snack service. While she was in the residents' room, Resident #2 was complaining about Resident #1's hollering. The CNA stated Resident #2 had told her, Y'all are going to have to do something to him. He's kept me awake for two nights. The CNA stated when she went back to the room a little later, Resident #1 did not respond to verbal or shaking him. CNA #1 stated she then turned on the room light and saw Resident #1 was very pale. She stated she yelled for the nurse. She stated when LPN #1 removed the sandwich and plastic wrap from Resident #1 she noted the wrapper had Resident #2's name on it and was dated as the 2:00 PM snack. On [DATE] at 7:00 PM, an interview with CNA #5 revealed Resident #1 was often awake during the night time hours. CNA #5 confirmed Resident #1 was not able to feed himself. She stated staff fed Resident #1 all meals and snacks. Review of Resident #1's Physician order [REDACTED]. There was no documented order for thickened liquids. On [DATE] at 10:45 AM, an interview with Agency Nurse #1 revealed at approximately 8:00 PM, she had heard Resident #1 stating I'm hungry, I'm hungry. The Agency Nurse stated on the night of [DATE], Resident #1 was restless and was moaning and barking like a dog. The LPN stated Resident #2 was hollering, Shut him the 'F' up. She stated she had made a call to Resident #1's physician and got an order for [REDACTED].>intramuscular. Agency Nurse #1 stated later when she was passing pills on [DATE] at approximately 8:45 PM, she was alerted that Resident #1 was found unresponsive. She stated when she got to the resident's room, LPN # 1 was removing food from Resident #1's mouth. Agency Nurse #1 said when Resident #2 was asked if he had given Resident #1 the sandwich, Resident #2 stated, I put it in his 'F-ing' mouth to shut him the 'F' up because he was hungry. A review of Resident #1's Face Sheet revealed the facility admitted him on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #1 had problems with long and short term memory and was moderately impaired for making decisions. The MDS also indicated Resident #1 required a mechanically altered diet and required a one person physical assist with eating. MDS also documented Resident #2 required two(2) person assist with bed mobility. Resident #2 On [DATE] at 10:45 AM, an interview with Agency Nurse #1 revealed on the night of [DATE] Resident #2 was agitated and hollering about Resident #1's disruptive behavior. Review of Resident #2's nurse notes for [DATE] failed to address the incident and Resident #2 remained in the room with Resident #1. The facility failed to provide any documentation of attempting to remove Resident #2 from the situation. Review of the facility's policy entitled, Room Changes, Revised ,[DATE], documented to assure the resident's appropriateness of placement within the facility, room changes are made for incompatibility with roommates. Interview, on [DATE] at 6:50 PM, with CNA #1 revealed on [DATE], she entered Resident #2's room and Resident #2 told her, Ya'll are gonna have to do something to him. He's kept me awake for two nights. Review of Resident #2's nurse notes and care plan revealed no documented evidence of any staff intervention. Review of an Incident Report and Police Report, both dated [DATE], revealed on [DATE], Resident #2 confessed to trying to stop Resident #1's yelling and hollering that he was hungry by putting a sandwich wrapped in plastic wrap in Resident #1's mouth. Resident #1 choked on the wrapped sandwich and expired. Resident #2 was no longer in the facility, and an interview was not possible due to his arrest. Interview and review of Resident #2's nurses notes revealed the facility failed to address Resident #2's verbalized needs and/or assess Resident #2 for a possible room change. Resident #2 continued to complain and request staff assistance in relieving Resident #1's yelling and disruptive behavior. The facility staff failed to intervene and address these continued verbalized complaints by Resident #2 regarding Resident #1 which, Resident #1's nurse notes revealed began the night of [DATE]. A review of Resident #2's Face Sheet revealed the facility admitted him on [DATE] with diagnoses, which included [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Symbolic Disorder, Anxiety, [MEDICAL CONDITION], and Diabetes. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #2 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact. Further review of the MDS showed Resident #2 experienced other behavioral symptoms not directed toward others on four (4) to six (6) days during the assessment period.

2 The facility must provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. MS CI # Based on record review, interview and job description review, the facility failed to ensure Social Services implemented goals, developed appropriate plans of care, and monitored residents to meet the mental and psychosocial needs of three (3) of 13 residents reviewed for behaviors. (Resident #1, Resident #2 and Resident #4) The facility failed to identify and address Resident #2's escalating agitation towards Resident #1 and failed to identify and address Resident #1's disruptive behaviors resulting in Resident #2 putting a sandwich wrapped in plastic in the mouth of Resident #1, who required a pureed diet, leading to the resident's asphyxiation (choking). The facility's failure to provide for the mental and psychosocial needs of these residents placed these residents in a situation that is likely to cause serious injury, impairment, or death to other residents. An Immediate Jeopardy (IJ) was determined to begin on 7/8/14 when Resident #2 became agitated and complained to the facility staff about his roommate's (Resident #1) behaviors of yelling out, moaning, and making noises. The State Agency identified the IJ on 7/10/14. The IJ was not removed prior to exit on 7/18/14 and is considered ongoing. Findings Include: Interview on 7/10/14 at 7:05 PM with the SSD revealed she had been employed at the facility since 1995. The SSD signed the job description for Social Service Director in 2011. Review of the Job Description signed by the Social Services Designee (SSD) entitled, Social Services Director, signed by the SSD and dated 6/17/11, revealed under, Job Summary: Directs and supervises social service program. Evaluates the social needs of each patient admitted and formulates a written plan of care. Responsibilities included: reviews and updates plan of care according to established policies; records continuing progress notes on the patient's social needs and response of the patient to delivered social services. Qualifications for the position included: A college degree is mandated in Sociology or another related field approved by State representatives. Additionally, the qualifications listed that the Social Service Director would be able to recognize and identify situations in which problems are such that referral is indicated. Interview on 7/16/14 at 11:09 AM with the SSD confirmed signing the facility Social Service Job Description and stated, I didn't have the qualifications and they changed it to Social Service Designee. The SSD was unable to recall signing a new job description. Interview on 7/12/14 at 10:30 AM with the SSD confirmed the facility had a contracted Licensed Clinical Social Worker (LCSW) on staff; however, the LCSW did not see residents routinely and did not document in the residents' medical records. The SSD stated the LCSW's responsibility was to check up on the SSD, look at care plans, and Social Service's assessments. She reported the LCSW came to the facility quarterly and would send a report to the administrator. Review of recommendations from the contracted LCSW, dated 12/6/13, revealed a resident (the LCSW failed to identify what resident) was combative with bath and there was no care plan that identified care needs. Recommendations from the LCSW, dated 3/5/14, documented the need to update care on several residents. LCSW failed to identify which residents. Interview with the SSD on 7/10/14 revealed when problems were reported to her she would investigate and document in the Social Notes. However, there was no documentation in the Social Notes to corroborate She stated, CNA (Certified Nurse Assistants) might document on the Jot Sheet which she confirmed was not part of the medical record. In a later interview on 7/15/14 at 11:35 AM, the SSD reported she did not routinely review the Jot Sheet nor the Nurse Notes. She confirmed she relied on verbal reports from staff and residents to obtain information on the residents. Review of the facility's policy entitled, Social Services Program, Latest Revision: 01/12, revealed the purpose of the facility's Social Service Program was to assure that sufficient and appropriate social services were provided to meet the resident's needs. Review of the facility's policy entitled, Room Changes, Revised 01/12, documented,The Social Service Designee/Social Worker, in conjunction with the DON, will assure that each resident is assigned a room suited to his/her needs. 2. Room changes are made for the following reasons: Incompatibility with roommates 3. All needs and requests for room changes will be handled by Social Services and/or the DON and supporting documentation will be maintained in the resident's medical record. Resident #1 Review of Resident #1's Nurse Notes revealed on the night of 7/6/14, Resident #1 was yelling out and moaning and the resident's roommate (Resident #2) was agitated and complaining about the yelling. The Nurses Notes showed the nurse on duty on 7/6/14 called Resident #1's physician and received an order for [REDACTED].#1. Review of Resident #1's Interdisciplinary Progress Notes revealed no documented evidence of monitoring or interventions implemented by the Social Services Designee (SSD) to address the behavior of hollering out and moaning which was disturbing the resident's roommate (Resident #2). A review of Resident #1's record revealed the facility admitted him on 2/3/14 with [DIAGNOSES REDACTED]. Muscle Weakness. Resident #2 Interview with the Social Services Designee (SSD) on 7/10/14 at 7:25 PM confirmed Resident #2 had a history of [REDACTED]. She stated Resident #2 had problems in the past. Interview on 7/14/14 at 12:00 (noon), the SSD stated Resident #2 was going to an outpatient psychiatric program in the past; however, due to medical problems, Resident #2 was unable to continue. Interview, on 7/10 /14 at 7:05 PM, confirmed Resident #2 was not attending any outpatient programs at the time of the incident (7/8/14). Review of Resident #2's nurse notes, provided by SSD, revealed the last entry for Resident #2 attending a day program was dated 3/29/12. Interview on 7/10/14 at 6:45 PM revealed the Administrator reported the facility moved Resident #2 to Resident #1's room approximately a week prior to the incident of 7/8/14. According to the Administrator, Resident #2 was moved due to his prior roommate complaining about Resident #2's behavior of defecating on the floor. The Administrator did not reveal any evaluations done after the room change. Review of Resident #2's Interdisciplinary Progress Notes revealed no documented evidence of monitoring or inventions implemented by SSD for these behaviors. A review of Resident #2's Face Sheet revealed the facility admitted him on 12/30/10 with [DIAGNOSES REDACTED]. Review of Resident #2's Department of Mental Health Pre-Admission Screening and Resident Review (PASRR) Determination, dated 3/29/11, revealed admission was approved with the following Recommendations: Specialized Services by Counseling and Mental Health; and Mental Health Rehabilitation Services provided by the Nursing Facility. Treatment recommendations consisted of medication monitoring, individual/family/group therapy, elderly psychosocial rehabilitation, and nursing assessment. Interview with SSD on 7/14/14 at 12:00 (noon) revealed Resident #2 attended a Intensive Outpatient Program (IOP) but had started having medical problems and had stopped. The SSD provided nurse notes which revealed the last time Resident #2 attended the IOP was dated 3/29/12. The SSD was unable to provide information of any attempts to resume treatment at IOP. Resident #4 Review of Resident #4's Nurse Notes for January 2014 through present revealed aggressive behaviors were documented four (4) times in February 2014, two (2) times in May 2014, two (2) times in June 2014, and one (1) time in July 2014. Review of the medical record for Resident #4 revealed the facility transferred Resident #4 to a behavior health unit for aggressive behavior on 5/21/14 and 6/16/14 and the notes indicated Social Services was notified. Review of Resident #4's progress notes and care plans revealed a lack of social services monitoring and interventions to address agitated/ aggressive behavior. Interview with the Social Services Designee (SSD) on 7/10/14 at 7:25 PM revealed the Social Service department was not monitoring any residents with identified behavioral problems. Interview on 7/12/14 at 3:55 PM with Social Services Designee (SSD) confirmed no interventions were developed to address the resident's aggressive behaviors. Review of the Face Sheet revealed the facility admitted Resident #4 on 6/4/13 with diagnoses, which included Alzheimer's disease. Review of the current Physician Orders, dated July 2014, revealed a [DIAGNOSES REDACTED].

2 A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under ?483.25; and any services that would otherwise be required under ?483.25 but are not provided due to the resident's exercise of rights under ?483.10, including the right to refuse treatment under ?483.10(b)(4). MS CI # Based on observation, interview, record review, and policy review the facility failed to develop care plan interventions to address and manage disruptive and aggressive behaviors for three (3) of 14 residents reviewed for care planning. The facility failed to develop interventions for Resident #1's Code status and disruptive yelling out and crys of hunger Resident #2's aggressive verbalizations; and Resident 4's aggressive behaviors toward other residents. The facility's failure to develop a comprehensive plan of care with specific interventions and approaches for managing behaviors exhibited by Resident #1 and Resident #2 created a situation that is likely to cause serious injury, harm death, or impairment to other residents. Resident #2's escalating agitation towards Resident #1 resulted in Resident #2 putting a sandwich wrapped in plastic into Resident #1's mouth to shut him the (F) up, which led to Resident #1's death in the facility on [DATE], was determined an Immediate Jeopardy (IJ). The IJ was identified by the State Agency on [DATE] and was determined to exist on [DATE]. The IJ was not removed prior to exit on [DATE] and is considered ongoing. Findings Include: Review of the facility's policy entitled, Care Plans-Comprehensive Assessment, Latest Revision: ,[DATE] revealed, The interdisciplinary team will develop a comprehensive care plan for resident that includes measurable objectives and timetables to meet a resident's optimal medical, nursing, dietary, and psychosocial needs and maximize the resident's level of functioning. Review of the facility's policy entitled, Care Plan Procedure, latest revision date ,[DATE], revealed, As new problems are identified they are added to the resident's care plan by the different disciplines. Resident #1 Review of Resident #1's Electronic Medication Administration Record [REDACTED]. Review of Resident #1's RESIDENT/FAMILY CONSENT FOR [MEDICAL CONDITION] RESUSCITATION indicated Resident #1 as having a Full Code Status and CPR should be performed on the resident in the case of emergency. Review of Resident #1's careplans revealed a care plan had not been developed for Resident #1's Full code status. Review of the Incident Report dated [DATE] at 8:55 PM revealed Resident #1 was found unresponsive with a sandwich wrapped in plastic lodged in his throat. This report indicated Resident #1 expired [DATE]. There was no documented evidence CPR was initiated. Interview with LPN #1 on [DATE] at 12:00 PM revealed on [DATE] she (LPN #1) responded to Resident #1's room and found him to be unresponsive. She stated Resident #1 was wearing a white bracelet which indicated the resident's Full Code status. LPN #1 confirmed CPR was not initiated per the plan of care. Review of Resident #1's nurse notes revealed on the night of [DATE] Resident #1 exhibited disruptive behavior by hollering out and moaning. Resident #1's physician was called and a one time order was given for [MEDICATION NAME] (anti-anxiety) medication, 1.0 milligram IM (intramuscular) injection. Review of Resident #1's care plans revealed no documented evidence a care plan had been developed with interventions to address the behavior of hollering out and moaning which was disturbing the resident's roommate (Resident #2). A review of Resident #1's Face Sheet revealed the facility admitted him on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #1 was moderately impaired for making decisions. The MDS also indicated Resident #1 required a mechanically altered diet and required one person physical assist with eating. Resident #2 Review of Resident #1's Nurses Notes (Resident #2's roommate) revealed on the night of [DATE] Resident #2 was agitated and complaining about Resident #1's disruptive behavior. Interview with the Social Services Designee (SSD) on [DATE] at 7:25 PM confirmed Resident #2 had a history of [REDACTED]. Review the Resident #2's current care plans revealed no documented evidence a care plan had been developed to address Resident #2's history of aggressive behaviors and Resident #2's escalating agitation towards Resident #1. Further review revealed no documented evidence a care plan had been developed for the areas identified on Minimum (MDS) data set [DATE] under behaviors. A review of Resident #2's Face Sheet revealed the facility admitted him on [DATE] with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of [DATE] revealed Resident #2 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. Upon further review, the MDS showed Resident #2 experienced the following: C. Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) . Section C was coded with a 2 which indicated the behaviors occurred on 4 to 6 days during the assessment period. Resident #4 Review of the Nurses Notes for Resident #4 revealed the facility transferred the resident to the local Behavior Health Unit for admission due to aggressive behavior on [DATE] and again on [DATE]. Review of the Nurse Notes from [DATE] through [DATE] revealed aggressive behaviors were documented four (4) times in February 2014, two (2) times in [DATE], two (2) times in [DATE], and one (1) time in [DATE]. Review of Resident #4's current care plans revealed no care plan had been developed to address the behaviors exhibited by Resident #4. These aggressive behaviors included biting. hitting, scratching, and cursing. In an interview, on [DATE] at 3:55 PM, the Social Services Designee (SSD) confirmed Resident #4 had exhibited aggressive behaviors and no care plan was developed for the resident's aggressive behaviors. Review of Resident #4's Comprehensive Care Plan (CP), dated [DATE], revealed a CP to address side effects of antipsychotic medications documented approaches to monitor and document behaviors and side effects every shift and report to the MD (Medical Doctor). The care plan did not address behaviors associated with aggression toward other residents. Review of Resident #4's Electronic Medication Administration Record [REDACTED]. Review of the EMAR revealed the EMAR listed target behavior as depression and paranoia. The EMAR did not address monitoring for aggressive behaviors. Review of FAce Sheet revealed the facility admitted Resident #4 on [DATE] with diagnoses, which included [MEDICAL CONDITION]. Review of the current physician orders, dated [DATE], revealed an additional [DIAGNOSES REDACTED].

2 Each resident must receive and the facility must 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. MS CI # Based on staff interviews, record reviews, policy reviews, and consent review, the facility failed to provide care in a manner that promoted the highest physical well-being for two (2) of 18 residents (Residents #1 and #2). The facility failed to provide the appropriate treatment and services as evidenced by the facility's failure to initiate Cardiopulmonary Resuscitation (CPR) on Resident #1, who was designated as a Full Code status , was found unresponsive in his room on [DATE] at 8:55 PM (Resident #1), and required CPR. In addition, the facility failed to provide Resident #2, psychology recommended physician ordered medications and Bi-Level Positive Air Pressure (Bi-Pap) Therapy. The facility's failure to provide CPR to Resident #1, who required CPR, placed other residents in need of CPR, in a situation that is likely to cause serious injury, harm, impairment, or death. The Immediate Jeopardy was determined to exist on [DATE] when Resident #2 placed a sandwich wrapped in plastic in the mouth of Resident #1, causing Resident #1 to asphyxiate (choke), subsequently requiring Resident 1's need for CPR. The facility's nursing staff failed to initiate CPR for Resident #1, and Resident #1 expired in the facility [DATE] at 8:55 PM. The State Agency identified the Immediate Jeopardy on [DATE]. The IJ was not removed prior to exit on [DATE] and is considered ongoing. Findings Include: Resident #1 A review of the facility's policy entitled Cardiac Resuscitation Policy (DNR or No Code) Latest Revision: ,[DATE] revealed; In the event of a cardiopulmonary arrest, basic CPR will be performed, unless, a Do Not Resuscitate Order has been made by the resident's physician and the resident or resident's appropriate representative has made a valid written request in advance not to initiate basic CPR. A review of the facility's document entitled Resident/Family Consent for Cardiopulmonary Resuscitation revealed I understand that CPR constitutes an extraordinary measure and SHOULD be done on this resident in case of extreme emergency Resident #1's Responsible Party had signed and initialed the form. A review of the facility's policy entitled Cardiac Resuscitation Policy stated A red identification bracelet will be placed on a resident with a DNR (No Code) indication and a DNR sticker will be placed on the alert sheet in the front of the chart so staff can easily identify the code status of resident. Staff will be in-serviced in the policy regarding DNR and trained to identify status per facility policy. A review of the facility's document entitled Resident Incident Report, dated [DATE], revealed facility staff found Resident #1 unresponsive in his room at 8:55 PM. When Licensed Practical Nurse (LPN) #1 noted food in the resident's mouth, LPN #1 performed finger sweeps and cleared a sandwich and the plastic wrap from Resident #1's airway. There was no documented evidence for initiation of CPR. On [DATE] at 12:00 PM, an interview with LPN #1 confirmed staff called her to Resident #1's room on [DATE] , and when she arrived in the room, Resident #1 was upright in the bed but slumped over. LPN #1 stated she noted bits of food on Resident #1's gown and immediately performed a finger sweep in the resident's mouth and retrieved part of a sandwich from the resident's mouth. LPN #1 stated she performed a second finger sweep and she retrieved the rest of the sandwich still wrapped in plastic from Resident #1's throat. LPN#1 confirmed she noted the resident to have a white bracelet on which indicated Resident #1 was a full code and did not know why she did not start CPR. The LPN stated she understood the system, but as she believed the resident was already dead, she did not initiate CPR. On [DATE] at 6:50 PM, an interview with CNA #1 confirmed the nurse did not administer CPR to Resident # 1. An interview on [DATE] at 7:30 PM, CNA #4 confirmed Resident #1 did not receive CPR. On [DATE] at 10:45 AM, an interview with Agency Nurse #1 confirmed Resident #1 was not responsive, was warm to the touch, but no staff initiated CPR. Review of Resident #1's record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 AM, an interview with Resident #1's attending physician confirmed the resident was a full code. The attending physician stated the facility had notified him on [DATE] that Resident #1 had expired and the facility failed to render CPR. The physician stated he could not defend the nurses who failed to provide CPR. Resident #2 (Psychological Consult Example) A review of the facility's document with a revision date of ,[DATE] and entitled Consultant Reports stated, The written report should contain documentation that indicates recommendations or specific plans. Facility staff shall act on recommendations or plans to correct, improve, or initiate action in a timely manner. A review of the contracted psychological services document entitled Note to Attending Physician, dated [DATE], indicated, Unless medically contraindicated, please: 1) Consider the addition of [MEDICATION NAME] or the [MEDICATION NAME] Patch to support cognitive functioning. Resident #2's attending physician checked he agreed and signed the recommendation on [DATE]. There was no documented evidence facility staff clarified or implemented the recommendation for Resident #2. An interview with the Director of Nursing (DON) on [DATE] at 4:30 PM revealed the recommendations by the contracted psychological services dated [DATE] were prior to her accepting the DON position. The DON stated staff now put all consultant recommendations in each physician's folder and hand deliver to each physician for review and signing. The DON confirmed there was no documentation facility staff implemented the recommendations dated and signed on [DATE] by the attending physician for Resident #2. Resident #2 (Bi-Pap Example) Resident #2 is no longer in the facility therefore observation of the resident was not possible. A review of Electronic Medication Administration Record (E-MAR) dated for June and [DATE] revealed the [MEDICAL CONDITION] had not been administered on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] and ,[DATE]. Interview on [DATE] at 10:45 AM with Agency Nurse #1 revealed she said she applied a regular oxygen mask to deliver the [MEDICAL CONDITION] therapy because she couldn't find a mask but it didn't work right. A review of the current revised printed Physicians Orders, dated [DATE], revealed Resident #2 had an order which read, Resident to have [MEDICAL CONDITION] (Bi-Level Positive Air Pressure) @ ,[DATE]/cm H2O (centimeters of water), full face mask, chin strap, heated humidifier, continuous O2 (oxygen) @ (at) 2L PM Q HS (2 liters per minute every hour of sleep). The revision date on the order was [DATE]. A review of a Monthly Recertification Note, dated [DATE], by Resident #2's attending physician stated that the resident has been in and out of the hospital in the emergency room with episodes of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Vitals look okay today although his O2 sats (saturations) are borderline most of the time. He has had quite a bit of work up recently but I think his main problem is something has happened to his C-PAP. I think he is getting hypoxic and this is causing other problems (no specific problems were specified in this note). A review of a delivery slip from the local medical supply company revealed a [MEDICAL CONDITION] machine was delivered to the facility on [DATE] for Resident #2's use. A compliance report from the medical supply company obtained from the memory chip in the [MEDICAL CONDITION] machine revealed the resident had not used the machine since [DATE] (approximately a year). A resident interview was not possible since Resident #2 was no longer in the facility; however, an observation made of Resident #2's room on [DATE] at 8:30 PM, revealed a [MEDICAL CONDITION] machine on Resident #2's bedside table. The tubing was connected to the machine; however, no mask was observed. CNA #5 stated when Resident #2 moved to the present room (approximately a week ago), there was not a mask with his belongings and confirmed it had been a long time since she had seen Resident #2 using a [MEDICAL CONDITION]. On [DATE] at 6:50 PM, an interview with CNA #1 confirmed she had never seen Resident #2 using the [MEDICAL CONDITION] after he moved into his current room. On [DATE] at 7:00 PM, CNA #5 confirmed she took care of Resident #2 every time she worked and had never witnessed the use of a [MEDICAL CONDITION]. An interview on [DATE] at 3:00 PM, with LPN #4 confirmed when the nurse initialed and checked the EMAR (Electronic Medication Administration Record), it meant the nurse had administered the treatment or medication. She stated if a resident refused, the nurse should indicate that on the EMAR and inform the Physician of the refusal. On [DATE] at 3:45 PM, LPN #7 revealed a check mark on the E-MAR indicated administration of a medication or treatment. LPN # 7 stated if a resident refused the medication or treatment, the nurse documented N on the E-MAR and the physician notified. On [DATE] at 4:00 PM, an interview with LPN # 8 confirmed a check mark on the E-MAR means administration of the medication or treatment. An N indicated refusal and reason to report to the physician. On [DATE] at 3:20 PM, an interview with LPN #3 revealed Resident #2 would always refuse use of the [MEDICAL CONDITION]. LPN #3 stated when a resident refused a treatment, the nurse was required to document in the Nurse ' s Notes and the physician notified. Resident #2's EMAR revealed no evidence of documentation of refusal of the [MEDICAL CONDITION].

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. by: MS CI # Based on record review, policy review, consent review, job description review, and staff interviews, the facility's Administration failed to ensure the facility used its resources effectively,to implement it abuse policies and procedures by recognizing escalating behaviors for prevention of resident to resident abuse; and subsequent protection of residents from residents who exhibit behaviors for two (2) of 19 residents (Residents #1 and Resident #2). The facility's failure to have effective Administrative oversight, implementation, and monitoring of its resources resulted in a situation that is likely to cause serious injury, impairment, harm, or death to residents. This situation resulted in an Immediate Jeopardy, and the State Agency identified the Immediate Jeopardy (IJ) on 7/10/14. The IJ was determined to exist on 07/08/14, and the IJ was not removed prior to exit on 7/18/14, and is considered ongoing. Findings Include: A review of the job description entitled Administrator documented, The administrator directs and coordinates all activities of the nursing home, in carrying out its objectives of providing the best possible care for each resident, in striving to create a sense of security and usefulness for the residents. The job description further read under Responsibilities the Administrator Evaluates, implements, and documents disposition of recommendations from the facility's committees and consultants. Reviews and reports to appropriate parties Policy and Procedures adopted by operating company. Interview, on 7/10/14 at 6:45 PM, with the Administrator confirmed his knowledge of Resident #2's room change about a week and a half ago due to Resident #2's attention seeking behaviors. The Administrator explained, He (Resident #2) would deficate on the floor, and his room mate objected to the hygiene practice. The Administrator also confirmed knowledge of Resident #2's admission to a behavioral unit last year for inappropriate touching of a female. The Administrator failed to provide any evidence of his monitoring of Resident #2's behavior or room change. The Administrator stated Resident #1 would call out 'I'm hungry' at times, repeatedly, when he had just ate. The Administrator confirmed the staff interventions for monitoring these behaviors was to just watch them. The Administrator stated They (staff) really don't know what behaviors are. The Administrator again failed to provide any evidence of his monitoring of Resident #1's behaviors.

2 A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions MS CI # Based on record review, interview, and policy review the facility failed to develop and implement appropriate plans of action to identify and correct quality deficiencies regarding (A) identifying residents with aggressive behaviors, (B) developing and implementing plans of care related to behaviors, and (C) monitoring residents with disruptive or aggressive behaviors and the failure to implement consultant recommendations for treatment and services and to honor Advance Directives. (Resident #1 and Resident #2) The facility's failure to identify, track, and trend issues for residents with behaviors, failure to follow through with treatment and services recommended by contracted consultants, and failure to honor the Full Code status resulted in an Immediate Jeopardy which was determined to begin on [DATE] Resident #2 became agitated and complained about his roommate's behaviors and placed a sandwich wrapped in plastic in the mouth of Resident #1 who was unable to physically remove it. Resident #1 asphyxiated (choked) and expired in the facility. This failure contributed to Resident #1's death in the facility and had the likelihood of resulting in serious injury, harm, impairment, or death to other residents. Findings Include: Review of the facility's policy entitled, Procedure for Quality Assessment (QA) and Improvement Program, Latest Revision: ,[DATE] revealed, The committee will establish the QA&I (Quality Assessment and Improvement) review each quarter using the outcome of the internal and external QA&I's, Regional's, Consultant's reports, accident/incident reports and complaints from families and/or residents. Each department must identify the problem areas, investigate and determine the probable cause, establish a plan of correction, and evaluate the outcomes. Review of the facility's policy entitled, Planning and conducting the Quality Assessment and Improvement Meeting Latest Revision: ,[DATE] revealed, Before the quarterly meeting, the chairperson shall. B. Identify any other appropriate issues to be addressed. C. Each Department head is a part of the QA&I committee and should pull together information on problem area identified and prepare for QA&I meeting. The following sequence is recommended for each discipline in planning the meeting: 1. Identify the problems *Discuss and Gain input from Medical Director *Review reports/results of internal audit *Review report/results of external audit *Review applicable portion of Committee reports and prior identified problems. Interview, on [DATE] at 11:45 AM with the Director of Nurses (DON), the DON explained the tracking of identified QA concerns was done by the Management Company's Quality Improvement (QI) nurse. This QI nurse was not in the facility on a routine basis. The DON stated the process of identifying concerns consisted of: If there were any staff reported concerns, she (DON) would take them to the Administrator. The concerns were brought to the QA meeting by the Administrator. The DON confirmed Certified Nursing Assistants (CNAs) were not involved in the QA meeting. The DON reported the QA committee failed to identify any concerns related to behavior monitoring or care planning for residents with aggressive/disruptive behaviors (Resident #1 and Resident #2) and they failed to address recommendations from contracted consultants (Licensed Certified Social Worker (LCSW)and Psychological Services). The DON confirmed behaviors exhibited by Resident #1, Resident #2 and Resident #4 had not been brought to the QA committee prior to this survey beginning on [DATE]. During an Interview on [DATE] at 3:40 PM, the Management Company's Quality Improvement (QI) nurse produced a resident specific behavior monitoring report. The QI nurse explained the report was specific for each resident (including Resident #1 and Resident #2). During an interview on [DATE] at 4:45 PM, the DON and the Assistant Director of Nursing (ADON) confirmed neither of them knew how to obtain the behavior report and had never seen one printed. During an interview on [DATE] at 4:40 PM, Social Services Designee confirmed she was not aware of the existence of the behavior monitoring report and did not know how to print it. Interview with the Administrator, on [DATE] at 12:10 PM, confirmed he had no documentation to support the reports had been used for QA purposes or any other behavior monitoring had been addressed by the QA Committee related to resident behaviors affecting others (including Resident #1 and Resident #2). The facility also failed to provide evidence addressing follow up of contract consultants recommendations including LCSW and contract psychologist services. Review of a statement on facility letterhead provided by the Administrator, dated [DATE] (unsigned), revealed the facility held an emergency Quality Assurance and Improvement Committee (QAPI) meeting on [DATE] (survey team entered on [DATE]). The documentation read topics included: Cardiopulmonary Resuscitation, Abuse Neglect, Behavior Monitoring, Resident Room Compatibility and [MEDICAL CONDITION] devices. The Quality Assurance and Improvement Committee also reviewed the functions of the Quality Assurance and Improvement Committee meeting process. A review of Resident #1's Face Sheet revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #1's most current Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #1 had problems with long and short term memory and was moderately impaired for making decisions. Resident #2's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses, which included [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Symbolic Disorder, Anxiety, [MEDICAL CONDITION], and Diabetes. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also revealed Resident #2 experienced other behavioral symptoms not directed toward others on four (4) to six (6) days during the assessment period.

2 The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. MS CI # Based on incident reports, staff written statements, staff interviews, and abuse policy review, the facility failed to: (A) assess residents, develop and implement care plans, and monitor residents with behaviors that could possibly lead to resident on resident conflict; (B) identify events and patterns that constituted abuse; (C) examine incidents to determine if policies and procedure revisions were needed; (D) protect residents for two (2) of eight (8) residents reviewed for abuse as evidenced by Resident #1 yelling out and moaning which caused increased anxiety for Resident #2. Resident #2 became agitated, asked staff to do something to stop his roommate's yelling, then placed a sandwich wrapped in plastic into Resident #1's mouth to shut him the 'F' up. (Resident #1 and Resident #2) The facility's failure to develop and utilize components of the abuse/neglect policy related to Resident #1's disruptive behaviors and Resident #2's escalating agitation and aggressive statements towards Resident #1 resulted in Resident #2 putting a sandwich wrapped in plastic in the mouth of Resident #1 leading to Resident #1's asphyxiation (choking) and death. The facility's failure to intervene in the residents' known behaviors contributed to the death of Resident #1 and has the likelihood of resulting in serious injury, harm, impairment, or death to other residents. The State Agency identified this Immediate Jeopardy (IJ) on 7/10/14. The IJ was determined to exist on 7/08/14, was not removed prior to exit on 7/18/14, and is considered ongoing. Findings Include: A review of the facility's document entitled Seven Components of Abuse and Neglect Regulations, with a revision date of 07/13, disclosed Screening of Employees, Training of Employees, Prevention of Abuse, Identification, Investigation of Abuse, Protection of the Resident, and Reporting Abuse were addressed in the facility's abuse policy. A Nurses Note dated 7/7/14 at 1:17 AM by Agency Nurse #1, revealed documentation of escalating behaviors between Resident #1 and Resident #2 in Resident #1's record. According to Resident #1's record documentation, Resident #1 was in his room screaming and restless and his roommate (Resident #2) stated he could not sleep. The Agency Nurse documented she called Resident #1's Physician at midnight, and received an order for [REDACTED].#1 documented when she made rounds after administering the [MEDICATION NAME], Resident #1 was asleep and resting quietly. Review of Resident #2's nurse notes for 7/6/14 revealed no documentation addressing the incident on 7/6/14, and Resident #2 remained in the room with Resident #1. The facility failed to provide any documentation of a room change assessment in order to remove Resident #2 from Resident #1's behaviors to protect both residents. During an interview on 7/12/14 at 10:45 AM, Agency Nurse #1 revealed on the night of 7/6/14, Resident #1 was restless and was moaning and barking like a dog. The LPN stated Resident #2 was hollering, Shut him the 'F' up. She stated she made a call to Resident #1's physician on 7/6/14 and got an order for [REDACTED]. She stated she saw Resident #1 unresponsive and Licensed Practical Nurse (LPN) #1 doing a finger sweep in Resident #1's mouth. When Resident #2 was asked if he had given Resident #1 the sandwich, Agency Nurse #1 said Resident #2 stated, I put it in his 'F-ing' mouth to shut him the 'F' up because he was hungry. The facility failed to provide evidence of the 7/6/14 behaviors being identified by staff as a possible pattern of behaviors leading to the harm of other residents, and provided no evidence the incident was reviewed to determine if policies and procedure revisions needed revision. On 7/10/14 at 6:50 PM, an interview with Certified Nurses Assistant (CNA) #1 revealed on 7/8/14, Resident #2 told her, Ya'll are gonna have to do something to him (roommate). He's kept me awake for two nights. Review of Resident #1's and Resident #2's medical records revealed no documentation behaviors were reported to the multidisciplinary team, appropriate interventions were initiated, care plans were revised or initiated, or monitoring of Resident #1 or Resident #2 was increased. Review of facility documents revealed no evidence of resident behavior assessments, care plan development/implementation, or resident monitoring after the 7/6/14 behaviors and before the 7/8/14 behaviors. Review also revealed no documented evidence of communication and implementation of interventions by the interdisciplinary team. Interviews with the facility staff revealed resident behaviors were exhibited by Resident #1 and Resident #2. The facility failed to document appropriate interventions for these known behaviors in the resident records. There was no evidence the charge nurse or social services was notified when behaviors were exhibited. A review of Resident #1's Face Sheet revealed the facility admitted him on 2/3/14 with [DIAGNOSES REDACTED]. The most current Minimum Data Set (MDS) with an Assessment Reference Date of 6/24/14 revealed Resident #1 had problems with long and short term memory and was moderately impaired for making decisions. The MDS also indicated Resident #1 required a mechanically altered diet and required a one person physical assist with eating. MDS also documented Resident #2 required two(2) person assist with bed mobility. A review of Resident #2's Face Sheet revealed the facility admitted him on 12/30/10 with diagnoses, which included [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Symbolic Disorder, Anxiety, [MEDICAL CONDITION], and Diabetes. The most current Minimum Data Set (MDS) with an Assessment Reference Date of 6/30/14 revealed Resident #2 had a Brief Interview for Mental Status score (BIMS) of 15, which indicated the resident was cognitively intact. Further review of the MDS showed Resident #2 experienced other behavioral symptoms not directed toward others on four (4) to six (6) days during the assessment period.

Based on observation, record review, facility staff, laboratory staff, Pharmacist and Physician interviews, and policy review, the facility failed to ensure that the appropriate treatment and services were provided for (1) of 13 residents reviewed. The facility failed to effectively monitor Resident #1 who was on [MEDICATION NAME] therapy as evidenced by the failure to obtain [MEDICATION NAME] times (PT)s/International Normalized Ratios (INRs) between 3/3/12 and 5/10/12. The laboratory results drawn 5/10/12 revealed critical blood levels related to the [MEDICATION NAME] therapy. It was determined that Substandard Quality of Care and Immediate Jeopardy were identified to begin on 03/05/12 and was removed on 5/12/12 at 6:45 p.m. The facility's Administrator, Director of Nursing, two (2) Corporate Registered Nurses (RNs) and Regional Director were notified of the Immediate Jeopardy on 5/11/12 at 1:57 p.m. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 5/12/12 at 6:00 p.m. Based on verification of the facility's corrective actions that were validated by staff interviews, in-service form reviews and record review, the Immediate Jeopardy (IJ) was removed on 05/12/12 at 6:40 p.m. and the scope and severity was lowered to a "D" level, which constitutes no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Resident # 1 An observation was made of Resident # 1 on 5/10/12 at 12:50 p.m. while she sat in a reclining Geri chair in the day room. Record Review revealed Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/5/12 revealed that she scored 7 of 15 on the Brief Interview for Mental Status (BIMS), which indicated severe cognitive impairment. Record Review of Resident # 1's "Physician's Telephone Order" dated "2/22/12" revealed "PT/INR ([MEDICATION NAME] Time/International Normalized Ratio) QOD (every other day) REPORT RESULTS TO MD (Medical Doctor)". This order had a D/C (discontinue) date of 4/6/12. Review of Resident #1's March 2012 and April 2012 cumulative Physician Orders revealed the following orders: (Name Brand) ([MEDICATION NAME]) 5 (five) mg (milligrams) tablet, give 1 (one) tablet on Monday, Wednesday, Thursday, Friday, Sunday dated 2/24/12; (Name Brand) ([MEDICATION NAME]) 7.5 (seven. five) mg (milligrams) tablet give 1 (one) tablet every Tuesday and Saturday dated 2/24/12; and PT/INR QOD Report results to MD dated 2/22/12. Record Review of Resident # 1's "Physician's Telephone Order" for April revealed PT/INR Q (every) week x (times) 1 (one) month. This was ordered on [DATE], and was discontinued on 4/6/12. Review of Resident #1's May 2012 cumulative Physician Orders revealed the following orders: (Name Brand) ([MEDICATION NAME]) 5 (five) mg (milligrams) tablet, give 1 (one) tablet on Monday, Wednesday, Thursday, Friday, Sunday dated 2/24/12; and (Name Brand) ([MEDICATION NAME]) 7.5 (seven. five) mg tablet give 1 (one) tablet every Tuesday and Saturday dated 2/24/12. The above orders were marked through with a pen and a hand written statement was added "DCD (Discontinued) 5/10/12". Record Review of the laboratory (lab) results for Resident # 1 revealed the following: 2/24/12 PT 14.1 H, PT Control 13.2, and INR 1.1; 2/26/12 PT 16.9 H, PT Control 13.0, and INR 1.4; 2/27/12 PT 20.9 H, PT Control 13.6, and INR 1.8; 2/28/12 PT 26.4 H, PT Control 13.5, and INR 2.3; 3/1/12 PT 25.1 H, PT Control 13.7, and INR 2.2; and 3/3/12 PT 31.6 H, PT Control 13.3, and INR 2.9. Record Review of the PT/INR drawn 5/10/12 at 4:49 p.m., revealed that the results were "PT over 75 HC (High Critical), PT Control 13.7, and INR over 10.0". Review of Resident # 1's "Physician's Orders" and lab results revealed there were no further documents until 5/10/12 related to use of [MEDICATION NAME] or obtaining PT/INR lab (laboratory) results. Review of Resident #1's Care Plan Need for Monitoring for Complications revealed "MONITOR LABS AS ORDERED AND REPORT ABNORMAL TO MD (Medical Doctor)". An interview on 5/10/12 at 1:15 p.m., with the Director of Nursing (DON), confirmed that there were no additional lab reports in the chart for PT/ INR for Resident #1, and stated that she will "research lab". An interview on 5/10/12 at 3:10 p.m., with Licensed Practical Nurse (LPN) #1, revealed that there were no PT/INR labs drawn in April or May 2012 for Resident #1. An interview on 5/10/12 at 3:25 p.m., with the DON, confirmed that there had been no PT/INR drawn since 3/3/12 for Resident #1. DON stated that one will be drawn in the a.m., with results to be received tomorrow. DON also stated, during the aforementioned interview, that there was an order received for PT/INR after it was brought to the attention of LPN #1. Review of Resident #1's "Physician's Telephone Order (s)" revealed an order dated 5/10/12 at 2:29 p.m., for "PT/INR Q (every) month", an order dated 5/10/12 at 5:16 p.m., to "Draw PT/INR. Call MD with results", an order dated 5/10/12 at 5:40 p.m. for "(Name Brand) (Vitamin K) tablet take 2 (two) tabs (tablets) at HS (hour of sleep/bedtime)" , and an order dated 5/10/12 at 5:46 p.m. to "Recheck PT/INR. All [MEDICATION NAME] was discontinued on 5/10/12. An interview on 5/11/12 at 9:25 a.m., with RN #1, revealed that she discontinued the order for PT/INR written on 4/5/12 for Resident #1. RN #1 stated we called the MD because Resident #1 was on bed rest related to a positive Homan's sign (which indicated a blood clot in her leg), and the Homan's sign was assessed as negative on 4/5/12. The MD discontinued the bed rest and the PT/INR. RN #1 stated that MD just said D/C (discontinue) the every week (PT/INR) and get her up ". RN #1 did not ask the MD when he wanted the next PT/INR, nor did the MD request PT/INR to be drawn on another. An interview with Resident #1's Medical Doctor, who is also the Medical Director for the facility, on 5/11/12 at 9:45 a.m., revealed "she had a blood clot and got better". He also stated he thinks "PT/INR order was discontinued the same day because she was doing better". The Attending Physician was asked, during the aforementioned interview, when a PT/INR is usually drawn when a resident is on [MEDICATION NAME], he stated "routinely once a month" . The only problem he was aware of related to Resident #1 was the blood clot. The Attending Physician denied any knowledge of any episodes of bleeding for Resident #1. The Attending Physician also stated that he did not discontinue the [MEDICATION NAME], just the PT/INR, and "would go back to once a month (PT/INR)". The attending physician was asked if he reviewed the PT/INR drawn 3/3/12, and he replied "I' m sure they notified me of the 3/3/12 results". Record Review of the PT/INR lab results for 3/3/2012 revealed lab result had not been stamped as being faxed to the Medical Doctor, nor had the MD signed the lab result. Review of the 3/6/12 "Progress Note" , signed by the MD stated "This patient has a blood clot in her left leg and is being treated with bed rest and blood thinner ([MEDICATION NAME]). Her Homan's sign is still positive (indicating a blood clot) so we will continue her present regimen". There were no orders written by the Attending Physician immediately following the PT/INR results. Review of the facility document, revised 4/12, "Guidelines for Reporting Abnormal Test Results to Physicians" revealed "[MEDICATION NAME] Time/INR, Any PT/INR outside the therapeutic range or where therapeutic range is not established or is unclear" should have "immediate" reporting to the Attending Physician. An interview with the facility's Consultant Registered Pharmacist (RPh) on 5/11/12 at 10:15 a.m., revealed "I do look at the labs every month" . She did not remember reviewing the labs for Resident #1. "Honestly, I do not remember and honestly, that would be my oversight" , she added. She also stated "I' m glad you brought that to my attention, I know that (Brand Name) ([MEDICATION NAME]) is so critical". Review of the facility document "Pharmacist's Notes" revealed that the RPh reviewed Resident #1's clinical record on 2/8/12, 3/22/12, 4/10/12 and 5/3/12. There were no recommendations for any of the clinical record reviews for PT/INR labs. Review of the "Consultant Pharmacist Monthly Report" for "March 12, April 12, and May 12" revealed the following: General Comments: "or the charts that have no recommendations today's review may have included but is not limited to the following: (a) check of all new orders written and their transcription since last visit check of evaluation schedule for psychoactive, psychopharmacological, sedative/hypnotic, and misc. (miscellaneous) (b) database entry and/or update of tracked drug data, (c) routine and prn (as needed) med (medication) utilization tracking (d) lab requirements vs. (versus) medication use (e) review of labs and special reports ...( n) follow- up previous review notes (o) other pertinent chart checks". An observation of all blood collection tubes for PT/INR labs (blue top tubes) was made on 5/11/12 beginning at 10:30 a.m. The East Nurses' Station had three (3) tubes which had an expiration date of 8/12. The West Nurses' Station had six (6) tubes which had an expiration date of 8/12. An interview on 5/11/12 at 10:45 a.m., with RN #2, regarding lab for PT/INR drawn 5/10/12, revealed that around 4:30 p.m. lab was drawn on Resident #1 and taken to lab. Between 5:00 p.m. and 6:00 p.m. the lab called RN #2 with the results. RN #2 revealed that the MD was notified right away of results and that Responsible Party was also notified of lab results. RN #2 stated that the Attending Physician gave orders to "discontinue the (Name Brand) ([MEDICATION NAME]) and wanted it (PT/INR) redrawn on Monday". RN #2 added "I think he called back to the facility and talked to the med (medication) nurse later with additional orders". Reviewed facility policy, revised 4/12, for "Laboratory Services" which revealed "1. The facility will provide or obtain the services of a clinical laboratory to meet the needs of the residents." Review of the facility policy also revealed "4. The attending physician will be notified of abnormal laboratory results promptly after the facility has been advised of the results". 'Guideline for Reporting Abnormal Test Results to Physicians' may be used when determining physician next office day notification. The notification of the Physician will be documented in the medical record." The policy further stated "7. All lab work must be retained in the residents chart and abnormal finding documented with report results and follow up from physician." Review of the facility statement "System for monitoring of labs", received 5/11/12 revealed "4: Medical records clerk audits labs, 5: Clerk ensures the lab order is put on the calendar and an order for [REDACTED]. An interview with the DON on 5/11/12 at 12:30 p.m. revealed that when the facility receives results "they either fax (facsimile) or call MD results" . Lab results are stamped with "MD notified" when they are faxed to the Physician. "When nurses fax lab, they received confirmation that it (fax) went through. We don't save the confirmation." When asked if the MD doesn't sign the lab sheet or write orders, how the facility knew that the MD was notified and aware of the lab results, the DON stated "You don't". An interview on 5/11/12 at 2:15 p.m. with the Lab Director for (Name of Hospital), which provided laboratory services for the facility, revealed the following information: "We call it (lab results) to the nurse on staff for critical or panic levels" . When asked the difference between critical and panic levels, she stated "They are the same" . The results for Resident #1 were "high critical" . The PT is the only result that has a high critical on the PT/INR. Anything above 4 INR, we call. INR results are standardized. The PT can vary a few points. Most physicians keep the INR between 2.5 (two.five) and 3.5 (three.five), depending on the patient's condition. For an INR of four (4), the PT is usually about 35 - 40 seconds. When asked about calibration for INR, she stated "We calibrate with every new lot number, which is about one time a year. We do QA (Quality Assurance) runs every eight (8) hour shift." All statements were made during the aforementioned interview. Record review of a "Record of Meetings" form revealed documentation of a QI meeting on 05-11-12 was conducted as a result of the facility being placed in Immediate Jeopardy related to lab orders. During this meeting a POC was established to ensure corrective measures will be taken to address this issue. The findings will be monitored for compliance based on the Plan of Correction and any deficient findings will be addressed through the Quality Improvement process. An interview with the Medical Director/Attending Physician on 5/12/12 at 8:20 a.m., during which the Attending Physician was notified that the facility had been placed in Immediate Jeopardy, he responded "O.K.". An interview with a Medical Laboratory Technician, (MLT) at (Name of Hospital), which provided laboratory services for the facility, on 5/12/12 at 9:24 a.m., revealed that when critical lab results are received, the Attending Physician is "not typically" notified. "We are the reference lab; it is their (facility's) responsibility to contact the MD". The AoC (Allegation of Compliance) of 5/12/2012 for Hillcrest Nursing Center contained corrective actions as follows: "Hillcrest Nursing Center was notified of Immediate Jeopardy status on 5/11/12 at 1:57 p.m. Medical Director (Physician number one ) was notified by Administrator on 5/11/2012 at 2:15 pm of Immediate Jeopardy Status. Resident number (#) 1 admitted on 2/ 27/2009 with orders for [MEDICATION NAME] related to [MEDICAL CONDITION]. On 2/22/2012 Physician ordered [MEDICATION NAME] Time / International Normalized Ratio (PT/INR) to be drawn every other day . PT/INR was drawn on 2/24/2012 and results were reported to Physician on 2/24/2012. PT/INR was drawn on 2/26/2012 and results were reported to Physician on 2/26/2012. PT/INR was drawn on 2/28/2012 and result were reported to Physician on 2/28/2012. PT/INR was drawn on 3/1/2012 and results were reported to Physician on 3/1/2012. PT / INR was drawn on 3/3/2012 . There were no PT/INR's drawn every other day after 3/3/2012 on Resident # 1.Physician order as of 3/3/2012 was PT /INR every other day. On 4/5/2012 Physician #1 wrote order for PT/INR to be drawn weekly for one month on Resident #1. On 4/6/2012 Physician discontinued order for PT/INR to be drawn weekly for one month. Physician #1 did not order PT/INR laboratory tests to continue after 4/6/2012. On 5/10/2012 Physician ordered a PT/INR to be drawn on Resident # 1 and results called to Physician. PT/INR was drawn on 5/10/2012 and results reported to Physician . Results of PT/INR drawn on 5/10/2012 was PT> 75.0, PT Control 13.7 and INR > 10.0 . Normal test results for PT/INR is as follows: PT 12-13.4 seconds, INR 2.5 - 3.5 . Physicians response was only instructions for new orders . New orders were received on 5/10/2012 to discontinue Physician order for [REDACTED]. PT/INR was drawn on Resident #1 on 5/12/2012. Results of PT/INR was PT - 14.1 seconds and INR- 1.1. Normal range for PT is 12- 13.4 seconds and INR is 2.5-3.5. Facility has identified all RN's ( Registered Nurses) and LPN's ( Licensed Practical Nurses). Staffing schedule for RN ' s and LPN ' s has been reviewed and adjusted . No Nurses will be allowed to work until Nurse has been inserviced. There is currently one RN and one LPN that are on medical leave. These Nurses will be inserviced before being scheduled to work. All Nurses on current schedule have been inserviced. Staff Development Nurse will track attendance to inservicing after each inservice using the staff census list . Inservicing has been initiated on 5/11/2012 with Nurses regarding recommended laboratory testing for Residents on [MEDICATION NAME] and notifying Physician of abnormal lab results by telephone with documentation of notification. Nurses were inserviced that lab results will not be faxed . Abnormal laboratory results will be reported to Physician by telephone. Lab Log ( exhibit # 1) will be used to track laboratory results received to ensure results have been reported to Physician. There are 17 residents currently receiving [MEDICATION NAME] at this time. On 5/10/2012 at 8:00 pm 100% audit was completed by DON ( Director of Nursing) and ADON ( Assistant Director of Nursing ) on Residents receiving [MEDICATION NAME]. Audit consisted of checking to ensure recommended laboratory tests are ordered on [MEDICATION NAME] Residents, ordered lab tests have been collected. Physician has been notified of lab results and any new Physician orders have been initiated.. There were no adverse findings found during audit. On 5/11/2012 at 11:00 pm Director of Nursing (DON) and Assistant Director of Nursing (ADON) completed a second 100% audit on Residents receiving [MEDICATION NAME]. Audit consisted of checking to ensure recommended laboratory tests are ordered on [MEDICATION NAME] Residents, ordered lab tests have been collected, Physician has been notified of lab results and any new Physician orders have been initiated . There were no adverse findings found during audit. On 5/13/2012 monitoring of every Resident on [MEDICATION NAME] for signs of bleeding was initiated on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Quality Assurance Meeting has been scheduled for Monday 5/14/2012 at 11:00 am. Medical Director ( Physician # 1 ) was notified on 5/11/2012 of Quality Assurance Meeting to be held on Monday 5/14/2012 at 11:00 am. Lab Log ( exhibit #1 ) will be used to track laboratory test results to ensure that laboratory tests have been drawn , results have been reported to Physician. Physician has responded and any new orders have been initiated. Date and time of Physician notification will be noted on Lab Log. Each Nurse will check Lab Log at the time the Nurse arrives on assigned shift to identify any laboratory tests that requires follow up. RN Supervisor will check Lab Log daily to ensure compliance with laboratory testing and reporting . DON or ADON will monitor laboratory tests monthly to ensure compliance with drawing recommended lab, notifying Physician and appropriate documentation of notification of laboratory results. DON and/or designee will review Physician orders monthly to ensure appropriate laboratory tests have been ordered for medications. Physician will be notified for any recommended laboratory tests." Verification of the AoC: Random interviews with Licensed Practical Nurses (LPNs) and a Registered Nurse (RN) were conducted on 5/12/12 between 6:32 p.m. and 6:44 p.m. to verify the in-services conducted for LPNs and RNs on 5/11/12 and 5/12/12, which addressed monitoring for bleeding and bruising when a resident is prescribed (Name Brand) [MEDICATION NAME], and telephoning all abnormal labs to the Physician. The following orders, "(Name Brand) ([MEDICATION NAME]) 5 mg (milligrams) tablet, give 1 (one) tablet on Monday, Wednesday, Thursday, Friday, Sunday", and "(Name Brand) ([MEDICATION NAME]) 7.5 (seven. five) mg tablet, give 1 (one) tablet every Tuesday and Saturday", were discontinued on 5/10/12 for Resident # 1." "(Name brand) Vitamin K 5 (five) milligrams two (2) tablets" were administered to Resident # 1, as ordered, at 9:00 p.m. on 5-10-12 and 5-11-12. Monitoring bleeding and bruising when a Resident is prescribed (Name Brand) [MEDICATION NAME] was added to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A lab log was also instituted to track laboratory results to ensure that laboratory tests have been drawn, abnormal results have been reported to Physician, that Physician has responded, and that any new orders had been initiated. Interview with LPN #2 on 5/12/12 at 6:39 p.m. revealed that nurses will be communicating with physicians by phone and documenting responses with the new form. All residents receiving (Name Brand) [MEDICATION NAME] (17 of 110 residents) had audits completed on 5/10/12 at 8:00 p.m. and on 5/11/12 at 11:00 p.m. by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Based on verification of the facility's corrective actions that were validated by staff interviews, in-service form reviews and record review, the Immediate Jeopardy (IJ) was removed on 05/12/12 at 6:40 p.m. and the scope and severity was lowered to a "D" level, which constitutes no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on observation, record review, staff interview, and policy review, the facility failed to meet professional standards of quality for three (3) of seventeen (17) charts reviewed (Residents #1, #3, and #6). Findings include: Resident #3 was readmitted on [DATE] with diagnoses, which included Mononeuritis, Dysphagia, and Chronic [MEDICAL CONDITION]. Review of the quarterly M.D.S. with an A.R.D. of 10-14-11 revealed that he scored 15 of 15 on the B.I.M.S., indicating he was cognitively intact. Observation on 1-25-12 at 11:30 a.m. of Resident #3 revealed him lying in bed while Registered Nurse #1 provided treatment. While performing a dressing change, R.N. #1 cleaned the wound with normal saline, patted dry with a 4" by 4" gauze, applied a normal saline dressing, and secured with a bordered adhesive dressing. Review of the Physician's Orders revealed an order dated 1-6-12 to "Clean with NS (normal saline). Pat dry with 4x4s (gauze), apply (trade name) [MEDICATION NAME], and cover with (trade name) bordered adhesive dressing. An interview on 1-25-12 at 12:00 p.m. with R.N. #1 was conducted. R.N. #1 stated that normal saline was the same as [MEDICATION NAME]. An interview on 1-25-12 at 2:55 p.m. was conducted with the R.N. Consultant, who confirmed that [MEDICATION NAME] and normal saline are not the same. Review of the facility policy, revised 5-11, entitled "Physician Orders - Transcribing and Implementing" did not specifically address following the Physician's orders. Based on observation, record review, staff, laboratory staff and Physician interviews and policy review, the facility failed to meet professional standards of quality for one (1) of 13 residents reviewed for laboratory results, as evidenced by Resident # 1 was on (Name Brand) [MEDICATION NAME] daily, but laboratory tests to monitor the medication ' s blood levels were not obtained between 3/3/12 and 5/10/12. The laboratory report, that was drawn 5/11/12, revealed critical blood levels related to the [MEDICATION NAME] usage. Observation of Resident #1 on 01/24/12 at 9:50 a.m. revealed that she was seated in a mechanical wheelchair in her room. Resident is neat and clean in appearance and is wearing a matching green pants suit. Record review of Resident #1 revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #1's most recent Minimum Data Set (MDS) was a quarterly assessment with an Assessment Reference Date (ARD) of 08/03/11. This assessment revealed Resident #1 was moderately impaired for daily decision making. The Physician ordered a [MEDICATION NAME] time test (a test to evaluate the ability of blood to clot properly) on 11/28/11 to be obtained weekly. There is no documented evidence in the medical that the January 17, 2014 [MEDICATION NAME] study was obtained. Interview with the Director of Nursing on 01/25/12 at 9:45 a.m. confirmed that the facility failed to obtain the [MEDICATION NAME] test on 01/17/12. The Director of Nursing provided a written statement that read, "[MEDICATION NAME] Lab was missed on (Resident's Name) on 01/17/12.

Based on observation, record review, facility staff, laboratory staff, Pharmacist and Physician interviews, and policy review, the facility failed to follow the physician's orders [REDACTED]. The facility failed to obtain [MEDICATION NAME] times (PT)s/International Normalized Ratios (INRs) between 03/05/12 to 04/04/12 for Resident #1. It was determined that Substandard Quality of Care and Immediate Jeopardy were identified to begin on 03/05/12 and was removed on 5/12/12 at 6:45 p.m. The facility's Administrator, Director of Nursing, two (2) Corporate Registered Nurses (RNs) and Regional Director were notified of the Immediate Jeopardy on 5/11/12 at 1:57 p.m. The facility submitted an acceptable credible Allegation of Compliance (AoC) on 5/12/12 at 6:00 p.m. Based on verification of the facility's corrective actions that were validated by staff interviews, in-service form reviews and record review, the Immediate Jeopardy (IJ) was removed on 05/12/12 at 6:45 p.m. and the scope and severity was lowered to a "D" level, which constituted no actual harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee. Findings include: Resident #1 Cross refer to F-309 for the facility's failure to effectively monitor Resident #1, who was on [MEDICATION NAME] therapy, as evidenced by the facility's failure to follow physician's orders [REDACTED]. The AOC (Allegation of Compliance) of 5/12/2012 for Hillcrest Nursing Center contained corrective actions as follows: "Hillcrest Nursing Center was notified of Immediate Jeopardy status on 5/11/12 at 1:57 p.m. Medical Director (Physician number one ) was notified by Administrator on 5/11/2012 at 2:15 pm of Immediate Jeopardy Status. Resident number (#) 1 admitted on 2/ 27/2009 with orders for [MEDICATION NAME] related to [MEDICAL CONDITION]. On 2/22/2012 Physician ordered [MEDICATION NAME] Time/International Normalized Ratio (PT/INR) to be drawn every other day. PT/INR was drawn on 2/24/2012 and results were reported to Physician on 2/24/2012. PT/INR was drawn on 2/26/2012 and results were reported to Physician on 2/26/2012. PT/INR was drawn on 2/28/2012 and result were reported to Physician on 2/28/2012. PT/INR was drawn on 3/1/2012 and results were reported to Physician on 3/1/2012. PT/INR was drawn on 3/3/2012. There were no PT/INR's drawn every other day after 3/3/2012 on Resident #1. Physician order [REDACTED]. On 4/5/2012 Physician #1 wrote order for PT/INR to be drawn weekly for one month on Resident # 1. On 4/6/2012 Physician discontinued order for PT/INR to be drawn weekly for one month. Physician #1 did not order PT/INR laboratory tests to continue after 4/6/2012. On 5/10/2012 Physician ordered a PT/INR to be drawn on Resident #1 and results called to Physician. PT/INR was drawn on 5/10/2012 and results reported to Physician . Results of PT/INR drawn on 5/10/2012 was PT> 75.0, PT Control 13.7 and INR > 10.0 . Normal test results for PT/INR is as follows: PT 12-13.4 seconds, INR 2.5 - 3.5 . Physicians response was only instructions for new orders . New orders were received on 5/10/2012 to discontinue Physician order [REDACTED]. PT/INR was drawn on Resident #1 on 5/12/2012. Results of PT/INR was PT - 14.1 seconds and INR- 1.1. Normal range for PT is 12- 13.4 seconds and INR is 2.5-3.5. Facility has identified all RN's ( Registered Nurses) and LPN's ( Licensed Practical Nurses). Staffing schedule for RN's and LPN's has been reviewed and adjusted . No Nurses will be allowed to work until Nurse has been inserviced. There is currently one RN and one LPN that are on medical leave. These Nurses will be inserviced before being scheduled to work. All Nurses on current schedule have been inserviced. Staff Development Nurse will track attendance to inservicing after each inservice using the staff census list . Inservicing has been initiated on 5/11/2012 with Nurses regarding recommended laboratory testing for Residents on [MEDICATION NAME] and notifying Physician of abnormal lab results by telephone with documentation of notification. Nurses were inserviced that lab results will not be faxed. Abnormal laboratory results will be reported to Physician by telephone. Lab Log ( exhibit # 1) will be used to track laboratory results received to ensure results have been reported to Physician. There are 17 residents currently receiving [MEDICATION NAME] at this time. On 5/10/2012 at 8:00 pm 100% audit was completed by DON ( Director of Nursing) and ADON (Assistant Director of Nursing) on Residents receiving [MEDICATION NAME]. Audit consisted of checking to ensure recommended laboratory tests are ordered on [MEDICATION NAME] Residents, ordered lab tests have been collected. Physician has been notified of lab results and any new Physician orders [REDACTED]. On 5/11/2012 at 11:00 pm Director of Nursing (DON) and Assistant Director of Nursing (ADON) completed a second 100% audit on Residents receiving [MEDICATION NAME]. Audit consisted of checking to ensure recommended laboratory tests are ordered on [MEDICATION NAME] Residents, ordered lab tests have been collected, Physician has been notified of lab results and any new Physician orders [REDACTED]. On 5/13/2012 monitoring of every Resident on [MEDICATION NAME] for signs of bleeding was initiated on Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Quality Assurance Meeting has been scheduled for Monday 5/14/2012 at 11:00 am. Medical Director (Physician # 1) was notified on 5/11/2012 of Quality Assurance Meeting to be held on Monday 5/14/2012 at 11:00 am. Lab Log (exhibit #1) will be used to track laboratory test results to ensure that laboratory tests have been drawn , results have been reported to Physician. Physician has responded and any new orders have been initiated. Date and time of Physician notification will be noted on Lab Log. Each Nurse will check Lab Log at the time the Nurse arrives on assigned shift to identify any laboratory tests that requires follow up. RN Supervisor will check Lab Log daily to ensure compliance with laboratory testing and reporting. DON or ADON will monitor laboratory tests monthly to ensure compliance with drawing recommended lab, notifying Physician and appropriate documentation of notification of laboratory results. DON and/or designee will review Physician orders [REDACTED]. Physician will be notified for any recommended laboratory tests." Verification of the AoC: Random interviews with Licensed Practical Nurses (LPNs) and a Registered Nurse (RN) were conducted on 5/12/12 between 6:32 p.m. and 6:44 p.m. to verify the in-services conducted for LPNs and RNs on 5/11/12 and 5/12/12, which addressed monitoring for bleeding and bruising when a resident is prescribed (Name Brand) [MEDICATION NAME], and telephoning all abnormal labs to the Physician. The following orders, "(Name Brand) ([MEDICATION NAME]) 5 mg (milligrams) tablet, give 1 (one) tablet on Monday, Wednesday, Thursday, Friday, Sunday", and "(Name Brand) ([MEDICATION NAME]) 7.5 (seven.five) mg tablet, give 1 (one) tablet every Tuesday and Saturday", were discontinued on 5/10/12 for Resident #1." "(Name brand) Vitamin K 5 (five) milligrams two (2) tablets" were administered to Resident # 1, as ordered, at 9:00 p.m. on 5-10-12 and 5-11-12. Monitoring bleeding and bruising when a Resident is prescribed (Name Brand) [MEDICATION NAME] was added to the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A lab log was also instituted to track laboratory results to ensure that laboratory tests have been drawn, abnormal results have been reported to Physician, that Physician has responded, and that any new orders had been initiated. Interview with LPN #2 on 5/12/12 at 6:39 p.m. revealed that nurses will be communicating with physicians by phone and documenting responses with the new form. All residents receiving (Name Brand) [MEDICATION NAME] (17 of 110 residents) had audits completed on 5/10/12 at 8:00 p.m. and on 5/11/12 at 11:00 p.m. by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). Based on verification of the facility's corrective actions that were validated by staff interviews, in-service form reviews and record review, the Immediate Jeopardy (IJ) was removed on 05/12/12 at 6:45 p.m. and the scope and severity was lowered to a "D" level, which constituted no actual harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.