Every finding on record at Lila Doyle Post Acute

Based on observation, interview, record review, facility document review, and facility policy review, the facility failed to assess a resident to determine the level of supervision required while outside and ensure the environment was safe. On 11/22/2025, Resident (R)4, a resident with severe cognitive impairment, was taken outside by a staff member and left without direct supervision of staff. The staff failed to ensure the gate that enclosed the area was secured and the resident's wheelchair brakes were locked. R4 rolled down a hill, fell out of their wheelchair, and sustained an impacted left femoral neck fracture. The facility failed to ensure fall risk interventions were implemented for R2 and R8. These deficient practices affected 3 (R2, R4, and R8) of 6 sampled residents reviewed for accidents.Findings included: A facility policy titled, Fall Management System revised 04/2025, revealed, This facility is committed to promoting resident autonomy by providing an environment remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. Policy: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. 1. An admission Record revealed the facility admitted R4 on 10/01/2016. According to the admission Record, the resident had a medical history that included diagnoses of vascular dementia, arthritis, and aphasia. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/23/2025, revealed R4 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. R4's Care Plan Report included a focus area initiated 11/18/2022 and revised 02/25/2025, that indicated the resident was at risk for falls related to gait/balance problems, unaware of safety needs, muscle weakness, vision/hearing impairment, and benign essential tremors. R4's Fall Risk Evaluation dated 10/20/2025, indicated the resident was at high risk for falls. R4's nursing Progress Notes electronically signed by Licensed Practical Nurse (LPN)5 and dated 11/22/2025, indicated as LPN5 exited the facility at approximately 2:21 PM, she noticed a commotion on the walkway with R4 on the ground. The nursing Progress Notes indicated R4 had an unwitnessed fall to the ground from their wheelchair and was observed grimacing and tearful and expressed pain/discomfort. The nursing Progress Notes indicated the resident was assessed to have an elevated blood pressure and pulse, a skin tear to their left elbow and left index finger, unable to move their left leg, and stated all over my bottom when they described the location of their pain. Per the nursing Progress Note, the resident was being transported by way of emergency medical services (EMS) to the local hospital for further evaluation and treatment. R4's ED [Emergency Department] Provider Note dated 11/22/2025, revealed the resident presented by EMS from a nursing home for evaluation of a fall. The ED Provider Note indicated, Patient [R4] is a resident of a local skilled nursing facility. [He/She] apparently was placed outside in a wheelchair to enjoy the very pleasant weather we were experiencing today and staff found [him/her] on the ground where [he/she] apparently fell. Patient has advanced dementia and as such is unable to provide a history. Per the ED Provider Note, Patient had an unwitnessed fall from [his/her] wheelchair and was complaining of pain on left side. Patient not on blood thinners and has been in [his/her] usual state of health prior to the fall. Imaging reviewed and impacted left femoral neck fracture. Blood work declined by family. After discussion with orthopedic surgery, no surgical intervention at this time; family elected to pursue comfort care and hospice. R4's nursing Progress Notes electronically signed by the Director of Nursing (DON) and dated 11/23/2025, revealed the interdisciplinary team (IDT) reviewed the resident's recent fall and determined the resident fell outside while monitored line of site by staff. The nursing Progress Notes indicated the IDT recommended R4 have 1:1 accompaniment by either staff or family member when outside when the resident returned to the facility. During an interview on 01/17/2026 at 12:21 PM, LPN5 stated she was assigned to care for R4 on 11/22/2025. LPN5 stated she left the unit for a break at the time R4 was assisted downstairs by LPN4. LPN5 stated when she returned to the unit, LPN4 notified her that she took R4 downstairs and let the resident sit outside with R5 and R6. LPN5 stated she told LPN4 that R4 was not supposed to go outside except with family or staff. LPN5 stated she immediately left the unit to go check on R4. LPN5 stated when she arrived at the front door to check on the resident, she saw multiple staff down the walkway that led away from the facility with the resident who was approximately 30 yards from the front door. LPN5 stated she approached the other staff and found the resident on the ground. LPN5 stated she was immediately notified that the resident had been found with their wheelchair flipped on top of them when LPN2 and LPN3 initially reached the resident. LPN5 stated R4 complained of severe pain in their buttocks and left hip pain and had skin tears to the left upper extremity. LPN5 stated she called 911 while the other nurses managed R4's skin tears. During an interview on 01/16/2026 at 4:00 PM, R5 stated they and R6 wanted to go outside on the day of R4's fall. R5 stated a hall nurse assisted them into the elevator along with R4 and took them outside. R5 stated they were outside approximately 15 minutes when they noticed R4 had their wheelchair turned in the direction of the gazebo and began to quickly roll down the hill. R5 stated R4 fell on the sidewalk. R5 stated they were not sure of the distance R4 got from them but the resident fell about halfway down the sidewalk from them. R5 stated that luckily the resident's wheelchair turned slightly to the right side and hit the curb which caused R4's wheelchair to stop. Per R5, R4 fell and their wheelchair landed on top of them. R5 stated R4 began screaming and they stood up from their own wheelchair and began screaming for help. R5 stated, after a few minutes, staff came out and assisted the resident until the ambulance arrived. R5 then pointed to their roommate, R6, as the other resident outside with them at the time of the incident. R5 stated R6 witnessed the events as well. R6 was then asked if there was anything they wished to add or modify from R5's recollection of the events described by R5. R6 stated they did not have anything more to add to the account other than they heard the resident screaming but could not see them from their line of sight. A quarterly MDS, with an ARD of 11/25/2025, revealed R5 had a BIMS score of 15, which indicated the resident had intact cognition. A quarterly MDS, with an ARD of 12/04/2025, revealed R6 had a BIMS score of 15, which indicated the resident had intact cognition. During an interview on 01/17/2026 at 12:40 PM, LPN4 stated she was on duty when R4 fell outside. LPN4 stated she was not assigned to R4 on that date; however, she was assigned to R5 and R6 who had both requested to go outside to enjoy the nice day. LPN4 stated she assisted R4, R5, and R6 on the elevator and took them to sit outside the facility near the front lobby desk. LPN4 stated after the residents were outside, she returned to the unit. LPN4 stated when R4's nurse (LPN5) returned to the unit from a break, she informed the nurse that she took the resident outside. LPN4 stated LPN5 told her that R4 could be outside only if the resident was with a staff member. According to LPN4, LPN5 notified her that she was going to check on the resident. LPN4 stated immediately after LPN5 left the unit, she received a telephone call from LPN2 that R4 had fallen outside. LPN4 stated she was aware R4 had confusion; however, she was not aware R4 could not go outside without supervision and verified she did not ask the resident's assigned nurse before she took the resident outside. During a follow-up interview on 02/03/2026 at 1:28 PM, LPN4 stated on 11/22/2025 when she assisted R4 to sit outside with R5 and R6, she parked R6 closest to the front lobby door directly in front of the first glass panel. LPN4 stated she left R4 sitting in front of R5 and R6 and did not lock the resident's wheelchair brakes because R4 self-propelled their wheelchair independently. During an interview on 01/16/2026 at 2:05 PM, LPN2 stated on 01/10/2026 she was at the nurses' station when she heard the receptionist scream for help. LPN2 stated both she and LPN3 immediately went to assist Receptionist #1. LPN2 stated when they reached the front door, they could see R4 down the sidewalk towards the gazebo. LPN2 stated the resident was lying on their left side and their wheelchair had flipped on top of them. LPN2 stated R4 had a skin tear to the left arm and was screaming about pain to their bottom. Per LPN2, when R4 was rolled to their back, they saw the resident's left leg was externally rotated and immediately called 911. LPN2 stated the resident resided on the second floor of the facility at the time and she was unsure how or when the resident was allowed outside of the facility. LPN2 stated R4 was highly impaired in their cognition and used a wheelchair for mobility. During an interview on 01/16/2026 at 1:43 PM, Receptionist #1 stated sometime after lunch on 11/22/2025, LPN4 from the second floor brought R4 downstairs from the unit on the second floor of the facility and left the resident outside with two other residents. Receptionist #1 stated LPN4 left the residents outside and returned to the facility. Receptionist #1 stated she began assisting visitors at the front desk after the residents were outside and became occupied with them for about 20 minutes or so when she looked up and noticed one of the residents standing up from their wheelchair which was unusual for the resident. Receptionist #1 stated the resident who stood up appeared to be trying to see something, so she got up from the desk, went outside and found R4 lying on their left side on the ground on a sloped walkway towards the gazebo. Receptionist #1 stated R4 was screaming out in pain and their wheelchair appeared to have flipped on top of them during the fall. Receptionist #1 stated she immediately ran inside the building and screamed for help. Receptionist #1 stated two nurses from the first floor responded and came outside to assist the resident. Receptionist #1 stated the resident was screaming in pain to their left lower extremity and had blood on their left arm. During an interview on 01/16/2026 at 3:14 PM, LPN3 stated she and LPN2 were notified by Receptionist #1 that help was needed. LPN3 stated when she and LPN2 approached the front door, they saw R4 on their left side screaming in pain. LPN3 stated R4 had rolled down a sidewalk towards a gazebo. LPN3 stated the resident was approximately 55 feet from the front door and had their wheelchair lying on top of them at the time. Per LPN3, R4 had a skin tear to the left arm and when they turned the resident over, they noticed the resident's left leg was externally rotated. LPN3 stated they immediately called EMS. LPN3 stated the resident was not appropriate to be left unattended due to their cognition. LPN3 stated Receptionist #1 notified her that the only reason she looked up to realize something was wrong was because another resident stood up from their wheelchair. During a follow-up interview on 01/31/2026 at 1:04 PM, LPN3 stated when she responded to R4's fall on 11/22/2025, the gate which was at the side of the patio at the front entrance did not contain a lock. During an interview on 02/02/2026 at 9:05 AM, the Maintenance Director stated he was familiar with R4's fall outside and stated at the time of the fall, the facility did not utilize the pad lock for security except during high windstorms. During an interview on 01/17/2026 at 11:11 AM, R4's responsible party (RP) stated they received a telephone call that there had been an accident and R4 fell after being left outside the facility unattended. The RP stated they rushed to the hospital where they found R4 in a lot of pain. The RP stated R4 was never allowed to go outside unattended because it would be like taking a two-year-old outside and saying do not go near the road, because [R4] had no concept of what they were doing. During an interview on 01/31/2026 at 10:44 AM, the Director of Nursing (DON) stated the facility did not have a policy on supervision. The DON stated if a resident required increased supervision, the facility would obtain and transcribe an order into the resident's electronic medical record. During a follow-up interview on 02/03/2026 at 2:55 PM, the DON stated in 11/2025, the facility allowed all residents to go outside per their resident's rights and confirmed the facility did not have a policy in place that outlined which residents could or could not go outdoors alone or established criteria to determine different levels of supervision to differentiate between the need for direct supervision of a staff member verses line of sight required for residents based on their individual needs. The DON stated he thought a receptionist should be able to maintain eye of sight supervision of residents when they were outside alone and continue to complete their other assigned duties such as answering telephone calls and assisting visitors at the receptionist desk. The DON stated he was not at the facility on 11/22/2025 when R4 fell from their wheelchair; however, he received a telephone call from LPN2 who notified him the resident had a fall outdoors and complained of hip pain and EMS was enroute. The DON stated the facility's investigation determined LPN4 took R4 off the unit and allowed the resident to go outside without a staff member present. The DON stated he was notified R4 rolled out of view of the receptionist and the receptionist responded by going outdoors and found that R4 fell. The DON stated his knowledge of the event was that the receptionist acknowledged the residents were outside and was to be supervising the residents in her line of sight. The DON stated it was determined during the investigation that the gate that aided in securing the patio sitting area was not latched when R4 was left outdoors without a staff member. The DON stated he was not aware that LPN4 did not lock R4's wheelchair brakes before the resident was left outside. Per the DON, locking a residents' brakes was a standard practice despite the resident's ability to self-propel their wheelchair. During an interview on 02/03/2026 at 9:05 AM, Nurse Practitioner (NP)52 stated she was familiar with R4, the resident had severe vascular dementia, and an inability to effectively communicate due to severe cognitive impairment. NP52 stated R4 was not an appropriate candidate to be left outdoors without direct observation and supervision of a staff member at all times and would not be appropriate to be monitored from the receptionist's desk. During an interview on 02/03/2026 at 11:48 AM, NP53 stated R4 was not an appropriate candidate to be outside without a staff member present. During an interview on 01/18/2026 at 4:07 PM, the Administrator stated she was notified R4 had a fall outside. The Administrator stated at the time of the accident, the facility allowed residents to go outside to sit if they were in the line of sight of a staff member. The Administrator stated she would have expected a more formal acknowledgement between the nurse and receptionist that the residents would be outside and were required to be watched. The Administrator stated residents with severe dementia always required direct observation. 2. An admission Record revealed the facility admitted R2 on 06/20/2025. According to the admission Record, the resident had a medical history that included diagnoses of aphasia, cerebrovascular accident, muscle weakness, abnormalities of gait, unsteadiness on feet, and dementia. R2's Care Plan Report included a focus area initiated 06/20//2025 and revised 09/18/2025, that indicated the resident was at risk for falls related to previous frequent falls, incontinence, unsteadiness, cognitive impairment, weakness, and pain and recent falls (with and without injury). Interventions directed staff to place a sensor alarm in the resident's wheelchair per the family request (initiated 09/23/2025). R2's Fall Risk Evaluation dated 09/13/2025, indicated the resident was at high risk for falls. A quarterly MDS, with an ARD of 12/11/2025, revealed R2 had a BIMS score of 0, which indicated the resident had severe cognitive impairment. R2's incident report prepared by Registered Nurse (RN)11 and dated 01/10/2026, indicated a certified nursing assistant (CNA) reported the resident was standing in the common area at supper time and fell. Per the incident report, the CNA reported the resident hit their head on the floor. The incident report indicated the resident lost consciousness and had a large bruise on the left side of their forehead. The incident report revealed that when the resident regained consciousness, they complained of left hip pain, emergency medical services was called to transport the resident to the local hospital for further evaluation. R2's hospital After Visit Summary dated 01/10/2026 revealed the resident has a nondisplaced pubic [pubis] body fracture (pelvis). This is a non-operative fracture and [he/she] can weight bear as tolerated. During an interview on 01/16/2026 at 4:15 PM, CNA6 stated she was on duty on 01/10/2026 during supper time when she heard a loud bang but found R2 on the floor unconscious. CNA6 stated both she and CNA14 checked R2's chair alarm after the fall and discovered the sensor chair pad alarm box was not in the on position and therefore did not sound when R2 stood up. During an interview on 01/17/2026 at 9:33 AM, CNA14 stated she was on duty at the time of R2's fall on 01/10/2026. CNA14 stated she checked R2's sensor chair pad alarm because it did not sound when the resident fell and discovered the alarm was turned off. CNA14 stated she notified RN11 that the chair alarm had been off. During an interview on 01/17/2026 at 8:56 AM, RN11 stated around supper on 01/10/2026, she was on A hall assisting a resident with their meal when she heard someone say, [R2, sit down. RN11 stated she initially did not think much of what she heard because staff frequently reminded R2 not to stand up. RN11 stated when she saw R2, the resident's head was being held off the floor by CNA14 and CNA6 was attempting to get the resident to wake up. RN11 stated R2 was found to be unconscious, and it took several minutes for the resident to come around. RN11 stated she discovered R2's sensor chair pad alarm was not on at the time of the fall. According to RN11, CNA15 toileted the resident prior to the supper meal and did not turn the chair sensor pad alarm back on. During an interview on 01/17/2026 at 10:00 AM, CNA15 stated she was assigned to R2 on 01/10/2026 and had toileted the resident shortly before the evening meal (supper) was served. CNA15 stated R2's chair alarm did not sound at the time of the fall. During an interview on 01/17/2026 at 10:20 AM, R2's family member stated they were notified the resident's chair alarm did not sound when the resident fell this past weekend (on 01/10/2026). During an interview on 01/18/2026 at 2:31 PM, the Assistant DON stated R2's chair alarm should always be on when the resident was in their chair. During a follow-up interview on 02/04/2026 at 10:45 AM, the DON stated he would expect the staff to follow all care planned interventions. During an interview on 02/04/2026 at 11:05 AM, the Administrator stated she expected staff to follow interventions listed on a resident's care plan. 3. An admission Record revealed the facility admitted R8 on 08/31/2022. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease, dementia, lack of coordination, need for assistance with personal care, muscle weakness, unsteadiness on feet, and abnormalities of gait and mobility. A quarterly MDS, with an ARD of 10/30/2025, revealed R8 had a BIMS score of 2, which indicated the resident had severe cognitive impairment. The MDS revealed R8 used a chair alarm daily. R8's Care Plan Report included a focus area initiated 12/16/2022 and revised 05/02/2025, that indicated the resident was at risk for falls related to limited mobility, impaired balance, disc disorder, osteoarthritis, Parkinson's disease, poor safety awareness, impulsivity, a history of falls, and a recent fall without major injury. Interventions directed staff to provide fall sensor alarms in the residents' bed and chair per family request (initiated 07/16/2025). R8's Order Summary Report with active orders as of 01/31/2026, revealed an order dated 07/16/2025, that specified may have sensor pads in bed and wheelchair to remind the resident not to get up unassisted every shift for safety. During an observation on 01/31/2026 at 2:21 PM and 2:50 PM, R8 was seated in a scoot chair in the common area and had a sensor chair pad alarm in place. The sensor chair pad alarm box revealed the switch on the bottom of the box was in the off position. During a concurrent observation and interview on 01/31/2026 at 2:54 PM, LPN36 stated she was assigned to care for R8 on 01/31/2026. LPN36 stated the sensor chair pad alarm was in place for R8 as it was used to alert staff when the residents lifted themselves or shifted their weight before the residents would fall. LPN36 observed the sensor chair pad alarm box and verified the switch was in the off position. LPN36 stated when the switch was in the off position, the sensor chair pad alarm was ineffective to alert staff before the resident attempted to get up. During an interview on 02/03/2026 at 2:55 PM, the DON stated R8 had a sensor chair pad alarm that was used to alert staff when the resident's weight was shifted in their chair. The DON stated if the switch was in the off position, it would not alert staff before the resident attempted to get up. During a follow-up interview on 02/04/2026 at 10:45 AM, the DON stated he would expect the staff to follow all care planned interventions. During an interview on 02/04/2026 at 11:05 AM, the Administrator stated she expected staff to follow interventions listed on a resident's care plan.

Based on interviews, record review, document review, and policy review, the facility failed to ensure 1 (Resident (R)2) of 2 sampled residents reviewed for abuse was not sexually abused by a visitor of the facility. On 10/30/2023, a certified nursing assistant (CNA) witnessed a visitor fondle (stroke or caress lovingly, or erotically) the breast of a cognitively impaired resident, R2. Instead of immediately intervening to separate the resident from the visitor, the CNA left the resident alone in their room to report the incident to a nurse, Licensed Practical Nurse (LPN)6. LPN6 then removed the resident from their room but did not escort the visitor out of the facility, as listed in the facility's abuse policy. The visitor hung around the facility and was later observed to be in close proximity of the resident and offered R2 some ice cream. One hour and nine minutes after CNA8 observed the visitor fondle the breast of R2, the visitor left the faciity on their own accord. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.45 (Abuse) at a scope and severity of J. The IJ began on 10/30/2023 when a visitor was observed fondling R2's breast in the resident's room. The visitor was not made to leave the facility and later was observed to offer the resident ice cream. The Executive Director (ED) and Director of Nursing (DON) were notified of the IJ on 11/04/2023 at 6:50 PM and provided the IJ template at that time. A Removal Plan was requested. The Removal Plan was accepted by the state survey agency on 11/05/2023 at 1:27 PM. The IJ was removed on 11/05/2023 at 3:06 PM after the surveyor performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of D that was not immediate jeopardy for F600. Findings included: Review of a facility policy titled, Abuse: Prevention of and Prohibition Against, revised in October 2022, revealed, It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated, This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Purpose: Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy revealed, Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Per the policy, Sexual abuse is non-consensual sexual contact of any type with a resident. A review of R2's Admission Record revealed the facility admitted the resident on 05/05/2023, with diagnoses that included Alzheimer's disease, dementia with mood disturbance, and need for assistance with personal care. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, revealed R2 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A review of R2's care plan, initiated on 05/07/2023, revealed the resident was at risk for impaired cognitive function and thought processes related to their diagnoses of Alzheimer's disease and dementia with mood disturbance. Review of the facility Initial Report dated 10/30/2023, revealed on 10/30/2023 at 1:45 PM, a certified nursing assistant (CNA) observed a visitor fondle (stroke or caress lovingly, or erotically) R2's right breast. The Initial Report revealed the CNA alerted a nurse, who observed the visitor attempt to close R2's door with only the resident and the visitor in the room. According to the Initial Report, the CNA and nurse removed the resident from their room and notified the Executive Director (ED) and Director of Nursing (DON), who then notified the resident's representative of the allegation. The Initial report indicated the family of the visitor were notified the visitor would not be allowed to the return to the facility until after the investigation was completed. Contained within the facility's investigation file was an undated document titled, ED Interview with [CNA8], which revealed CNA8 witnessed a visitor of another resident (R3) in R2's room having a conversation with the resident. Per the document, R2 was seated in a wheelchair while the visitor stood beside the resident. The document indicated CNA8 witnessed the visitor touch R2's right breast over the resident's clothing. During an interview on 11/04/2023 at 11:20 AM, CNA8 stated as she sat in the day room, she observed a visitor as they pushed R2 from the dining room. Per CNA8, then about 10 minutes later as she walked down the hall, she noted this same visitor as they stood in front, to the side of R2, and the visitor rubbed R2's breast over the top of the resident's clothing. According to CNA8, when she witnessed the incident, instead of separating the resident from the visitor, she immediately went to get the nurse. CNA8 reported the nurse went to R2's room and removed the resident from the room. According to CNA8, she did not know what happened to the visitor, but the nurse reported the incident to supervisor, who then informed the DON. In an interview on 11/04/2023 at 10:55 AM, Licensed Practical Nurse (LPN)6 stated on Monday, 10/30/2023, CNA8 informed her that she had witnessed a visitor rubbing the breast of R2. LPN6 stated she immediately went to R2's room and found the resident's room door partially closed. Per LPN6, she asked the visitor to leave, and she took R2 to the common area in front of the nursing station. According to LPN6, the visitor then came and stood by R2 and offered the resident some ice cream. LPN6 stated she then notified the DON. During an interview on 11/04/2023 at 1:30 PM, LPN5 stated as she completed her medication pass, she observed CNA8 and LPN6, who were visibly upset as the CNA had observed a visitor fondle the breast of R2. LPN5 stated she did witness the visitor make a motion with their head for them and R2 to go to a more secluded area in the common area. LPN5 stated the visitor tried to give R2 some ice cream. According to LPN5, the visitor just hung out in the common area. During an interview on 11/04/2023 at 2:15 PM, the DON stated once she was notified of the incident, she assessed and interviewed R2. The DON stated on her way to assess the resident, she observed the visitor leave the facility with their spouse. The DON stated she asked the staff to clarify their observations then she proceeded to assess the resident. According to the DON, she initiated the investigation by interviewing the resident, who denied being touched inappropriately by anyone, then reported her findings to the ED. Per the DON, she notified the local police and the resident representative (RP) for R2, who stated they wanted to press charges against the visitor. Contained within the facility's investigation file was an undated document titled, DON Victim Assessment and Interview Statement for [R2], revealed on 10/30/2023 at approximately 2:25 PM, the DON assessed and interviewed R2 after being notified of the alleged abuse of the resident by a visitor of the facility. Per the document, the resident acknowledged they had memory problems, and the DON noted the resident had no visible alterations and denied pain or distress. Review of the local sheriff's office report with an incident date of 10/30/2023, revealed the sheriff was dispatched to the facility in reference to an alleged sexual assault. Per the report, the victim, R2, and the suspect were not related and were strangers to each other. Per the report, R2 suffered from dementia and could not recall the incident. The report revealed, CNA8 observed the suspect fondle the breast of R2. In a telephone interview on 11/04/2023 at 11:21 AM, the RP of R2 stated they received a call from the DON who stated the resident had been inappropriately touched by a visitor, who had pushed the resident from the lower-level dining room to the resident's room. The RP stated they were told the visitor was observed to fondle the breast of R2, as the resident sat in their wheelchair. The RP stated when they arrived, R2 seemed fine, but was not the same. The RP explained that on the next day (10/31/2023), the resident was sent to the emergency room due to perineal area bleeding which was found to be from a severe urinary tract infection. Per the RP, R2 did not recall the incident because of their diagnosis of dementia. The RP acknowledged they were pressing charges against the visitor and wanted the resident moved. R2 was unavailable for interview and observations at the time of the survey. During an interview on 11/04/2023 at 3:00 PM, the ED stated the DON notified her on 10/30/2023 around 2:30 PM, that a visitor had touched the right breast of R2 over the resident's clothing. The ED stated the visitor's spouse was called and notified of the allegation and that the visitor was not allowed back in the facility. The ED stated the police were notified. According to the ED, there was video footage from the facility's surveillance system, which showed the visitor took the resident to their room. Per the ED, she had not watched the video footage so she could not speak to the time the abuse potentially occurred. A review of the Timeline of Events form 10/30/2023 Abuse Reporting, obtained from the facility's video surveillance camera and signed by the ED, revealed the following on 10/30/2023- - At 11:53 AM, the visitor entered the facility. - At 12:52 PM, the visitor began to push R2 back to their room. - At 12:57 PM, the visitor and R2 enter the resident's room. - At 1:16 PM, CNA8 observed the visitor fondle the breast of R2. The nurse entered the resident's room and brought the resident to common area. - At 1:20 PM, R2 began to propel their wheelchair down the hallway. - At 1:21 PM, a CNA brought R2 back to the common area. - At 1:28 PM, R2 began to propel their wheelchair down the hallway. - At 1:31 PM, R2 spoke with the visitor, their spouse, and R3, who were all present in R3's room. - At 1:33 PM, a CNA brought R2 to the common area. - At 1:46 PM, the visitor and R2 were seated together at table in the common area. - At 1:48 PM, the visitor left the common area. - At 2:25 PM, the visitor and their spouse exited the facility. On 11/05/2023 at 1:27 PM, the facility submitted an acceptable Removal Plan, which revealed, 1. R2 was immediately interviewed and assessed by the Director of Nursing on 10/30/2023. R2 has a diagnosis of Alzheimer's and has a BIMs score of 6, which indicates sever [sic] impairment. R2 denies that any incident occurred with the [male/female] visitor. There was no physical trauma noted during the body assessment. The FNP [family nurse practitioner] was notified of R2's new onset of [perineal] bleeding on 10/31/23 and completed an assessment noting no physical trauma. R2 was transferred to the hospital for evaluation and remains at the hospital. A psychosocial care plan was developed and implemented on 11/4/2023. 2. All residents currently residing at [name of facility] had the potential to be affected by this alleged deficient practice. 3. The medical director was notified of the immediate jeopardy on 11/4/2023. 4. The following education was initiated for all staff by the Director of Nursing and/or Designee on 11/4/2023. a. Abuse Prohibition Policy and Procedure, specifically, that an alleged perpetrator must be removed from the building immediately. b. A staff member(s) will stay in the vicinity of the alleged perpetrator until the alleged perpetrator exits the facility to ensure resident safety. c. Staff have the ability, responsibility, and authority to have any alleged perpetrator exit the facility, either voluntarily or by calling the police. 5. All staff will be educated on Abuse Prohibition Policy and Procedure prior to their next worked shift. 6. Family of alleged perpetrator has been notified [he/she] is not to return to facility. If alleged perpetrator would return to the facility, [he/she] will be asked to leave immediately and law enforcement will be notified. 7. Ad hoc [a Latin term that meant for this or for this situation] IDT/QA [interdisciplinary team/quality assurance] meeting held on 11/4/2023 to discuss the IJ and develop the removal plan 8. Monitoring a) Upon R2's return from the hospital, resident will be interviewed by social services daily x 3 days (72 hours) to determine if there are any psychosocial changes noted. This interview will be documented in a social services note. b) The facility Psychiatrist will evaluate R2 monthly for 6 months. c) Psychosocial evaluations will be completed weekly on R2 for 6 weeks. d) Any changes noted in psychosocial behavior will be documented in the medical record and will be addressed with IDT. 9. All corrections were completed on 11/5/2023. 10. The immediacy of the IJ was removed on 11/5/2023. Onsite verification: Onsite verification was conducted on 11/05/2023 to verify the facility had implemented the Removal Plan. The onsite verification included staff interviews that revealed staff were knowledgeable of abuse, the reporting requirements, and the how to implement protection of the resident once an allegation of abuse had been observed; the staff were knowledgeable they should not allow the visitor in the facility and what should be done should the visitor attempt to enter the facility; a review of the facility's in-service education revealed staff were provided education on 11/4/2023 and 11/05/2023 regarding their responsibility to protect residents from abuse; residents were interviewed and voiced no concerns related to abuse; employee files were reviewed and no concerns were identified; a review of the facility's staffing revealed no concerns; and a review of the facility's QA meeting notes revealed no concerns. The IJ continued until 11/05/2023 at 3:06 PM, when the surveyor verified elements of the Removal Plan had been implemented. The noncompliance remained on 11/05/2023 for no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Based on interviews, record review, document review, and policy review, the facility failed to conduct a thorough investigation following an allegation of sexual abuse for 1 resident (Resident #2) of 2 sampled residents reviewed for abuse. Findings included: Review of a facility policy titled, Abuse: Prevention of and Prohibition Against, revised in October 2022, revealed, 4. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the Administrator or his/her designee. The policy specified, 5. The investigation will include the following; * An interview with the person(s) reporting the incident; * An interview with the resident(s); * Interviews with any witnesses to the incident, including the alleged perpetrator, as appropriate; * A review of the resident's medical record; * An interview with staff members (on all shifts) who may have information regarding the alleged incident; * Interviews with other residents to whom the accused employee provides care or services or who may have information regarding the alleged incident; * An interview with staff members (on all shifts) having contact with the accused employee; and * A review of all circumstances surrounding the incident. Per the policy, 7. At the conclusion of the investigation, the Facility will attempt to determine in abuse, neglect, misappropriation of resident property, or exploitation has occurred. 8. The investigation, and the results of the investigation, will be documented. A review of Resident #2's Admission Record revealed the facility admitted the resident on 05/05/2023, with diagnoses that included Alzheimer's disease, dementia with mood disturbance, and need for assistance with personal care. A review of the quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/12/2023, revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. A review of Resident #2's care plan, initiated on 05/07/2023, revealed the resident was at risk for impaired cognitive function and thought processes related to their diagnoses of Alzheimer's disease and dementia with mood disturbance. Review of the facility Initial Report dated 10/30/2023, revealed on 10/30/2023 at 1:45 PM, a certified nursing assistant (CNA) observed a visitor fondle (stroke or caress lovingly, or erotically) Resident #2's right breast. The Initial Report revealed the CNA alerted a nurse, who observed the visitor attempt to close Resident #2's door with only the resident and the visitor in the room. According to the Initial Report, the CNA and nurse removed the resident from their room. Per the Initial Report, the Executive Director (ED) and Director of Nursing (DON) were notified, who then notified the resident's representative of the allegation. Review of the facility investigation file revealed statements were only obtained from the staff who witnessed the visitor fondle the breast of Resident #2, CNA #8; the nurse who CNA #8 reported the incident to, Licensed Practical Nurse (LPN) #6; the victim, Resident #2; and the visitor's (perpetrator's) spouse. The facility investigation file did not include an interview with the alleged perpetrator, interviews with staff members who may have had information regarding the incident, interviews with other residents who may have had information regarding the incident or interaction with the visitor, a review of all circumstances that surrounded the incident, or a determination as to whether abuse occurred. During an interview on 11/04/2023 at 2:15 PM, the DON stated once she was notified of the incident, she assessed and interviewed Resident #2. The DON stated on her way to assess the resident, she observed the visitor leave the facility with their spouse. The DON stated she asked the staff to clarify their observations then she proceeded to assess the resident. According to the DON, she initiated the investigation by interviewing the resident, who denied being touched inappropriately by anyone, then reported her findings to the ED. Per the DON, she notified the local police and the resident representative (RP) for Resident #2, who stated they wanted to press charges against the visitor. The DON stated the facility only obtained statements from CNA #8 and LPN #6. Per the DON, no other statements were obtained during the investigation. The DON explained what constituted a thorough investigation included an interview from everyone involved. During an interview on 11/04/2023 at 3:00 PM, the ED stated the DON notified her on 10/30/2023 around 2:30 PM, that a visitor had touched the right breast of Resident #2 over the resident's clothing. The ED stated the visitor's spouse was called and notified of the allegation and that the visitor was not allowed back in the facility. The ED stated the police were notified. According to the ED, there was video footage from the facility's surveillance system, that showed the visitor took the resident to their room. Per the ED, she had not watched the video footage so she could not speak to the time the abuse potentially occurred. The ED agreed that it would have been important for her to review the video footage for a thorough investigation to have been completed. The ED stated education was provided to the staff on 10/31/2023, but resident protection was not reviewed in detail. Per the ED, the topics discussed included immediate response/action, notification of the in-house supervisor, and assurance the victim was removed from the situation. The ED stated the staff were not provide education on how the staff should ensure the resident was protected from a visitor. Per the ED, during the investigation, she did not interview the dining room staff or any other staff that worked on the second floor. The ED explained that she spoke with other residents about any interactions they may have had with the visitor, but she did not have written documentation of such interviews.

Based on observations, interviews, record review, and review of the facility's policy, the facility failed to promote the dignity of 1 (Resident (R) 6) of 1 resident who was observed with staff standing while assisting the resident to eat. Findings include: Review of the facility's policy titled, Resident Rights: Respect and Dignity, dated 10/04/16, revealed . You have the right to be treated with respect and dignity . reside and receive services in the facility reasonable accommodation of your needs and preferences . Review of R6's Admission Record located in the resident's electronic medical record (EMR) under the Profile tab, revealed R6 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; Alzheimer's disease with late onset, encounter for palliative care, need for assistance with personal care, lack of coordination, and disorders of muscle. Review of R6's quarterly Minimum Data Set (MDS), with an assessment reference date (ARD) of 06/08/23, located in the resident's EMR under the MDS tab, indicated the facility assessed R6 to have a Brief Interview for Mental Status (BIMS) score not listed, which indicated the resident was severely cognitively impaired and had memory problems. The MDS also indicated R6 was totally dependent and required one person assistance with eating. Review of R6's Care Plan located in the resident's EMR under the Care Plan tab and dated 06/27/23, revealed R6 . has nutritional problem or potential nutritional problem related resident is fed by staff and has Alzheimer's disease . Review of R6's Physician's Orders located in the resident's EMR under the Orders tab and dated 07/2023, revealed R6 was ordered a regular diet with a pureed texture and thin liquids. During an observation of the lunch meal on 07/11/23 from 12:55 PM to 1:02 PM, revealed R6 was being assisted with eating while in her bed by Registered Nurse (RN)1, who was standing beside her while assisting R6 to eat. There was a chair noted in the room at this time on the wall near the resident's bedside dresser. During an interview on 07/11/23 at 1:04 PM, RN1 stated she should have been sitting down. She confirmed she could have figured out a different way to feed the resident other than standing and she had received education on how to assist residents with meals and sitting down was a part of the education. During an interview on 07/13/23 at 3:39 PM, the Director of Nursing (DON) stated the expectations for staff assisting residents with meals would be for staff to provide dignity to residents by sitting next to them to feed the residents.

Based on observation, interview and record review, the facility failed to implement the care plan for 1 (Resident (R)43) of 1 resident reviewed for skin conditions. Specifically, the failure to apply the skin protection devices placed R43 at risk for additional skin tears. Findings include: Review of R43's Medical Diagnosis, located in R43's electronic medical record (EMR) found in the Medical Diagnosis tab, revealed R43 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; diabetes, heart failure, and pressure ulcer. Review of a Nursing Note dated 05/01/23 at 5:08 AM and located in the Progress Notes tab of R43's EMR, noted, . When changing the pt's [patient's] PICC (Special IV line) dressing, while removing the tegaderm it was noticed that she had a 4x2 skin tear that was actively bleeding, approx. [approximately] 2 cm (centimeters) above the pt's PICC insertion side. While using sterile technique, bordered gauze was applied to tear. Review of a Nursing Note dated 06/07/23 at 10:32 AM and located in the Progress Notes tab of R43's EMR, noted, . Cna [SIC] was preparing resident for shower when they discovered 2 skin tears. one on upper left arm and one on back of lower right leg resident states she does not know how these happened wound orders given. family made aware staff will monitor for s/s [signs and symptoms] of infection . Review of R43's Care Plan located in the EMR, found in the Care Plan tab, and initiated on 06/15/23, revealed, . Has Skin Tear/potential for skin tear . Interventions/Tasks Derma Saver arm and leg sleeves applied . Review of a Nursing Note dated 06/26/23 at 10:32 AM and located in the Progress Notes tab of R43's EMR, noted, . During morning assessment, this nurse was notified by the resident, of a skin tear upon the right elbow that occurred over the weekend . Wound orders in place, and family notified . During an interview and observation of R43 on 07/11/23 at 11:00 AM, R43 was observed to have scabs on both arms and the Derma Saver arm sleeves were not in place. R43 stated her skin tears easily. During an observation on 07/12/23 at 11:12 AM, revealed R43 lying in bed without the Derma Saver arm sleeves. During an interview on 07/11/23 at 11:25 AM, Certified Nursing Assistant (CNA)2 stated the resident's skin was sensitive and tore easily. CNA2 stated she always puts a sheet between the resident and the sling when using the lift for transfers. During an interview on 07/12/23 at 2:13 PM, CNA3 stated the nurse told her R43 was supposed to wear arm sleeves. CNA3 said she had not seen the arm sleeves in about a week. CNA3 stated she was going to check with laundry to see if they had been sent for a wash. During an interview on 07/12/23 at 3:30 PM, Licensed Practical Nurse (LPN) 1 said she looked everywhere in the resident's room and could not find the arm sleeves. During an interview on 07/12/23 at 4:30 PM, the Assistant Director of Nursing (ADON), who was also the wound care nurse, confirmed the care plan for the arms sleeves was not implemented. The ADON stated she added the arm sleeves to the care plan as a nursing intervention and thought they had been in place.

Based on interview and record review, the facility failed to ensure 1 (Resident (R)135) of 3 sampled residents reviewed for nutrition and/or hydration status had accurate care plans. This placed R135 at risk for choking and/or aspiration related to the consistency of liquids. Findings include: Review of Medical Diagnosis located in R135's electronic medical record (EMR) and under the Diagnosis tab, revealed R135 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; dysphagia (difficulty in swallowing) and dementia. Review of Physicians Orders located in R135's EMR under the Orders tab and dated 06/27/23, documented, . Special Instructions: MEDS CRUSHED IN APPLE SAUCE .MECHANICAL SOFT DIET NECTAR THICK CONSISTENCY, no straws . Review of Physicians Orders located in R135's EMR under the Orders tab and dated 07/12/23, documented, . Monitor for signs of aspiration pna [pneumonia]: lungs sounds, increased cough, vs [vital signs] . Review of R135's Speech Therapy SLP Discharge Summary, Discharge Recommendations and Status dated 07/06/23, documented, . Oral intake Solids = Puree consistencies . Liquid = Nectar thick liquids . it is recommended the patient use the following strategies during oral intake: alternation of liquid/solids, alternation of tastes, bolus size modifications and general swallow techniques/precautions, along with the following maneuvers: upright posture for [greater than]30 minutes after meals and upright posture during meals . During an interview on 07/13/23 11:34 AM, the Speech Therapist (ST) stated R135 was having problems clearing his airway after taking thin liquids and that is why she put him on nectar thick. She said he did better if he was sitting up. Review of the Care Plan located in R135's EMR under the Care Plan tab and with an initiation date of 06/19/23 and revised date of 07/10/23, failed to identify swallowing difficulties as a problem and failed to list interventions as directed by the Speech Therapist (ST) upon discharge. The care plan identified R135 as having nutritional problems related to a fracture of the left femur. Interventions included, . Diet as ordered by the physician. Mechanical soft ground with thin liquids . During an interview on 07/13/23 at 8:39 AM, the Minimum Data Set Coordinator (MDSC) confirmed the care plan was not accurate related to the resident's diet and swallowing issues.

Based upon observation, interview, and record review, the facility failed to ensure 1 (Resident (R) 135) of 6 residents observed receiving medications, received nectar thick liquids with the medication pass as ordered by the physician. This placed R135 at risk of choking and aspiration. Findings include: Review of Medical Diagnosis located in R135's electronic medical record (EMR) under the Diagnosis tab, revealed R135 was admitted to the facility on [DATE] with diagnoses that included but was not limited to; dysphagia (difficulty in swallowing) and dementia. Review of Physicians Orders located in R135's EMR under the Orders tab and dated 06/27/23, revealed, . Special Instructions: MEDS CRUSHED IN APPLE SAUCE . MECHANICAL SOFT DIET NECTAR THICK CONSISTENCY, no straws . Review of R135's Speech Therapy SLP Discharge Summary Discharge Recommendations and Status, dated 07/06/23, documented, . Oral intake Solids = Puree consistencies .Liquid = Nectar thick liquids . During an observation of the medication pass on 07/12/23 at 9:04 AM, Licensed Practical Nurse (LPN)3 placed R135's medications into a small med cup and took a glass with water into R135's room. LPN3 spoke with the resident, who was lying in bed with the head of the bed elevated close to 90 degrees. LPN3 determined that due to R135's condition, his medications should be crushed and given in applesauce. LPN3 then crushed the medications and administered them to R135 in applesauce. R135 swallowed the meds in the applesauce with no issues. LPN3 then proceeded to give R135 thin water through a straw. R135 quickly drank half of the glass of thin water and then began to cough. R135 kept coughing for several minutes to clear his airway. LPN3 remained in the room until the resident could talk and his airway had been cleared. Upon returning to the medication cart, LPN3 referenced R135's physician orders revealing R135 should only have nectar thick liquids with his crushed meds. During an interview on 07/12/23 at 10:00 AM, LPN3 stated she was an agency nurse and only here for one day. LPN3 confirmed the physician's orders should be referenced before administering medications. LPN3 stated she had worked at this facility one other time, but it was on a different unit. LPN3 had the roster of residents on her assigned hallway with instructions for giving medications, including the type of liquid to be used. The list did not include R135. During an interview on 07/12/23 at 5:32 PM, the Director of Nursing (DON) stated they submit shifts that need to be covered to the agency who then tries to send nurses that have worked at the facility before. The DON stated there was no orientation or observation for administering medications because they were all familiar with the EMR and should know to reference the orders if necessary to find out a resident's status. During an interview on 07/13/23 at 8:18 AM, LPN2 stated he was responsible for keeping the resident list updated. He said R135 had recently moved from another room into his current room and had not been added to the hallway roster. LPN2 stated agency nurses were familiar with the EMR system and should reference the medication pass instructions before giving the medications.

Based on interview, record review, and review of facility policy, the facility failed to ensure 1 (Resident (R)5) of 5 sampled residents reviewed for vaccinations were up to date with the pneumococcal vaccination. This placed R5 at increased risk for serious illness related to respiratory infections. Additionally, the facility failed to ensure physician standing orders for the pneumococcal vaccine were individualized to the resident. Findings include: Review of the facility's policy titled, Immunizations-Influenza and Pneumococcal revised on 10/2022, revealed, . For Pneumococcal Immunizations refer to the CDC (Centers for Disease Control) website: Pneumococcal Vaccination: Summary of Who and when to vaccinate or Pneumococcal Vaccination Timing for Adults . Two types of Pneumococcal vaccines are available for adults: Pneumococcal Conjugate Vaccines (PCV13, PCV15, and PCV 20) . Pneumococcal Polysaccharide Vaccine (PPSV23) . The resident or the resident's representative has the opportunity to decline immunizations(s) . Review of the referenced document from the CDC website titled, Pneumococcal Vaccine Timing for Adults revealed, . For those who previously received PPSV23 but who have not received any pneumococcal conjugate vaccine (e.g., PCV13, PCV15, PCV20), You may administer one dose of PCV15 or PCV20 . The minimum interval is at least 1 year . Their pneumococcal vaccinations are complete . 1. Review of R5's Order Summary Report found in the electronic medical record (EMR) under the Orders tab, revealed R5 was admitted to the facility on [DATE]. Review of Medical Diagnosis found in R5's EMR under the Medical Diagnosis tab, revealed R5 had diagnoses that included but was not limited to; respiratory failure, unspecified with hypoxia (low oxygen), and dementia. Review of Clinical-Immunizations found in R5's EMR under the Immunization tab, revealed R5 received a Pneumococcal Polysaccharide Vaccine (PPSV23) on 02/26/21. Review of R5's Active Orders dated 07/13/23 and located under the Orders tab of the EMR, revealed, . May have Pneumonia Vaccine if resident has not received in the past 5 years . During an interview on 07/13/23 at 3:16 PM, the Infection Preventionist (IP) confirmed R5 had not received the second conjugate dose of the vaccine. The IP was unable to find an assessment, consent, or declination showing that R5 was offered a second conjugate dose. The IP confirmed the standing orders for the Pneumococcal Vaccine needed to be individualized to the resident to follow the CDC guidelines, as referenced in the facility policy.

Based on record review and interview, the facility failed to identify and implement an action plan timely related to medication errors for 12 of 12 months reviewed. The findings included: Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 01/10/19 at 10:25 AM of Resident #100's Progress Notes revealed a re-admission note dated 06/11/18 that indicated on 06/10/18 the resident was lethargic with poor PO (by mouth) intake and was sent to the emergency department. A drug screen performed at the hospital was positive for opiates for which the resident did not have an order. A progress note dated 06/13/18 indicated suspicion here that (s/he) may have mistakenly been given roommate's quetiapine on 6/9 evening (and) level was drawn here (and) is (positive). Review of the Nurse's education transcript dated 11/01/17 to 01/11/19 revealed the nurse completed education entitled Medication Written Competency Examination-Combo (combination) Adult and Peds (Pediatrics) on 09/19/18 through the hospital, after her/his last day of employment at the facility. Review of the medication errors log provided by the facility revealed the facility had 3-9 medication errors per month from (MONTH) (YEAR) through (MONTH) (YEAR). In (YEAR) the medication errors log revealed 7 medication errors in (MONTH) and December. In (YEAR) the medication errors log revealed 9 medication errors in January, 5 in February, 6 in March, 3 in (MONTH) and May, 6 in June, 8 in July, 6 in August, 3 in (MONTH) and October, 5 in (MONTH) and 4 in December. During an interview on 01/10/19, the Director of Nursing (DON) provided documentation of an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting on (MONTH) 3, 2019. Review of the committee minutes revealed a new documentation system to start in (MONTH) of 2019, the font on the MAR (medication administration record) was to be adjusted, and the nurse educator and pharmacist will randomly check nurses for medication pass competency. The DON confirmed the facility had not implemented a plan earlier.

Based on record review, interview, and review of the US National Library of Medicine National Institutes of Health Pharmacy and Therapeutics Journal, the facility failed to ensure that staff followed the 5 Rights of Medication Administration for Resident #100. 1 of 7 residents reviewed for medication administration. The findings included: Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 1/10/19 at 10:25 AM of Resident #100's Progress Notes revealed a re-admission note dated 06/11/18 that indicated on 06/10/18 the resident was lethargic with poor PO (by mouth) intake and was sent to the emergency department. A drug screen was positive for opiates. A [DIAGNOSES REDACTED]. A 06/13/18 progress note indicated suspicion here that (s/he) may have mistakenly been given roommate's quetiapine on 6/9 evening (and) level was drawn here (and) is (positive). Review of Resident #100's laboratory studies revealed the resident also had a positive [MEDICATION NAME] level. Review of the US National Library of Medicine National Institutes of Health Pharmacy and Therapeutics Journal, volume 35 dated October, 2010 revealed Most health care professionals, especially nurses, know the five rights of medication use: the right patient, the right drug, the right time, the right dose, and the right route-all of which are generally regarded as a standard for safe medication practices. During an interview on 01/10/19, the Director of Nursing confirmed the documentation indicated the resident received the wrong medication based on laboratory tests and that the nurse didn't follow the 5 rights of medication administration.

Based on record review, and interview the facility failed to ensure resident rights related to choices in treatment. Staff ignored Resident #61's refusal for use of [MEDICATION NAME]. 1 of 1 resident reviewed for Foley catheter. The findings included: The facility admitted Resident #61 on 08/14/2018 with [DIAGNOSES REDACTED]. Review of Resident #61's nurse's notes revealed on 11/04/2018 the nurse explained the procedure for inserting a Foley catheter to the resident. The resident stated (s/he) was allergic to [MEDICATION NAME]. At that point the nurse stated the Physicians progress note dated 10/5/2018 stated the resident was not allergic to [MEDICATION NAME]. [MEDICATION NAME] was used, and the Foley catheter inserted using sterile technique. During an interview on 01/08/19 at approximately 04:37 PM Resident #61 stated The Nurse said (s/he) had to put the Foley in, (s/he) had an order. I didn't object to the Foley, just the [MEDICATION NAME] (s/he) was going to use. I had an allergy to it, so I told (her/him) it is against my will. (S/he) kept saying I have a doctor's order and I have to do this. The order came from my doctor stating that I did not have an allergy to [MEDICATION NAME]. My daughter even told them I did not. After the [MEDICATION NAME] was used and the Foley put in, I burned for days and felt like I was swollen in my vagina, (s/he) cried when (s/he) got in trouble for not listening to me.

Based on record review, interview, and review of the facility's policy Notification of Change the facility failed to notify the physician and/or family timely of a change in condition for Resident #100, 1 of 2 residents reviewed for change in condition. The findings included: The facility admitted Resident #100 on 05/18/18 with [DIAGNOSES REDACTED]. On 01/10/19 at 01:44 PM, review of the Daily Skilled Nurse's Note for Resident #100 dated 06/08/18 through 06/10/18 revealed on 06/08/18 the resident was alert and able to voice needs. There was no documentation on 06/09/18. On 06/10/18 at 05:00 AM, the nurse documented the resident was lethargic. At 07:30 AM, the day shift nurse also documented the resident was lethargic but responds to staff. At 11:00 AM, the resident continued to be lethargic and responding to staff but was incontinent and refused breakfast and morning medications. At 11:22 AM, the family was in the resident's room and were concerned about the resident's condition and the nurse paged the physician to notify (him/her) of the resident's condition. Further review of Resident #100's record revealed a SBAR (Situation/ Background/ Assessment/ Request) Communication Form dated 06/10/18 that indicated the resident had decreased consciousness as indicated by the signs/ symptoms described as lethargic, won't eat, wake up, incontinent. The report also indicated the family was notified of the resident's condition at the facility at 11:00 AM and the physician was notified at 11:22 AM. Review of the facility's policy entitled Notification of Change revealed the facility must immediately inform the resident, consult with the resident's physician and if known, notify the resident's legal representative of (sic) interested family member when there is . a significant change in the resident's physical, mental, or psychosocial status . During an interview on 01/10/19 at 04:28 PM, the Director of Nursing (DON) confirmed the documentation indicated the family was aware of the change in the resident's condition at 11:00 AM when they came to visit, and the MD was notified at 11:22 AM. The DON further stated s/he would have expected the nurse to notify someone earlier and stated the Nurse Practitioner would have been the best person to notify.

Based on record review and interview, the facility failed to ensure that Resident #100, 1 of 1 resident reviewed, was free of significant medication errors as evidenced by laboratory results positive for Opiates and quetiapine. The findings included: Resident #100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 01/10/19 at 10:25 AM of Resident #100's Progress Notes revealed a re-admission note dated 06/11/18 that indicated on 06/10/18 the resident was lethargic with poor PO (by mouth) intake and was sent to the emergency department. Labs drawn on 06/10/18 at the hospital included a drug screen that was positive for opiates. A [DIAGNOSES REDACTED]. A progress note dated 06/13/18 indicated suspicion here that (s/he) may have mistakenly been given roommate's quetiapine ([MEDICATION NAME]) on 6/9 evening (and) level was drawn here (and) is (positive). Review of an incident and investigation file revealed a copy of Resident 100's roommate's nursing note dated 06/09/18 indicating the roommate received medication for a complaint of back pain and [MEDICATION NAME] on that date. The file contained a Narcotic Inventory Record for the roommate that indicated 1 tablet of [MEDICATION NAME]/ APAP ([MEDICATION NAME]) 5/325 milligrams was signed out on 06/09/18 at 09:30 PM. Further review revealed Resident #100's roommate who had an order for [REDACTED]. Res (resident) states people have been in room who have not. Res refused meds 5 x (times) this AM stated they're not going to do me any good or how do I know they are the right ones. Additional review revealed an Opiates Expanded, Quantitative, Urine test done on Resident #100 that was positive for [MEDICATION NAME]. During an interview on 01/10/19 at 04:28 PM, the Director of Nursing confirmed the documentation indicated the resident received the wrong medication based on laboratory tests.

Based on record review and interview, the facility failed to ensure that all required disciplines participated in, and attended the care plan meeting for Residents #79, #93, #100 and #95. 4 of 18 residents reviewed for care plans. The findings included: The facility admitted Resident #79 on 11/21/18 with [DIAGNOSES REDACTED]. On 01/09/18 at approximately 04:00 PM, review of Resident #79's care plan revealed the only person present for the care plan was the Registered Nurse (RN). There was no indication that a Certified Nursing Assistant (CNA) or a dietary representative participated in the care plan or attended the care plan meeting. During an interview on 01/09/19, Minimal Data Set (MDS) Coordinator, confirmed there was documentation of RN participation only in the care plan for Resident #79. The MDS Coordinator stated that with the short-term rehab residents, the MDS Coordinator usually goes to the room and reviews the care plan with the resident or resident representative but the other disciplines do not attend. The facility admitted Resident #93 on 03/22/18 with [DIAGNOSES REDACTED]. On 01/09/19 at 04:23 PM, review of Resident #93's care plan revealed no documentation that a Certified Nursing Assistant participated in the care plan or attended the care plan meeting. During an interview on 01/09/18, the MDS Registered Nurse #1 confirmed there was no indication the CNA attended the care plan meeting or participated in the care plan for Resident #93. The facility admitted Resident #100 on 05/18/18 with [DIAGNOSES REDACTED]. On 01/09/18 at approximately 01:37 PM, review of Resident #100's care plan revealed no documentation that the RN was the only person present at the care plan meeting. There was no documentation that a CNA or any other discipline attended. During an interview on 01/09/19, Minimal Data Set (MDS) Coordinator, confirmed there was documentation of RN participation only in the care plan for Resident #100. The MDS Coordinator stated that with the short-term rehab residents, the MDS Coordinator usually goes to the room and reviews the care plan with the resident or resident representative but the other disciplines do not attend. The facility admitted Resident #95 with [DIAGNOSES REDACTED]. Review of Resident #95's record on 01/11/19 at 09:57 revealed the Baseline Care Plan was signed by the Registered Nurse and the resident. During an interview on 01/11/19, Registered Nurse #1 confirmed that the Baseline Care Plan for Resident #95 had no signatures to show it was developed by a representative from Dietary and a Certified Nursing Assistant.

Based on review of facility files and interview, the facility failed to implement written policies and procedures that prohibit and prevent abuse. Resident #97's wallet went missing during care by Certified Nursing Assistant (CNA #3). 1 of 1 resident reviewed for misappropriation. The facility failed to obtain a criminal background check from the state of residency prior to employment for 1 of 1 Certified Nursing Assistant (CNA) reviewed for misappropriation. The findings included: Review of the facility investigation revealed that Resident #97 reported to facility staff on 08/06/2018 at approximately 10:30 AM that (his/her) wallet went missing during care by CNA #3. Review of Registered Nurse (RN) #4's statement revealed that Resident # 97 told staff member that (CNA #3) was helping (him/her) to the bathroom and asked (him/her) to hold onto (his/her) wallet. Resident # 97 stated that (s/he) asked (CNA #3) about (his/her) wallet and (CNA #3) told (him/her) that (s/he) put the wallet in the bedside table. When Resident #97 woke up on 8/6/2018, (s/he) reported that (s/he) checked the bedside table and the wallet was not there. During an interview on 01/10/19 at 10:20 AM RN #4 Confirmed her/his statements with additional information that RN #4 remembered that Resident #97's daughter/son was not concerned about replacement of the resident's wallet, but that s/he was mostly upset about the loss of sentimental pictures that were in the resident's wallet. Review of CNA #2 statements revealed that CNA #2 reported to the Licensed Practical Nurse (LPN) that Resident # 97 told (her/him) that (his/her) wallet was missing and (Resident #97) stated that the male CNA young man who put (him/her) to bed last night put it in (his/her) pocket, and then (s/he) asked (CNA #3) what (s/he) did with the wallet. CNA #2 stated that Resident #97 stated (S/he) (CNA #3) put the wallet in (his/her) top drawer, and states the wallet is not in the drawer. Resident #97 then reported to the LPN the same timeline of events reported to the CNA. During an interview on 01/08/19 at 2:43 PM Resident #97 stated s/he had almost $60 in his/her wallet. During an interview on 01/10/19 at 2:12 PM Resident #97's daughter/son stated that Resident #97 told him/her that a male CNA took his/her wallet. The daughter/son stated that Resident #97 did have some money in his/her wallet but was not sure on how much, s/he stated, maybe fifty to seventy dollars. Resident #97's daughter/son stated that the facility notified her/him of the incident, but the facility did not replace the missing wallet. Review of the facility policy titled Abuse, Neglect, Exploitation and Reasonable Suspicion of a Crime in a Subacute Facility stated At Greenville Health System (GHS) residents (patients) residing in a Subacute Unit have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and exploitation/misappropriation of financial and personal property. Review of CNA #3's employee file revealed that CNA #3 was a travel CNA that worked for a staffing agency. Review of CNA #3's personnel record provided to the facility by the staffing agency revealed that the CNA's background screening report included searches of counties that the perpetrator resided in West Virginia and documents his/her residency. A West Virginia county criminal records search was included for the counties that the perpetrator resided in West Virginia. Noted in the documentation that West Virginia does not provide a Statewide search. Review of the facility policy titled Abuse, Neglect, Exploitation and Reasonable Suspicion of a Crime in a Subacute Facility stated All potential employees will be screened for history of abuse, neglect or exploitation/mistreatment of [REDACTED]. A. The following screening interventions should be conducted prior to employment 1. Inquiry of state, local and federal jurisdictions for criminal convictions by the Greenville Hospital System (GHS) Human Recourse Department or its contracted affiliate .

Based on review of facility files and interview, the facility failed to ensure residents remained free from misappropriation of resident property. Resident #97's wallet went missing during care by Certified Nursing Assistant (CNA #3). 1 of 1 resident reviewed for misappropriation. The findings included: The facility admitted Resident # 97 on 11/1/2017 with the [DIAGNOSES REDACTED]. Review of Resident #97's medical record revealed a Brief Interview for Mental Status (BIMS) Score of 9. Review of the facility investigation revealed that Resident #97 reported to facility staff on 08/06/2018 at approximately 10:30 AM that (his/her) wallet went missing during care by CNA #3. The investigation revealed that the alleged perpetrator was identified by Resident #97 as the Certified Nursing Assistant (CNA) #3 that provided care on the previous evening shift on 08/05/2018. Resident #97 reported his/her missing wallet the next morning at approximately 10:30 AM. CNA #3 had already completed his/her shift and had left prior to the resident reporting his/her wallet missing. Review of Registered Nurse (RN) #4's statement revealed that Resident # 97 told staff member that (CNA #3) was helping (him/her) to the bathroom and asked (him/her) to hold onto (his/her) wallet. Resident # 97 stated that (s/he) asked (CNA #3) about (his/her) wallet and (CNA #3) told (him/her) that (s/he) put the wallet in the bedside table. When Resident #97 woke up on 8/6/2018, (s/he) reported that (s/he) checked the bedside table and the wallet was not there. During an interview on 01/10/19 at 10:20 AM RN #4 Confirmed her/his statements with additional information that RN #4 remembered that Resident #97's daughter/son was not concerned about replacement of the resident's wallet, but that s/he was mostly upset about the loss of sentimental pictures that were in the resident's wallet. Review of CNA #2 statements revealed that CNA #2 reported to the Licensed Practical Nurse (LPN) that Resident # 97 told (her/him) that (his/her) wallet was missing and (Resident #97) stated that the male CNA young man who put (him/her) to bed last night put it in (his/her) pocket, and then (s/he) asked (CNA #3) what (s/he) did with the wallet. CNA #2 stated that Resident #97 stated (S/he) (CNA #3) put the wallet in (his/her) top drawer, and states the wallet is not in the drawer. Resident #97 then reported to the LPN the same timeline of events reported to the CNA. During an interview on 01/08/19 at 2:43 PM Resident #97 stated s/he had almost $60 in his/her wallet. During an interview on 01/10/19 at 2:12 PM Resident #97's daughter/son stated that Resident #97 told him/her that a male CNA took his/her wallet. The daughter/son stated that Resident #97 did have some money in his/her wallet but was not sure on how much, s/he stated, maybe fifty to seventy dollars. Resident #97's daughter/son stated that the facility notified her/him of the incident, but the facility did not replace the missing wallet.

Based on interview and chart review, the facility failed to update the baseline care plan for Resident #98, 1 of 6 residents reviewed for Baseline Care Plan. The findings included: The facility admitted Resident #98 with [DIAGNOSES REDACTED]. Review of Resident #98's Baseline Care Plan on 01/09/19 at 3:40 PM revealed the Baseline Care Plan had not been updated with the following physician's orders [REDACTED]. 12-19-18 [MEDICATION NAME] 10mg by mouth daily. 12-20-18 [MEDICATION NAME] 4 milligrams dissolving tabs every 8 hours as needed nausea/vomiting. 12-27-18 Type, cross, and transfuse 1 unit Packed Red Blood Cells (PRBS) [DIAGNOSES REDACTED]. Review of Resident #98's Nurses Notes on 12/27/18 at 0950 AM revealed Resident #98 was sent at 10am receive a transfusion. During an interview on 01/10/19 at 10:30am, Register Nurse #2 confirmed that the Baseline Care Plan had not been updated.

Based on review of facility files and interview, the facility failed to ensure that all alleged violations related to mistreatment, exploitation, neglect, or abuse were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. The facility did not report the 2 hour and the 5-day reports for Resident #61 within the required time frames. One of three incidents reviewed for reporting. The findings included: The facility admitted Resident #61 on 08/14/2018 with [DIAGNOSES REDACTED]. Review of the Incident Report and Investigation for an incident that occurred on 11/04/2018 revealed that the incident was not reported to the State Agency within the required time frame. There was no documentation of a 2-hour report being sent to the State Agency. The 24- Hour report was submitted to the State Agency on 11/08/2018 and the Five-Day Follow-Up Report was submitted on 11/12/2018. During an interview with the Director of Nursing on 01/11/2019 at approximately 10:30 AM, confirmation was obtained that the facility was late in reporting to the State Agency within the required time frames.

Based on record review and interview, the facility failed to accurately code the comprehensive MDS (Minimal Data Set) assessment relevant to Hospice and prognosis for Resident #62, 1 of 1 resident reviewed for Hospice. The findings included: Resident #62 was admitted to the facility with [DIAGNOSES REDACTED]. On 11/13/17, at approximately 2:30 PM, record review revealed an order dated 07/11/17 to admit Resident #62 to Hospice. Further review at 2:41 PM revealed a Significant Change in Status MDS (Minimal Data Set) assessment dated [DATE]. Section J, Health Conditions, Question J1400, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? was coded as No. In addition, Section O, Special Treatments and Programs, Question O0100 K Hospice Care, was coded as No. On 11/14/17, review of CMS ' s (Center for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, October, 2016, page J-23, Prognosis, Question J1400 revealed the following coding instructions: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. During an interview on 11/15/17 at 4:54 PM, MDS RN (Registered Nurse) #1 confirmed the Significant Change in Status Assessment was coded inaccurately. In addition, the RN confirmed the subsequent Quarterly Assessment was also coded inaccurately.

Based on record review and interviews a Certified Nursing Assistant failed to follow care plan on transferring for Resident # 129. ( 1 of 1 resident reviewed for following care plan.) The findings included: Closed record review and facility investigation records for Resident # 129's fall on 6/10/16 revealed that the resident did experience a fall during the transfer of the resident to the bathroom. The resident told CNA #1 she/he needed to go to the bathroom. The CNA (Certified Nursing Assistant) tried to encourage the resident to use the bedpan. The resident refused and said he/she wanted to go to the bathroom. Resident # 129 had a BIMS (Brief Interview of Mental State) score of 15, which signified the resident was alert, oriented, and able to make own decisions. The resident also stated he/she had been walking with a walker. The resident would not wait for the CNA to check for transfer status [REDACTED]. As the CNA walked with the resident, the resident's leg started to give way. The CNA turned to get a wheelchair, but the resident fell sustaining a 4 cm (centimeter) x .5 cm skin tear to his/her right forearm. The resident's transfer status should have been 2 person assist with use of gait belt. Interview with Director of Therapy on 10/20/16 at 9:30 AM confirmed that on the date of the incident the resident was indeed able (in the therapy department) to ambulate on level surfaces for 42 feet maximum distances with rolling walker supervised minimum assist ( helper provides verbal cues or touching /steadying assistance as patient completes activity.) The Resident had not been cleared to ambulate by herself with a walker. Care plan on the unit still listed transfer resident with gait belt and 2 person assist.

On the days of the Recertification and Extended Survey, based on record review and interview, the facility failed to identify and develop a plan of action to correct deficient practices. The facility failed to identify the failure of staff to report and follow facility policy related to repeated events that had the potential to affect the safety of Resident # 164. The systemic failure of the facility to have a system in place to identify potentially serious behaviors placed all cognitively impaired, mobile resident at risk for harm or injury. Cross refer to F323 as it relates to the failure of the facility to provide adequate supervison to prevent potentially serious harm and or injury. The findings included: Based on record review and interview, it was determined that Resident # 164 had on four occasions attempted to ingest potentially harmful items. There was no evidence that the facility had identified the documented concern, nor developed a plan of action to assure the safety of the resident, until it was brought to their attention during the survey process. This was verified during a meeting on 4/8/14 at approximately 4 PM with multiple members of the Interdisciplinary Team, including but not limited to members of Administration. During the meeting, it was confirmed the team was not aware of the repeated occurrences and therefore had not developed an action plan. On the days of the Recertification and Extended Survey, based on observations,full and/or limited record reviews, interviews,and review of the facility policies, it was determined on 4/8/14 at approximately 4:45 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-323 at a scope and severity level of "J". The Immediate Jeopardy existed on 12/26/13 when a resident removed a nutritional supplement from a medication trash receptacle and drank the contents. The resident continued to exhibit unsafe behaviors by actually/ attempting to ingest potentially dangerous substances for three additional occurrences. The last documented incident occurred on 4/6/14. The facility Administrator was informed of the immediate jeopardy on 4/8/14 at 4:45 PM. In addition, CFR 483.75 F-520 cited at a "J" related to the failure of staff to report and follow facility policy related to repeated events that had the potential to affect the safety of Resident # 164. The systemic failure of the facility to have a system in place to identify potentially serious behaviors placed all cognitively impaired, mobile resident at risk for harm or injury. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/9/14 at approximately 10:30 AM. The AOC included the following: Resident # 164 was assessed by nurse at the time of each incident, There were no negative effects from any of the incidents. The glove that was noted to be in the mouth of Resident # 164 was examined by the nurse and was intact. Resident # 164 was also assessed by the facility Medical Director on 4/9/14 at 8:30 AM and was noted to have no negative outcomes as a result of any of the incidents, This incident was isolated and has not impacted other residents, However, there are many cognitively impaired, residents that are mobile and have the potential to exhibit this type of behavior; there have not been any other reports of residents in the facility that have attempted to ingest potentially hazardous items. Steps to prevent recurrence Behavior management plan in place ( see below) as of 4/8/14 at 5:00 PM. RN evening supervisor removed all gloves that were in reach by other resident's on 4/8/14 at 6:00 pm DON and RN Evening Supervisor made rounds throughout the facility on 4/8/14 at 6 :00 PM removing any potentially hazardous items such as plants, puzzles, rolls of trash bags, [MEDICATION NAME] and pens. The Cavi wipes on the the med carts were also all replaced with a more secure bag. Resident # 164 has a private sitter for the remainder of the evening on 4/8/14. There were 2 nurses involved with the four behavior incidents. They will be disciplined appropriately regarding proper procedure of notification and event reporting by 4/9/14 at 12:00 PM. The care plan of Resident # 164 was updated by the MDS Coordinator on 4/8/14 at 5:00 PM to address Resident # 164's potential for ingesting potentially hazardous items. Education Education of all staff as a result of this incident began at 5:00 PM on 4/8/14 by Staff Development Coordinator and Nurse Management. It will be ongoing until all staff have been in-serviced. No staff will be allowed to work until they have signed off on all required education. Nurses and CNAs have been provided with an education sheet outlining what their responsibility is when an event occurs that has the potential for putting a resident in danger. They are required to sign that they have read and understand the information before returning to work. All agency personnel will be required to read and sign the education sheet before working any shift in the facility. A policy has been updated to include proper procedure for disposal of gloves. All staff, including agency staff will be inserviced on the new policy. The facility alleges compliance on 4/9/12 at 10:30 AM. Behavior Management Schedule (for Resident # 164) Monday through Friday Wakes up each day at 8:)) AM and bedtime is 8:00 PM 8:00-10:00 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 10:00 - 11:00 am - Activities Staff (If both assistants are unavailable the activity director will be responsible) 11:00- 11:30 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 11:30 am - 12:15 pm - Goes to dining room with her husband, (if husband does not come, she will remain at the Nurses' station supervised) 12:15 pm - 2:00 pm - Restorative CNA Staff (there are two restorative CNAs and will not have the same day off) 2:00 - 4:00 pm - Namaste Program with Nursing staff 4:00 - 8:00 pm - 1:1 with sitter (facility will provide) If at any time a staff member/sitter is unavailable it will be the responsibility of the nurse manager to cover the time slot. Saturday and Sunday - sitters will be provided from 8am to 8pm Based on staff interviews, random observations of resident areas on 2 of 2 nursing care units and review of documentation of in-services provided by the facility, the Survey Team on 4/9/14 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Jeopardy at F-520 was removed and the citation lowered in scope and severity to a "D".

On the days of the Recertification and Extended Survey, based on record review and interview, the facility failed to provide adequate supervision to prevent Resident #164 from actual/attempting to ingest potentially hazardous items on four separate occasions. The facility also failed to provide supervision to prevent Resident #119 from leaving the building unsupervised. (2 of 5 residents reviewed for Accidents related to behaviors.) The findings included: Resident # 164 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. During the days of the survey on 4/8 and 4/9/2014 the resident was observed out of bed in a mobile chair in which s/he able to self propel using his/her feet. The resident was noted to be very verbal, repeating statements to staff, visitors or to self. On 4/8/14, nurses notes were reviewed from the current record and the thinned medical record. The nurses notes contained documentation of four incidents that had the potential to place the resident at risk for serious harm/injury including: 12/26/13 ..."noted to pull Boost from the med(ication) cart trash can and drank it." 01/06/14 "Resident tried to eat puzzle piece and Christmas ornament this AM." 02/03/14 Resident found to be eating a flower that a visitor had given her/him. 04/06/14 "Resident found to be chewing on purple glove." Copies of the incident report for each occurrence was requested and one was provided. The provided report indicated the date the incident occurred was 12/26/13 and it was last updated on 1/8/14 (case closed). It recorded the resident by name; indicated there was no apparent injury and it was "behavioral". Action taken: "called pharmacy to get new trash cans with lids. Informed nurses to keep trash can empty one off hall and make sure residents are not getting into the trash. Talked to resident about getting trash out of the can not to put thing (sic) into....mouth." Immediately after reviewing the incident report, this surveyor observed the trash receptacles of the three medications carts on the unit. All trash containers had lids that closed. One trash container was in the open position and contained a minimal amount of paper garbage. Further discussion with the Unit Care Coordinator and the Director of Nursing revealed no other incident reports had been completed and Administratively they were unaware of the additional three occurrences. In reviewing the one completed incident report, the DON verified the intervention of talking to the resident was not appropriate due to the resident's [DIAGNOSES REDACTED]. As a result of this lack of awareness, there had been no investigation into each of the occurrences; the plan of care of had not updated; and no behavioral management plan had been developed to assure the resident's safety, placing the resident at risk for serious harm or injury. At approximately 3:45PM, observation of the resident's room revealed a shoe-bag type bag hung on the doorway of the room. Mid center of the door, reachable from chair height was a box of purple colored gloves, readily accessible. The Unit Manager, when interviewed stated the Resident # 164's room had been changed this afternoon as the roommate was placed on precautions. S/he verified that because of the resident's confusion, s/he would likely return to his/her own room. After viewing the isolation supplies, the Unit Care Coordinator repositioned the supplies so that the gloves were not immediately accessible. Additionally, the facility admitted Resident #119 with [DIAGNOSES REDACTED]. Review of the medical record on 4/08/14 revealed the Nurses' Notes dated 12/17/13 indicated, "Spoke to Resident about him/her being seen going out to mail box with (sic) by (him/herself). Educated Resident on the risk of uneven ground outside, that (he/she) should not be going outside without supervision. Stated (he/she) understood and would not go to mailbox but instead give us the out going mail." Review of the Physician's Progress Note dated 12/23/13 indicated, "Pt (patient) has been observed going outside in (sic) and I asked (him/her) & (he/she) seems to be aware that (he/she) should not but likely forgets." Review of the Care Plan with latest review date of 3/04/14 revealed Actual or Potential Risk for Falls was identified as a problem area. Risk factors listed on the care plan included "Dementia and possible decreased safety awareness." In addition, Impaired Decision-Making related to Dementia was also listed as a problem area. During an interview on 4/08/14 at approximately 3:00 PM, the Assistant Director of Nursing (ADON) indicated that the facility did not complete an Incident Report concerning the resident going outside to the mailbox unattended. During an interview on 4/09/14, Registered Nurse (RN) #2 was asked about procedures staff should follow when this type of behavior occurred. RN #2 stated that staff should inform their manager and documentation should be included on the Follow-up Log. RN #2 stated that an Incident Report should be done if injury occurred. RN #2 further stated that a verbal report should be given to oncoming shifts, and the Unit Manager should investigate to find out what happened. RN #2 stated that occurrences would be discussed during the Resident at Risk meetings with recommendations to prevent recurrence. No documentation was provided to the surveyor prior to exit to indicate how staff had addressed safety issues with the resident or how staff would monitor and provide supervision to ensure this behavior did not recur. It was determined on 4/8/14 at approximately 4:45 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-323 at a scope and severity level of "J". The Immediate Jeopardy existed on 12/26/13 when a resident removed a nutritional supplement from a medication trash receptacle and drank the contents. The resident continued to exhibit unsafe behaviors by actually/ attempting to ingest potentially dangerous substances for three additional occurrences. The last documented incident occurred on 4/6/14. The facility Administrator was informed of the immediate jeopardy on 4/8/14 at 4:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/9/14 at approximately 10:30 AM. The AOC included the following: Resident # 164 was assessed by nurse at the time of each incident, There were no negative effects from any of the incidents. The glove that was noted to be in the mouth of Resident # 164 was examined by the nurse and was intact. Resident # 164 was also assessed by the facility Medical Director on 4/9/14 at 8:30 AM and was noted to have no negative outcomes as a result of any of the incidents, This incident was isolated and has not impacted other residents, However, there are many cognitively impaired, residents that are mobile and have the potential to exhibit this type of behavior; there have not been any other reports of residents in the facility that have attempted to ingest potentially hazardous items. Steps to prevent recurrence Behavior management plan in place ( see below) as of 4/8/14 at 5:00 PM. RN evening supervisor removed all gloves that were in reach by other resident's on 4/8/14 at 6:00 pm DON and RN Evening Supervisor made rounds throughout the facility on 4/8/14 at 6 :00 PM removing any potentially hazardous items such as plants, puzzles, rolls of trash bags, crayons and pens. The Cavi wipes on the the med carts were also all replaced with a more secure bag. Resident # 164 has a private sitter for the remainder of the evening on 4/8/14. There were 2 nurses involved with the four behavior incidents. They will be disciplined appropriately regarding proper procedure of notification and event reporting by 4/9/14 at 12:00 PM. The care plan of Resident # 164 was updated by the MDS Coordinator on 4/8/14 at 5:00 PM to address Resident # 164's potential for ingesting potentially hazardous items. Education Education of all staff as a result of this incident began at 5:00 PM on 4/8/14 by Staff Development Coordinator and Nurse Management. It will be ongoing until all staff have been in-serviced. No staff will be allowed to work until they have signed off on all required education. Nurses and CNAs have been provided with an education sheet outlining what their responsibility is when an event occurs that has the potential for putting a resident in danger. They are required to sign that they have read and understand the information before returning to work. All agency personnel will be required to read and sign the education sheet before working any shift in the facility. A policy has been updated to include proper procedure for disposal of gloves. All staff, including agency staff will be inserviced on the new policy. The facility alleges compliance on 4/9/12 at 10:30 AM. Behavior Management Schedule (for Resident # 164) Monday through Friday Wakes up each day at 8:)) AM and bedtime is 8:00 PM 8:00-10:00 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 10:00 - 11:00 am - Activities Staff (If both assistants are unavailable the activity director will be responsible) 11:00- 11:30 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 11:30 am - 12:15 pm - Goes to dining room with her husband, (if husband does not come, she will remain at the Nurses' station supervised) 12:15 pm - 2:00 pm - Restorative CNA Staff (there are two restorative CNAs and will not have the same day off) 2:00 - 4:00 pm - Namaste Program with Nursing staff 4:00 - 8:00 pm - 1:1 with sitter (facility will provide) If at any time a staff member/sitter is unavailable it will be the responsibility of the nurse manager to cover the time slot. Saturday and Sunday - sitters will be provided from 8am to 8pm Based on staff interviews, random observations of resident areas on 2 of 2 nursing care units and review of documentation of in-services provided by the facility, the Survey Team on 4/9/14 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Jeopardy at F-323 was removed and the citation lowered in scope and severity to a "D".

On the days of the survey, based on observation, record review and interview, the facility failed to implement a generalized plan of care for safety concerns for Resident # 164. (1 of 5 sampled residents reviewed for behaviors and implementation of the plan of care). Resident # 164 had a generalized plan of care addressing safety. However, the resident was able to attempt to ingest potentially hazardous substances on four occasions. Cross refer to F323 as it relates to the failure of the facility to provide adequate supervison to prevent potentially serious harm and or injury. The findings included: Resident # 164 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. On 4/8/14, the resident's ongoing care plan that was begun on admission, revealed problem areas addressing (but not limited to): A. A potential for decline in mood, behavior, and or psychosocial status related to a change in environment noting the resident feels depressed related to missing home. B. Resident wanders up and down halls frequently looking for (spouse). Exhibits socially inappropriate behaviors at times i.e. places hands down pants. [DIAGNOSES REDACTED]. Resident has impaired decision making related to severe Alzheimer dementia. D. Potential for falls/injury. Included in the approach to address the problem areas noted above were interventions including: "frequent safety checks; observe for non-verbal signs of distress; determine if decisions made by the resident endanger the resident or others. Intervene if necessary; Staff must anticipate needs; psych consult if ordered; when wandering remove resident from other resident;s room and any unsafe situations; when being socially inappropriate re-direct resident and assess for unmet needs; keep resident in supervised areas; observe for mood/behavior symptoms during one to one as needed visits (tearfulness, withdrawal, verbalizations of distress, sleep problem, agitation, delusional thinking etc., notify MD/RP (responsible party) of any new onset or significant change in mood/behavior symptoms." On 4/8/14, nurses notes were reviewed from the current record and the thinned medical record. The nurses notes contained documentation of four incidents that had the potential to place the resident at risk for serious harm/injury including: 12/26/13 ..."noted to pull Boost from the med(ication) cart trash can and drank it." 01/06/14 "Resident tried to eat puzzle piece and Christmas ornament this AM." 02/03/14 Resident found to be eating a flower that a visitor had given her/him. 04/06/14 "Resident found to be chewing on purple glove." Further review of the plan of care noted that none of the above behaviors were listed on the plan of care. During an interview with the MDS (Minimum Data Set COordinator) on 4/8/14 at 4:23 PM, s/he agreed the plan of care did not address the specific behaviors but stated it did include general safety approaches. S/he did not dispute that if the generalized safety plan had been followed, it would be unlikely the resident would have been able to successfully attempt to eat potenially hazardous items on four different occassions. On the days of the Recertification and Extended Survey, based on observations,full and/or limited record reviews, interviews,and review of the facility policies, it was determined on 4/8/14 at approximately 4:45 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-323 at a scope and severity level of "J". The Immediate Jeopardy existed on 12/26/13 when a resident removed a nutritional supplement from a medication trash receptacle and drank the contents. The resident continued to exhibit unsafe behaviors by actually/ attempting to ingest potentially dangerous substances for three additional occurrences. The last documented incident occurred on 4/6/14. The facility Administrator was informed of the immediate jeopardy on 4/8/14 at 4:45 PM. In addition, CFR 483.20 (K)(3)(ii) F-282 cited at a "J" related to Resident # 164 having only a generalized plan of care addressing safety. However, the resident was able to attempt to ingest potentially hazardous substances on four occasions. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/9/14 at approximately 10:30 AM. The AOC included the following: Resident # 164 was assessed by nurse at the time of each incident, There were no negative effects from any of the incidents. The glove that was noted to be in the mouth of Resident # 164 was examined by the nurse and was intact. Resident # 164 was also assessed by the facility Medical Director on 4/9/14 at 8:30 AM and was noted to have no negative outcomes as a result of any of the incidents, This incident was isolated and has not impacted other residents, However, there are many cognitively impaired, residents that are mobile and have the potential to exhibit this type of behavior; there have not been any other reports of residents in the facility that have attempted to ingest potentially hazardous items. Steps to prevent recurrence Behavior management plan in place ( see below) as of 4/8/14 at 5:00 PM. RN evening supervisor removed all gloves that were in reach by other resident's on 4/8/14 at 6:00 pm DON and RN Evening Supervisor made rounds throughout the facility on 4/8/14 at 6 :00 PM removing any potentially hazardous items such as plants, puzzles, rolls of trash bags, [MEDICATION NAME] and pens. The Cavi wipes on the the med carts were also all replaced with a more secure bag. Resident # 164 has a private sitter for the remainder of the evening on 4/8/14. There were 2 nurses involved with the four behavior incidents. They will be disciplined appropriately regarding proper procedure of notification and event reporting by 4/9/14 at 12:00 PM. The care plan of Resident # 164 was updated by the MDS Coordinator on 4/8/14 at 5:00 PM to address Resident # 164's potential for ingesting potentially hazardous items. Education Education of all staff as a result of this incident began at 5:00 PM on 4/8/14 by Staff Development Coordinator and Nurse Management. It will be ongoing until all staff have been in-serviced. No staff will be allowed to work until they have signed off on all required education. Nurses and CNAs have been provided with an education sheet outlining what their responsibility is when an event occurs that has the potential for putting a resident in danger. They are required to sign that they have read and understand the information before returning to work. All agency personnel will be required to read and sign the education sheet before working any shift in the facility. A policy has been updated to include proper procedure for disposal of gloves. All staff, including agency staff will be inserviced on the new policy. The facility alleges compliance on 4/9/12 at 10:30 AM. Behavior Management Schedule (for Resident # 164) Monday through Friday Wakes up each day at 8:)) AM and bedtime is 8:00 PM 8:00-10:00 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 10:00 - 11:00 am - Activities Staff (If both assistants are unavailable the activity director will be responsible) 11:00- 11:30 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 11:30 am - 12:15 pm - Goes to dining room with her husband, (if husband does not come, she will remain at the Nurses' station supervised) 12:15 pm - 2:00 pm - Restorative CNA Staff (there are two restorative CNAs and will not have the same day off) 2:00 - 4:00 pm - Namaste Program with Nursing staff 4:00 - 8:00 pm - 1:1 with sitter (facility will provide) If at any time a staff member/sitter is unavailable it will be the responsibility of the nurse manager to cover the time slot. Saturday and Sunday - sitters will be provided from 8am to 8pm Based on staff interviews, random observations of resident areas on 2 of 2 nursing care units and review of documentation of in-services provided by the facility, the Survey Team on 4/9/14 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Jeopardy at F-282 was removed and the citation lowered in scope and severity to a "D".

On the days of the survey, based on interview, record review and review of facility policies related to "Care Plan Modification" (effective 2/2012, the facility failed to review and revise the plan of care for 2 of 5 sampled residents reviewed for careplan revision related to behaviors. Resident # 164's care plan was not revised to reflect the repeated ingestion of potentially harmful substances, placing the resident at risk for serious harm. Resident #119's careplan was not revised to reflect the resident was observed outside the facility without supervision. Cross refer to F323 as it relates to the failure of the facility to provide adequate supervision to prevent potentially serious harm and or injury. The findings included: Resident # 164 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. On 4/8/14, a review of the Minimum Data Set (MDS) completed on 2/6/14 revealed the resident had a BIMS (Brief Interview Mental Status) of 3, indicative of cognitive impairment. The resident was documented as having adequate hearing, speech and vision. Resident # 164 was dependent on staff for assistance with bed mobility, transfers, dressing, hygiene and toileting. S/he was non-ambulatory. The resident was able to feed self after set-up and had no swallowing concerns. Once out of bed the resident was seated in a mobility chair with wheels. The resident was able to move the chair by using his/her feet. On admission, the resident was receiving antipsychotic medications that had since been discontinued. Review of the resident's ongoing care plan that was begun on admission revealed problem areas addressing (but not limited to): A. A potential for decline in mood, behavior, and or psychosocial status related to a change in environment noting the resident feels depressed related to missing home. B. Resident wanders up and down halls frequently looking for (spouse). Exhibits socially inappropriate behaviors at times i.e. places hands down pants. [DIAGNOSES REDACTED]. Resident has impaired decision making related to severe Alzheimer dementia. D. Potential for falls/injury. On 4/8/14, nurses notes were reviewed from the current record and the thinned medical record. The nurses notes contained documentation of four incidents that had the potential to place the resident at risk for serious harm/injury including: 12/26/13 ..."noted to pull Boost from the med(ication) cart trash can and drank it." 01/06/14 "Resident tried to eat puzzle piece and Christmas ornament this AM." 02/03/14 Resident found to be eating a flower that a visitor had given her/him. 04/06/14 "Resident found to be chewing on purple glove." None of the incidents were noted on the the resident's careplan and there were no interventions found specific to the repeated ingestion of the potentially harmful items. During an interview with the MDS coordinator on 4/8/14 at approximately 4:23pm, s/he verified the plan of care had not been revised to reflect any of the incidents. S/he stated it was the responsibility of the nurse who writes the nurses note to update the careplan with each incident. The facility admitted Resident #119 with [DIAGNOSES REDACTED]. Review of the medical record on 4/08/14 revealed the Nurses' Notes dated 12/17/13 indicated, "Spoke to Resident about him/her being seen going out to mail box with (sic) by (him/herself). Educated Resident on the risk of uneven ground outside, that (he/she) should not be going outside without supervision. Stated (he/she) understood and would not go to mailbox but instead give us the out going mail." Review of the Physician's Progress Note dated 12/23/13 indicated, "Pt (patient) has been observed going outside in (sic) and I asked (him/her) & (he/she) seems to be aware that (he/she) should not but likely forgets." Review of the Care Plan with latest review date of 3/04/14 revealed Actual or Potential Risk for Falls was identified as a problem area. Risk factors listed on the care plan included "Dementia and possible decreased safety awareness." In addition, Impaired Decision-Making related to Dementia was also listed as a problem area. Further review of the care plan indicated that the care plan was not updated to reflect that the resident had gone outside the facility without supervision and did not include interventions or approaches to address this behavior and to prevent recurrence. During an interview on 4/09/14, Registered Nurse (RN) #2 was asked to review the documentation in the Nurses' Notes and Physician's Progress Notes related to Resident #119 going outside to the mailbox unattended. At that time, RN #2 was asked how care plans are updated and how staff are made aware of information to include on resident care plans. RN #2 stated that information is gathered from Incident Reports, verbal reports to oncoming shifts, Resident at Risk Meetings, Interdisciplinary Team meetings, and other forms of staff communications. RN #2 stated that any staff member can update a care plan. RN #2 reviewed Resident #119's care plan and stated that he/she would expect that the care plan would be updated to reflect that the resident went outside of the facility unsupervised to the mailbox. During an interview on 4/09/14, the Assistant Director of Nursing (ADON) reviewed the resident's care plan and agreed that the care plan should have been updated to reflect that the resident went outside of the facility unattended and should include interventions to prevent recurrence. The facility provided policy/procedure titled "Care Plan Modification" (effective date 2/2012) stated: The addition of a new patient problem or modification (updating) of an existing problem on the patient's careplan is the responsibility of the the licensed nurse, dietician, dietician assistant, therapist, social worker and activity director....Update care plan promptly. The patient's care plan will be modified as indicated based on pertinent observations, assessments, physician orders [REDACTED]. On the days of the Recertification and Extended Survey, based on observations,full and/or limited record reviews, interviews,and review of the facility policies, it was determined on 4/8/14 at approximately 4:45 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-323 at a scope and severity level of "J". The Immediate Jeopardy existed on 12/26/13 when a resident removed a nutritional supplement from a medication trash receptacle and drank the contents. The resident continued to exhibit unsafe behaviors by actually/ attempting to ingest potentially dangerous substances for three additional occurrences. The last documented incident occurred on 4/6/14. The facility Administrator was informed of the immediate jeopardy on 4/8/14 at 4:45 PM. In addition, CFR 483.20 (d) (3) F-280 cited at a "J" related to Resident # 164's care plan not revised to reflect the repeated ingestion of potentially harmful substances, placing the resident at risk for serious harm. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/9/14 at approximately 10:30 AM. The AOC included the following: Resident # 164 was assessed by nurse at the time of each incident, There were no negative effects from any of the incidents. The glove that was noted to be in the mouth of Resident # 164 was examined by the nurse and was intact. Resident # 164 was also assessed by the facility Medical Director on 4/9/14 at 8:30 AM and was noted to have no negative outcomes as a result of any of the incidents, This incident was isolated and has not impacted other residents, However, there are many cognitively impaired, residents that are mobile and have the potential to exhibit this type of behavior; there have not been any other reports of residents in the facility that have attempted to ingest potentially hazardous items. Steps to prevent recurrence Behavior management plan in place ( see below) as of 4/8/14 at 5:00 PM. RN evening supervisor removed all gloves that were in reach by other resident's on 4/8/14 at 6:00 pm DON and RN Evening Supervisor made rounds throughout the facility on 4/8/14 at 6 :00 PM removing any potentially hazardous items such as plants, puzzles, rolls of trash bags, [MEDICATION NAME] and pens. The Cavi wipes on the the med carts were also all replaced with a more secure bag. Resident # 164 has a private sitter for the remainder of the evening on 4/8/14. There were 2 nurses involved with the four behavior incidents. They will be disciplined appropriately regarding proper procedure of notification and event reporting by 4/9/14 at 12:00 PM. The care plan of Resident # 164 was updated by the MDS Coordinator on 4/8/14 at 5:00 PM to address Resident # 164's potential for ingesting potentially hazardous items. Education Education of all staff as a result of this incident began at 5:00 PM on 4/8/14 by Staff Development Coordinator and Nurse Management. It will be ongoing until all staff have been in-serviced. No staff will be allowed to work until they have signed off on all required education. Nurses and CNAs have been provided with an education sheet outlining what their responsibility is when an event occurs that has the potential for putting a resident in danger. They are required to sign that they have read and understand the information before returning to work. All agency personnel will be required to read and sign the education sheet before working any shift in the facility. A policy has been updated to include proper procedure for disposal of gloves. All staff, including agency staff will be inserviced on the new policy. The facility alleges compliance on 4/9/12 at 10:30 AM. Behavior Management Schedule (for Resident # 164) Monday through Friday Wakes up each day at 8:)) AM and bedtime is 8:00 PM 8:00-10:00 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 10:00 - 11:00 am - Activities Staff (If both assistants are unavailable the activity director will be responsible) 11:00- 11:30 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 11:30 am - 12:15 pm - Goes to dining room with her husband, (if husband does not come, she will remain at the Nurses' station supervised) 12:15 pm - 2:00 pm - Restorative CNA Staff (there are two restorative CNAs and will not have the same day off) 2:00 - 4:00 pm - Namaste Program with Nursing staff 4:00 - 8:00 pm - 1:1 with sitter (facility will provide) If at any time a staff member/sitter is unavailable it will be the responsibility of the nurse manager to cover the time slot. Saturday and Sunday - sitters will be provided from 8am to 8pm Based on staff interviews, random observations of resident areas on 2 of 2 nursing care units and review of documentation of in-services provided by the facility, the Survey Team on 4/9/14 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Jeopardy at F280 was removed and the citation lowered in scope and severity to a "D".

On the days of the Recertification and Extended Survey, based on record review, interview, review of facility policies that were not fully implemented, the facility failed to use its resources effectively and efficiently to maintain the highest practicable mental and psychosocial well-being for Resident # 164. The resident was able to attempt the ingestion of potentially hazardous products on four occasions. Lack of sufficient documentation and or communication resulted in Administration denying being informed. The systemic failure placed all cognitively impaired, mobile residents at risk for harm. Cross refer to F323 as it relates to the failure of the facility to provide adequate supervision to prevent potentially serious harm and or injury. The findings included: Record review on 4/7, 4/8 and 4/9/14 revealed Resident # 164 had successfully attempted ingestion of potentially harmful substances starting on 12/26/13 and most recently documented on 4/6/14. During the investigation of the incidents, it was revealed the resident;s careplan had not been updated to include any of the incidents; a careplan that was in place related to generalized safety measures was not followed; a plan to prevent reoccurrence(s) had not been developed; facility policies and procedures had not been followed related to documentation and reporting; and Administration denied being fully aware of 3 of 4 incidents. As a result of the systemic Administrative failure to be informed, investigate and address the concerns placed not only Resident # 164 at risk for further injury and or harm but also placed all cognitively impaired, behavioral, mobile residents at risk. It was determined on 4/8/14 at approximately 4:45 PM that Immediate Jeopardy and/or Substandard Quality of Care existed in the following areas: CFR 483.25 F-323 at a scope and severity level of "J". The Immediate Jeopardy existed on 12/26/13 when a resident removed a nutritional supplement from a medication trash receptacle and drank the contents. The resident continued to exhibit unsafe behaviors by actually/ attempting to ingest potentially dangerous substances for three additional occurrences. The last documented incident occurred on 4/6/14. The facility Administrator was informed of the immediate jeopardy on 4/8/14 at 4:45 PM. The facility provided an Allegation of Compliance (AOC) that was acceptable on 4/9/14 at approximately 10:30 AM. The AOC included the following: Resident # 164 was assessed by nurse at the time of each incident, There were no negative effects from any of the incidents. The glove that was noted to be in the mouth of Resident # 164 was examined by the nurse and was intact. Resident # 164 was also assessed by the facility Medical Director on 4/9/14 at 8:30 AM and was noted to have no negative outcomes as a result of any of the incidents, This incident was isolated and has not impacted other residents, However, there are many cognitively impaired, residents that are mobile and have the potential to exhibit this type of behavior; there have not been any other reports of residents in the facility that have attempted to ingest potentially hazardous items. Steps to prevent recurrence Behavior management plan in place ( see below) as of 4/8/14 at 5:00 PM. RN evening supervisor removed all gloves that were in reach by other resident's on 4/8/14 at 6:00 pm DON and RN Evening Supervisor made rounds throughout the facility on 4/8/14 at 6 :00 PM removing any potentially hazardous items such as plants, puzzles, rolls of trash bags, [MEDICATION NAME] and pens. The Cavi wipes on the the med carts were also all replaced with a more secure bag. Resident # 164 has a private sitter for the remainder of the evening on 4/8/14. There were 2 nurses involved with the four behavior incidents. They will be disciplined appropriately regarding proper procedure of notification and event reporting by 4/9/14 at 12:00 PM. The care plan of Resident # 164 was updated by the MDS Coordinator on 4/8/14 at 5:00 PM to address Resident # 164's potential for ingesting potentially hazardous items. Education Education of all staff as a result of this incident began at 5:00 PM on 4/8/14 by Staff Development Coordinator and Nurse Management. It will be ongoing until all staff have been in-serviced. No staff will be allowed to work until they have signed off on all required education. Nurses and CNAs have been provided with an education sheet outlining what their responsibility is when an event occurs that has the potential for putting a resident in danger. They are required to sign that they have read and understand the information before returning to work. All agency personnel will be required to read and sign the education sheet before working any shift in the facility. A policy has been updated to include proper procedure for disposal of gloves. All staff, including agency staff will be inserviced on the new policy. The facility alleges compliance on 4/9/12 at 10:30 AM. Behavior Management Schedule (for Resident # 164) Monday through Friday Wakes up each day at 8:)) AM and bedtime is 8:00 PM 8:00-10:00 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 10:00 - 11:00 am - Activities Staff (If both assistants are unavailable the activity director will be responsible) 11:00- 11:30 am - Nurses' station/Unit Secretary (If Secretary leaves the desk, resident will be assigned to another staff member) 11:30 am - 12:15 pm - Goes to dining room with her husband, (if husband does not come, she will remain at the Nurses' station supervised) 12:15 pm - 2:00 pm - Restorative CNA Staff (there are two restorative CNAs and will not have the same day off) 2:00 - 4:00 pm - Namaste Program with Nursing staff 4:00 - 8:00 pm - 1:1 with sitter (facility will provide) If at any time a staff member/sitter is unavailable it will be the responsibility of the nurse manager to cover the time slot. Saturday and Sunday - sitters will be provided from 8am to 8pm Based on staff interviews, random observations of resident areas on 2 of 2 nursing care units and review of documentation of in-services provided by the facility, the Survey Team on 4/9/14 verified the Allegation of Compliance for the Immediate Jeopardy was in effect prior to exiting the facility. The immediacy of the Jeopardy at F-490 was removed and the citation lowered in scope and severity to a "D".

On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of the policy provided by the facility entitled "Blood Testing Glucometer" dated ,[DATE] and "Checking Expiration Dates on Supplies" dated ,[DATE], and information provided by the manufacturer, Wexford Labs; the facility failed to be administered in a manner that ensured staff were trained in the prevention of bloodborne pathogens related to cleaning and disinfecting 3 of 4 multiple-resident use glucometers with a disinfectant wipe that had not expired. Concerns were identified with 30 residents who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. The findings included: 1. Cross refer to F441. Based on observations, full and/or limited record reviews, interviews, and review of the policies provided by the facility entitled "Blood Testing Glucometer" dated ,[DATE] and "Checking Expiration Dates on Supplies" dated ,[DATE], the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect glucometers between each resident use were not expired. Concerns were identified with 30 residents who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. 2. The facility did not have a policy or procedure in place related to expired medical supplies or to identify who was responsible to ensure that medical supplies had not expired. During an interview on [DATE] at 10:40 AM, when asked about the date (,[DATE]) on the policy for checking expiration dates on medical supplies, the Administrator stated that before yesterday (when the concern was identified), the facility did not have a policy relative to checking supplies for expiration dates. During an interview on [DATE] at 11:45 AM, the Housekeeping Supervisor who provided the expired wipes stated he had been unaware that the wipes had an expiration date. During an interview on [DATE] at 1:35 PM, The Medical Director stated that he didn't always agree with expiration dates, but added that the expiration date was there for a reason and should be checked. Immediate Jeopardy was determined to exist on [DATE] at 10:00 AM after expired Cleancide wipes used to clean 3 of 4 multiple-resident use glucometers were found. The Cleancide wipes had expiration dates of "0910" imprinted on their containers. Based on information provided by Wexford Labs and reviewed [DATE], the original expiration date had been revised and the new expiration date for the lot would be [DATE]. This placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. 483.75 Administration F-490 was identified at a scope and severity level of "K". The facility Administration failed to assure that appropriate polices and procedures were in place and implemented related to the cleaning of Glucometers used for multiple residents. The systemic failure of the facility to effectively clean the Glucometers placed the residents at risk for serious harm. Prior to exit from the facility, the survey team determined that the facility had fully initiated their stated allegation of compliance as submitted on [DATE] removing the immediacy of the deficient practice. Appropriately dated cleaning wipes were verified to be available and in use; staff education was completed and verified by interview to have been effective. The citation at F-490 remained but was lowered in scope and severity to an "E".

On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of the policies provided by the facility entitled "Blood Testing Glucometer" dated ,[DATE] and "Checking Expiration Dates on Supplies" dated ,[DATE], and information provided by the manufacturer, Wexford Labs; facility nursing staff failed to provide services that met professional standards of quality when the facility did not ensure that expired "Cleancide" disinfecting wipes were not used to clean 3 of 4 multiple-resident use glucometers prior to use. Concerns were identified with 30 residents who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. The findings included: Cross refer to F441 as it relates to facility nursing staff failure to ensure that expired Cleancide disinfecting wipes were not used to clean multiple-resident use glucometers prior to use. Observation during medpass on the first floor on [DATE] at 5:45 PM revealed Licensed Practical Nurse #5 checking a FSBS on a resident using one of the facility's glucometers located on the medication cart. After the procedure, she removed one disinfectant wipe from a container located inside a cloth bag hanging on the side of the medcart. She proceeded to wipe the glucometer off with the wipe. The surveyor asked to look at the wipes container which contained "Cleancide" wipes, Lot # 3 with "exp 0910" printed on the bottom of the container. The surveyor showed the container to the nurse who was unsure if the "exp 0910" meant that the wipes had expired. Observation on [DATE] at approximately 6:00 PM revealed a 2nd medication cart on the first floor which had a container of "Cleancide" wipes with "exp 0910" printed on the container. This was verified by LPN #6 who stated "That has expired and is no longer good". The nurse then removed the container from the medcart. Observation of the soiled utility room on the 1st floor on [DATE] at approximately 6:09 PM with the DON and LPN #8 revealed a cabinet holding 3 containers of "Cleancide" wipes. One container was less than ,[DATE] full and had "exp 0910" printed on the container. Two other containers which were full had "exp 0811" and "exp 0910" printed on the bottom of the containers respectively. When asked if the "Cleancide" wipes were the only ones used to clean the glucometers, the DON said yes. According to the DON, Housekeeping staff obtained the wipes from the hospital. Observation on [DATE] at 6:10 PM of one 2nd floor medcart revealed a container of "Cleancide" wipes with "exp 0811" printed on the container. This was verified by LPN #3 who stated she was not aware an expiration date was on the container. Continued observation at 6:12 PM revealed another medcart on the 2nd floor with a container of "Cleancide" wipes with "exp 0910" printed on the container. This was verified by LPN #7. Observation on [DATE] at 6:25 PM revealed a container of "Cleancide" wipes on a stand near the therapy department in the basement. Printed on the bottom of the container was "exp 0910". This was verified by Registered Nurse (RN) #1. At 6:35 PM, RN #1 informed a surveyor that new containers of wipes had been delivered from the hospital. During an interview on [DATE] at 6:30 PM, the DON and Pharmacy Consultant were present. The DON was asked if they had any disinfectant wipes used to clean glucometers in the building which had not expired. The DON looked to the Pharmacy Consultant who stated that all the wipes used to clean glucometers that had been upstairs had expired. The DON verified that 2 of 3 medcarts on both floors (total of 4 medcarts) had expired wipes; and one medcart on each floor did not contain any wipes at all. She stated that they had to call security and have them bring CaviWipes from the hospital that were in date. She stated they could use the CaviWipes to clean the glucometers. During an interview on [DATE] at 8:42 PM, LPN #5 verified there were 2 glucometers on the 1st floor that were used on residents. She believed there were 2 glucometers on the 2nd floor used by nursing staff. The nurse was asked if she had ever checked the wipes for an expiration date before. She shook her head no and stated she had never thought about it before. During an interview on [DATE] at 9:05 PM, LPN #8 stated she had not been aware that wipes expired. Observation during medpass on [DATE] at 8:08 AM revealed in date CaviWipes on a 2nd floor medcart. During an interview at the time, LPN #9 stated that before this morning she had not known to check wipes to ensure they were not expired. During an interview on [DATE] at 8:30 AM, LPN #10 stated she knew that the wipes needed to be checked for expiration, but admitted she did not do this every day. Observation during medpass on [DATE] at 8:40 AM revealed in date CaviWipes on the other 2nd floor medcart. When asked, RN #1 stated she had not been aware that wipes expired. She added that since the container of wipes are in a bag, the nursing staff was probably just pulling the wipe out of the container while still in the bag without removing the container to check for an expiration date. Review of the facility protocol entitled "Blood Testing Glucometer" dated ,[DATE] revealed under "Infection Control" that the "..Accu-chek Inform meter will be disinfected between each patient testing using a damp (not wet) CleanCide Wipe. CleanCide Wipe must be squeezed, wrung, or blotted on paper towel to prevent excess disinfecting agent from damaging the Accu-chek Inform meter...". Review of a "Product Shelf Life Information" information sheet provided by the facility revealed the "Ready to use Product" Cleancide Wipes had a shelf life of 2 years. The bottom of the page included a notation that "All concentrates and products sold ready to use have their expiration date stamped on the bottle or canister". Review of the policy entitled "Checking Expiration Dates on Supplies" dated ,[DATE] revealed that "All supplies used ...will be used within the product dates specified by the manufacturer. 1. Product expiration dates will be checked by each user prior to use of the product. 2. When cleaning product is opened for use, the expiration date will be checked and written on the top of the cleaning product by the person opening the product. 3. Medical supplies will be checked for product expiration monthly by the unit secretary and before use by the nurse, CNA, or other user. 4. Products nearing the expiration date will be discarded." During an interview on [DATE] at 10:40 AM, the DON and Administrator were present. When asked, the DON stated that all contents of the medcarts are checked for expiration by nursing staff, the pharmacy, and the pharmacy consultant. When asked if staff checked the germicidal wipes for expiration, she stated "Obviously not". Review on [DATE] of [DATE] Medication Administration Records revealed 30 residents had received FSBS monitoring in the month of November. These 30 residents had FSBS done from 3 times in the month to up to 4 times daily. Based on information provided by Wexford Labs and reviewed [DATE] at 9:45 AM, the original expiration dates of the Cleancide wipes had been revised to add one year to the expiration dates of "0910" and "0811" making the new expiration dates [DATE] and [DATE] respectively. The letter provided by Wexford Labs stated, "In reviewing our records, I have 2 shipments of CleanCideWipes that were sent to Oconee Medical Center: February 2009, lot # 3 was sent. This was produced in early [DATE] and based on our current aging studies, would have had a revised expiration date of ,[DATE]. [DATE], lot #2269 was sent. This currently has a revised expiration date of ,[DATE]. This is a relatively new product so our aging studies only go out 3 years. In [DATE], we will test our retained samples and determine if the product remains stable for 4 years. To date, our studies indicate that the product is very stable and does not deteriorate over time". Immediate Jeopardy was determined to exist on [DATE] at 10:00 AM after expired Cleancide wipes used to clean multiple-resident use glucometers were found. The Cleancide wipes had expiration dates of "0910" imprinted on their containers and were being used to clean 3 of 4 glucometers used by the facility. Based on information provided by Wexford Labs and reviewed [DATE], the original expiration date had been revised and the new expiration date for the lot would be [DATE]. This placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.20 F-281 was identified at a scope and severity of "K". Facility Licensed staff failed to follow standard precautions related to blood borne pathogens and failed to appropriately clean Glucometers used for multiple residents with an appropriate cleansing agent. Prior to exit from the facility the survey team determined that the facility had fully initiated their stated allegation of compliance as submitted on [DATE] removing the immediacy of the deficient practice. Appropriately dated cleaning wipes were verified to be available and in use; staff education was completed and verified by interview to have been effective. The citation at F-281 remained but was lowered in scope and severity to an "E".

On the days of the survey, based on observations, full and/or limited record reviews, interviews, review of the policies provided by the facility entitled "Blood Testing Glucometer" dated ,[DATE] and "Checking Expiration Dates on Supplies" dated ,[DATE], and information provided by the manufacturer, Wexford Labs; the facility failed to ensure a sanitary environment to prevent the development and transmission of disease and infection by failing to ensure wipes used to disinfect 3 of 4 glucometers between each resident use were not expired. Concerns were identified with 30 residents who received Finger Stick Blood Sugar (FSBS) monitoring in [DATE]. The findings included: Observation during medpass on the first floor on [DATE] at 5:45 PM revealed Licensed Practical Nurse #5 checking a FSBS on a resident using one of the facility's glucometers located on the medication cart. After the procedure, she removed one disinfectant wipe from a container located inside a cloth bag hanging on the side of the medcart. She proceeded to wipe the glucometer off with the wipe. The surveyor asked to look at the wipes container which contained "Cleancide" wipes, Lot # 3 with "exp 0910" printed on the bottom of the container. The surveyor showed the container to the nurse who was unsure if the "exp 0910" meant that the wipes had expired. Observation on [DATE] at approximately 6:00 PM revealed a 2nd medication cart on the first floor which had a container of "Cleancide" wipes with "exp 0910" printed on the container. This was verified by LPN #6 who stated "That has expired and is no longer good". The nurse then removed the container from the medcart. Observation of the 1st floor supply room revealed a cabinet holding 2 containers of "Sanihands ALC" which expired ,[DATE]. According to LPN #8, nursing staff did not use these wipes to clean the glucometers. Observation of the soiled utility room on the 1st floor on [DATE] at approximately 6:09 PM with the DON and LPN #8 revealed a cabinet holding 3 containers of "Cleancide" wipes. One container was less than ,[DATE] full and had "exp 0910" printed on the container. Two other containers which were full had "exp 0811" and "exp 0910" printed on the bottom. When asked if the "Cleancide" wipes were the only ones used to clean the glucometers, the DON said yes. According to the DON, Housekeeping staff obtained the wipes from the hospital. Observation on [DATE] at 6:10 PM of one 2nd floor medcart revealed a container of "Cleancide" wipes with "exp 0811" printed on the container. This was verified by LPN #3 who stated she was not aware an expiration date was on the container. Continued observation at 6:12 PM revealed another medcart on the 2nd floor with a container of "Cleancide" wipes with "exp 0910" printed on the container. This was verified by LPN #7. Observation on [DATE] at 6:25 PM revealed a container of "Cleancide" wipes on a stand near the therapy department in the basement. Printed on the bottom of the container was "exp 0910". This was verified by Registered Nurse (RN) #1. At 6:35 PM, RN #1 informed a surveyor that new containers of wipes had been delivered from the hospital. During an interview on [DATE] at 6:30 PM, the DON and Pharmacy Consultant were present. The DON was asked if they had any disinfectant wipes used to clean glucometers in the building which had not expired. The DON looked to the Pharmacy Consultant who stated that all the wipes used to clean glucometers that had been upstairs had expired. The DON verified that 2 of 3 medcarts on both floors (total of 4 medcarts) had expired wipes; and one medcart on each floor did not contain any wipes at all. She stated that they had to call security and have them bring CaviWipes from the hospital that were in date. She stated they could use the CaviWipes to clean the glucometers. During an interview on [DATE] at 8:42 PM, LPN #5 verified there were 2 glucometers on the 1st floor that were used on residents. The nurse was asked if she had ever checked the wipes for an expiration date before. She shook her head no and stated she had never thought about it before. During an interview on [DATE] at 9:05 PM, LPN #8 stated she had not been aware that wipes expired. Observation during medpass on [DATE] at 8:08 AM revealed in date CaviWipes on a 2nd floor medcart. During an interview at the time, LPN #9 stated that before this morning she had not known to check wipes to ensure they were not expired. During an interview on [DATE] at 8:30 AM, LPN #10 stated she knew that the wipes needed to be checked for expiration, but admitted she did not do this every day. Observation during medpass on [DATE] at 8:40 AM revealed in date CaviWipes on the other 2nd floor medcart. When asked, RN #1 stated she had not been aware that wipes expired. She added that since the container of wipes are in a bag, the nursing staff was probably just pulling the wipe out of the container while still in the bag without removing the container to check for an expiration date. Review of the facility protocol entitled "Blood Testing Glucometer" dated ,[DATE] revealed under "Infection Control" that the "..Accu-chek Inform meter will be disinfected between each patient testing using a damp (not wet) CleanCide Wipe. CleanCide Wipe must be squeezed, wrung, or blotted on paper towel to prevent excess disinfecting agent from damaging the Accu-chek Inform meter...". Review of a "Product Shelf Life Information" information sheet provided by the facility revealed the "Ready to use Product" Cleancide Wipes had a shelf life of 2 years. The bottom of the page included a notation that "All concentrates and products sold ready to use have their expiration date stamped on the bottle or canister". Review of the policy entitled "Checking Expiration Dates on Supplies" dated ,[DATE] revealed that "All supplies used ...will be used within the product dates specified by the manufacturer. 1. Product expiration dates will be checked by each user prior to use of the product. 2. When cleaning product is opened for use, the expiration date will be checked and written on the top of the cleaning product by the person opening the product. 3. Medical supplies will be checked for product expiration monthly by the unit secretary and before use by the nurse, CNA, or other user. 4. Products nearing the expiration date will be discarded." During a phone interview on [DATE] at 9:45 AM, a representative from Wexford Labs was asked about the "Cleancide" wipes. She stated that some of the "Cleancide" wipes had an extended expiration date of one year from the date printed on the container. She asked for the lot numbers of the expired products and was provided with one from the container observed in use during the medpass. During an interview on [DATE] at 10:40 AM, the DON and Administrator were present. When asked, the DON stated that all contents of the medcarts are checked for expiration by nursing staff, the pharmacy, and the pharmacy consultant. When asked if staff checked the wipes for expiration, she stated "Obviously not". The DON stated they used CleanCide wipes but had also used other bleach wipes in the past but could not remember the name or brand of the bleach wipes used previously. The Administrator stated that the facility did have wipes that were in date until a certain point. According to the DON, the facility hired a new Housekeeping Supervisor in [DATE], and sometime in the last couple of months; when they realized they were out of wipes, she told him that he needed to get some. The Administrator stated that they ran out of wipes and that the new Housekeeping Supervisor had found the CleanCide wipes in the basement. He stated the previous Housekeeping Supervisor had created a stash and was ordering them as she needed. When asked about the facility policy provided dated ,[DATE] related to checking expiration dates on supplies, the Administrator stated that the hospital had a policy, but before yesterday the facility did not have one. The DON was asked if any of the residents in the facility had any known blood borne diseases such as Hepatitis or HIV (Human Immunodeficiency Virus). She provided a note stating that "No residents in the facility as of [DATE] have known HIV or Hepatitis or any other blood borne pathogen". During an interview on [DATE] at 11:45 AM, the Housekeeping Supervisor and Dietary/Housekeeping Director were present. The Housekeeping Supervisor stated that he started working for the facility the first part of [DATE]. He stated that some time after that (He couldn't be sure of the time frame), one of the nurses approached him needing wipes to clean the glucometer. He found the CleanCide wipes in the basement. He stated there were 7 containers and he brought some to the nurse on the 1st floor. When asked, the Housekeeping Supervisor stated he did not know to check the CleanCide wipes for an expiration date. When asked if they knew the name of any wipes being used to clean the glucometers before the CleanCide wipes, they could not recall. When asked if any other brand of wipes had been used since the Housekeeping Supervisor retrieved the CleanCide wipes from the basement, the Housekeeping Supervisor stated that no, he had not ordered any or brought in any other wipes. He stated that he didn't even know that he was supposed to be ordering the wipes. The Housekeeping Director was asked for any invoices related to the CleanCide wipes. He provided a Purchase Order from the hospital which indicated an order was placed by the hospital to Wexford Labs for 10 cases of "Clean-Side" Wipes on [DATE]. According to Inventory Control, this was the last time the wipes were ordered. The Housekeeping Director also provided a note from Inventory Control at the hospital which indicated that the facility (Both the 1st and 2nd floors) had received CaviWipes from the hospital in January and [DATE]. It also stated that Clorox wipes were also dispensed in [DATE] to facility. However, according to the note, no CaviWipes or Clorox wipes had been issued to the Housekeeping Department at the facility in 2011. During an interview on [DATE] at 1:35 PM, The Medical Director stated that he didn't always agree with expiration dates, but added that the expiration date was there for a reason and should be checked. Review on [DATE] of [DATE] Medication Administration Records revealed 30 residents had received FSBS monitoring in the month of November. These 30 residents had FSBS done from 3 times in the month to up to 4 times daily. Review of the facility Infection Control Logs from [DATE] to the present along with the Monthly Nosocomial Infection Report for 2011 revealed no incidents of residents with blood borne infections. Interviews of 7 licensed nurses on [DATE] at approximately 4:00 PM revealed nursing staff were knowledgeable on checking the germicidal wipes for expiration before using them to clean glucometers. Review of staff education on the policy of checking medical supplies for expiration dates revealed nursing staff had either been called and informed of the new policy on checking the wipes for expiration prior to use or attended the inservice on the units on [DATE]. According to the DON, all of the licensed nurses except for one had been contacted; and a message had been left for the one nurse that she would not be allowed to work until she had received information relative to the new policy on checking supplies for expiration dates prior to use. Based on information provided by Wexford Labs, received via facsimile on [DATE], the original expiration dates of the Cleancide wipes had been revised to add one year to the expiration dates of "0910" and "0811" making the new expiration dates [DATE] and [DATE] respectively. The letter provided by Wexford Labs stated, "In reviewing our records, I have 2 shipments of CleanCide Wipes that were sent to Oconee Medical Center: February 2009, lot # 3 was sent. This was produced in early [DATE] and based on our current aging studies, would have had a revised expiration date of ,[DATE]. [DATE], lot #2269 was sent. This currently has a revised expiration date of ,[DATE]. This is a relatively new product so our aging studies only go out 3 years. In [DATE], we will test our retained samples and determine if the product remains stable for 4 years. To date, our studies indicate that the product is very stable and does not deteriorate over time". Review of the Cleancide Wipes Technical Data Sheet on the Wexford Labs Website revealed the wipes are an EPA registered germicidal wipe. According to information on the website, the wipes are Tuberculocidal, Bactericidal, Virucidal, and Fungicidal and were "...formulated to clean hard nonporous surfaces such as stainless steel, chrome, glass, plastic, and vinyl". The Cleancide Wipes "Meets OSHA (Occupational Safety and Health Administration) Requirements for Bloodborne Pathogens". The Active ingredient is listed as being Citric Acid. Immediate Jeopardy was determined to exist on [DATE] at 10:00 AM after expired Cleancide wipes used to clean multiple-resident use glucometers were found. The Cleancide wipes had expiration dates of "0910" imprinted on their containers and were being used to clean 3 of 4 glucometers used by the facility. Based on information provided by Wexford Labs, received via facsimile on [DATE], the original expiration date had been revised and the new expiration date for the lot would be [DATE]. This placed residents receiving FSBS at risk for transmission of potentially infectious bloodborne pathogens. CFR 483.65 F-441 was identified at a scope and severity of "K". The findings related to the Immediate Jeopardy were identified related to the facility failure to assure that Glucometers used for multiple residents were appropriately cleansed and disinfected with an appropriate cleansing agent between use to prevent the transmission of blood borne pathogens. There were 30 residents residing in the facility who received blood glucose testing with the use of the Glucometer in [DATE]. The systemic failure of the facility to effectively clean the Glucometers placed the residents at risk for serious harm. Prior to exit from the facility the survey team determined that the facility had fully initiated their stated allegation of compliance as submitted on [DATE] removing the immediacy of the deficient practice. Appropriately dated cleaning wipes were verified to be available and in use; staff education was completed and verified by interview to have been effective. The citation at F-441 remained but was lowered in scope and severity to an "E".