Every finding on record at Methodist Sepcialty Care Center

Based on observation, staff interviews, record review and facility policy review the facility failed to develop and implement a comprehensive person-centered care plan that addressed a resident's documented and known pattern of refusing bath care for one (1) of (1) residents reviewed for care planning (Resident #27). Findings include:Record review of the facility policy Care Plans revised 2/13/25 revealed, .The plan of care should be reviewed and/or updated after each quarterly and comprehensive review as well as with any when changes in treatments and/or needs arise.4. Upon identification of a change in status the Minimum Data Set (MDS) nurse and the Interdisciplinary Team (IDT) should discuss the resident condition and collaborate on intervention options, updating/modifying the care plan as needed. a. The MDS Coordinator will determine whether a significant change in status assessment is warranted.A record review of the comprehensive care plan revealed that it did not address Resident #27's documented and known pattern of refusing bath care. The care plan contained no measurable goals, no interventions specific to managing or responding to refusal of hygiene care, and no documentation reflecting the resident's exercise of his right to refuse treatment.During an observation at 11:29 AM on 6/3/26 observed Certified Nursing Assistant (CNA) #2 and CNA #3 enter Resident #27's room to provide a bath. At this time the resident began shaking his head No multiple times and CNA # 2 and CNA #3 asked the resident if they could provide a bed bath and he refused to allow care to be provided. An interview at 11:31 AM on 6/3/26, with CNA #2 and CNA #3 revealed Resident #27 refuses care at times and they always notify the nurse when he refuses care.An interview with Licensed Practical Nurse (LPN) #1 at 11:33 AM, on 6/3/26 revealed the resident refuses care at times sometimes including baths and will refuse to get up to his chair or will get up then immediately want back in to the bed. She noted that he is always very alert and cognizant of what is going on in his room but is nonverbal so he uses head nods to communicate his wishes.An interview with the Director of Nursing (DON) on 6/3/26 at 3:00 PM confirmed missing days with no documentation of baths dating back to March as well as days where CNAs marked NA (Not Applicable) or RR (Resident Refused). She stated that baths should be documented by the CNA each shift whether they are provided or refused. She noted that the resident typically refuses baths at times but noted they had issues in the past where CNAs had to be reminded to document refusal. She confirmed that the resident is known to often refuse care and the family has been notified. An interview with the resident's sister at 3:35 PM on 6/3/26 revealed she visited the resident recently. She thinks around March and she noticed the resident had a foul odor. She noted that she was concerned he wasn't being bathed. She also explained that she had discussed this concern with the Interdisciplinary Team during care plan meetings in the past.An interview at 10:01 AM with the DON on 6/4/26 revealed the resident's CNAs had been documenting baths in two different spots. Some were documenting under shoulder/bath, and some were under tub/shower. She noted that CNAs were documenting either NA or RR when the resident refused care.An interview with the DON at 11:20 AM on 6/4/26 revealed the person responsible for updating care plans is the Minimum Data Set (MDS) nurse who updates them quarterly and as needed if new problems arise. She noted that failure to update care plans with new concerns could lead to residents receiving inadequate care. She also stated that it is her expectation that staff communicate needs appropriately to the care plan nurse so the care can be added to each resident's care plan.An interview at 11: 37 AM with the MDS nurse on 6/4/26 revealed she is responsible for updating the care plan for nursing on each resident. She noted that each discipline updates problems and interventions for each resident, for example she writes nursing interventions, Respiratory writes respiratory interventions, and dietary writes dietary interventions. She confirmed that the comprehensive care plan did not address the resident's frequent refusal of baths. She noted that the importance of maintaining an up-to-date care plan is to keep staff informed of ongoing problems with interventions to address them. She noted that a complication of not updating a care plan correctly could be that the resident does not receive appropriate care. She also noted that staff never came to her to inform her of the resident's refusal of care to specifically add it to the care plan.An interview at 11:45 AM on 6/4/26 with Registered Nurse (RN) #1 on 6/4/26 revealed that the resident frequently refuses baths, wound care, and at times refused to get up into his wheelchair. She noted that she never specifically notified the care plan nurse of his refusal of care, She explained that it was up to the CNAs to notify the floor nurse of refusal so they can try to educate the resident on the importance of hygiene, however, she noted that she could have gone directly to the care plan nurse to discuss this issue.An interview with the CNA coordinator (LPN #1) at 11:50 AM on 6/4/26 revealed Resident #27 had been refusing baths at times for the past year. She noted that while she never specifically told the care plan nurse that the resident had a problem with refusing baths, the IDT and family have discussed this multiple times during care plan meetings where they meet with the care plan nurse and discuss ongoing issues or health concerns quarterly.A record review of the admission Record revealed Resident #27 was admitted on [DATE] with diagnoses that included intracranial injury.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/1/26 revealed the resident was unable to perform a Brief Interview for Mental Status due to being nonverbal.A record review of the bath log covering the last three (3) months revealed that Resident #27 had one (1) documented refusal on 3/19/26 and refusals in April included 4/7/26, 4/8/26, 4/9/26, 4/12/26, 4/13/26, and 4/26/26. Refusals in May included 5/8/26, 5/9/26, 5/19/26, 5/20/26, and 5/21/26.

Based on record review, staff interviews, and facility policy review, the facility failed to ensure a resident's environment remained as free of accident hazards to prevent accidents for one (1) of (1) residents reviewed for falls and accident prevention. (Resident #39). Findings include:A record review of the facility policy, Fall Assessment and Prevention dated 5/14/25, reveals, .II. Procedure .Prior to turning resident, upper side rails should be fully raised and in locked position .A record review facility reported an incident (FRI) #2974987, to the Complaint Unit on 4/4/2026, titled Risk Management Accident/Incident Investigation Summary. The summary revealed that Resident #39 sustained a fall during activities of daily living (ADL) care. Upon the facility investigation and an interview with Certified Nursing Assistant (CNA)#1 involved, it was determined that one of the side rails on the left may not have been fully engaged at the time of the incident. As a result, Resident #39 fell to the floor in a supine position, sustaining a 2cm (centimeter) laceration to the scalp with bleeding. In an interview with the Registered Nurse (RN) on shift at the time of the incident (RN #1) at 1:15 PM on 6/3/ 2026, she described that the incident occurred between 5:00 AM and 6:00 AM on 4/4/2026. Following her medication pass, CNA #1 informed her that Resident #39 was on the floor. Upon entering the room, she observed Resident #39's leg resting on the bottom left rail with the rest of his body on the floor and blood near his head. The bottom left rail was raised; the top left rail was down. She noted that as a routine part of her own practice, she ensures rails are locked by pulling up on each one to confirm they are secure. She also noted that Resident #39 is obese and emphasized the necessity of keeping rails up and ensuring they are locked for this resident. In an interview with CNA #1 on 6/3/26 at 2:00 PM, she recalled the incident, which occurred on 4/4/2026, in the early morning hours after 4:00 AM. She entered Resident #39's room for general rounds and to provide a bath near the end of her shift. After positioning the bed and completing care to the top portion of the resident's body, she prepared to lower the top right rail to reposition the resident to his side, while the remaining rails remained raised. As she pulled the top sheet to reposition Resident #39, he unexpectedly slid over the left side and landed on his back with his head striking the feeding pole. One leg came to rest on the bottom left rail. She noted Resident #39 did not exhibit any facial grimacing. The top left rail had dropped partially. She opened the door and informed a nearby nurse of the situation.CNA #1 further stated that going forward, she would physically check each rail to confirm it is locked before beginning care. She admitted that she had not done this in the past because it had never been an issue.In an interview with the Certified Nursing Assistant (CNA) Coordinator/Licensed Practical Nurse (LPN #1) at 3:10 PM on 6/3/2026, she stated that staff are educated during orientation regarding the importance of ensuring side rails are in the locked position when providing care. She acknowledged that all staff are required to check rails before moving residents. In an interview with the Director of Nursing (DON) at 3:41 PM on 6/3/2026, she stated that it has always been standard procedure to check bed rails before providing any care to residents and that every new hire is trained on this protocol during orientation and receives annual reminders. She reveals that this important to ensure the safety of the resident.A record review of the local hospital provider notes dated 4/4/2026, revealed the following imaging findings: small right frontal scalp hematoma near the vertex.A record review of the Orientation Checklist revealed the following entry for Day 3: Please ensure side rails are up and secured prior to care. CNA #1 acknowledged this requirement by signing on 2/20/26.A record review of the admission Record revealed the facility admitted Resident #39 on 7/20/22, with diagnoses including Anoxic Brain Damage, Not Elsewhere Classified, and Persistent Vegetative State.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/27/2026, revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating Resident #39 was unable to complete the cognitive assessment, consistent with the resident's persistent vegetative state diagnosis.

Based on observations, interviews, and record review, the facility failed to procure, store, prepare, distribute, and serve food under sanitary conditions for two (2) of four (4) survey days. Specifically, the facility failed to ensure deteriorating fruits and vegetables were removed from food storage and service areas and failed to properly clean and sanitize a food thermometer between food items during food temperature monitoring. Findings Include:A record review of the facility's policy, Food Receiving and Storage policy, effective December 2016, revealed Food shall be received and stored in a manner that complies with safe food handling practices .A record review of the facility's policy, Preventing Foodborne Illnesses Food Handling policy effective December 2016 revealed Food will be stored prepared and handled and served so that the risk of food borne illness is minimized .On 6/1/26 at 10:02 AM, observed two 1-pound boxes of strawberries in the refrigerator with received and storage dates of 5/30/2026.The strawberries were moldy and deteriorating. The Dietary Manager (DD1) confirmed the strawberries were deteriorated and reported dietary staff were responsible for inspecting produce upon receipt and throughout storage.On 6/1/26 at 10:04 AM, during an observation, a clear container of lemons in the refrigerator contained three lemons that were soft to the touch and deteriorating. DD1 reported the lemons had been used on the salad bar earlier that day.On 6/1/26 at 10:06 AM, during an observation, a three-pound bag of tangerines with a received date of 5/27/2026 contained several overly ripe, soft, and deteriorating tangerines. DD1 reported tangerines were prepared and served based on resident requests.On 6/1/26 at 10:07 AM, during an observation, a clear zip-lock bag containing three tomatoes packaged on 5/30/2026 included one tomato that had begun to deteriorate. DD1 reported produce was used daily and staff were responsible for inspecting and discarding deteriorating items.On 6/1/26 at 10:08 AM, during observation, a box of romaine lettuce contained both fresh leaves and leaves that had begun to break down within the same container. DD1 reported staff stocking the salad bar were responsible for discarding deteriorated lettuce leaves.On 6/1/26 at 10:10 AM, during an observation, 27 cartons of reduced-fat milk with a Best By date of 5/31/2026 were present. DD1 reported the date reflected a Best By date and the milk remained acceptable for use based on manufacturer guidelines and facility practices.On 6/1/26 at 10:12 AM, during an observation, three deteriorating tangerines were present on a resident snack cart located in the dry goods room. DD1 removed the deteriorating tangerines from service during the observation.On 6/3/26 at 9:45 AM, an interview with Registered Dietitian (RD) revealed the Dietary Manager was responsible for supervising dietary staff, monitoring food storage practices, and ensuring compliance with dietary procedures.On 6/3/26 at 10:45 AM, during an observation, DD1 used the same alcohol wipe to clean a food thermometer between multiple food temperature checks, including steamed rice, potato casserole, and cabbage. DD1 did not obtain a new wipe between uses and then obtained a different wipe after questioning. The thermometer was not cleaned and sanitized between food items.On 6/4/26 at 1:05 PM, an interview with the Administrator revealed expectations were for dietary staff to inspect and discard deteriorating produce prior to use and to conduct inspections prior to food distribution to ensure deteriorated produce was removed from service areas.

Based on observation, record review, interview and facility policy review, the facility failed to ensure proper hand hygiene practices were performed during urinary catheter care for one (1) of (1) resident observed with an indwelling urinary catheter. Resident #12.Findings included: A record review of facility policy Handwashing/Hand Hygiene revised 12/30/24 revealed, All staff should perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .6. e. Before and after handling an invasive device (e.g., urinary catheters.) On 6/2/26 at 1:33 PM, Resident #12 was observed for foley catheter care provided by Certified Nursing Assistant (CNA)#4. While providing care, CNA#4 cleansed the catheter three times with wipes before removing her gloves and applying new gloves without performing hand hygiene in between. She then cleansed the penis with cleansing wipes and removed her gloves once more and applied new gloves without performing hand hygiene and cleansed the site again with wipes. In an interview with CNA #4 at 1:37 PM on 6/2/26 she confirmed that she forgot to perform hand hygiene during catheter care each time she changed gloves. She noted that the consequences of not changing gloves could lead to infections of the catheter or a urinary tract infection for the resident. An interview with the Director of Nursing (DON) at 2:10 PM on 6/3/26 revealed staff should always perform hand hygiene any time they remove their gloves to avoid the risk of spreading infection to residents. She noted that wearing gloves does not replace the need for hand hygiene. An interview at 10:40 AM on 6/4/26 with the Infection Preventionist revealed that CNA #4 should have performed hand hygiene with each glove change to avoid spreading contamination or infection to the resident's catheter site. She stated each time they remove their gloves; they are potentially dragging bacteria from the catheter site across their hands. Failing to properly clean their hands appropriately, puts the resident at risk for a urinary tract infection. Record review of the admission Record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses that included anoxic brain injury. A review of the Minimum Data Set (MDS) with an Assessment Reference (ARD) date of 4/8/26 revealed the resident was unable to complete a Brief Interview for Mental Status (BIMS) due to vegetative state. A record review of the Order Summary Report with active orders as of 6/2/26 revealed an order dated 8/5/24 Clean foley cath (catheter) daily and prn (as needed) with soap and water or with peri wipes.

Based on observation, interview, and record review, the facility failed to ensure that services provided met professional standards of quality related to wound care orders for one (1) of four (4) sampled residents (Resident #1). Findings include: On 10/30/25 at 10:33 AM, during a telephone interview the complainant for CI MS# 2648872 revealed she had visited Resident #1 at the facility on 10/12/25 and observed that the resident had a silver dollar sized blister on the resident's left foot. She stated that she was concerned that the wound care was not being done according to physician's orders. She reported that when she questioned the charge nurse, the nurse did was not able to provide information regarding the wound.Record review of the admission Record: revealed the facility admitted Resident #1 on 5/13/21 with diagnoses that included, and the resident had diagnoses of quadriplegia, C5-C7 complete.Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/24/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section GG indicated revealed that Resident #1 was dependent for all activities of daily living, unable to stand or walk and dependent on a respirator.Record review of the Care Profile revealed physician orders for Resident #1 that included Right foot: Protect with dry dressing. Change M/W/F (Monday, Wednesday, Friday) Assess every shift RN (Registered Nurse) every day shift with a start date of 10/18/24, ruptured blister to left heel: Clean with normal saline, Pat dry with gauze. Apply calcium alginate to wound bed cover with outer dressing. Mange M/W/F and PRN (as needed) soilage/dislodgment every day shift with a start date of 10/28/25 and LEFT GREAT TOE OPEN LESION: CLEAN WITH NS (normal saline), PAT DRY WITH GAUZE, APPLY CALCIUM ALGINATE TO WOUND BED. COVER WITH OUTER DRESSING, CLEAN M/W/F AND PRN FOR SOILAGE/DISLODGEMENT. EVERY DAY SHIFT with a start date of 10/02/25.Record review of the Treatment Administration Record for Resident #1 for October 2025 revealed documentation signed by RN #2 of the application of dry dressing to right foot, application of calcium alginate with outer dressing on ruptured blister on left heel, treatment and application of dressing to toes of the resident's left foot on 10/29/25.Record review of the Progress Notes for Resident #1 dated 10/11/15 through 10/13/25 revealed that nursing staff identified a new skin issue on Resident #1's left foot.On 10/30/25 at 2:00 PM, interview with the Director of Nurses (DON) revealed she had received a call from the RR for Resident #1 on or around 10/13/25 inquiring about a new skin issue on the resident's left foot/heel and wound cate concerns. She confirmed that there was documentation that nursing staff had identified the new skin issue on 10/11/25. She stated that she expected the nursing staff to provide care according to the residents' plan of care and physician orders according to current professional standards of practice and infection control standards. She confirmed that the nurses assigned to the care of each resident and the Nurse Supervisor were, along with herself, responsible for supervision of resident care. She stated that the facility had contracted wound care that were present in the facility five (5) days weekly, Monday through Friday and that if wound care was ordered or needed on Saturday or Sunday, the resident's assigned nurse for the shift would be responsible for provision of wound care. She confirmed that the facility instructed all Certified Nurses' Aides (CNAs) to notify the resident's assigned nurse if there were new skin concerns identified, or any problem noted with soilage or dislocation of existing dressing.On 10/30/25 at 3:00 PM, observation of Resident #1, with the DON and Administrator in attendance, revealed the resident had a flex heel boot on each foot with no dressing on her left or right foot. There was a sliver dollar sized (approximately 1.5 inches in diameter) ruptured blister on the inner aspect of her left heel with an approximately 1/8 inch by 1/4 inch open area. Note: 1/8 inch is the approximate width of two stacked pennies, 1/4 inch is the approximate width of four stacked pennies.On 10/30/25 at 3:24 PM, during an interview CNA #2 confirmed she had been on duty for the dayshift (7:00 AM through 3:00 PM) on 10/12/25 and that she made rounds for her assigned resident group twice between 7:00 AM and 10:30 AM, which included Resident #1. She stated that there had been a reconfiguration of resident assignments at approximately 10:30 AM and CNA #3 was assigned to Resident #1 at that time. She stated that she had checked Resident #1 during that time.On 10/30/25 at 3:35 PM, interview with Registered Nurse (RN) #2 revealed that she and RN #1 were contracted wound care certified nurses and worked Monday through Friday at the facility. RN #2 confirmed that she and RN #1 had provided wound care and dressing changes for Resident #1 on 10/29/25 and said she would expect to find dressings with their initials and dated 10/29/25 on both (left and right) feet of Resident #1 and could not explain why there were not any in place at 3:00 PM. She stated that the next scheduled dressing changes were due on 10/31/25. RN #2 explained that the importance of the dry dressing ordered for Resident #1's right foot was to prevent skin injury, and she confirmed that the resident had open area on her left foot with an order for calcium alginate to provide a moist wound environment that promoted epithelial cell growth and wound closure with antimicrobial agents. RN #2 explained that the wound care orders for Resident #1 included orders for the dressings to be changed as needed for soilage and dislodgement, if the dressing became soiled or displaced during hours or days when they were not on duty that any nurse on duty could change the dressings as needed. They confirmed that CNAs were instructed to report soilage or dislodgement of dressings to the residents assigned nurse. On 10/30/25 at 4:00 PM, an interview with RN #3 revealed she was the RN Supervisor for the Dayshift on 10/30/25 and said she did not know why Resident #1's dressings were not in place or why no one reported that the dressings needed to be changed or reapplied. She stated she did know when the dressings were removed or why. She confirmed that she and the other nurses were responsible for supervision of resident care.On 10/30/25 at 4:45 PM, during an interview the Administrator and DON confirmed that they had observed that Resident #1 had no dressings in place on her feet at 3:00 PM and that it was the responsibility of the nurses to supervise the care of residents and the responsibility of the CNAs to report any issues with soilage or dislodgment of wound care dressings to the nurses. The DON and Administrator confirmed that Resident #1 should have had dressings in place on her right and left feet according to physician's orders. The Administrator and DON confirmed that failure to ensure that Resident #1's dressings were clean, intact and applied correctly was not acceptable according to professional standards of practice.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure one (1) of two (2) residents observed for incontinent care (Resident #41) received appropriate incontinence care to prevent the potential for urinary tract infections and skin breakdown. Specifically, staff failed to completely cleanse the resident during perineal care, resulting in fecal matter remaining on the resident's skin and in the perineal area. Findings Include: A review of the facility's policy titled Perineal Care, revised 05/21/25, revealed: to cleanse and dry the perineal area to promote comfort, prevent infection and skin irritation, and to emphasize good perineal hygiene. On 05/18/25 at 11:59 AM, Resident #41 was observed in bed with a tracheostomy in place. A strong odor of feces was noted in the room. On 05/19/25 at 11:36 AM, Resident #41 was observed in a wheelchair with eyes closed. A strong fecal odor remained in the room. On 05/19/25 at 1:20 PM, an observation of perineal care was conducted by Certified Nursing Assistant (CNA) #1, assisted by CNA #2. The CNAs used a total lift to transfer the resident from a specialized motorized wheelchair to the bed. A moderate amount of yellow feces was observed in the wheelchair. CNA #1 wiped the vaginal area front to back several times and assisted the resident onto her right side. CNA #2 wiped the buttocks front to back. The CNAs then turned the resident and applied a clean brief. The State Agency (SA) surveyor observed feces on the resident's lower left thigh and requested the CNAs check for cleanliness. Upon turning the resident to her right side, the CNAs wiped the left thigh two times, and each wipe revealed feces. CNA #1 then re-cleaned the vaginal area, wiping six additional times until no feces remained. A clean brief was reapplied following this care. On 05/19/25 at 1:52 PM, during an interview, CNA #2 stated it is very important that Resident #41 receive thorough perineal care to prevent odor and bed sores. She confirmed that feces were left on the resident's thigh and vaginal area after the initial cleaning. She admitted she did not see the feces but acknowledged that CNA #1 wiped the vaginal area six additional times to remove it. On 05/19/25 at 1:58 PM, during an interview, CNA #1 stated, It is very, very important that the care is done completely. She confirmed that she left feces in the vaginal area and that she had to wipe it six additional times to properly clean the resident. She stated, I did not provide care properly. On 05/21/25 at 9:40 AM, during an interview, the Director of Nursing (DON) stated that CNAs should provide a bath when a resident has a significant amount of stool. She confirmed that Resident #41 should have been cleaned thoroughly, and failure to do so could lead to infection and skin breakdown. She added that her expectation is that staff do a great job keeping residents clean and dry and confirmed that the facility has high expectations for staff performance. A record review of Resident #41's Admission Record revealed an original admitted [DATE] with a diagnosis of Neurogenic bowel, not elsewhere classified. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/25 revealed the resident was severely cognitively impaired and was totally dependent on staff for toilet hygiene, per Section GG.

Based on observation, resident and staff interviews, and facility policy review, the facility failed to secure smoking materials in a safe manner for one (1) of two (2) smokers in the facility. Resident #15 Findings Include: Review of facility policy titled Smoking Program with a revision date of 3/10/2023 revealed under, Procedure . Residents should have smoking materials labeled and locked in the medication room. Residents should not have smoking, vaping, lighters or other smoking devices or material in their possession or in their room . An observation and interview on 4/10/2024 at 9:15 AM, with Resident #15 revealed he was sitting in a motorized wheelchair in his room. A small green box that was labeled (proper name of cigarette brand) was lying on his lap. The contents of the box contained 10 cigarettes and the resident acknowledged that he had a cigarette lighter in his possession as well. An observation and interview on 4/10/2024 at 9:20 AM, with Registered Nurse (RN) #1, confirmed Resident #15 had a pack of cigarettes and a lighter in his possession, which was a fire hazard for the facility. She revealed smoking materials were to be kept locked at the nurse's desk and never in the possession of the resident. An interview with the Director of Nursing (DON) on 4/10/2024 at 4:50 PM, confirmed smoking materials were to be stored in the medication room due to potential accident hazards. Record review of Resident #15's Safe Smoking assessment dated [DATE] revealed . Resident Observation .Does resident attempt to keep smoking paraphernalia on self or in room? No was answered. Record review of Resident #15's Face Sheet revealed the facility admitted the resident on 11/06/2008 with medical diagnoses that included Quadriplegia and Tobacco use.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication had a stop date for two (2) of five (5) residents reviewed for unnecessary medications. Resident #27 and Resident #33 Findings Include: Review of the facility policy titled Medication Management dated 1/2024 revealed, Based on a comprehensive assessment of a resident, the facility must ensure: . PRN (as needed) orders for psychotropic drugs are limited to 14 days. Exceptions: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN (as needed) order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN (as needed) order. Resident #27 Record review of the April 2024 Physician Orders for Resident #27 revealed an order dated, 10/25/23, Xanax (antianxiety) 0.5 - 1.0 MG (milligram) tablet: Administer 0.5 - 1.0 milligram(s) by mouth PRN Q (every) 8 HRS (hours) PRN (as needed) for anxiety with no stop date. Record review of Resident #27's Face Sheet revealed the facility admitted the resident on 11/03/2017 with medical diagnoses that included Quadriplegia, Post-traumatic stress disorder, Generalized anxiety disorder, and Major depressive disorder. Resident #33 Record review of the April 2024 Physician Orders revealed an order dated 8/3/23 for Clonazepam 0.5 mg (milligram) tablet Administer 0.5 milligram(s) by mouth as necessary daily PRN. There was not a stop date for this medication. Record review of Face Sheet revealed Resident #33 was admitted to the facility on [DATE] with diagnoses of Quadriplegia, Major depressive disorder, and Generalized anxiety disorder. An interview on 4/10/24 at 4:25 PM, with the facility's Pharmacy Consultant revealed he was aware of the regulations requiring a stop date for PRN psychotropic medications. He stated these residents were a special population that had been on those medications for a long period of time. He confirmed Resident #27's PRN order for Xanax did not have a stop date and confirmed Resident #33 had an active order for PRN Clonazepam, which was a psychotropic medication, that did not have a stop date as required. He also revealed he had not notified the physician that PRN psychotropic medications required a stop date. During an interview on 4/10/24 at 4:30 PM, the DON revealed she was unaware of the requirement for PRN psychotropic medications to have a stop date. 41878

Based on observation, staff interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by lack of a biohazard container in one (1) of three (3) residents on transmission-based precautions on initial entrance to the facility. Resident #25 Findings include: Record review of facility policy titled, Tracheostomy Care revised 4/11/24, revealed, Procedure: Remove and throw away inner cannula . i. If resident is on MDRO (multi-drug resistant organism) isolation, dispose of in biohazard bag. Record review of facility policy titled, Isolation - Categories of Transmission-Based Precautions, dated 4/1/24, revealed, .Policy Interpretation and Implementation: 1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. An observation and interview on 04/09/24 at 10:40 AM, revealed signage on Resident #25's door for droplet isolation. An interview with the Respiratory Therapy (RT) Supervisor revealed the resident had bacteria in his sputum that required droplet isolation and gowns, gloves, masks, and goggles were needed when entering room. Record review of lab results of the sputum culture dated 3/15/24, revealed result of Carbapenem-resistant pseudomonas aeruginosa Heavy growth. Record review of the April 2024 Physician Orders revealed an order dated 2/17/24 for Droplet isolation due to carbapenem-resistant pseudomonas aeruginosa in sputum. An observation and interview on 4/10/24 at 10:45 AM, with Licensed Practical Nurse (LPN) #1 revealed there was not a biohazard container for trash in the resident's room and the personal protective equipment (PPE) was being discarded in a regular trash can with a white plastic liner. LPN #1 revealed this resident was in droplet isolation and the infection control staff determined what to use for disposal of items in the isolation rooms and she was unsure why a red biohazard container was not used. An interview with the Infection Preventionist on 4/10/24 at 10:55 AM, revealed only residents in isolation for clostridium difficile colitis (C-diff) used a red biohazard trash system. She revealed Resident #25 tested positive for carbapenem-resistant pseudomonas aeruginosa in his sputum and for that bacteria, the staff contained the trash in a regular trash bag and it was disposed of with the regular trash. During an interview on 4/10/24 at 3:30 PM, the Director of Nursing revealed she thought items from a resident positive for carbapenem-resistant pseudomonas aeruginosa could be disposed of in the regular trash if there was not a large amount of bodily fluid on the items. She confirmed that the inner trachea cannula of Resident #25 contained sputum fluid from the trachea and had the potential to spread infection. She stated the regular trash bag had no identifying information that would alert others of the infectious waste. She confirmed that by not disposing of infectious material properly, the potential for the spread of infection could increase. Record review of Face Sheet revealed the resident was admitted to the facility on [DATE] with the diagnoses of Hemiplegia, dependence on respirator ventilator status, and Tracheostomy status.

Based on interviews and record reviews, the facility failed to maintain a resident's dignity by ensuring adequate privacy when two (2) nonclinical staff members were allowed to remain in a resident's room during Activities of Daily Living (ADL) care. Resident #1 Record review of the facility's Resident's Rights revealed .17. To Privacy and Respect - A resident has the right to privacy in .personal care . You shall be treated with consideration, respect and full recognition of your dignity . On 1/21/22 at 9:48 AM, during an interview with the Administrator, he stated the facility reported an incident that occurred on 1/17/2022 in which two environmental services employees (Housekeeper #1 and Housekeeper #2) were talking with Resident #1 and two Certified Nursing Assistants (CNA #1 and CNA #2) in the resident's room. The CNA's used the ceiling lift to assist Resident #1 to the bed and continued to undress the resident while the environmental services employees were in the room. After the resident complained about the event, the facility immediately suspended the employees and began to investigate and make the appropriate notifications to the physician, Mississippi State Department of Health (MSDH), and the Attorney General's Office (AGO). The resident felt embarrassed and humiliated because of the actions of the CNA's and the Environmental Services employees. After the investigation was completed, all four employees were terminated. On 1/21/22 at 12:00 PM, in an interview with RN #1, First Shift Supervisor, she said Resident #1 asked to see her on Tuesday morning (1/18/2022). She has a good rapport with the resident and when the resident told her what had happened, she immediately notified the DON and Administrator. Resident #1 has not been withdrawn since the event and has not expressed that she is afraid of staff or afraid of any reprisal from making the complaint. On 1/21/22 at 12:11 PM, in an interview with Resident #1, she stated the event occurred on Monday around 2:00 p.m. She had been up in her wheelchair, fully dressed in pants and a shirt. CNA #1 and CNA #2 came with her to the room, as well as Housekeeper #1 and Housekeeper #2. Resident #1 did not know what they were doing in her room and they had no business in my room. Resident #1 said the CNAs were upset because they had to put her back to bed after being up for two hours. When the CNA's began to undress her, she did not know why they (the housekeeper's) didn't walk out, and she kept thinking they were going to leave. She said, I just kept thinking why did they do this? This really happened and I don't know why. Resident #1 confirmed she did not feel comfortable telling the CNAs to tell the housekeeping staff to leave because she could tell they were already upset. She chose not to say anything to them to keep down confusion and an argument, but she was embarrassed and humiliated. A Record review of the Risk Management Accident/Incident Investigation summary revealed the Administrator, Assistant Administrator, and the Director of Nursing (DON) conducted an investigation. The date of the accident/incident is 1/17/2022. The Description of Accident/Incident Resident was undressed and left uncovered during ADL care in the presence of non-clinical (Environmental Services) employees . Injury/Adverse Effects Resident was embarrassed and humiliated . Assessment/Treatment Provided .Resident expressed that she was embarrassed and humiliated by the experience . Investigation Summary . Two Environmental Services employees, Housekeeper #1 and Housekeeper #2 (not assigned to Resident #1's room) followed CNA #1 and CNA #2 into Resident #1's room and remained in the room talking with the CNAs during the entire transfer and ADL care. Resident #1's clothing was removed from the waist down and she was left uncovered in plain view of Housekeeper #1 and Housekeeper #2 .Resident #1 indicated she felt embarrassed and humiliated from being exposed for a prolonged period of time with the Environmental Services Employees watching all of her ADL Care. CNA #1 and CNA #2 were interview by DON via telephone on 1/19/22 and confirmed they allowed the Environmental Services employees to remain in the room during ADL care. CNA #1 indicated she knew Housekeeper #1 and Housekeeper #2 were not supposed to be in the room but continued with the ADL care and transfer. CNA #2 indicated she was aware Resident #1 is a very modest and private person and the Environmental Services employees were not supposed to be in the room . A record review of the Face Sheet revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of a written statement signed by RN #1 dated 1/18/22 revealed I was called to (Resident #1's Room) today by resident to issue a complaint about CNAs who cared for her on 1/17/22. Resident asked to be put to bed between 1400-1430 (2:00 PM to 2:30 PM). CNA #1 and CNA #2 went into room to put her back in bed and two houskeepers walked in behind them carrying on and joking. The CNA's put her in the bed and started undressing her. They took her pants and brief off to clean her up. She stated she kept thinking there should be privacy when they undress me. They just kept joking and kidding around with the houskeepers. She kept thinking that they would tell the houskeepers to leave but they never did. She stated she felt very uncomfortable, embarrassed and humiliated. She voiced that she is a very private person and it was not right. She stated she was told when she came here that everybody has to knock on my door and they cannot come in when personal care is being provided. She stated that the two housekeepers just stood there and watched while they undressed her. A record review of a written statement signed by the DON and the Assistant Administrator, dated 1/18/2022 revealed RN #1, Shift Manager received a complaint from Resident #1, regarding CNA #1 and CNA #2. Assistant Administrator and I went to resident's room to discuss the incident. Resident #1 stated that she asked CNA #1 to put her back in bed around 2:00 PM yesterday. CNA #2 was with CNA #1. She said they were fussy about putting her back in bed. Resident #1 said the two housekeepers, Housekeeper #1 and Housekeeper #2, followed them into her room. The housekeepers were standing around looking at her pictures on the wall and Resident #1 said she kept thinking they were going to leave. She said that they were not even housekeepers that usually cleaned her room. CNA #1 and CNA #2 proceeded to lift her out of her wheelchair with the ceiling lift, and put her onto the bed .After getting Resident #1 into the bed, CNA #2 and CNA #1 removed her pants and brief, leaving her exposed from the waist down. She said all she had on was a shirt. The two housekeepers were still in the room and both of them were staring at her. Resident #1 said when she knew the housekeepers were still in her room looking at her, she felt humiliated and ashamed . Record review of a written statement signed by the DON revealed, 1/18/22 at 16:30 (4:30 PM). Statement from CNA #1 via telephone . I informed CNA #1 that the complaint was regarding getting a resident back into bed (Resident #1) and removing her pants and brief with another CNA assisting her with two housekeepers were present in the room .CNA #1 said she knew they weren't supposed to be in the room, but since Resident #1 was talking to them they went ahead and put her in the bed and removed her pants and brief . CNA #1 said, we weren't talking to Resident #1 when we were putting her in bed . Record review of a written statement signed by the DON revealed, 1/18/22 at 16:45 (4:45 PM). Statement from CNA #2 via telephone .I informed CNA #2 that the complaint was regarding assisting another CNA getting a Resident #1 back into bed, removing her pants and brief while two housekeepers were present in the room. CNA #2 said she told them they needed to leave the room. She said she knows Resident #1 won't even get undressed in front of her husband. The houseepers were standing in the entry way of the room and Resident #1 told they didn't need to leave since they were by the door and couldn't see anything . Record review of Course Completion History dated 1/18/2022 revealed Housekeeper #1 and Housekeeper #2 completed a course titled Understanding Abuse and Neglect Self-Paced on 12/14/ 1. Record review of Course Completion History dated 1/21/2022 revealed CNA #1 completed eCOURSE: Protecting Resident Rights in Nursing Facilities on 12/26/202 which indicated CNA #1 received training on Resident Rights. Record review of Transcript for CNA #2 revealed Course name e-COURSE: Protecting Resident Rights in Nursing Facilities was completed on 12/14/202 which indicated CNA #2 was received training on Resident Rights.

Based on record review, interview, and facility policy review, the facility failed to provided a written notice of transfer to the Resident Representative to include reason for transfer, facility transferred to, the name of the Ombudsman with address and phone number, or the appeal rights of the resident for two (2) of two (2) residents reviewed for transfer to the hospital. This affected Resident #21 and #18. Findings include: Facility Policy Review, titled Transfer or Discharge Notice, revealed the facility would not provide a written notice of transfer for an immediate transfer or discharge required by a resident's urgent medical needs. The policy failed to address the discharge/transfer notice to be provided to the resident and/or resident representative upon transfer to the hospital as soon as practicable. Resident #21: A review of the resident's medical record revealed [REDACTED]. An interview on 01/09/19 at approximately 4:42 PM, with Registered Nurse (RN) #1, confirmed Resident #21's hospitalization . An interview on 01/19/19 at 5:00 PM, with the Assistant Administrator, indicated the facility had completed a written notice of transfer to the hospital to the resident's family. A copy of the transfer notice was requested. A review of the copy of the transfer notice provided by the facility Administrator revealed the document did not include a reason for the transfer, the name of the facility that the resident was being transferred to, the name of the Ombudsman with address and phone number, nor the appeal rights of the resident. An interview on 01/10/19 at 9:13 AM, with the Medical Record Director, revealed she is responsible for sending the transfer letters. The Medical Record Director stated the facility's Bed Hold Letter is the document sent to the resident or resident Responsible Party (RP) when a resident is transferred from the facility. She also reviewed the Bed Hold Letter for the resident and confirmed the letter did not have the reason for transfer, the name of the facility that the resident was transferred to, the name of the Ombudsman with address and phone number, nor the appeal rights of the resident. Resident #18 During an interview on 01/10/19 at 2:28 PM, Registered Nurse (RN) #2 revealed Resident #18 went to the hospital in respiratory distress on 1/4/2018. Resident #18 was transferred via ambulance. Resident #18 is currently in the hospital. A Review of the transfer letter revealed that the document did not have a reason for transfer of the resident, the name of the facility that the resident was being transferred to, Name of Ombudsman with address and phone number nor the appeal rights of the resident. An interview on 01/10/19 at 3:31 PM, with the Assistant Administrator, revealed the facility's interpretation of the guideline was that the Bed Hold Letter was sufficient for notification of transfer. She stated the facility's interpretation of the requirements of a transfer letter was based on guidance from the Centers for Medicare and Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey and Certification Group dated 5-12-17, and the bed hold letter the facility issues met the requirement for notice of transfer for a person who was transferred to the hospital with return anticipated.

Based upon staff interview, record review and facility policy review, the facility failed to follow the care plan for incontinence and catheter care for two (2) of 15 care plans reviewed: Resident #2, and Resident #3. Findings Include: Review of the facility's policy titled Care Plans dated 07/14/14, revealed that a comprehensive individualized care plan will be developed for each resident by the interdisciplinary team. The policy did not include information about following the care plan. Resident #3: Review of the care plan for Resident #3, with the last review date of 08/01/17, revealed that when providing bowel incontinent care, a washing of the Perineal area is to be done in a motion of front to back. During an observation of incontinent care, on 09/13/17 at 9:30 AM, provided for Resident #3, Certified Nursing Assistant (CNA) #1 wiped from back to front four (4) times during care while cleaning Resident #3's buttocks area. During an interview on 09/14/17 at 1:30 PM, Registered Nurse (RN) #2/ Minimum Data Set (MDS) Coordinator/ Care Plan Coordinator, confirmed that Resident #3's care plan for incontinent care included cleaning from front to back and that it was the expectation of the care plan approach for incontinent care to be followed. During an interview on 09/14/17 at 4:10 PM and again on 09/15/17 at 9:10 AM, the Director of Nursing (DON), confirmed that the approach to wipe from back to front, when providing incontinent care, is the incorrect method to use. The DON stated that the care plan developed for each resident is to be followed. A review of the face sheet revealed Resident #3 was admitted to facility on 05/20/16, with [DIAGNOSES REDACTED]. A review Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/17, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. Resident #2 A review of Resident #2's care plan, dated 8/30/16, revealed to anchor the catheter to prevent pulling of the meatus and change the leg band monthly and as needed. During an incontinent observation on 9/13/17 at 1:30 PM, CNA #4 failed to secure/anchor the tip of the catheter while providing catheter care and failed to provide a catheter strap to prevent possible urethral trauma. CNA #4 pulled away from the urethra twice with a towel, without anchoring the tubing. Resident #2 jumped both times. An interview on 9/13/17 at 3:15 PM, with CNA #4, confirmed she did not secure the tip of the catheter during catheter care. CNA #4 also confirmed she failed to provide a catheter strap. CNA #4 said she was nervous and forgot to hold the tip of the catheter to prevent possible trauma to the urethra and failed to put a catheter strap on after Resident #2 took a shower this morning. During an interview on 9/14/17 at 3:35 PM, Registered Nurse (RN #2) confirmed CNA #4 failed to follow the care plan by not securing the catheter during catheter care and not providing a catheter strap to prevent trauma to the urethra. A review of the facility's face sheet revealed the facility admitted Resident #2 on 8/24/16, with diagnoses, which included [MEDICAL CONDITION], Fractured 4th/5th Cervical Vertebra, Sacral Ulcer, Neuromuscular Dysfunction of the bladder and Depression. A review of Resident #2's Quarterly MDS, with an ARD of 8/1/17, revealed Resident #2 had a BIMS score of 15, which indicated the resident was cognitively intact.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide incontinent/catheter care in a manner to prevent possible spread of infection and/or trauma for three (3) of seven (7) incontinent/catheter care observations: Resident #2, Resident #3 and Resident #9. Findings Include: Review of the facility's policy titled Perineal Care, revised May 23, 2016, revealed to gently wash the Perineal area from front to back. Front to back cleaning helps to minimize fecal contamination with urinary meatus and vaginal area in women. Resident #3: During an observation of incontinent care for Resident #3, on 09/13/17 at 9:30 AM, Certified Nursing Assistant (CNA) #1 wiped from back to front four (4) times during care while cleaning Resident #3's buttocks area. During an interview on 9/13/17 at 1:55 PM, CNA #1 confirmed that she did not clean the resident's buttocks area according to how she was trained. CNA #1 stated that she had been in-service and had competency skills check-off conducted by a facility nurse. CNA #1 stated, I got mixed up. During an interview on 09/13/17 at 2:00 PM, CNA #2/ CNA Supervisor, confirmed that wiping from front to back during Perineal care was the correct procedure. CNA #2 also stated that all the CNAs have had several in-services and skills check offs for Perineal care. During a review of the facility check off document titled Peri-Care Audit, dated 06/29/17, it was revealed that Certified Nursing Assistant (CNA) #1 had received a skills checkoff observation for incontinent care on 06/29/2017. During a review of the facility in-service documentation titled Perineal Care, dated 05/31/17, it was revealed that CNA #1 had a facility in-service on Perineal care using the front to back cleaning procedure on 08/23/17. During an interview on 09/14/17 at 4:10 PM, the Director of Nursing (DON) confirmed that wiping from back to front during Perineal care was not correct. The DON stated that CNA #1 had been trained to wipe from front to back and that she (CNA#1) knew better. A review of the face sheet revealed the facility admitted Resident #3 on 05/20/16, with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/17, revealed Resident #3's Brief Interview for Mental Status (BIMS) score was 15, which indicated no cognitive impairment. Resident #2 During an incontinent observation for Resident #2, on 9/13/17 at 1:30 PM, CNA #4 failed to secure the tip of the catheter with her hand to keep from pulling as she provided care. CNA #4 also failed to provide a catheter strap to anchor the tubing to prevent possible urethral trauma due to pulling/tension on the tubing. CNA #4 pulled away from the urethra twice with a towel during care and Resident #2 jumped both times. During an interview on 9/13/17 at 3:15 PM, CNA #4 confirmed she did not secure the tip of the catheter during catheter care. CNA #4 also confirmed she failed to provide a catheter strap. CNA #4 said she was nervous and forgot to hold the tip of the catheter to prevent possible trauma to the urethra and failed to put a catheter strap on after Resident #2 took a shower this morning. During an interview on 9/14/17 at 9:30 AM, CNA #2 confirmed that CNA #4 failed to prevent possible trauma to the urethra by not securing the tip of the catheter during catheter care and not providing a catheter strap. A review of the facility's face sheet revealed the facility admitted Resident #2 on 8/24/16, with [DIAGNOSES REDACTED]. A review of Resident #2's Quarterly MDS, with an ARD of 8/1/17, revealed Resident #2 had a BIMS score of 15, which indicated the resident was cognitively intact. Resident #9 During an incontinent observation on 9/12/17 at 10:00 AM, CNA #3 failed to secure the tip of the catheter while providing catheter care. She wiped down the tubing without securing the base of the tubing to help prevent urethral trauma. During an interview on 9/13/17 at 3:15 PM, CNA #3 confirmed she did not secure the tip of the catheter during catheter care and could have caused trauma/injury due to pulling the tubing. CNA #3 said she was nervous and forgot to hold the tip of the catheter to prevent possible trauma to the urethra. An interview with CNA #2 on 9/14/17 at 9:30 AM, confirmed that CNA #3 failed to prevent possible trauma to the urethra by not securing the tip of the catheter during catheter care. A review of the facility's face sheet revealed the facility admitted Resident #9 on 5/15/17, with diagnoses, which included [MEDICAL CONDITION], Pressure Ulcer, C2 Cervical Spinal Cord Injury and Depression. A review of Resident #9's Quarterly MDS, with an ARD of 8/8/17, revealed Resident #9 had a BIMS score of 15, which indicated the resident was cognitively intact.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure placement was checked on a feeding tube and the tubing flushed prior to the administration of medication for Resident #16. The facility further failed to ensure enteral medications were administered via gravity flow for Resident #5, a resident with a feeding tube. This was observed of two (2) of three (3) licensed nursing staff administering enteral medication for two (2) of three (3) feeding tube observations. Findings include: Review of the facility's policy titled, Medication Administration: Enteral Tubes, dated 12/2012, revealed enteral tube placement is to be verified by inserting a small amount of air into the tubing and by aspiration of stomach contents before administering medication into the tube. The enteral tubes are to be flushed before administration of medications with at least 15 milliliters (ml) of water. When administering medications per enteral tube, nurses are to allow medications to flow down the feeding tube via gravity. Resident #16 - An observation of medication pass for Resident #16, by Registered Nurse (RN) #1, was conducted on 7/6/16 at 8:31 AM. RN #1 prepared the liquid medication, [MEDICATION NAME] at the medication cart. RN #1 entered Resident #16's room, placed the medication on Resident #16's overbed table. RN #1 picked up a clear plastic graduated container from Resident #16's sink vanity and placed water in it. She placed the water on Resident #16's overbed table. RN #1 disconnected Resident #16's Jejunostomy (J tube) tubing from the feeding pump tubing. She attached the barrel of the cath tip syringe to the J tube's port and poured the liquid [MEDICATION NAME] into the J tube. RN #1 did not verify tube placement or flush the tubing with water, before the medication administration. In an interview on 7/6/16 at 2:16 PM, RN #1 acknowledged she did not verify placement or flush Resident #16's J tube before administering the [MEDICATION NAME] medication. RN #1 said she verified tube placement once per shift when administering medication and just forgot to flush the J tube before administering the [MEDICATION NAME]. RN #1 stated that it was important to check for placement to ensure medication was going into the right spot. An interview with the Director of Nursing (DON) on 7/6/16 at 6:23 PM, revealed nurses are supposed to flush the feeding tubes with water before and after administration of medication, and verify placement by auscultation of the tubes and aspiration of stomach contents. Review of Resident #16's cumulative Physician order [REDACTED]. Review of Resident #16's Facesheet revealed the facility admitted Resident #16 on 5/13/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], revealed Resident #16 had severely impaired cognitive skills for decision making and was totally dependent on staff for eating, dressing and toileting. Resident #5 During an observation of medication pass for Resident #5 on 7/6/16 at 8:55 AM, Licensed Practical Nurse (LPN) #1 prepared Resident #5's medications by crushing [MEDICATION NAME] and Losartan Potassium. Resident #5's Vitamin C was in liquid form and [MEDICATION NAME] was in powder form. LPN #1 placed each medication in a separate cup. LPN #1 added water to the cups containing the crushed [MEDICATION NAME] and Losartan Potassium and the powdered [MEDICATION NAME]. At bedside, LPN #1 checked for placement of Resident #5's feeding tube using a catheter tip syringe. LPN #1 then flushed the tube with 30 ml of water using the plunger of the syringe to push the water into the feeding tube. LPN #1 then used the push method to administer the [MEDICATION NAME], Losartan Potassium and Vitamin C. She administered the [MEDICATION NAME] via gravity. After all medications were administered, LPN #1 used the push method to flush the tubing with water. In an interview on 7/6/16 at 2:31 PM, LPN #1 acknowledged she did not administer Resident #5's medications via tube per facility policy of gravity infusion. LPN #1 said sometimes she had a hard time letting the medication infuse via gravity with residents, and did not attempt to administer by gravity this time. LPN #1 said she did not know why it was important to allow medication to flow via gravity in residents with enteral tubes. In an interview with the DON on 7/6/16 at 6:23 PM, she said it was a better option to instill medication into a enteral tube using gravity flow, unless it was a very thick suspension. Review of the facility's Facesheet revealed the facility admitted Resident #5 on 3/21/16, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed Resident #5 had severely impaired cognitive skills and was totally dependant on staff for all activities of daily living to include eating, bathing and transfers.

Based on observation, staff interview, and facility policy review, the facility failed to prevent potential cross-contamination by ensuring nursing staff donned and changed gloves during medication set-up and administration for Resident #16 and Resident #17. The facility further failed to ensure nursing staff did not insert a bare finger inside pill pouches to open them for Resident #5. This was observed on three (3) of six (6) residents during medication pass observation. Findings include: The facility's policy titled Infection Control, dated 4/2015), Section VI - Standard Precautions, revealed gloves are to be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces. The facility's policy titled Subcutaneous Insulin, dated 09/2010, revealed gloves are to be put on before giving an injection. Resident #16 During an observation of medication pass for Resident #16 on 7/6/16 at 8:31 AM, Registered Nurse (RN) #1 prepared liquid medication to be administered. RN #1 entered Resident #16's room and placed the plastic medication cup on the resident's overbed table. RN #1 entered Resident #16's bathroom and washed her hands. She then put on a pair of disposable gloves. RN #1 picked up a clear plastic graduated container containing a cath tip syringe. She turned the faucet handle on to place water into the container with her gloves on. After placing water in the container, RN #1 turned off the faucet with the same gloves on. RN #1 then placed her gloved hands on Resident #16's overbed table and rolled it to the bedside. She then touched the feeding pump and placed it on pause. RN #1 then used the same gloves to disconnect Resident #16's jejunostomy (J tube) from the feeding pump tubing. RN #1 connected the cath tip syringe to the port of the J tube and administered the medication [MEDICATION NAME]. RN #1 reattached the J tube to the feeding pump tubing and turned the feeding pump back on. She then touched the rolling overbed table and moved it away from Resident #16's bedside. RN #1 entered the resident's bathroom and removed her gloves for the first time during the medication pass for Resident #16. In an interview on 7/6/16 at 2:16 PM, RN #1 acknowledged she washed her hands and donned gloves initially before med pass for Resident #16, but did not change gloves after touching the sink faucet handles, overbed table, and feeding pump. RN #1 said this could cause contamination and was an infection control concern. During an interview with the Director of Nursing (DON) on 7/6/16 at 6:23 PM, the DON stated that nurses are to change gloves after objects were touched to prevent possible contamination. Review of the facility's Facesheet revealed the facility admitted Resident #16 on 5/13/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed Resident #16 had severely impaired cognitive skills for decision making and was totally dependent on staff for all activities of daily living to include eating, dressing and toileting. Resident #5 Observation of medication pass preparation for Resident #5 by Licensed Practical Nurse (LPN) #1, on 7/6/16 at 8:50 AM, revealed the LPN #1 obtained clear plastic pill pouches for [MEDICATION NAME] and Losartan Potassium to be crushed. LPN #1 opened each pill pouch by placing her bare forefinger into the top of the pouch to open them before placing the pills into the pouches. During an interview on 7/6/16 at 2:31 PM, LPN #1 acknowledged placing her finger in the pill pouches to open them and said she just wasn't thinking when she did that. She said doing this could create a high risk for infection. In an interview with the DON on 7/6/16 at 6:23 PM, she said nurses should press a pill pouch with the fingers to open it. A review of the facility's Facesheet revealed the facility admitted Resident #5 on 3/21/16, with [DIAGNOSES REDACTED]. Review of the Admission MDS, dated [DATE], revealed Resident #5 had severely impaired cognitive skills and was totally dependant on staff for all activities of daily living to include eating, bathing and transfers. Resident #17 Review of Resident #17's cumulative Physician order [REDACTED]. The Physician order [REDACTED]. During observation of medication pass for Resident #17 on 7/6/16 at 11:00 AM, LPN #2 obtained a blood glucose reading on Resident #17 while wearing gloves. The result was 158. LPN #2 explained she would prepare the scheduled 25 units of insulin and add an additional 5 units of sliding scale for the reading of 158. LPN #2 withdrew 30 units of insulin from the vial and entered Resident #17's room. She swiped Resident #17's skin with alcohol and injected the insulin without any gloves on. In an interview on 7/6/16 at 11:16 AM, LPN #2 acknowledged she did not wear gloves while administering the insulin injection to Resident #17. LPN #2 said she only wears gloves with residents who are on isolation or when administering meds to a tube fed resident. During an interview on 7/6/16 at 6:23 PM, the DON said nurses are to wear gloves with injections to prevent possible cross-contamination. Review of the facility's Facesheet revealed the facility admitted Resident #17 on 10/12/07. Resident #17's [DIAGNOSES REDACTED]. Review of the most recent Annual MDS, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #17 was cognitively intact. This MDS also assessed Resident #17 as totally dependent on staff for transfers, dressing and bathing.

Based on record review, staff interview, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with a wound to the left heel for one (1) of 17 residents reviewed for care plans; Resident #1. Findings include: Review of the facility's policy titled, Care Plans, dated 07/14, revealed a comprehensive care plan would be developed for each resident. The care plan is to be updated or revised after each quarterly review and when a significant change in assessment occurs. Nursing is assigned to update the care plan when changes in treatment or needs arise. A review of the facility's policy titled, Resident Assessment, dated 12/10, revealed residents should be assessed by a Registered Nurse (RN) on admission and on an ongoing basis. The plan of care should be reviewed and revised according to policy. Resident #1 A review of the annual Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 05/03/16, revealed Section M (Skin Conditions) was checked for a stage three (3) pressure wound. The Care Area Assessment Summary (Section V), revealed Pressure Ulcer had triggered, and the current care plan would be continued. A review of the cumulative physician orders [REDACTED].#1. Review of the care plan for Resident #1, revealed there was not a care plan developed to address the wound to the left heel. The Surveyor did note that there was a care plan for a wound to the right heel. Interview on 07/05/16 at 2:06 PM, with Registered Nurse (RN) #1 during the initial tour of the facility, revealed Resident #1 had a pressure ulcer to the left heel. Interview on 07/07/16 at 4:55 PM, with RN #1, confirmed Resident #1 had a pressure ulcer to the left heel. RN #1 revealed she was responsible for the Minimum Data Set assessment and care plan for Resident #1. Upon review of Resident #1's care plan, RN #1 revealed care plan was inaccurate. RN #1 stated, That's my mistake. RN #1 revealed Resident #1 previously had a wound to the right heel that was now healed. Observation on 07/07/16 at 10:50 AM, with RN #4, revealed wound care was provided to the left heel. Resident #1 was noted to have a wound to the left heel which was cleaned with normal saline, packed with foam dressing, and [DEVICE] applied at 125 mm/hg. A review of the Face Sheet revealed the facility admitted Resident #1 on 06/01/15, with [DIAGNOSES REDACTED]. A review of the annual MDS assessment with an ARD of 05/03/16, revealed Resident #1 scored 15 on the Brief Interview of Mental Status (BIMS) which indicated no cognitive impairment.

CI MS # Based on observation, interview, record review and policy review the facility failed to notify one (1) of five (5) residents reviewed, Resident #1, of an incident of a significant medication error when Resident #1 received another resident's medications. Findings included: Review of the facility's Resident Rights policy, provided by the Director of Nursing (DON) on 9/22/15, revealed: The resident has the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. Review of a 9/7/15 Accident/Incident Investigation Summary revealed Licensed Practical Nurse (LPN) #1 administered Resident #1 medications that were ordered for Resident #2 in error during the 9:00 AM medication pass. Significant medications received by Resident #1 included controlled medications [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg. There was no documented evidence that Resident #1 was notified of the medication error when it occurred. Observation and interview with Resident #1 on 9/21/15 at 1:30 PM revealed he was alert and oriented to person, place and time. Resident #1 stated he was aware he'd been given the wrong medication on 3-11 shift when his Responsible Party (RP) and Registered Nurse (RN) #2 told him. Resident #1 stated he had not been notified that morning when the error had occurred. Interview with LPN #1 on 9/21/15 at 10:00 AM revealed she had given Resident #1 medications that were ordered for Resident #2 at the 9:00 AM medication pass on 9/7/15. LPN #1 stated she did not tell Resident #1 that he received medications in error because she and the charge nurse wanted to get a true picture of the resident. Interview with RN #1 on 9/22/15 at 11:05 AM, with the Director of Nurses (DON) present, revealed she had not notified Resident #1 of the medications he received in error on 9/7/15 because she didn't want him to get unnecessarily upset and wanted an accurate assessment of condition. RN #1 stated she and LPN #1 decided to monitor Resident #1 during the shift to see how he reacted, that's why he wasn't notified. The DON stated Resident #1 should have been notified of receiving the wrong medications because that was his right. The facility admitted Resident #1 on 10/12/07 with [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/15 revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 denotes intact cognition.

CI MS # Based on observation, interview, record review and policy review the facility failed to develop and/or revise the care plan for one (1) of five (5) residents reviewed, Resident #1, as evidenced by not revising the care plan for a urinary tract infection and not initiating a care plan for monitoring due to receiving medications that weren't prescribed. Findings included: Review of the facility's Care Plans policy dated 7/14/14, revealed: A comprehensive individualized plan of care will be developed for each resident. The care plan will be updated or revised after each quarterly review, and when a significant change in assessment occurs. Nursing and Respiratory Therapy should update care plan when changes in treatment or needs arise. Review of the resident's care plans revealed there was no documented evidence of a care plan for monitoring Resident #1 for adverse effects of medication he received in error. Review of an Accident/Incident Investigation Summary, dated 9/7/15, and a Quality Care Control Report (for medication error) dated 9/7/15 revealed Resident #1 received medications in error that were ordered for Resident #2 in error by LPN #1 during the 9:00 AM medication pass. Significant medications received by Resident #1 included controlled medications [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg. These medications were not routinely taken by Resident #1 and could cause side effects such as drowsiness, agitation, nausea, sedation, and confusion. Documentation on the Quality Care Control Report included vital signs monitored, check resident every hour, and Responsible Party (RP) notified. Review of an Emergency Department (ED) Chart dated 9/8/15 revealed Resident #1 presented to the ED at 11:04 AM with complaint of Altered Level of Consciousness and Confusion. Resident #1's [DIAGNOSES REDACTED].#1 was treated with Bactrim DS for seven (7) days. Review of Resident #1's care plan dated 1/24/08 revealed a potential for UTI associated with Supra-pubic catheter. There was no documented evidence Resident #1's care plan was revised to include the UTI for 9/8/15 with interventions for treatment. Interview with RN #1 on 9/22/15 at 11:05 continuing with the Director of Nursing (DON) present at 12:20 PM during the interview, revealed she did not think it was appropriate to care plan the medication error. RN #1 stated vital signs were already care planned. RN #1 stated Resident #1 was monitored by herself and other staff for adverse effects, vitals taken, and no adverse effects were noted. The DON stated the care plan for Resident #1 should have been updated to include monitoring for adverse effects of receiving the wrong medication and the UTI. Interview with RN #4 on 9/21/15 at 4:15 PM revealed the nurses were to update/revise care plans when they take off orders, usually the Charge Nurse. The facility admitted Resident #1 on 10/12/07 with [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/15 revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 denotes intact cognition.

CI MS Based on observation, interview, record review and policy review the facility failed to ensure residents were free from significant medication errors for one (1) of five (5) residents reviewed, Resident #1, as evidenced by Resident #1 received another resident's medication in error which included controlled medications with the potential for adverse effects such as Central Nervous System (CNS)/ Respiratory Depression. Findings included: Review of the facility's policy Medication Administration General Guidelines, dated 12/12, revealed: Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. Documentation under the Medication Administration section #4: Medications are to be administered at the time they are prepared. 10. Residents are identified before medication is administered using at least two resident identifiers. Methods of identification may include: a. Check identification band. b. check photograph attached to medical record. c. Verify resident identification with other nursing care center personnel. 16. Medications supplied for one resident are never administered to another resident. Review of a facility Accident/Incident Investigation Summary, completed on 9/7/15, revealed Resident #1 was administered medications in error by LPN #1 that were ordered for Resident #2 during the 9:00 AM medication pass. Significant medications received by Resident #1 included [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg all of which were controlled substances. Review of a Quality Care Control Report revealed a Medication Related event occurred on 9/7/15 at 9:00 AM when the wrong patient got the wrong medication related to environmental factors of the resident receiving AM care at the time of medication preparation and administration and failure to follow established policies and procedures. The report documented Resident #1 received Resident #2's medications when medications were brought back to the cart for Resident #1 when AM care was being provided. LPN prepared Resident #2's medication and administered to Resident #1 when his door opened after care had been provided. The report documented Resident #1 was monitored throughout the shift and without adverse reactions. Review of Nurse's notes dated 9/8/15 at 2:00 AM revealed Resident #1 vomited a medium amount of dark brown fluid around 11:40 PM (9/7/15) and again at 1:30 AM. Resident #1 was alert, awake and responsive to commands. Vitals were taken with a slightly elevated blood pressure and pulse rate. A Nurse's note dated 9/8/15 at 6:32 AM revealed Resident #1 had vomited at 3:00 AM and [MEDICATION NAME] was administered IM. Resident was noted to be talking on the phone with no one on the phone and saying he was going to get up and go for a walk. A Nurse's note dated 9/8/15 at 6:48 AM revealed Resident #1 talking to a peanut can like a telephone and saying how yesterday's lunch upset his stomach. Further Nurse's notes 9/8/15 at 11:46 AM reveal a late entry for 9:00 AM revealed Resident #1's RP wanted him sent out to the hospital because of his confusion. The physician was notified and stated to ask RP if she wanted the resident treated here or to send him out due to suspected UTI. RP chose to send Resident to the hospital. Review of a hospital Emergency Department (ED) report dated 9/8/15 revealed Resident #1 arrived at 11:04 AM with a complaint of confusion and altered mental status. Resident #1 received an initial dose of antibiotic by mouth and Normal Saline 1000 milliliters intravenous (IV) during his stay. Labs, EKG (Electro-cardiogram), and X-rays were ordered and reviewed in the ED. Final [DIAGNOSES REDACTED]. Resident #1 was discharged with antibiotics for the UTI on 9/8/15 at 5:20 PM. Observation and interview with Resident #1 on 9/21/15 at 1:30 PM and again 9/22/15 at 12:50 PM, revealed he was alert and oriented to person, place and time. Resident #1 recalled being told by the RP and RN #2 of receiving the wrong medication later in the day (9/7/15). Resident #1 stated he knew staff was in and out all day. Resident #1 stated he was okay all day then ate some tuna salad for supper and thought it had soured on his stomach. Resident #1 stated around midnight he got sick on his stomach and thought he vomited twice. Resident #1 stated he did get a little confused and his RP kept asking if he wanted to go to the hospital. Resident #1 stated he was never out of it but did think he said some things that weren't quite right. Resident #1 stated he went to the hospital the next day and they ran some tests and sent him back with medication for his kidneys. Resident #1 stated sometimes he got like that with his kidneys. Resident #1 stated he could not say for sure it was the medication that made him sick, thought it was the tuna. Interview with LPN #1 on 9/21/15 at 10:00 AM revealed she had prepared Resident #1's medications for the 9:00 AM medication pass on 9/7/15 and didn't administer them because the resident was receiving AM care. LPN #1 stated she returned to the medication cart and labeled Resident #1's medication cup and started preparing Resident #2's medications. LPN #2 stated Resident #1's door opened and the Certified Nursing Aide (CNA) came out so she just gave Resident #1 the medications she had in her hand. LPN #1 stated when she returned to the medication cart and saw the labeled cup for Resident #1 she realized she'd given Resident #1 the medication for Resident #2 and immediately told the charge nurse. LPN #1 stated Resident #1 was monitored throughout the shift with no change in his status. LPN #1 stated she informed the CNAs and other nurses so they could observe Resident #1 as well. LPN #1 stated Resident #1 had no drowsiness and only abnormality was his blood pressure was a little elevated but nothing unusual for him. LPN #1 stated Resident #1 received all of the medications in the cup that was due for Resident #2, with review of the list of medications for Resident #2 (Vitamin E 400 IU, Vitamin D 1200 mg, Multivitamin, [MEDICATION NAME] 15 mg, [MEDICATION NAME] ER 30 mg, Potassium 10 meq, [MEDICATION NAME] 60 mg, [MEDICATION NAME] 75 mg, and [MEDICATION NAME] 30 mg). Interview with RN #3 on 9/22/15 at 1:15 PM revealed she worked 9/8/15 day shift and Resident #1 wasn't his usual self, he was confused. RN #3 stated she was informed of the medication error from the day before and of the vomiting during the night. RN #3 stated she did notify the physician and he said normally when Resident #1 acted that way it was a UTI. RN #3 stated the RP called during that time and wanted Resident #1 sent to the hospital because of his confusion and the physician said if she wanted him sent out rather than be treated there to go ahead and send him. RN #3 stated she was informed Resident #1 did have a UTI. Interview with RN #5 on 9/22/15 at 4:45 AM revealed Resident #1 did have vomiting during the 11-7 shift 9/8/15 and [MEDICATION NAME] IM was administered with no further vomiting. RN #5 stated Resident #1 told her it was the tuna he'd eaten that had soured on his stomach. RN #5 stated Resident #1 answered questions appropriately when she had assessed him and was alert. RN #5 stated she was notified of Resident #1's confusion later in the shift and reported it to the day shift for them to call the physician because resident was not in grave condition and the physician didn't like to be called before 8:00 AM unless an emergency. Interview with the Director of Nursing (DON) with the Administrator present, on 9/21/15 at 11:25 AM revealed Resident #1 was given the wrong medications by LPN #1 on 9/7/15 and she was notified on 9/8/15 of the medication error. The DON stated Resident #1 should not have been given the wrong medication. The DON stated it was not an identification problem, LPN #1 just picked up the wrong cup of medications and was suspended/counseled for not following the policy/procedure. The DON stated medications that can't be given should be labeled and secured until they could be given. The DON verified the medications Resident #1 received could have caused potential harm. The DON stated Resident #1 was monitored with no adverse effects on day and evening shifts and when he became confused with some vomiting on the night shift the physician thought he might have a UTI because he has a history of UTI with confusion. Interview with the Administrator on 9/22/15 at 10:15 AM revealed he understood the concerns with the medication error for Resident #1 and that it was significant and could have caused sedation and other problems/effects. The Administrator stated the incident was reported due to the medications that were involved. The Administrator stated staff monitored Resident #1 with no adverse effects throughout the day. The Administrator stated Resident #1 said it was the fish that made him sick and resident has a history of UTI with confusion so he couldn't say he went to the hospital due to the medication error. The facility admitted Resident #1 on 10/12/07 with [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/15 revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 denotes intact cognition.

CI MS # Based on interview, record review, and policy review the facility failed to ensure accurate and complete medical records for one (1) of five (5) residents reviewed, Resident #1, as evidenced by failure to completely document monitoring of the resident after a significant medication error and failure to document changing the Supra-pubic catheter as ordered. Findings include: Review of the facility's policy from the Medication Policy & Procedure Manual with an effective date 03/10, revealed a section: Reporting, Quality Management & Improvement of Medication Errors: Procedure: A. When a medication error occurs: 1. The health professional recognizing the error will: a. Assess and intervene as appropriate with the patient. b. Notify the attending physician and other physicians as indicated according to the category of error. c. Follow any orders given by the physician and document the patient status on the medical record, including time of occurrence. d. Chart the following in the Nurse's Notes: date, time, drug, dose, route, who administered the drug, patient response, and any interventions initiated. e. Complete a Quality Care Control Report (QCC Report) completing all pertinent information and forward to the Nursing Manager or Patient Care Supervisor. Review of the facility's 9/7/15 Accident/Incident Investigation Summary revealed Licensed Practical Nurse (LPN) #1 administered in error Resident #1 medications that were ordered for Resident #2 during the 9:00 AM medication pass. Significant medications received by Resident #1 included [MEDICATION NAME] 30 milligrams (mg), [MEDICATION NAME] Extended Release 30 mg, and [MEDICATION NAME] 75 mg all of which were controlled substances. Review of Resident #2's Medication Administration Record (MAR) revealed Resident #1 also received the following medications that were not prescribed for him on 9/7/15 for 9:00 AM: Vitamin E, Vitamin D, Potassium Chloride, Multivitamin, and [MEDICATION NAME]. Review of a Non-Urgent Nursing Communication to Physician form dated 9/7/15 revealed documentation of Resident #1 receiving the wrong AM medications which were [MEDICATION NAME] ER 30 mg, [MEDICATION NAME] 30 mg, [MEDICATION NAME] 75 mg, [MEDICATION NAME] 30 mg, MVI, Vitamin D, [MEDICATION NAME] 60 mg, and KCL 10 meq. We monitoring resident closely. No adverse reactions noted. Vital signs (VS) 0910 Temperature (T) 98, Pulse (P) 91, Respirations (R) 18 and Blood Pressure (B/P) 155/91. VS at 1130: T 98, R 18, BP 99. Blood Sugar 153. This was signed by RN #1. Review of Resident #1's Nurse's Notes for 9/7/15 revealed no documentation of the medication error, no documentation of monitoring or interventions for 7-3 or 3-11 shifts. Review of a physician's orders [REDACTED].#1's Supra-pubic catheter. Review of the Nurse's notes, MAR and Treatment Record revealed no documentation of Resident #1's cather change. Interview with RN #1 on 9/22/15 at 11:05 AM and continuing through 12:20 PM when the Director of Nursing (DON was present, revealed she monitored Resident #1 throughout the shift on 9/7/15 after Resident #1 was given the wrong medications and he had no adverse effects. RN #1 stated she didn't normally document unless there was a change and he had no change. RN #1 stated she may not have completely documented but she did document the physician communication form and that was placed with the nurse's notes. Interview with RN #2 on 9/21/15 at 3:30 PM revealed he worked 3-11 on 9/7/15 and 9/8/15. RN #2 was aware of the medication error for Resident #1 on 9/7/15. RN #4 stated Resident #1 had no problems throughout the 3-11 shift on 9/7/15 and was monitored frequently. RN #5 reviewed the Nurse's notes for Resident #1 and verified there was no documentation for 9/7/15 on the 3-11 shift. RN #2 stated he was not good at documenting. RN #5 stated he was pretty sure he changed Resident #1's Supra-pubic catheter but verified there was no documentation that the catheter was changed. Interview with the DON with RN #1 present on 9/22/15 at 12:20 PM revealed there should have been documentation in the Nurse's notes as the policy says (for medication errors). The DON verified there was no documentation in the Nurse's notes for 7-3 and 3-11 shift for the medication error and for the catheter change for Resident #1. The facility admitted Resident #1 on 10/12/07 with [DIAGNOSES REDACTED]. Resident #1's most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/15 revealed he was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 denotes intact cognition.

Based on staff interview, record review and facility policy review, the facility failed to develop a comprehensive care plan related to contact isolation and to include supervision for wandering behavior for one (1) of seven (7) resident care plans reviewed (Resident #1). The facility's failure to develop a comprehensive care plan for Resident #1 related to contact isolation and supervision for wandering behaviors resulted in the likelihood of Resident #1 and other residents being placed in a situation in which could lead to serious harm. This resulted in an Immediate Jeopardy (IJ) identified on 05/01/2015 and determined to exist on 02/16/2015. The facility was notified on 05/01/2015 of the Immediate Jeopardy. An acceptable credible Allegation of Compliance (AOC) was received on 05/03/2015. The State Agency survey team (SA) determined the Immediate Jeopardy (IJ) was removed prior to exit on 05/04/2015. The Scope and Severity for the IJ at 42 CFR-483.20(d) (F279) was lowered to a D while the facility develops and implements a plan of correction for the deficient practice. Findings include: A review of the facility policy Care Plans revision date 07/14/2014 revealed POLICY: A comprehensive individualized plan of care will be developed for each resident. The care plan will be updated or revised after each quarterly review, and when a significant change in assessment occurs. PROCEDURE: Nursing and Respiratory Therapy should update care plan when changes in treatment or needs arise. A review of the facility policy, ISOLATION GUIDELINES & TRANSMISSION-BASED PRECAUTIONS dated 7/14/14, revealed Initiate the precautions as soon as the patient has been assessed and a need established according to the CDC recommendations. and Nursing is responsible for enforcing all precautions as outlined on the laminated Precautions card found on the patient's door. This includes monitoring visitors and patients. If the patient is transported out of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment. Review of Resident #1's complete plan of care revealed no evidence of a care plan for supervision and wandering behavior with contact isolation. Interview with the Director of Nursing (DON) on 5/1/15 at 1:10 PM confirmed no care plan was developed to address Resident #1's need for Contact Isolation and for increased supervision needs related to her wandering behaviors while on Contact Precautions. The DON also stated the Care Plan noted to keep bed in the low position but did not address the Canopy bed. Review of Resident #1's Physician's Order dated 02/16/2015 revealed Contact Isolation: VRE ([MEDICATION NAME] Resistant Entercocci) in urine,[MEDICAL CONDITIONS] in sputum. Record review of the facility's Departmental Notes revealed an entry on 2/16/15 at 5:41 PM by RN #3 noted Resident #1 was admitted to the facility on Contact Isolation for VRE in urine [MEDICAL CONDITION] from [MEDICAL CONDITION] (in sputum). RN #3 noted while she was at the desk the bed alarm went off and she entered Resident #1's room and resident had gotten out of bed between the rails and was standing by the bed holding onto the side rails. RN #3 noted she placed Resident #1 up in wheelchair with a seat belt in use and placed in the day room in order to watch her more closely. Review of the admission record revealed the facility admitted Resident #1 on 2/16/15 with the [DIAGNOSES REDACTED]. A review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/15, revealed a Staff Interview for Mental Status assessment of Severely Impaired for daily decision-making skills. This assessment further revealed Resident #1 was independent (with no assistance needed) for ambulation in room, in corridor, and locomotion on/off unit. Resident was also assessed as having no impairments with Range of Motion. Restraints in bed where assessed as being used daily for Resident #1. The facility was notified on 05/01/2015 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (AOC) on 05/03/2015. A QA committee was held at 6:00 PM on 5/1/2015. The following persons were in attendance for the Quality Assurance meeting: Medical Director, DON, RN Shift Supervisor, RN, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and Administrator. The committee reviewed the existing policy on Infection Control, Isolation guidelines- Transmission based precautions. It was determined that no revisions were needed to the existing policy. The committee determined that a new policy and procedure for one on one supervision should be formulated. The QA committee developed the new policy and procedure One on One Supervision and then it was approved and signed by the medical director on 5/1/15 at 7:05 P M. The QA committee determined that all staff should be in-serviced on the existing Infection Control, Isolation guidelines- Transmission based precautions and newly developed One on One Supervision policy. The QA committee met again on 5/2/2015 at 4:00 PM. Resident Assessment and Care Plan policies were reviewed and will remain as is. The One on One supervision policy and procedure was reviewed and revised to reflect it will be documented on the TAR. A new policy and procedure for behavior and a new behavior protocol were developed by the QA committed and approved and signed by the medical director at 5:20 PM on 5/2/2015. It was determined that audits should be conducted on all 56 residents in the facility to determine at risk behavior, care plan accuracy, new signs and symptoms consistent with VRE [MEDICAL CONDITION] infection, infection control risk, and unmet psychosocial needs. Audits were conducted on 5/2/15 by the QA team members. DON, RN Shift Supervisor, RN, RAI Coordinator, LPN 1 and 2 audited at risk behavior, care plans, signs and symptoms [MEDICAL CONDITION] and VRE, and infection control risks. At risk behavior was also audited by the Social Worker and Recreational Therapist. Care plans were also audited by Respiratory Therapy Supervisor 1 and 2, Social Worker, Physical Therapist and Recreational Therapist. Psychosocial needs were audited by the Social Worker. The audits were completed on all 56 residents. After auditing all 56 residents, the audits reflected no residents have new signs and symptoms consistent with VRE [MEDICAL CONDITION], no residents have at risk behavior as evidenced by the Behavior Protocol tool, no residents are in violation of the isolation policy, no new psychosocial needs have been identified and no care plan updates were required. In-services were conducted by DON, RN Shift Supervisor, RN. LPN 1 and LPN 2 assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN. All staff was in-serviced on the revised one on one supervision policy, existing isolation guide lines- Transmission based precautions, and newly developed Behavior Policy and behavior protocol tool. In addition, clinical staff was in-serviced on the existing Resident Assessment and Care Plan policy. All staff was in-serviced by 5/2/15 at 11:45 PM. No staff were or will be allowed to work until they had completed the assigned in-services. Attorney General's Office notified at 7:23 PM on 5/1/2015. The State Agency survey team validated the facility's credible Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ) was determined to be removed prior to exit from the facility on 05/04/2015. The credible Allegation of Compliance (AOC) was verified by staff interviews, record review of in-services, and QA meeting documentation reviewed on 05/04/2015 across all disciplines beginning at 10:30 AM to 5:30 PM. The State Agency (SA) surveyors validated by interview and committee sign in record review that a Quality Assurance (QA) committee meeting was held at 6:00 PM on 05/01/2015 with the following persons attending: The Medical Director, DON, RN Shift Supervisor, RN 1, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and the Administrator. The SA validated that the facility's existing policies on Infection Control, Isolation guidelines-Transmission based precautions were reviewed with no revisions made. The SA validated that the QA committee identified the need for and formulated a new policy and procedure for One on One Supervision. The SA validated that the One on One Supervision policy was approved and signed by the Medical Director on 5/1/2015 at 7:05 PM. The SA validated through staff interview that the QA committee met again on 05/02/2015 at 4:00 PM to review the Resident Assessment and Care Plan policies and no revisions were made. The SA validated through staff interview, the One on One Supervision policy, created on 05/01/2015, and procedure was reviewed and revised to reflect it would be documented on the TAR. The SA validated through staff interview that a new policy and procedure for behavior and a new behavior protocol were developed by the QA committee. The SA validated by staff interview and QA meeting documentation the new policy and procedure for behavior and the new behavior protocol were approved and signed by the medical director on 05/01/2015 at 7:05 PM. The SA validated by audit record reviewed, interview with staff that audits on all 56 resident records were conducted on 05/02/2015 by the QA team members. The DON, RN Shift Supervisor, RN 1, RAI Coordinator and LPNs 1 and 2 audited resident records for: at risk behaviors, care plans, signs and symptoms [MEDICAL CONDITION] and VRE, and infection control risks. The SA validated by QA records and staff interview resident's records were reviewed by the social worker, and respiratory therapist. The SA validated through staff interview and QA documentation that care plans were also audited by Respiratory Supervisors 1 and 2, Social Worker, Physical Therapist, and Recreational Therapist for any necessary updates. The SA verified by staff interview and QA documentation the psychosocial needs of all residents were audited by the social worker. The SA validated by staff interview and QA documentation that the audits reflected no residents had new signs and symptoms consistent with VRE [MEDICAL CONDITION], no resident had at risk behavior as evidenced by utilization of the behavior protocol tool, no residents were in violation of the isolation policy, no new psychosocial needs were identified, and no care plan updates were required. The SA validated by record review that in-services were conducted by the DON, RN Shift Supervisor, RN 1 and LPNs 1 and 2 (these LPN's assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN 1) on the revised One on One Supervision policy, existing isolation guidelines- Transmission based precautions, and the newly developed Behavior Policy and behavior protocol tool. The SA validated by staff interview and in-service sign in sheet that clinical staff was also in-serviced on the existing Resident Assessment and Care Plan policies. The SA validated no staff were allowed to work until they completed the assigned in-services. The SA validated the Attorney General's Office was notified at 7:23 PM on 5/1/2015, by review of report submitted to the agency. The SA validated the IJ was removed prior to exit on 5/4/15.

Based on observation, interview and record review, the facility failed to provide supervision to ensure the safety of Resident #1 and other resident related to Resident #1's wandering, climbing, and behaviors for one (1) of seven (7) residents reviewed. (Resident #1) The facility failed to provide supervision for the safety of Resident #1 and other residents residing in the facility as evidenced by Resident #1 going in and out of other residents rooms while on contact isolation, and with severely impaired cognitive status from an anoxic brain injury. Resident #1 was found on top of an armoire, canopy bed, and nightstand and was found in tracheostomy residents' rooms. Record review revealed 29 out of 31 residents on the third floor had a Tracheostomy on 2/16/15, the day the facility admitted Resident #1. An Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 5/1/15, and was determined to exist on 2/16/15 when Resident #1 was admitted to the facility on isolation and began having wandering behaviors on the tracheostomy unit without supervision. The facility was notified on 5/1/15 of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The facility submitted a credible Allegation of Compliance (AOC) on 5/3/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 5/4/15. Therefore, F323 was lowered from J level deficiencies to D level or isolated deficiency while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] and was discharged from the facility on 04/10/15. Resident #1 was not available for observation during the survey process. During an interview with the Medical Director and Resident #1's Primary Physician on 5/2/15 at 12:50 PM revealed the facility admitted Resident #1 with a positive culture for [DIAGNOSES REDACTED] Entercocci (VRE) in the urine and Methicillin Resistant Staphylococcus Aureus (MRSA) in the sputum and was placed on Contact Isolation. He confirmed prior to the day the facility admitted Resident #1, the hospital removed the tracheostomy and later that day the resident stood at the bedside and began walking. He confirmed the facility notified him regarding Resident #1 walking freely about the facility and in other resident's rooms. We talked about her wandering around and the potential for her going in and out of other residents rooms. The risk (s) is always there if the resident can get around. We did have the concern for an elopement risk. Record review revealed 29 out of 31 residents on the third floor had a tracheostomy on 2/16/15, the day the facility admitted Resident #1. This list indicated on 4/10/15 there were 26 out of 31 residents with a tracheostomy on the third floor, where Resident #1 remained while at the facility. An interview with Licensed Practical Nurse (LPN) #5 on 05/01/15 at 11:00 AM, LPN #5 confirmed Resident #1 did not comprehend instructions and Resident #1 would attempt to pull out her own peg tube, so she required the use of an abdominal binder. After a resident called for help, LPN #5 found Resident #1 in another resident's room. While another resident was up in a wheelchair, LPN #5 confirmed she found Resident #1 in that resident's bed. Record review of the facility's Departmental Notes revealed an entry on 3/4/15 at 10:44 PM in which RN #2 documented Resident #1 entered another resident's room and got in the bed while that resident was up. This was while Resident #1 was under Admitting Physician orders [REDACTED]. Interview with the Licensed Social Worker (LSW) on 05/01/14 on 12:10 PM revealed, The day before or the same day she left, she got on the elevator with me, and I remember thinking that if she got on here with me, she could get on here and go down. We all watched her, that was part of the problem, we had no way to watch her and no where to send her. Record review of a Quality Care Control Report with the reference date of 3/4/15 at 9:36 PM, it was noted Resident #1 was observed sitting on the floor at the Nursing Station. The nurse documented she heard a thud and Resident #1 was found on the floor but no-one was able to describe exactly how it occurred. The Director of Nursing (DON) signed she reviewed this document and was made aware of Resident #1 found on floor. No other Quality Care Control Reports was provided by the facility for Resident #1 for the duration of her stay. In an interview with the Registered Nurse (RN) Shift Supervisor and the Respiratory Therapy Supervisor (RTS) on 5/1/15 at 3:00 PM, both stated they observed Resident #1 going in and out of other residents' rooms. The RTS stated on one occasion when Resident #1's family came to visit, she ran into her room then ran into other residents' rooms. In an interview with Certified Nursing Assistant (CNA) #1 on 4/30/15 at 6:20 PM, she confirmed Resident #1 moved freely about the unit when up but stated, We tried to stay with her; we just watched her. CNA #1 confirmed Resident #1 would have someone assigned to her on some days to keep an eye on her. In an interview with the Director of Nursing (DON), on 5/1/15 at 1:10 PM, the DON indicated Resident #1 was put in the canopy bed for safety because of the rambling and wandering behavior. She stated Resident #1 was found on top of it one time when referring to the canopy bed. She confirmed on some shifts they assigned a Certified Nursing Assistant (CNA) to monitor her, but confirmed the facility did not have documentation of this. She also stated Resident #1 was at risk for elopement and needed to be on a locked unit. A review of the Captivity Progress note for 02/25/15, the Recreational Therapist (RT) Interim (also signed by RT), documented, (name of Physical Therapist) and I went to observe the resident in her room and accompanied by (name of RAI Coordinator) and (name) social worker. (Name of Physical Therapist) unzipped resident's bed and resident rapidly moved to the chair. This documentation continued to describe observing resident attempting to open other resident's doors, and the staff decided Resident #1 was an elopement risk. The progress note added Resident #1 was then cued back to her room where she laid down in the bed, and staff zipped enclosure to bed back and left the room. In an interview with the facility's Administrator, on 5/3/15 at 2:35 PM, revealed the facility had contacted a sitter service to attempt to find a sitter for Resident #1 (to provide supervision) but was unable to find one. Record review of the facility's Departmental Notes revealed an entry dated 3/4/15 at 10:44 PM by RN #3 that noted Resident #1 stood in chair and got on top of the bedside table then was helped down off the table and sat back in chair. RN #3 also documented Resident #1 was found sitting on top of TV cabinet (Armoire). An observation of room 321, which was the room occupied by Resident #1 during the resident's stay, on 5/4/15 at 11:10 AM and an interview with the Senior Mechanic at this time, revealed the Armoire was 60 and one-half inches tall. The bedside table was 31 and three-fourths inches. The over-bed table while in the lowest position was 27 and one-half inches, and in the highest position was 44 inches. Record review of the facility's Departmental Notes revealed an entry on 3/5/15 at 10:04 PM by LPN #4, that read Resident #1 continued to run out of room and down the hall to room 330, an empty room, and slamming door behind her. LPN #4 documented a staff member remained with Resident #1 in her room most of the shift but Resident #1 continued to climb on furniture in the room and attempted to push on the netting on the bed. Record review of the facility's Departmental Notes revealed an entry on 4/7/15 at 2:50 PM by Licensed Practical Nurse (LPN) #3, which documented Resident #1 shoved LPN #3 into night stand then shook her bed and climbed on top of her bed and unable to get her down. LPN #3 then documented the DON came into the room and was unable to get resident down from the bed. She then documented the Social Worker (SW), Minimum Data Set (MDS) Coordinator and Respiratory Therapist Supervisor (RT) came into the room and was able to talk resident down from the bed. Record review of the Safety Enclosure Bed manufactures description, indicated the Enclosure Bed that was rented and delivered for Resident #1 was 72 inches in height. The facility did not have a policy to direct staff on increasing supervision for residents at risk for harm and to meet Resident #1's assessed needs. Review of the admission record revealed the facility admitted Resident #1 on 2/16/15 with the [DIAGNOSES REDACTED]. In a review of the Admission Minimum Data Set (MDS) with the reference date of 4/10/15, Resident #1's Brief Interview for Mental Status (BIMS) was 99, which indicated Resident #1 was unable to complete this interview. The facility was notified on 05/01/2015 of the Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC). The facility submitted a credible Allegation of Compliance (AOC) on 05/03/2015. A QA committee was held at 6:00 PM on 5/1/2015. The following persons were in attendance for the Quality Assurance meeting: Medical Director, DON, RN Shift Supervisor, RN, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and Administrator. The committee reviewed the existing policy on Infection Control, Isolation guidelines- Transmission based precautions. It was determined that no revisions were needed to the existing policy. The committee determined that a new policy and procedure for one on one supervision should be formulated. The QA committee developed the new policy and procedure One on One Supervision and then it was approved and signed by the medical director on 5/1/15 at 7:05 P M. The QA committee determined that all staff should be in-serviced on the existing Infection Control, Isolation guidelines- Transmission based precautions and newly developed One on One Supervision policy. The QA committee met again on 5/2/2015 at 4:00 PM. Resident Assessment and Care Plan policies were reviewed and will remain as is. The One on One supervision policy and procedure was reviewed and revised to reflect it will be documented on the TAR. A new policy and procedure for behavior and a new behavior protocol were developed by the QA committed and approved and signed by the medical director at 5:20 PM on 5/2/2015. It was determined that audits should be conducted on all 56 residents in the facility to determine at risk behavior, care plan accuracy, new signs and symptoms consistent with VRE or MRSA infection, infection control risk, and unmet psychosocial needs. Audits were conducted on 5/2/15 by the QA team members. DON, RN Shift Supervisor, RN, RAI Coordinator, LPN 1 and 2 audited at risk behavior, care plans, signs and symptoms of MRSA and VRE, and infection control risks. At risk behavior was also audited by the Social Worker and Recreational Therapist. Care plans were also audited by Respiratory Therapy Supervisor 1 and 2, Social Worker, Physical Therapist and Recreational Therapist. Psychosocial needs were audited by the Social Worker. The audits were completed on all 56 residents. After auditing all 56 residents, the audits reflected no residents have new signs and symptoms consistent with VRE or MRSA, no residents have at risk behavior as evidenced by the Behavior Protocol tool, no residents are in violation of the isolation policy, no new psychosocial needs have been identified and no care plan updates were required. In-services were conducted by DON, RN Shift Supervisor, RN. LPN 1 and LPN 2 assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN. All staff was in-serviced on the revised one on one supervision policy, existing isolation guide lines- Transmission based precautions, and newly developed Behavior Policy and behavior protocol tool. In addition, clinical staff was in-serviced on the existing Resident Assessment and Care Plan policy. All staff was in-serviced by 5/2/15 at 11:45 PM. No staff were or will be allowed to work until they had completed the assigned in-services. Attorney General's Office notified at 7:23 PM on 5/1/2015. The State Agency survey team validated the facility's credible Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ) was determined to be removed prior to exit from the facility on 05/04/2015. The credible Allegation of Compliance (AOC) was verified by staff interviews, record review of in-services, and QA meeting documentation reviewed on 05/04/2015 across all disciplines beginning at 10:30 AM to 5:30 PM. The State Agency (SA) surveyors validated by interview and committee sign in record review that a Quality Assurance (QA) committee meeting was held at 6:00 PM on 05/01/2015 with the following persons attending: The Medical Director, DON, RN Shift Supervisor, RN 1, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and the Administrator. The SA validated that the facility's existing policies on Infection Control, Isolation guidelines-Transmission based precautions were reviewed with no revisions made. The SA validated that the QA committee identified the need for and formulated a new policy and procedure for One on One Supervision. The SA validated that the One on One Supervision policy was approved and signed by the Medical Director on 5/1/2015 at 7:05 PM. The SA validated through staff interview that the QA committee met again on 05/02/2015 at 4:00 PM to review the Resident Assessment and Care Plan policies and no revisions were made. The SA validated through staff interview, the One on One Supervision policy, created on 05/01/2015, and procedure was reviewed and revised to reflect it would be documented on the TAR. The SA validated through staff interview that a new policy and procedure for behavior and a new behavior protocol were developed by the QA committee. The SA validated by staff interview and QA meeting documentation the new policy and procedure for behavior and the new behavior protocol were approved and signed by the medical director on 05/01/2015 at 7:05 PM. The SA validated by audit record reviewed, interview with staff that audits on all 56 resident records were conducted on 05/02/2015 by the QA team members. The DON, RN Shift Supervisor, RN 1, RAI Coordinator and LPNs 1 and 2 audited resident records for: at risk behaviors, care plans, signs and symptoms of MRSA and VRE, and infection control risks. The SA validated by QA records and staff interview resident's records were reviewed by the social worker, and respiratory therapist. The SA validated through staff interview and QA documentation that care plans were also audited by Respiratory Supervisors 1 and 2, Social Worker, Physical Therapist, and Recreational Therapist for any necessary updates. The SA verified by staff interview and QA documentation the psychosocial needs of all residents were audited by the social worker. The SA validated by staff interview and QA documentation that the audits reflected no residents had new signs and symptoms consistent with VRE or MRSA, no resident had at risk behavior as evidenced by utilization of the behavior protocol tool, no residents were in violation of the isolation policy, no new psychosocial needs were identified, and no care plan updates were required. The SA validated by record review that in-services were conducted by the DON, RN Shift Supervisor, RN 1 and LPNs 1 and 2 (these LPN's assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN 1) on the revised One on One Supervision policy, existing isolation guidelines- Transmission based precautions, and the newly developed Behavior Policy and behavior protocol tool. The SA validated by staff interview and in-service sign in sheet that clinical staff was also in-serviced on the existing Resident Assessment and Care Plan policies. The SA validated no staff were allowed to work until they completed the assigned in-services. The SA validated the Attorney General's Office was notified at 7:23 PM on 5/1/2015, by review of report submitted to the agency. The SA validated the IJ was removed prior to exit on 5/4/15.

Based on interview and record review, the facility failed to maintain contact isolation to prevent the potential for spread of infection from a resident with [MEDICATION NAME] Resistant Entercocci (VRE) in her urine and Methicillin Resistant Staphylococcus Aureus (MRSA) in her sputum for one (1) of seven (7) residents reviewed for contact precautions. (Resident #1) The facility failed to maintain contact isolation precaution for Resident #1. This placed residents at risk for infections when the facility failed to ensure contact isolation for Resident #1 and allowed Resident #1 to go in and out of other residents rooms while on contact isolation. Resident #1 was also in the common areas such as the day room where other residents had access. An Immediate Jeopardy (IJ) was identified on 5/1/15, and was determined to exist from 2/16/15, when the facility admitted Resident #1 with behaviors and the facility failed to ensure contact isolation precautions. The facility was notified on 5/1/15 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (AOC) on 5/3/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 5/4/15. Therefore, F441 was lowered from J level deficiency to a D level or isolated deficiency while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: The facility's policy entitled Isolation Guidelines and Transmission-Based Precautions; dated 4/17/2002, revealed Transmission-Based Precautions for MRSA, VRE and Clostridium difficile (C-diff) was examples of microorganisms that required Contact Precautions. For Contact Precautions, the patient should be placed in a private room or with another resident known or suspected to be infected with the same microorganisms. This policy indicated if the patient is transported out of the room ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment. The Centers for Disease Control (CDC) read VRE is often passed from person to person by the contaminated hands of caregivers. VRE can get onto a caregiver's hands after they have contact with other people with VRE or after contact with contaminated surfaces. VRE can also be spread directly to people after they touch surfaces that are contaminated with VRE. Healthcare facilities use special precautions to help prevent the spread of VRE to others. In an interview with Resident #1's Primary Physician (MD) on 5/2/15 at 11:10 AM, confirmed the facility admitted Resident #1 from a local hospital with MRSA in her sputum identified during a [MEDICATION NAME] but that her tracheostomy was pulled prior to her admission to the facility. The MD also confirmed the facility admitted Resident #1 with VRE in the urine and because of the potential of that organism Resident #1 was placed on Contact Isolation. The MD stated, We put her in contact isolation, it was questionable but we erred on the side of caution. We never actually got the culture results. We were going to re-cath (re-catheterize) her. MD continued, We never actually got another culture. That fell through the cracks, and that was my fault. A review of the last cultures for sputum and urine performed in hospital, prior to Resident #1's admission to the facility revealed a positive sputum culture for MRSA on 01/15/15, which stated, Patient may be an isolation risk, and a positive urine culture on 02/04/15 for VRE. Record review of the Physician's admission orders [REDACTED]. The orders revealed Resident #1 was admitted to room [ROOM NUMBER] on the third floor which was the tracheostomy unit. According to a facility list, 29 out of 31 residents on the third floor had a tracheostomy on 2/16/15 when the facility admitted Resident #1 on Contact Isolation. Review of February, March, and April printed monthly Physician order [REDACTED]. Record review of the physician's orders [REDACTED]. Review of Resident#1's urine culture on collected on 3/12/15 had a report of no growth at 24 hours. Review of lab reports revealed no evidence of a clear sputum culture. Record review of the facility's Departmental Notes revealed an entry on 2/16/15 at 5:41 PM by RN #3 noted Resident #1 was admitted to the facility on Contact Isolation for VRE in urine and MRSA from trach (tracheostomy). Record review of the facility's Departmental Notes revealed an entry on 3/1/15 at 7:34 AM by LPN #6 of Resident #1 having a bowel movement (BM) and smearing it on various surfaces in the room to include bed, chairs, doors, doorknobs and light switches. Record review of the facility's Departmental Notes revealed an entry on 3/4/15 at 10:44 PM by RN #2 of Resident #1 running all around the third floor attempting to enter other resident's rooms and the linen room. RN #2 also documented Resident #1 entered another resident's room and got in the other resident's bed while that resident was out of bed. RN #2 documented Resident #1 then entered the room of another resident. Record review of the facility's Departmental Notes revealed on 3/5/15 at 10:04 PM LPN #4 documented Resident #1 was noted to have her hand in her pants touching her genitals then touching surfaces throughout the facility. In an interview with the Registered Nurse (RN) Shift Supervisor and the Respiratory Therapy Supervisor (RTS) on 5/1/15 at 3:00 PM, the RN Shift Supervisor and the RTS stated Resident #1 was observed going in and out of other residents' rooms. The RTS stated when family came to visit, Resident #1 would run into other residents' rooms. An interview on 5/1/15 at 2:25 PM with the Resident Assessment Instrument (RAI) Coordinator revealed she saw Resident #1 go in and out of other residents rooms. The RAI coordinator stated she witnessed Resident #1 touch her genitals and undress. The RAI Coordinator confirmed the resident had VRE in her urine and MRSA in her sputum per validated notes. She confirmed the resident was off isolation when discharged . She reported there was a physician's orders [REDACTED].#1 was up, related to contact isolation and monitor every 30 minutes. The RAI Coordinator confirmed isolation was discontinued 3/13/15. She stated Resident #1 going in and out of other residents rooms put the other residents at risk, and that's when we tried to find other placement because she put them (the other residents) at risk. Review of the physician orders [REDACTED]. Keep door closed while resident out of bed due to contact isolation protocol related to MRSA in sputum and VRE in urine and resident wandering. 2. Round and monitor resident Q (every) 30 minutes ATC (around the clock). The facility admitted Resident #1 on 2/16/15 with the [DIAGNOSES REDACTED]. In a review of the Admission Minimum Data Set (MDS) with the reference date of 4/10/15, Resident #1's Brief Interview for Mental Status (BIMS) was 99, which indicated Resident #1 was unable to complete this interview. The facility was notified on 05/01/2015 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (AOC) on 05/03/2015. A QA committee was held at 6:00 PM on 5/1/2015. The following persons were in attendance for the Quality Assurance meeting: Medical Director, DON, RN Shift Supervisor, RN, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and Administrator. The committee reviewed the existing policy on Infection Control, Isolation guidelines- Transmission based precautions. It was determined that no revisions were needed to the existing policy. The committee determined that a new policy and procedure for one on one supervision should be formulated. The QA committee developed the new policy and procedure One on One Supervision and then it was approved and signed by the medical director on 5/1/15 at 7:05 P M. The QA committee determined that all staff should be in-serviced on the existing Infection Control, Isolation guidelines- Transmission based precautions and newly developed One on One Supervision policy. The QA committee met again on 5/2/2015 at 4:00 PM. Resident Assessment and Care Plan policies were reviewed and will remain as is. The One on One supervision policy and procedure was reviewed and revised to reflect it will be documented on the TAR. A new policy and procedure for behavior and a new behavior protocol were developed by the QA committed and approved and signed by the medical director at 5:20 PM on 5/2/2015. It was determined that audits should be conducted on all 56 residents in the facility to determine at risk behavior, care plan accuracy, new signs and symptoms consistent with VRE or MRSA infection, infection control risk, and unmet psychosocial needs. Audits were conducted on 5/2/15 by the QA team members. DON, RN Shift Supervisor, RN, RAI Coordinator, LPN 1 and 2 audited at risk behavior, care plans, signs and symptoms of MRSA and VRE, and infection control risks. At risk behavior was also audited by the Social Worker and Recreational Therapist. Care plans were also audited by Respiratory Therapy Supervisor 1 and 2, Social Worker, Physical Therapist and Recreational Therapist. Psychosocial needs were audited by the Social Worker. The audits were completed on all 56 residents. After auditing all 56 residents, the audits reflected no residents have new signs and symptoms consistent with VRE or MRSA, no residents have at risk behavior as evidenced by the Behavior Protocol tool, no residents are in violation of the isolation policy, no new psychosocial needs have been identified and no care plan updates were required. In-services were conducted by DON, RN Shift Supervisor, RN. LPN 1 and LPN 2 assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN. All staff was in-serviced on the revised one on one supervision policy, existing isolation guide lines- Transmission based precautions, and newly developed Behavior Policy and behavior protocol tool. In addition, clinical staff was in-serviced on the existing Resident Assessment and Care Plan policy. All staff was in-serviced by 5/2/15 at 11:45 PM. No staff were or will be allowed to work until they had completed the assigned in-services. Attorney General's Office notified at 7:23 PM on 5/1/2015. The State Agency survey team validated the facility's credible Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ) was determined to be removed prior to exit from the facility on 05/04/2015. The credible Allegation of Compliance (AOC) was verified by staff interviews, record review of in-services, and QA meeting documentation reviewed on 05/04/2015 across all disciplines beginning at 10:30 AM to 5:30 PM. The State Agency (SA) surveyors validated by interview and committee sign in record review that a Quality Assurance (QA) committee meeting was held at 6:00 PM on 05/01/2015 with the following persons attending: The Medical Director, DON, RN Shift Supervisor, RN 1, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and the Administrator. The SA validated that the facility's existing policies on Infection Control, Isolation guidelines-Transmission based precautions were reviewed with no revisions made. The SA validated that the QA committee identified the need for and formulated a new policy and procedure for One on One Supervision. The SA validated that the One on One Supervision policy was approved and signed by the Medical Director on 5/1/2015 at 7:05 PM. The SA validated through staff interview that the QA committee met again on 05/02/2015 at 4:00 PM to review the Resident Assessment and Care Plan policies and no revisions were made. The SA validated through staff interview, the One on One Supervision policy, created on 05/01/2015, and procedure was reviewed and revised to reflect it would be documented on the TAR. The SA validated through staff interview that a new policy and procedure for behavior and a new behavior protocol were developed by the QA committee. The SA validated by staff interview and QA meeting documentation the new policy and procedure for behavior and the new behavior protocol were approved and signed by the medical director on 05/01/2015 at 7:05 PM. The SA validated by audit record reviewed, interview with staff that audits on all 56 resident records were conducted on 05/02/2015 by the QA team members. The DON, RN Shift Supervisor, RN 1, RAI Coordinator and LPNs 1 and 2 audited resident records for: at risk behaviors, care plans, signs and symptoms of MRSA and VRE, and infection control risks. The SA validated by QA records and staff interview resident's records were reviewed by the social worker, and respiratory therapist. The SA validated through staff interview and QA documentation that care plans were also audited by Respiratory Supervisors 1 and 2, Social Worker, Physical Therapist, and Recreational Therapist for any necessary updates. The SA verified by staff interview and QA documentation the psychosocial needs of all residents were audited by the social worker. The SA validated by staff interview and QA documentation that the audits reflected no residents had new signs and symptoms consistent with VRE or MRSA, no resident had at risk behavior as evidenced by utilization of the behavior protocol tool, no residents were in violation of the isolation policy, no new psychosocial needs were identified, and no care plan updates were required. The SA validated by record review that in-services were conducted by the DON, RN Shift Supervisor, RN 1 and LPNs 1 and 2 (these LPN's assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN 1) on the revised One on One Supervision policy, existing isolation guidelines- Transmission based precautions, and the newly developed Behavior Policy and behavior protocol tool. The SA validated by staff interview and in-service sign in sheet that clinical staff was also in-serviced on the existing Resident Assessment and Care Plan policies. The SA validated no staff were allowed to work until they completed the assigned in-services. The SA validated the Attorney General's Office was notified at 7:23 PM on 5/1/2015, by review of report submitted to the agency. The SA validated the IJ was removed prior to exit on 5/4/15.

Based on interview, record review, and facility policy review the facility failed to provide effective administration to ensure Resident #1's and other residents' well-being for one (1) of seven (7) residents reviewed. The facility's failed to ensure Resident #1 received adequate supervision for wandering behaviors and measures to prevent the spread of infection. Resident #1 was admitted to the facility with an [MEDICAL CONDITIONS] on 02/16/15 and contact isolation [MEDICAL CONDITIONS] in sputum, and VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]) in urine. The facility's failure resulted in the likelihood of infection or serious harm, injury, or death to other residents due to lack of supervision, lack of implementation of care plan and failure to implement measures to prevent the spread of infection. Immediate Jeopardy was identified on 05/01/15 and was determined to exist on 02/16/15, when Resident #1 began exhibiting behaviors of wandering with an order for [REDACTED]. The facility was notified on 05/01/15 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (AOC) on 05/03/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 05/04/15. Therefore, F490 was lowered from J level deficiencies to D level or isolated deficiencies while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included: A review of the signed job description for the Director of Long Term Care, signed by the Administrator on 09/30/2010, revealed Specific responsibilities include the promotion of residents rights, implementation of admission, transfer and discharge policies, establishing policies to monitor and report resident behavior and facility practices, promoting quality of life, promoting safety for residents and staff, conducting resident assessments, promoting quality of life, promoting safety for residents and staff, conducting resident assessments, promoting quality of care , providing nursing services, dietary services, physician services, specialized rehabilitative services, dental services, pharmacy services, infection control, maintaining the physical environment and providing general administration to the facility. 4. Hire, train, motivate and retain the adequate number of staff members necessary to perform the duties of the center. 6. Maintain current knowledge of changes in practices and requirements in the field of long term care. 2. Effectively implement quality assurance audits designed to identify potential deficient practices in the long term care center. Interview with the Administrator on 05/03/15 at 2:35 PM, confirmed Resident #1 was discussed during her attendance at the weekly Quality Improvement (QI) meetings; however, no changes to level of care were attempted. The Administrator confirmed Resident #1 was not moved off the unit where other residents had tracheostomies, and staffing was not amended to address Resident #1's needs, to prevent harm to other residents through the spread of infection. The Administrator also confirmed the facility failed to keep Resident #1 from entering other residents' rooms while on contact isolation and failed to keep Resident #1 from engaging in self injurious behaviors. The Administrator stated the facility contacted several sitter services. The Administrator confirmed she did not attend the care plan review meetings; therefore, was not involved in the care plan process for Resident #1). The Administrator confirmed ultimate responsibility for the care of all residents and all staff. The facility did not have a policy to direct staff on increasing supervision for residents at risk for harm and to meet Resident #1's assessed needs. A review of the in-service for staff on 02/16/15 provided by the medical equipment company, which provided the enclosure bed, revealed all staff were not in-serviced on the use and safety of the enclosure bed. Review of the admission record revealed the facility admitted Resident #1 on 2/16/15 with the [DIAGNOSES REDACTED]. A review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/15, revealed a Staff Interview for Mental Status assessment of Severely Impaired for daily decision-making skills. This assessment further revealed Resident #1 was independent (with no assistance needed) for ambulation in room, in corridor, and locomotion on/off unit. Resident was also assessed as having no impairments with Range of Motion. Restraints in bed where assessed as being used daily for Resident #1. The facility was notified on 05/01/2015 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (AOC) on 05/03/2015. A QA committee was held at 6:00 PM on 5/1/2015. The following persons were in attendance for the Quality Assurance meeting: Medical Director, DON, RN Shift Supervisor, RN, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and Administrator. The committee reviewed the existing policy on Infection Control, Isolation guidelines- Transmission based precautions. It was determined that no revisions were needed to the existing policy. The committee determined that a new policy and procedure for one on one supervision should be formulated. The QA committee developed the new policy and procedure One on One Supervision and then it was approved and signed by the medical director on 5/1/15 at 7:05 P M. The QA committee determined that all staff should be in-serviced on the existing Infection Control, Isolation guidelines- Transmission based precautions and newly developed One on One Supervision policy. The QA committee met again on 5/2/2015 at 4:00 PM. Resident Assessment and Care Plan policies were reviewed and will remain as is. The One on One supervision policy and procedure was reviewed and revised to reflect it will be documented on the TAR. A new policy and procedure for behavior and a new behavior protocol were developed by the QA committed and approved and signed by the medical director at 5:20 PM on 5/2/2015. It was determined that audits should be conducted on all 56 residents in the facility to determine at risk behavior, care plan accuracy, new signs and symptoms consistent with VRE [MEDICAL CONDITION] infection, infection control risk, and unmet psychosocial needs. Audits were conducted on 5/2/15 by the QA team members. DON, RN Shift Supervisor, RN, RAI Coordinator, LPN 1 and 2 audited at risk behavior, care plans, signs and symptoms [MEDICAL CONDITION] and VRE, and infection control risks. At risk behavior was also audited by the Social Worker and Recreational Therapist. Care plans were also audited by Respiratory Therapy Supervisor 1 and 2, Social Worker, Physical Therapist and Recreational Therapist. Psychosocial needs were audited by the Social Worker. The audits were completed on all 56 residents. After auditing all 56 residents, the audits reflected no residents have new signs and symptoms consistent with VRE [MEDICAL CONDITION], no residents have at risk behavior as evidenced by the Behavior Protocol tool, no residents are in violation of the isolation policy, no new psychosocial needs have been identified and no care plan updates were required. In-services were conducted by DON, RN Shift Supervisor, RN. LPN 1 and LPN 2 assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN. All staff was in-serviced on the revised one on one supervision policy, existing isolation guide lines- Transmission based precautions, and newly developed Behavior Policy and behavior protocol tool. In addition, clinical staff was in-serviced on the existing Resident Assessment and Care Plan policy. All staff was in-serviced by 5/2/15 at 11:45 PM. No staff were or will be allowed to work until they had completed the assigned in-services. Attorney General's Office notified at 7:23 PM on 5/1/2015. The State Agency survey team validated the facility's credible Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ) was determined to be removed prior to exit from the facility on 05/04/2015. The credible Allegation of Compliance (AOC) was verified by staff interviews, record review of in-services, and QA meeting documentation reviewed on 05/04/2015 across all disciplines beginning at 10:30 AM to 5:30 PM. The State Agency (SA) surveyors validated by interview and committee sign in record review that a Quality Assurance (QA) committee meeting was held at 6:00 PM on 05/01/2015 with the following persons attending: The Medical Director, DON, RN Shift Supervisor, RN 1, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and the Administrator. The SA validated that the facility's existing policies on Infection Control, Isolation guidelines-Transmission based precautions were reviewed with no revisions made. The SA validated that the QA committee identified the need for and formulated a new policy and procedure for One on One Supervision. The SA validated that the One on One Supervision policy was approved and signed by the Medical Director on 5/1/2015 at 7:05 PM. The SA validated through staff interview that the QA committee met again on 05/02/2015 at 4:00 PM to review the Resident Assessment and Care Plan policies and no revisions were made. The SA validated through staff interview, the One on One Supervision policy, created on 05/01/2015, and procedure was reviewed and revised to reflect it would be documented on the TAR. The SA validated through staff interview that a new policy and procedure for behavior and a new behavior protocol were developed by the QA committee. The SA validated by staff interview and QA meeting documentation the new policy and procedure for behavior and the new behavior protocol were approved and signed by the medical director on 05/01/2015 at 7:05 PM. The SA validated by audit record reviewed, interview with staff that audits on all 56 resident records were conducted on 05/02/2015 by the QA team members. The DON, RN Shift Supervisor, RN 1, RAI Coordinator and LPNs 1 and 2 audited resident records for: at risk behaviors, care plans, signs and symptoms [MEDICAL CONDITION] and VRE, and infection control risks. The SA validated by QA records and staff interview resident's records were reviewed by the social worker, and respiratory therapist. The SA validated through staff interview and QA documentation that care plans were also audited by Respiratory Supervisors 1 and 2, Social Worker, Physical Therapist, and Recreational Therapist for any necessary updates. The SA verified by staff interview and QA documentation the psychosocial needs of all residents were audited by the social worker. The SA validated by staff interview and QA documentation that the audits reflected no residents had new signs and symptoms consistent with VRE [MEDICAL CONDITION], no resident had at risk behavior as evidenced by utilization of the behavior protocol tool, no residents were in violation of the isolation policy, no knew psychosocial needs were identified, and no care plan updates were required. The SA validated by record review that in-services were conducted by the DON, RN Shift Supervisor, RN 1 and LPNs 1 and 2 (these LPN's assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN 1) on the revised One on One Supervision policy, existing isolation guidelines- Transmission based precautions, and the newly developed Behavior Policy and behavior protocol tool. The SA validated by staff interview and in-service sign in sheet that clinical staff was also in-serviced on the existing Resident Assessment and Care Plan policies. The SA validated no staff were allowed to work until they completed the assigned in-services. The SA validated the Attorney General's Office was notified at 7:23 PM on 5/1/2015, by review of report submitted to the agency. The SA validated the IJ was removed prior to exit on 5/4/15.

Based on interview, record review, and facility policy review, the facility failed to provide a Quality Assurance program to identify and meet the needs of Resident #1, who required increased supervision, and contact isolation for one (1) of seven (7) residents reviewed. The facility's failure to implement a Quality Assurance (QA) program, that identified the needs of the residents when an ambulatory Resident #1 with severely impaired cognition from an [MEDICAL CONDITIONS] and who was ordered on contact isolation was allowed to enter into residents with tracheostomies rooms. The QA program failed to address Resident #1's needs for increased supervision for wandering, climbing behavior, and contact isolation. Resident #1 was found by staff on top of an armoire, canopy bed and nightstand, and in other resident's rooms. The facility's failure to have an effective QA process resulted in the likelihood of ongoing potential for other residents to be at risk for lack of monitoring and supervision when required and the implementation of safe infection control practice to prevent the spread of diseases, which could result in harm or death. Immediate Jeopardy was identified on 05/01/15 and was determined to exist on 02/16/15, when Resident #1 was admitted to the facility and the resident was ambulatory without effective contact isolation and supervision. The facility was notified on 05/01/15 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (AOC) on 05/03/15, the State Agency (SA) survey team validated the facility's Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ), was determined to be removed prior to exit from the facility on 05/04/15. Therefore, F520 was lowered from J level deficiencies to D level or isolated deficiencies while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings included: A review of the facility's Quality Assurance program signed by the Administrator on 08/13/2014, revealed, The QI (Quality Indicator) committee will review at weekly and quarterly meetings and determine outcome and need to continue or discontinue with identified problem area. Review of the Quality Assurance Committee meetings between 02/16/15 and 04/10/15, when Resident #1 was at the facility, revealed a Quality Assurance meeting was held on 04/29/15, with the RAI Coordinator, Social Worker, Medical Director, DON, and Administrator all present. In the meeting agenda, Infection Control for January- March of 2015 was discussed along with Resident Accidents/Incidents during these months as well. Despite both of these areas being a concern related to Resident #1, no interventions (to include tracking and review of interventions) were implemented by the Quality Assurance team to increase staffing/supervision for Resident #1, follow protocol for contact isolation as related to Resident #1 admitted with VRE in urine [MEDICAL CONDITION] in sputum. Restraint use was not addressed on the meeting agenda at all. Interview with the Medical Director (MD) on 05/02/15 at 12:50 PM, MD stated Resident #1 was discussed weekly by staff but was unsure about weekly QA meeting. Interview with the Social Service Director (SSD) on 05/01/14 at 12:10 PM, revealed Resident #1 was discussed at times during annual and quarterly care plan meetings for other residents which were held weekly. (Resident #1 did not have a care plan meeting while admitted to the facility). The SSD stated, We would talk about her informally, but no specific meeting for her change. Review of the admission record revealed the facility admitted Resident #1 on 2/16/15 with the [DIAGNOSES REDACTED]. A review of Resident #1's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/23/15, revealed a Staff Interview for Mental Status assessment of Severely Impaired for daily decision-making skills. This assessment further revealed Resident #1 was independent (with no assistance needed) for ambulation in room, in corridor, and locomotion on/off unit. Resident was also assessed as having no impairments with Range of Motion. Restraints in bed where assessed as being used daily for Resident #1. The facility was notified on 05/01/2015 of the Immediate Jeopardy (IJ). The facility submitted a credible Allegation of Compliance (AOC) on 05/03/2015. A QA committee was held at 6:00 PM on 5/1/2015. The following persons were in attendance for the Quality Assurance meeting: Medical Director, DON, RN Shift Supervisor, RN, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and Administrator. The committee reviewed the existing policy on Infection Control, Isolation guidelines- Transmission based precautions. It was determined that no revisions were needed to the existing policy. The committee determined that a new policy and procedure for one on one supervision should be formulated. The QA committee developed the new policy and procedure One on One Supervision and then it was approved and signed by the medical director on 5/1/15 at 7:05 P M. The QA committee determined that all staff should be in-serviced on the existing Infection Control, Isolation guidelines- Transmission based precautions and newly developed One on One Supervision policy. The QA committee met again on 5/2/2015 at 4:00 PM. Resident Assessment and Care Plan policies were reviewed and will remain as is. The One on One supervision policy and procedure was reviewed and revised to reflect it will be documented on the TAR. A new policy and procedure for behavior and a new behavior protocol were developed by the QA committed and approved and signed by the medical director at 5:20 PM on 5/2/2015. It was determined that audits should be conducted on all 56 residents in the facility to determine at risk behavior, care plan accuracy, new signs and symptoms consistent with VRE [MEDICAL CONDITION] infection, infection control risk, and unmet psychosocial needs. Audits were conducted on 5/2/15 by the QA team members. DON, RN Shift Supervisor, RN, RAI Coordinator, LPN 1 and 2 audited at risk behavior, care plans, signs and symptoms [MEDICAL CONDITION] and VRE, and infection control risks. At risk behavior was also audited by the Social Worker and Recreational Therapist. Care plans were also audited by Respiratory Therapy Supervisor 1 and 2, Social Worker, Physical Therapist and Recreational Therapist. Psychosocial needs were audited by the Social Worker. The audits were completed on all 56 residents. After auditing all 56 residents, the audits reflected no residents have new signs and symptoms consistent with VRE [MEDICAL CONDITION], no residents have at risk behavior as evidenced by the Behavior Protocol tool, no residents are in violation of the isolation policy, no new psychosocial needs have been identified and no care plan updates were required. In-services were conducted by DON, RN Shift Supervisor, RN. LPN 1 and LPN 2 assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN. All staff was in-serviced on the revised one on one supervision policy, existing isolation guide lines- Transmission based precautions, and newly developed Behavior Policy and behavior protocol tool. In addition, clinical staff was in-serviced on the existing Resident Assessment and Care Plan policy. All staff was in-serviced by 5/2/15 at 11:45 PM. No staff were or will be allowed to work until they had completed the assigned in-services. Attorney General's Office notified at 7:23 PM on 5/1/2015. The State Agency survey team validated the facility's credible Allegation of Compliance (AOC) and the Immediate Jeopardy (IJ) was determined to be removed prior to exit from the facility on 05/04/2015. The credible Allegation of Compliance (AOC) was verified by staff interviews, record review of in-services, and QA meeting documentation reviewed on 05/04/2015 across all disciplines beginning at 10:30 AM to 5:30 PM. The State Agency (SA) surveyors validated by interview and committee sign in record review that a Quality Assurance (QA) committee meeting was held at 6:00 PM on 05/01/2015 with the following persons attending: The Medical Director, DON, RN Shift Supervisor, RN 1, LPN 1, Recreation Therapist, Physical Therapist, RAI Coordinator, Housekeeping Supervisor, Respiratory Therapy Supervisor, LPN 2, Social Worker, Administrative Consultant and the Administrator. The SA validated that the facility's existing policies on Infection Control, Isolation guidelines-Transmission based precautions were reviewed with no revisions made. The SA validated that the QA committee identified the need for and formulated a new policy and procedure for One on One Supervision. The SA validated that the One on One Supervision policy was approved and signed by the Medical Director on 5/1/2015 at 7:05 PM. The SA validated through staff interview that the QA committee met again on 05/02/2015 at 4:00 PM to review the Resident Assessment and Care Plan policies and no revisions were made. The SA validated through staff interview, the One on One Supervision policy, created on 05/01/2015, and procedure was reviewed and revised to reflect it would be documented on the TAR. The SA validated through staff interview that a new policy and procedure for behavior and a new behavior protocol were developed by the QA committee. The SA validated by staff interview and QA meeting documentation the new policy and procedure for behavior and the new behavior protocol were approved and signed by the medical director on 05/01/2015 at 7:05 PM. The SA validated by audit record reviewed, interview with staff that audits on all 56 resident records were conducted on 05/02/2015 by the QA team members. The DON, RN Shift Supervisor, RN 1, RAI Coordinator and LPNs 1 and 2 audited resident records for: at risk behaviors, care plans, signs and symptoms [MEDICAL CONDITION] and VRE, and infection control risks. The SA validated by QA records and staff interview resident's records were reviewed by the social worker, and respiratory therapist. The SA validated through staff interview and QA documentation that care plans were also audited by Respiratory Supervisors 1 and 2, Social Worker, Physical Therapist, and Recreational Therapist for any necessary updates. The SA verified by staff interview and QA documentation the psychosocial needs of all residents were audited by the social worker. The SA validated by staff interview and QA documentation that the audits reflected no residents had new signs and symptoms consistent with VRE [MEDICAL CONDITION], no resident had at risk behavior as evidenced by utilization of the behavior protocol tool, no residents were in violation of the isolation policy, no new psychosocial needs were identified, and no care plan updates were required. The SA validated by record review that in-services were conducted by the DON, RN Shift Supervisor, RN 1 and LPNs 1 and 2 (these LPN's assisted with in-services under the guided supervision of the DON, RN Shift Supervisor and RN 1) on the revised One on One Supervision policy, existing isolation guidelines- Transmission based precautions, and the newly developed Behavior Policy and behavior protocol tool. The SA validated by staff interview and in-service sign in sheet that clinical staff was also in-serviced on the existing Resident Assessment and Care Plan policies. The SA validated no staff were allowed to work until they completed the assigned in-services. The SA validated the Attorney General's Office was notified at 7:23 PM on 5/1/2015, by review of report submitted to the agency. The SA validated the IJ was removed prior to exit on 5/4/15.