Every finding on record at Newnan Health and Rehabilitation

Based on observations, staff interviews, and review of the facility's Storage Areas policy, the facility did not ensure food was labeled, dated, and stored correctly. Specifically, opened items were not dated or discarded when they expired. These deficient practices had the potential to place 77 residents at risk of foodborne illness.Findings include:Review of the facility's policy titled Storage Areas last review dated 12/27/2025 documented that It is the intent of this center to store food in a manner that maintains quality and safety. The guidelines stated: Items should be inspected for quality and temperature control upon receipt. Items should be covered, sealed, labeled, and dated appropriately.Observation on 02/10/2026 at 8:48 AM with [NAME] CC revealed that the dry, freezer, and cold storage areas contained food items on the floor, and several opened items were not properly dated. [NAME] CC stated they had just received a delivery and had not yet had time to store the items. Bread was also found past the labeled date, and [NAME] CC acknowledged she had forgotten to update the dates. During the tour, the Kitchen Manager joined and confirmed that staff did not have time to put away the delivery. In the refrigerator, multiple trays of tea, water, juice, and soda were observed without dates.Interview on 02/12/2026 at 11:30 AM with the Kitchen Manager revealed that staff do not date boxes if the manufacturer's label already includes a date. She acknowledged that if staff forget to label opened food items and they expire, residents could get sick.Interview on 12/12/2026 at 11:38 AM with the Assistant Kitchen Manager BB stated that they usually pick the food items up off the floor, label and date them within 45 minutes of delivery and that it is either her, the kitchen manager or cook AA who is responsible for putting up the truck. She revealed that a negative outcome could be residents getting sick.Interview on 12/12/2026 at 11:39 AM with [NAME] AA revealed when a truck comes with a delivery, the items should be labeled and dated.

Based on observations, staff interviews, record review, and review of the facility's policies titled Pharmacy Services, the facility failed to ensure that one of six medication carts were securely locked. This deficient practice had the potential to compromise medication security and integrity, placing residents as risk for harm related to medication diversion, tampering, or administration errors. Findings include:Review of the facility's policy titled Pharmacy Services, reviewed 12/31/2025, Medication Storage in the Care Center: Intent to facilitate safe, secure, and proper storage of medications and biologicals following manufacturer's recommendations or those of the supplier. GUIDELINE . Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Medication Cart security: The Director of Nursing (DON) is responsible for controlling access to the medication care. Medication Cart Keys: Medication Cart keys must be in possession of the assigned nurse or certified medication aid, as applicable. An extra set of medication cart keys should be stored in a secure area managed by the DON. A document process should be in place to track keys issued for each medication cart in the center.Interview/Observation on 02/11/2026 at 9:31 AM revealed that Certified Medication Technician (CMT) DD walked away from an unlocked medication cart to enter a resident's room to perform a blood pressure check. The surveyor remained by the cart until CMT DD returned. CMT DD confirmed that she had left the cart unlocked. She further stated that the cart is left unlocked because she does not have the key to lock it, explaining that the other shift CMTs sometimes take the key home. When asked what the disadvantages would be of leaving the medication cart open, CMT DD stated that someone could come and take medications out of the cart.Interview on 02/12/2026 at 11:53 AM with the Director of Nursing (DON) confirmed that her expectation was that medication carts should always be locked unless they were in active, visible use. The DON stated that the facility did not have backup keys and that keys should not be taken home.Interview on 02/12/2026 at 11:54 AM with the Administrator confirmed the same expectations was that medication carts should always be locked unless they were in active, visible use.

Based on observations, staff interviews, record review, and review of the policy titled SKILLED NURSING SERVICES Preventative Maintenance Schedule, the facility failed to ensure that resident room equipment and furnishings, specifically Packaged Terminal Air Conditioner (PTAC) unit filters and window blinds were maintained for one of two halls. These deficient practices had the potential to place residents at risk for unsanitary conditions and a reduced quality of life.Findings include: Review of the facility policy titled SKILLED NURSING SERVICES Preventative Maintenance Schedule dated 12/27/2025 documented that it was the intent of the center to develop preventative maintenance schedules to facilitate the maintenance of the building and equipment to ensure a safe and operable environment for residents.Review of the facility records titled DIRECT SUPPLY TELS Logbook Documentation for PTAC Inspections revealed that PTAC units were cleaned every six months and as needed. Further review revealed that the last facility wide cleanings were documented on April 14, 2025, and September 9, 2025.Observations on 02/10/2026 at 9:26 AM, and again on 02/12/2026 at 10:47 AM, on the 200 Hall revealed that four of the 13 resident rooms, rooms 217, 219, 221, and 227, had PTAC unit mesh filters with a buildup of dirt and debris. Further observations on these dates revealed that one room, room [ROOM NUMBER], had torn window blinds in need of repair in one of the 13 resident rooms.Observations/interview on 02/12/2026 at 10:53 AM revealed that the Maintenance Director viewed the filters and acknowledged they should have been cleaned. The Maintenance Director stated he was uncertain of the specific schedule for filter cleanings at that time but confirmed that rooms were inspected regularly and blinds should not have been in disrepair. During a follow up interview at 11:46 AM, the Maintenance Director stated that the PTAC units were cleaned every six months and as needed and verified that the last facility wide cleaning occurred on September 9, 2025. He further stated that the cleaning schedule required more frequent intervals to prevent the heavy buildup of dirt and debris that was observed.Interview on 02/12/2026 at 1:10 PM with the Administrator revealed that it was her expectation that PTAC filters were cleaned on a regular basis. The Administrator stated the facility had already changed the schedule from every six months to every month starting that day. The Administrator further stated that dirty filters could lead to the worsening of resident allergies.

Based on observations, interviews, record review, and review of the facility's policy Falls Management, the facility failed to prevent accidents for one of 11 sampled residents (R) (R13) which resulted in a fall with a major injury. On 11/19/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 12/17/2024 at 12:15 pm. The noncompliance related to the IJ was identified to have existed on 11/1/2024. An Acceptable Removal Plan was received on 12/18/2024. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 12/19/2024. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of facility staff's conformance with the facility's policies and procedures governing accident hazards. Findings included: A review of the policy titled Falls Management dated 12/29/2023 revealed an episode where a patient lost balance and would have fallen if not for staff intervention is a fall. The presence or absence of a resultant injury is not a factor in the definition of a fall. When a patient is found on the floor, the center is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred. A review of R13's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Further review revealed that R13 had five falls since admission (9/28/2022, 9/29/2022, 12/2/2022, 6/29/2023, and 11/1/2024.) A review of R13's hospital discharge record revealed she was hospitalized from 11/1/2024 to 11/7/2024 due to a fall with a major injury that resulted in a right forehead/frontal scalp laceration with soft tissue hematoma; moderate chronic microvascular ischemic changes; left thalamic and right pontine lacunar infarcts; an acute nondisplaced oblique fracture involving the anterior inferior corner of C2; cervical spondylosis with moderate spinal canal narrowing at C5-6 and C6-7. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R13 presented with a Brief Interview for Mental Status (BIMS) score assessment of 15, indicating no cognitive impairment, and that R13 had impairment on one side to her lower extremity. A review of the Care Plan, with the revised date of 11/19/2024 revealed that R13 had a history of falls and would demonstrate the ability to use assistive devices safely and consistently during the review. A review of the facility nursing progress note dated 1/12/2024 revealed that R13 stated that she was having problems sitting on the wheelchair cushion. It was noted that the writer observed the resident sitting up in her wheelchair and sliding forward. It was documented that the writer examined the wheelchair cushion and there were no defects observed; the physical therapist was notified of the resident status/sliding forward when sitting properly; a physical therapy referral was ordered to assess and treat. A review of the Event Initial Note dated 11/1/2024 revealed that R13 was observed in the hallway being escorted by the Activities Director to an activity via her wheelchair. Staff noted that the wheelchair suddenly stopped, and the resident fell forward to the floor and hit her head/face. Further review of the Event Initial Note revealed that R13 was alert and was bleeding from a laceration on the head. A review of the Discharge Instructions dated 11/7/2024 from the acute care hospital revealed that R13 was discharged with an order for Bacitracin twice a day to the laceration and to follow up with a stroke and neurosurgeon. During an observation on 11/19/2024 at 11:43 am, R13 was observed in bed. She had a black-like line in the center of her forehead. During an interview with R13, she stated that she fell while being transported by the Activities Director (AD). R13 confirmed Certified Nursing Assistant (CNA) WW called AD for something, but the AD stopped short and R13 fell out of the wheelchair and hit her head. R13 stated that she was in the hospital for eight days. During an interview on 11/21/2024 at 12:20 pm, R13 stated that she got her stitches removed and her head was sore. During an interview on 11/21/2024 at 3:19 pm, the DON confirmed she was not employed when R13 experienced the fall with a major injury. She confirmed that the AD explained to her that she was transporting R13 and was not touching the wheelchair when R13 fell . The DON mentioned that R13 was doing something to her shoes and another resident called the AD and that's when R13 fell . During an interview on 11/21/2024 at 3:25 pm, the Resident Assessment Instrument (RAI) Director LL stated that R13 explained to her that she was being pushed to an activity when someone called the AD. She stated that the AD stopped short and R13 fell out of the wheelchair. During a phone interview on 11/21/2024 at 3:42 pm, the previous DON (DON SS) stated that she spoke with R13 right after the event. She stated that R13 explained to her that she was being pushed to activities and asked the staff to stop so she could fix her shoes. She stated that R13 said when she bent down to fix the Velcro strip on her shoe, she fell forward. During an interview on 11/21/2024 at 4:02 pm with the AD, she confirmed she was escorting R13 to bible study when another resident called for help. She stated that she left R13 in the wheelchair in the hallway to answer the other resident, however, when she returned to R13, she noticed the resident tumbling forward onto the floor. The AD mentioned she was told by R13's daughter, that she might have been trying to tie her shoes. The AD mentioned she didn't remember seeing anyone in the hall, but the CNA and staff came after the fall to assist. During an interview on 11/21/2024 at 4:56 pm, the Administrator revealed she has been in the position for two years. She stated that she did not complete an investigation into the fall resulting in a major injury for R13, but she did the AD what happened. The Administrator mentioned she did not interview any of the other staff that day but trusted that the former DON was doing what needed to be done. During an interview on 11/22/2024 at 10:42 am, R13 stated that when she fell on [DATE], it knocked her out a little. R13 confirmed she was sitting completely in the wheelchair and holding onto the armrest during the transport, but the AD stopped short, and the cushion came out of the chair, and she fell to the floor. R13 stated that before the fall, she used to get up and was able to perform her Activities of Daily Living (ADL) care but now she cannot. During an interview on 11/22/2024 at 10:57 am, the Director of Rehabilitation UU confirmed R13 has an order for rehab that she received late Tuesday afternoon (11/19/2024) and the evaluation is pending. She revealed that she just learned about R13's fall on 11/20/2024. During an interview on 11/22/2024 at 11:12 am Occupational Therapist (OT) VV mentioned she heard of R13's fall when a CNA told her she was having more trouble with performing her ADL care independently and was not getting up as much since falling on 11/1/2024. OT VV confirmed that the therapy referral was received on 11/19/2024. During an interview on 11/22/2024 at 11:39 am, the DON explained the recent investigation concluded that the AD witnessed the fall that R13 had on 11/1/2024. DON mentioned AD reported that another resident called her and asked what time bible study was. The chair was not locked, and the resident fell forward. The DON emphasized that R13 was alert and oriented before the fall but has become confused since the fall. The facility implemented the following actions to remove the IJ: 1. On 11/19/2024, a therapy screen was done for R13 by the Physical Therapist. On 11/22/2024, a Physical Therapy assessment was completed for R13. On 11/22/2024, the Social Worker completed a behavioral assessment. No changes were identified for R13. On 12/3/2024, a care plan conference was held with R13 and her (family) with the Social Worker, the RAI Registered Nurse (RN), the Licensed Practical Nurse (LPN), the Restorative Nurse, the Dietary Manager, the Charge Nurse LPN, the CNA. R13 stated she had no problems or concerns. On 12/6/2024, Speech Therapy completed an assessment for R13. On 12/17/2024, the Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. On 12/17/2024, the Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth q day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. On 12/17/2024, a Medical Doctor assessed R13, with no concerns noted at that time. On 12/17/2024, the Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated on 11/1/2024 and 11/8/2024 by a licensed practical nurse, and on 12/17/2024 by an RN for R13. 2. The DON who conducted the original investigation on 11/1/2024 is no longer employed; she resigned on 11/7/2024. Newly hired DON as of 11/11/2024 began a new root cause analysis on 11/19/2024. The root cause was completed for R13 on 11/22/2024. 3. On 12/17/2024, an ad hoc Quality Assurance Process Improvement (QAPI) and performance improvement plan (PIP) was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division [NAME] President, Administrator, Division Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, Admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed. 4. From 12/17/2024 through 12/18/2024, the Division [NAME] President and Divisional Nurse provided education to the Administrator, DON, and Social Worker on the job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EMR to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EMR upon admission/readmission and post-fall as indicated. Nurses are to follow up with therapy to ensure a timely review of referrals (within 72 hours). Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed. (Patient exhibiting any signs/symptoms of anxiety such as restlessness, nausea, elevated heart rate, difficulty sleeping). If the patient is noted to exhibit signs of anxiety, nursing to assess the patient and report to the provider as indicated. The Administrator, the DON, and the Social Worker received education. 5. Corrective action for other residents having the potential to be affected by the same deficient practice: All residents who reside in the facility who are transported and have had a fall have the potential to be affected by the alleged deficiency. 6. Systemic changes are made to ensure that the deficient practice will not recur. On 12/18/2024 oversight was provided by the Divisional Nurses (DN) to ensure the DON completed a root cause analysis of residents with falls within the past 30 days. On 12/18/2024 oversight by DN to ensure that 8 of 8 therapy referrals were completed by the RAI coordinator was completed. On 12/18/2024 an oversight by DN of Social Worker to confirm that eight or eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, including weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by a Regional Dietitian on 12/17/2024. On 12/18/2024 DVP and DN made observational rounds to supervise the Administrator, DON, and Social Director of the day-to-day operations to include adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. DN attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. DVP and DN confirmed that education had been completed with staff for falls and safety transportation. 7. Quality Assurance plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection Grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the POC. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this POC will be validated by the DVP and /or DN and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary. 8. All corrective actions were completed on 12/18/2024. The facility alleges that the IJ was removed on 12/19/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the Therapy Referral dated 11/19/2024 documented that a therapy screening was completed. A review of the Physical Therapy Certification document with a completion date of 11/22/2024. A review of the Behavioral Assessment V3.0 was completed by the Social Worker) on 11/22/2024. There were no new behaviors at that time. A review of the Care Plan Conference V2.0 was updated as her annual conference on 12/3/2024. Conference notes state R13 is interested in seeing the counselor). A review of the Speech/Language Pathology Certification assessment was completed on 12/6/2024. A review of the Occupational Therapy Daily Note dated 12/17/2024 documented R13 was seen for positioning and wheelchair review. A cushion 16 x 18 was placed in wheelchair providing more support to hips and the footrests were exchanged to appropriate length was completed. A review of the RD Nutritional Assessment V4.0 dated 12/17/2024 documented a significant change due to recent weight loss along with new orders. A review of the GA MedGroup assessment dated [DATE] was completed related to post-fall. Further review of the document revealed that continue to follow with psychiatric services. A review of the Psychiatric Diagnosis Evaluation revealed that R13 was seen on 12/17/2024 and an evaluation was conducted. A review of the Care plan dated 11/1/2024, 11/19/2024, 12/17/2024, and 12/18/2024 was updated for the focus to falls or near falls. A review of the Care plan dated 11/19/2024 was updated to focus on Fall Risk. 2. Review of the previous Director of Nursing resignation letter dated 11/7/2024. A review of the current offer letter for the DON position is dated 11/11/2024 as the hire date. A review of the Root Cause Analysis was completed on 11/22/2024. 3. A review of the audit tool titled Utilization Wheelchair and Safe Transfer/Transport dated 11/21/2024 revealed residents were questions about the safety in the building, if they felt if staff were pushing them fast, and any staffing concerns. No concerns with the review. 4. A review of the Ad hoc QAPI and PIP dated 12/17/2024 revealed Division vice president, Administrator, Division nurse, Director of nursing, licensed nurse, Medical director, Social Service, Financial controller, Maintenance director, Resident assessment instrument nurses, Wound care nurse, Environmental services director, Activity director, health information manager Environmental/ laundry supervisor, Admission nurse, Human Resources Partner service, and scheduler were all in attendance for the meeting. 5. A review of the document titled Job description, roles, and responsibilities was signed off by the Administrator, DON, Division Nurse, and Social Worker on 12/17/2024. 6. A review of the in-service education titled F689 Free of Accident Hazards/Supervision/Devices dated 12/17/2024 and 12/18/2024 documented that 99 staff signatures were signed off on being educated. A review of the in-service education titled Anxiety/Post Fall/ Safe Transfer dated 12/17/2024 and 12/18/2024 documented that 99 staff signatures were signed off on being educated. 7. Confirmed by observations on 12/20/2024. 8. A review of the residents who had a fall within 30 days was completed. Eight residents identified that had a fall. A review of eight identified residents for psychiatric assessment, weight loss, root cause analysis, and therapy related to recent falls in the facility were reviewed and determined to be completed on 12/17/2024 and 12/18/2024. A review of Grid 1 titled, Review of fall from 11/18/2024 to 12/18/2024 was identified and completed for residents who had fallen. 9. A review of the Quality Improvement Data Collection Grid 3 dated 12/19/2024 documented audits indicated for psychological assessments, post falls, therapy referrals, root cause, weight loss, or decline were completed on residents that were identified as recent falls (eight of eight residents) within the last 30 days. The interview on 12/20/2024 at 1:56 pm revealed DON is responsible for Grid 2 and the Administrator comes behind her and checks to see if it is completed. Then the Administrator goes to check Grid 3. The Division nurse and the Division [NAME] President Nurse check behind the administrator to collect accurate data. DON confirmed that Grid 3 and Grid 2 are being audited daily. The target date will be daily for four weeks; then twice a week for four weeks; and then weekly for four weeks. 10. It was verified that the corrective actions were completed by 12/18/2024 and the immediate jeopardy was removed on 12/19/2024.

Based on record review, staff interviews, and review of the Administrator and Director of Nursing (DON) Job Description, the facility's Administration failed to address concerns with the facility's Fall Management and Transportation of Patients procedures; and failed to ensure that one of 11 sampled residents (R) (R13) was free from accident hazards related to transporting within the facility. Further, the administration failed to ensure that a therapy assessment and psychosocial harm assessment were completed for R13 post-fall and that staff were educated on safely transporting residents in the facility. On 11/19/2024, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 12/17/2024 at 12:15 pm. The noncompliance related to the IJ was identified to have existed on 11/1/2024. An Acceptable Removal Plan was received on 12/18/2024. Based on observation, record review, a review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 12/19/2024. The facility remained out of compliance while the facility continued management-level staff oversight as well as continuing to develop and implement a Plan of Correction (POC). This oversight process includes an analysis of facility staff's conformance with the facility's policies and procedures governing accident hazards. Findings included: A review of the Administrator Job Description revised February 2022, revealed the Administrator is responsible for directing the day-to-day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long-term care centers, and as may be directed by the Regional [NAME] President, to provide appropriate care for our patients. A review of the Director of Nursing Job Description revised March 2021 revealed that the DON is responsible for planning, organizing, developing, and directing the overall operation of our Nursing Services Department in accordance with current federal, state, and local regulations governing our nursing center, and as directed by the Administrator and/or the Medical Director, to provide appropriate care. A review of R13's electronic medical record (EMR) revealed that she was admitted to the facility on [DATE]. Further review of Progress Notes revealed that R13 had five falls in the facility: 9/28/2022, 9/29/2022, 12/2/2022, 6/29/2023, and 11/1/2024. On 11/1/2024, R13 was sent out to an acute care hospital and was admitted there from 11/1/2024 to 11/8/2024 due to a fall with a major injury. A review of the hospital records dated 11/8/2024 revealed that R13 was discharged from the acute care hospital with the diagnoses of seven sutures and fractures with diagnoses of cervical (C) 2, endplate fracture, right frontal scalp laceration, cervical spondylosis with a moderate spinal canal with narrowing at C5-6. The fall resulted in a right forehead/frontal scalp laceration with soft tissue hematoma, moderate chronic microvascular ischemic changes, left thalamic and right pontine lacunar infarcts, and acute nondisplaced oblique fracture involving the anterior inferior corner of C2. During an interview on 11/21/2024 at 4:56 pm, the Administrator revealed she has been in the position for two years and that the former DON resigned from the facility on 11/7/2024. The new DON was hired on 11/11/2024. The administrator confirmed that she did not complete a full investigation or a root cause analysis of the 11/1/2024 fall for R13 because the former DON told her it was not a reportable incident. She stated that she asked the Activities Director (AD) what happened but confirmed that she did not interview any other staff working on the day of the incident. The facility implemented the following actions to remove the IJ: 1. On 11/19/2024, a therapy screen was done for R13 by the Physical Therapist. On 11/22/2024, a Physical Therapy assessment was completed for R13. On 11/22/2024, the Social Worker completed a behavioral assessment. No changes were identified for R13. On 12/3/2024, a care plan conference was held with R13 and her (family) with the Social Worker, Registered Nurse (RN), Licensed Practical Nurse (LPN), Restorative Nurse, Dietary Manager, Charge Nurse LPN, and CNA. R13 stated she had no problems or concerns. On 12/6/2024, Speech Therapy completed an assessment for R13. On 12/17/2024, the Occupational Therapy department evaluated R13 for positioning and wheelchair review. A 16x18 inch cushion was placed in the wheelchair providing more even support to hips and the footrests were exchanged for more appropriate length allowing Bilateral Lower Extremity flexibility. On 12/17/2024, the Registered Dietitian assessment was done for R13 weight loss, with a new order for a nutritional supplement (one carton by mouth every day was ordered. Continue weekly weight. Speech Therapy to evaluate and treat. No recommendation currently. On 12/17/2024, a Medical Doctor assessed R13, with no concerns noted at that time. On 12/17/2024, the Psych Physician conducted an evaluation post-fall for R3, no recommendation at this time. The plan of care was reviewed and updated on 11/1/2024 and 11/8/2024 by an LPN, and on 12/17/2024 by an RN for R13. 2. The DON who conducted the original investigation on 11/1/2024 is no longer employed; she resigned on 11/7/2024. Newly hired DON as of 11/11/2024 began a new root cause analysis on 11/19/2024. The root cause was completed for R13 on 11/22/2024. 3. On 12/17/2024, an ad hoc Quality Assurance Process Improvement (QAPI) and performance improvement plan (PIP) was developed and initiated. The meeting discussion included plan development and citations. In attendance at the meeting were the Division [NAME] President, Administrator, Divisional Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI nurses, Wound Care Nurse, Environmental Services Director, AD, health information manager Environmental/ laundry supervisor, Admission Nurse, HR Partner Service, Scheduler, for the accident. The existing Fall Management policies and concluded no revisions were needed. 4. On 12/17/2024 Division [NAME] President and Divisional Nurse provided education to the Administrator, DON, and on 12/18/2024 the Social worker on job description, roles and responsibilities, and duties to ensure the safety of all residents. Education provided on the falls management policy included that nurses should observe and interview the patient and/or witnesses to determine the possible cause of the fall and complete the Initial Event in the EHR (Electronic Health Record) to capture the investigation of the fall and assessment of the patient and how to use the QAPI tool The 5 Whys and that nursing is to complete therapy referral in EHR upon admission/readmission and post-fall as indicated. Nursing to follow up with therapy to ensure timely review of referral (within 72 hours). Therapy to complete an assessment post-fall as indicated to include completion of an evaluation of the wheelchair to determine if the wheelchair was appropriate for the patient. Resident transport safety to prevent falls/injuries. Nursing and social services to follow up and assess patients for psychosocial harm post-fall to determine if behavioral health services are needed. (Patient exhibiting any signs/symptoms of anxiety such as restlessness, nausea, elevated heart rate, difficulty sleeping). If the patient is noted to exhibit signs of anxiety, nursing to assess the patient and report to the provider as indicated. The administrator, DON, and Social Worker received the education. 5. On 12/18/2024, oversight was provided by the Divisional Nurse to ensure the DON completed a root cause analysis of residents with falls within the past 30 days. On 12/18/2024 oversight by the Divisional Nurse to ensure that eight of eight therapy referrals were completed by RAI coordinator was completed. On 12/18/2024 oversight by Divisional Nurse of Social Worker to confirm that eight of eight social visits were completed to ensure no evidence was noted of further treatment psychosocial harm post fall, to include weight loss, increased anxiety, or further decline. One of eight patients identified with weight loss post-fall was reviewed by the Regional Dietitian on 12/17/2024. 6. On 12/18/2024, the Division [NAME] President and the Divisional Nurse made observational rounds to supervise the administrator, DON, and Social Worker of the day-to-day operations including adhering to the falls policy and that oversight was being provided by the administration to ensure patients were being transported safely. The Divisional Nurse attended the clinical meeting to ensure that falls were being reviewed per the guideline to include performing a root cause analysis and 72-hour observations were completed to include observation of signs of psychosocial harm. The Division [NAME] President and the Divisional Nurse confirmed that education had been completed with staff for falls and safety transportation. 7. Quality Assurance Plans to monitor facility performance to ensure corrections are achieved and are permanent. A quality improvement data collection grid 3 tool was developed and initiated by the Administrator and is being utilized daily to monitor the implementation of the Plan of Correction. The DON or Assistant DON will be responsible for ensuring the completion of this tool. The results of the monitoring completed under this plan of correction will be validated by the Division [NAME] President and /or Divisional Nurse and submitted daily to the QAPI committee for review and further follow-up. The quality improvement data collection grid will continue until the QAPI committee deems it is no longer necessary. 8. All corrective actions were completed on 12/18/2024. The facility alleges that the IJ was removed on 12/19/2024. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of R13 electronic health records dated 11/19/2024 revealed A review of the Therapy Referral dated 11/19/2024 documented a therapy screening was completed. A review of the Physical Therapy Certification documents a completion date of 11/22/2024. A review of the Behavioral Assessment V3.0 was completed by the Social Worker on 11/22/2024. There were no new behavioral concerns at that time. A review of the Care Plan Conference V2.0 was updated as her annual conference on 12/3/2024. The conference notes stated that R13 was interested in seeing the counselor. It was verified that a referral was sent for counseling services as requested at the care plan conference. A review of the Speech/Language Pathology Certification assessment was completed on 12/6/2024. A review of the Occupational Therapy Daily Note dated 12/17/2024 documented R13 was seen for positioning and wheelchair review. A cushion 16 x 18 was placed in wheelchair providing more support to the hips and the footrests were exchanged to appropriate length was completed. A review of the Registered Dietician Nutritional Assessment V4.0 dated 12/17/2024 documented a significant change due to recent weight loss along with new orders being completed. A review of the (name of company) assessment dated [DATE] was completed related to post-fall. Further review of the document revealed that continue to follow with psychiatric services. A review of the Psychiatric Diagnosis Evaluation revealed that R13 was seen on 12/17/2024 and an evaluation was conducted. A review of the Care plan dated 11/1/2024, 11/19/2024, 12/17/2024, and 12/18/2024 was updated for the focus to falls or near falls. A review of the Care plan dated 11/19/2024 was updated for the focus on Fall Risk. 2. A review of evidence revealed in the previous DON resignation letter dated 11/7/2024. A review of the current offer letter for the DON position is dated 11/11/2024 as the hire date. A review of the Root Cause Analysis was completed on 11/22/2024. 3. A review of evidence revealed the Ad hoc QAPI and PIP dated 12/17/2024 revealed the Division [NAME] President, Administrator, Divisional Nurse, DON, LPN, Medical Director, Social Worker, Financial Controller, Maintenance Director, RAI Nurses, Wound Care Nurse, Environmental Services Director, Activity Director, Health Information Manager, Environmental/ Laundry Supervisor, Admission Nurse, Human Resources Partner Service, and Scheduler were all in attendance for the meeting. 4. A review of the Job description, roles, and responsibilities was signed off on by the Administrator, DON, Division Nurse, and Division [NAME] President on 12/17/2024. During an interview conducted on 12/20/2024 at 4:33 pm, the Administrator, DON NN, and Social Worker II confirmed in-service received along with Performance Assessment Review (PAR), Quality Assurance, and Performance Improvement (QAPI) meetings completed. All participants revealed during the PAR meetings weight loss, falls, behaviors, and new admissions with behaviors. All participants confirmed they are responsible for PAR meetings along with the charge nurse, Minimum Data Set (MDS) coordinator, Dietary Manager, ADON, and sometimes therapist. All participants revealed in QAPI meetings regarding falls the root cause, psychosocial, weight loss decline, therapy referrals, and plans in place with the Administrator will be reviewed with DON, and all falls are included. 5. A review of evidence revealed the review of the audit tool titled Utilization Wheelchair and Safe Transfer/Transport dated 11/21/2024 revealed residents were questions about the safety in the building, if they felt if staff were pushing them fast, and any staffing concerns. No concerns with the review. Interviews were conducted on 12/20/2024 with five cognitively intake residents who were transported with assistance in a wheelchair: (R6 interviewed at 11:50 am, R34 interviewed at 11:33 am, R36 interviewed at 11:30 am, R58 interviewed at 11:56 am, and R243 interviewed at 11:38 am) They all confirmed they received wheelchair assistance, and were transported at an adequate pace, they feel safe during transport and have no concerns. 6. A review of Evidence revealed the 5 Whys for the root cause analysis was completed on 11/22/2024. A review of eight identified residents for psychiatric assessment, weight loss, root cause analysis, and therapy related to recent falls in the facility was reviewed and determined to be completed on 12/17/2024 and 12/18/2024. Observation on 12/19/2024 at 1:56 pm revealed Activities Director (AD) TT wheeling a resident down the hall appropriately with no signs of complications; using both hands on the wheelchair handle. Meanwhile transporting at a slow pace. Observation on 12/19/2024 at 2:37 pm revealed Occupational Therapist (OT) VV transporting the resident in a wheelchair with foot pedals with no signs of complications. A review of the in-service education titled F835 Administration - Root cause of accident post falls follow up dated 12/17/2024 and 12/18/2024 documented that 99 staff signatures were signed off on being educated. Interviews were conducted and verified as having been educated: on 12/19/2024, Nurse BB was interviewed at 1:40 pm, three Certified Medical Assistants (CMA's) were interviewed on 12/19/2024 (CMA PPP at 3:30 pm; CMA HHH at 2:30 pm; CMA III at 2:26 pm) Six Certified Nursing Assistant (CNA's) was interviewed on 12/19/2024 (CNA OOO at 3:25 pm; CNA KKK at 2:23 pm; CNA JJJ at 2:19 pm; CNA LLL at 2:09 pm; CNA EE at 1:52 pm; CNA WW at 1:45 pm; Maintenance Director NNN interviewed at 2:46 pm; Admission Coordinator QQ was interviewed at 2:43 pm; Assistant DON of Nursing MMM was interviewed at 2:00 pm. Interviews were conducted and verified as having been educated: on 12/20/2024 with Administrative Assistant SSS at 9:48 am; Resident Assessment Instrument (RAI) Director LL interviewed at 9:55 am; Agency Nurse Practitioner (NP) QQQ interviewed at 9:59 am; Healthcare Navigator RRR interviewed at 10:03 am. 7. A review of the Quality Improvement Data Collection Grid 3 dated 12/18/2024 documented audits indicated for validation of audit completion was done by the DON/ADON for psychosocial assessment, post-falls, therapy referrals, root cause analysis, weight loss or decline from falls. An interview on 12/20/2024 at 1:56 pm revealed DON is responsible for Grid 2 and the Administrator comes behind her and checks to see if it is completed. Then the Administrator goes to check the Grid The Divisional Nurse and the Division [NAME] President Nurse check behind the administrator to collect accurate data. DON confirmed that Grid 3 and Grid 2 are being audited daily. The target date will be daily for four weeks. Then twice a week for four weeks; then weekly for four weeks. 8. It was verified that the corrective actions were completed by 12/18/2024 and the immediate jeopardy was removed on 12/19/2024.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled ADL Plan of Care, the facility failed to provide activities of daily living (ADL) care for three of 40 sampled residents (R) (R34, R36, and R43). This deficient practice had the potential to cause risk for unmet needs and a diminished quality of life. Findings included: A review of the policy titled ADL Plan of Care, with the revised date of 12/29/2023, revealed that it is the intent stated to develop and communicate residents' needs for assistance with ADL care; residents' ADL care needs are assessed on admission and are addressed on the baseline care plan and communicated to staff; that nursing develops the resident ADL care plan; and the plan is updated in conjunction with comprehensive care plan as needed. 1. A review of the electronic medical record (EMR) revealed that R34 was admitted to the facility on [DATE] with pertinent diagnoses including, but not limited to, legal blindness and a history of falling. A review of R34's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15, which indicated R34 was cognitively intact at the time of the assessment; that R34 required substantial assistance with upper body dressing; and that R34 was dependent on staff for ADL care with one/two or more-person assistance. A review of R34's care plan dated 9/11/2024 indicated a problem of self-care deficit based on refusals of showers. Goals included, but were not limited to, the resident would be able to assist with turning and positioning himself in bed and would accept assistance. Interventions included, but were not limited to, staff are to assist R34 with ADL care as needed. During an observation on 11/19/2024 at 9:39 am, R34 was observed resting in bed awake and alert. His fingernails were long and there was a dark brown colored substance under each fingernail. During an interview with R34 at this time, he stated that his fingernails needed cleaning up. During an observation on 11/20/2024 at 1:05 pm, R34's fingernails were still long and unclean with a dark brown substance under all nails on both hands. An interview with Certified Nursing Assistant (CNA) JJ on 11/20/2024 at 1:10 pm confirmed R34 requires help with his ADL care which includes nail care. CNA JJ has not had him on her assignment for the past week. CNA JJ confirmed that R34's fingernails were long and needed to be trimmed and cleaned. 2. A review of the EMR revealed R36 was admitted to the facility on [DATE] with diagnoses including, but not limited to, type 2 diabetes mellitus with hyperglycemia, hemiplegia and hemiparesis, and cerebral infarction. A review of the quarterly MDS assessment dated [DATE] revealed that R36 presented with a BIMS score of 15 and that he was dependent on staff for ADL care with one/two or more-person assistance. A review of the care plan dated 11/7/2024 indicated R36 presented with a self-care deficit (7/14/2024). Interventions included, but were not limited to, staff to assist R36 with ADL care. During an observation on 11/19/2024 at 9:35 am, R36 was resting in bed. His fingernails were long and a dark brown colored substance was observed under his nails. During an interview with R36, he stated he had been at the facility for six months. He stated, My fingernails need some attention, they don't do them real often. During an observation on 11/20/2024 at 3:05 pm, R36 was observed in the hallway and his nails were still untrimmed and not clean. 3. A review of the EMR revealed resident R43 was admitted to the facility on [DATE] with a diagnosis of depression. A review of the quarterly MDS assessment dated [DATE] revealed R43 presented with a BIMS of 15 and required substantial assistance with ADL care with one/two or more-person assistance. A review of the care plan dated 11/4/2024 indicated R43 presented with a self-care deficit. Interventions included, but were not limited to, staff to assist the resident with ADL care as needed. An observation on 11/19/2024 at 11:08 am revealed that R43 was awake and alert lying on the right side in bed. His fingernails were long and had a dark substance underneath all nails. He stated that the staff does provide nail care, but he was unsure how often. He confirmed that his nails were long and needed cleaning. During an interview on 11/20/2024 at 1:05 pm, Certified Nursing Assistant (CNA) EE stated that she was unsure why R43's fingernails were not cleaned. During an interview on 11/21/2024 at 4:13 pm, the Director of Nursing (DON) stated that she has been at the nursing home in this role for a very short time, less than two weeks. DON further stated she is still familiarizing herself with the new facility she has expectations for staff to provide nail care for residents who cannot do it for themselves.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Use of Oxygen Therapy, the facility failed to obtain an active physician order for oxygen therapy and implement appropriate infection control for one of 11 sampled residents (R) (R489). This deficient practice had the potential to cause respiratory illness and inappropriate oxygen therapy. Findings included: A review of the facility's policy titled Use of Oxygen Therapy, revised 7/1/2024, section titled Intent revealed that it is the intent of the facility to ensure that patients maintain optimal oxygenation via the proper oxygen device and concentration when appropriate and medically indicated. The section titled Guideline stated that a Physician's order for oxygen should be obtained . The care plan should include oxygen as ordered. A review of R489's electronic medical record (EMR) revealed that R489 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to dyspnea, gastroesophageal reflux disease, and dependence on renal dialysis. A review of R489's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates R489 was cognitively intact; that R489 had impairments on both sides of lower extremities and was dependent on assistance for activities of daily living (ADLs); that R489 has shortness of breath (SOB) when sitting at rest; and that R489 was on oxygen therapy and dialysis. A review of R489's care plan dated 9/17/2024 indicated a focus on respiratory changes. Goals included, but were not limited to, Patient will not require hospitalization as a result of respiratory changes during the review period. Interventions included, but were not limited to, Administer medications and/or treatments as ordered, monitor vital signs, and notify MD. A review of R489's care plan dated 9/17/2024 indicated a focus on respiratory difficulties/risk for further decline. Goals included, but were not limited to, Patient will not require hospitalization as a result of respiratory changes during the review period. Interventions included, but were not limited to, Administer respiratory medications/treatments as ordered, monitor vital signs, notify a physician of changes, and oxygen as ordered. A review of R489's Physician's Orders included, but was not limited to, Oxygen: Nasal Cannula 2 Liters per minute (LPM) nasally every eight hours as needed SOB/ wheezing. This order started on 8/25/2024 and was discontinued on 10/17/2024. During an interview on 11/19/2024 at 10:48 am, R489 stated that she receives oxygen at night. During an observation at this time, the oxygen was turned on, but the resident was not wearing the nasal cannula. The nasal cannula was not placed in a bag. There was no date or time observed documented on the tubing. During an observation on 11/20/2024 at 9:46 am, R489 was wearing the oxygen nasal cannula, and the oxygen was turned on. During an interview on 11/20/2024 at 10:05 am, Licensed Practical Nurse (LPN) FF confirmed that R489 was currently wearing the oxygen nasal cannula. She was unsure who gave R489 the nasal cannula to put on. An interview with LPN FF and the Admissions Coordinator (AC) on 11/20/2024 at 10:10 am revealed that R489's oxygen order was discontinued as of November 2023 and confirmed that residents need to have an active order to be on oxygen therapy. The AC stated that she is responsible for ensuring oxygen orders are current for residents newly admitted to the facility or readmitted from hospitals. An observation made on 11/21/2024 at 12:11 pm in R489's room revealed that R489 was not in the room and the nasal cannula was hanging off the oxygen concentrator and not placed in a bag. The piece that goes into R489's nose was touching the floor. An interview with LPN FF on 11/21/2024 at 12:11 pm confirmed the nasal cannula was hanging off the oxygen concentrator and not placed in a bag. She further stated that the nasal cannula should be placed in a plastic bag when not in use. An interview with the Director of Nursing (DON) on 11/21/2024 at 12:16 pm revealed that she expected residents to have active oxygen therapy orders when receiving oxygen therapy. She further stated that she expected the nasal cannula to be placed in a bag when not in use.

Based on record review, staff interviews, and review of the facility policy titled, Pharmacy Services-Medication Administration-General, the facility failed to ensure that medications were obtained from the pharmacy in a timely manner for one of 10 sampled residents (R) (R#2). Specifically, medication for R#3 was obtained from the medication cart on another resident unit and given to R#2. Findings include: Review of the facility policy titled, Pharmacy Services-Medication Administration-General revealed: Borrowed Medications: Medications supplied for one patient are not to be administered to another patient. Interview on 8/11/2023 at 12:08 p.m. with the Administrator and the Director of Nursing (DON) revealed on 5/28/2023 R#2 had an order for morphine sulfate. The medication had not arrived from the pharmacy. R#2 was complaining of a headache, so the hospice nurse, Registered Nurse (RN) II, administered R#3's morphine sulfate to R#2. Licensed Practical Nurse (LPN) DD joined the conversation and stated she received a call from the facility charge nurse, RN GG, who was overseeing the care of R#2. LPN DD stated she was informed that the Hospice nurse, RN II, went to another unit and obtained a dose of morphine sulfate from R#3's medication and gave the dose of medication to R#2. Interview on 8/16/2023 at 4:09 p.m. with RN II revealed R#2 had an order for morphine sulfate (milligrams (MG) not given). RN II reported the charge nurse on duty at the facility was not able to retrieve the morphine sulfate from the facility's automated medication dispensing machine. Interview on 8/16/2023 at 4:17 p.m. with RN JJ, she reported she received a call from RN II on 5/28/2023 indicating R#2s morphine sulfate had not been delivered by the pharmacy to the facility. RN JJ reported R#2 was admitted to Hospice service on 5/17/2023. RN JJ indicated that on 5/18/2023, Hospice put in the order that went over to the pharmacy for R#2's morphine sulfate. RN JJ also indicated it was not standard practice to use medication from another resident, but R#2 was in severe pain. RN JJ reported the morphine sulfate was listed on R#2's Medication Administration Record (MAR) and indicated LPN FF had to give RN II the morphine sulfate from the narcotic box, signed it out, and RN II administered the morphine sulfate to R#2. Interview on 8/16/2023 at 5:03 p.m. with LPN FF revealed RN II came from Unit 3 to Unit 2 and asked LPN FF for the morphine sulfate from R#3's medication in the medication cart. LPN FF reported that RN II indicated RN JJ said it was ok to do so. LPN FF reported she gave the morphine sulfate to RN II because RN II indicated she knew there was another bottle of morphine sulfate in the medication cart, and it was for R#3. LPN FF reported the morphine sulfate was listed on the MAR for R#3, although she had not needed it for R#3. Interview on 8/16/2023 at 5:22 p.m. with the DON revealed the morphine sulphate prescribed for R#2 had not been delivered to the facility before R#2 requested it on 5/28/2023. The DON reported when medications come into the facility, the Unit Managers on the 3:00 p.m. to 11:00 p.m. shift must confirm that each resident's medication has arrived, then place the medications in the medication room. The DON reported R#2 was admitted to hospice on 5/17/2023, and the incident happened on 5/28/2023. Interview on 8/16/2023 at 6:15 p.m. with Nurse Supervisor LPN DD revealed it was not standard practice for a nurse to remove medication from R#3's medication to administer to R#2. LPN DD reported RN II signed out the morphine sulfate for R#3 and put R#2's name on it.

Based on observation, staff interview, and review of policy titled Skilled inpatient Services: Food Preparation and Distribution the facility failed to ensure food was delivered to residents receiving meals on the hallway in a sanitary manner related to proper hand sanitation and covering of food items when transported down the hallway. This deficient practice was observed for three of three meals service observations. Findings include: Review of policy titled Skilled Inpatient Services: Food Preparation and Distribution 6.Distribution a. All items transported from the kitchen to designated service areas or patient rooms will be covered. 1. Observation on 7/8/19 beginning ay 12:44 p.m. on 100 hall revealed the meal cart was placed at the top of the hall near room [ROOM NUMBER] and delivered to rooms [ROOM NUMBERS]. The food cart door remained opened while trays were being delivered. Further observation of meal tray delivery, revealed that the cart was placed on the other end of the hall between rooms [ROOM NUMBERS] and Certified Nursing Assistant (CNA) AA was observed carrying a meal tray to room [ROOM NUMBER] at the other end of the hallway. There was a piece of pie on the meal tray for each tray delivered and it was not covered. Observation on 300 hall on 7/9/19 at 5:29 p.m. revealed that the fruit cup on each meal tray was noted to be uncovered. The trays was carried from the first room on the hall (room [ROOM NUMBER]) to the last room on the hall (room [ROOM NUMBER]) for a total of five trays served that had uncovered fruit cups. Observation on the 300 hall on 7/10/19 at 12:18 p.m. revealed that the food cart was in the hallway between rooms [ROOM NUMBERS]. Meal trays were delivered to rooms [ROOM NUMBER] and the dessert on each tray was uncovered. Observation on 7/10/19 at 12:26 p.m. the food cart was parked at double doors at the top of the hall near room [ROOM NUMBER]. Meal trays were delivered to rooms 103, 105, 108, and 109 with the dessert on each tray uncovered. An interview with the Food Service Manager (FSM) on 7/10/19 at 1:57 p.m. revealed that items are considered covered when leaving the kitchen because they are in the food cart. The FSM further revealed that the CNAs are to take cart from room to room and not carry trays down the hall. A interview with the Assistant Director of Nursing (ADON) on 7/10/19 at 3:00 p.m. revealed that during orientation the procedure for meal delivery is addressed and the food cart should be pushed down the hall from one room to the other. She further revealed that food should be covered when in the hallways and that if items come on the food cart uncovered this would not be a problem if the food trays are not taken directly from the cart and into the resident's room. 2. An observation of the resident's lunch meal tray delivery and set up was conducted on 7/8/19 at 12:57 p.m., observing two Certified Nurse Assistants (CNAs) on Unit I delivering trays to residents that choose to dine in their rooms, rooms 114-129. Trays were delivered from a centrally located kitchen food cart, near the nurse's station. Fourteen residents were served and assisted with tray set up by CNA AA and CNA DD. Observation at this time revealed that CNA DD failed to wash her hands or use gel hand sanitizer after assisting with tray set up for R#485 after assisting tray set up for R##38 . The CNA was also observed delivering a regular tray with regular utensils to room [ROOM NUMBER] for R#480 in contact isolation. All trays delivered were observed removed from the kitchen cart and carried to each individual room at both ends of the hall with uncovered lemon meringue pie/dessert. An observation was conducted on 7/9/19 at 5:30 p.m. to observe delivery and set up of the dinner meal trays for residents choosing to dine in their rooms. Observation of delivery by CNA II and CNA HH on Unit 1, rooms 101-129 revealed that trays were delivered to 13 rooms with an uncovered fruit desert during the tray pass, including to both ends of the hall. Certified Nurse Assistant II was observed delivering and assisting with tray set up that included- removing lids from drinks, opening salt and pepper packets and applying to the food, opening straws and cutting up food for residents in rooms 103, 104, 109, 112, and 118, leaving each of those rooms without using hand sanitizer or washing her hands prior to going to assist the next resident. 3. Observation of dining for 200-hall on 7/8/19 at 1:18 p.m. revealed that the pie on several meal trays was uncovered. The meal cart was parked at the halfway point in the hall and trays were carried up the hallway over 25 feet with the uncovered pie.

Based on observations, record review, staff interviews, and review of the policy titled, Pharmacy Services Medication Storage in the Care Center the facility failed to properly label and discard expired biological's by the expiration date printed on the medications in three of four medication carts inspected. Findings include: Review of the facility policy titled Pharmacy Services Medication Storage in the Care Center (12/17) revealed: #18. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, reordered from the pharmacy, if current order exists. Observation on 7/10/19 at 8:24 a.m., of the Unit 3 Medication Cart, Short Hall, was completed with, Licensed Practical Nurse (LPN) FF which revealed the following non-labeled and expired medications: [REDACTED] [MEDICATION NAME] Ophthalmic 3.5 grams (g) (ointment) expired on 6/2019, [MEDICATION NAME] and [MEDICATION NAME] 30 g (cream) expired on 6/2019, Fast Acting Mi-Acid (12 ounces) 355 milliliter (mL) (liquid) was open with no open date. An interview with Licensed Practical Nurse (LPN) on 7/10/19 at 8:33 a.m. confirmed that the medications (meds) listed above were not properly labeled/or expired. LPN FF further revealed that when meds are opened then a label showing the date they were opened should be placed on that medications and when meds are expired, they are removed from supply and put in the medication disposal box located on Unit One. Observation on 7/10/19 at 9:25 a.m. of the Unit 1- Medication Cart, Side A, with LPN CC revealed the following non-labeled and expired medications: [REDACTED] [MEDICATION NAME] 80 g (ointment) open with no open date, [MEDICATION NAME] and [MEDICATION NAME] B sulfates and [MEDICATION NAME] Ophthalmic 3.5 g (1/8 oz.) (ointment) open with no open date, [MEDICATION NAME] 40 extended release tablets open with no open date, [MEDICATION NAME] cream 1% 30 g (1oz) open with no open date. An interview with LPN CC on 7/10/19 at 9:32 a.m. confirmed that the medications listed above were not properly labeled. LPN CC stated these reusable medications should have been labeled with open dates and she does not know why this did not happen. Observation on 7/10/19 at 10:22 a.m. of Unit 3- Medication Cart, Long Hall with LPN FF revealed the following non-labeled and expired medications: [REDACTED] two tubes of Proctozone-HC 2.5% 30 g (1.1 oz.) (cream) with no open date, two tubes of Aspercreme w/ [MEDICATION NAME] 4.7 oz. open with no open date, Bio freeze Gel 3 oz. open with no open date, [MEDICATION NAME] 15 g (cream) open with no open date, [MEDICATION NAME] 1 oz. (cream) open with no open date, mupirocin 2% 22 g (ointment) expired on 4/2019, [MEDICATION NAME] sodium Topical Gel 1% with no open date, Sore Throat Spray 6 oz. with dates cannot be read, [MEDICATION NAME] 180 tablets with no open date, and 8 packs of ipratromin [MEDICATION NAME] and [MEDICATION NAME] sulfate 3 milligram (mg), with an expiration date of 5/2019. An interview on 7/10/19 at 10:32 a.m. with LPN FF confirmed that the medications listed above were not properly labeled/expired or contained an expiration date that could not be read. She further revealed that when meds are opened a label showing the date they were opened should be placed on those medications and when meds are expired, they are to be removed from supply and put in the medication disposal box located on Unit One. Observation on 7/10/19 at 10:48 a.m. of Unit 2- Medication Cart, C with LPN RR revealed the following non-labeled medications: [REDACTED] Bio freeze Gel 3 oz. open with no open date, three tubes of [MEDICATION NAME] and [MEDICATION NAME] Cream, 30 g, open with no open date, [MEDICATION NAME] ointment, 30 g, open with no open date, and two containers of miconazorb AF antifungal powder 2.5 oz, open with no open date. An interview with LPN RR, at this time, verified that the medications listed above were not properly labeled. She stated when meds are opened a label showing the date they were opened should be placed on that medications and when meds are expired, they are removed from supply and put in the medication disposal box located on Unit One. An interview with the Assistant Director of Nursing on 7/11/19 at 9:26 a.m. revealed that all open medications should be labeled with a tag that has the date in which the medication was opened. She also states that all expired medications should be removed from the cart or storage upon expiration which should be done daily and checked by the night nurse. She acknowledges that the expired medications found in medication carts should not have been there and should have been removed and placed in the designated expired medications container located on Unit 1. She further revealed that her expectations are that staff should ensure there are no expired medications and that medications have an opened date label.

Based on observation, staff interview and record review the facility failed to ensure proper precautions were used while removing trays from the room of two residents (R#57 and R#480) of three residents on transmission based precautions, failed to use proper sanitation when cleaning glucometers on two of three halls, and failed to use sanitary techniques when administering medications on one of three halls. Findings include: 1. An Observation of R#57 on 7/8/19 at 12:14 p.m. revealed that resident (R) #57 was on contact precautions. Observation revealed signage on the entrance door to the resident's room and a table outside of the room containing personal protective equipment. An observation on 7/9/19 at 9:05 a.m. revealed that the resident had regular dishes in their room. The signage for contact precautions on the resident's door documented that patient dedicated equipment was to be used. An observation and interview on 7/9/19 at 9:33 a.m. of Certified Nursing Assistant (CNA) KK revealed that she donned a gown and gloves before entering the resident's room but did not sanitize her hands prior to entering the room. CNA KK was then observed to removed the resident's tray after eating then walking down the hall carrying the uncovered tray with bare hands. An interview with the CNA KK, at this time, confirmed that the resident was on contact precautions. She further revealed that protective equipment was stored outside the door in the bedside table. She stated that all equipment for the resident had to be left inside the resident's room. She further revealed that they used to cover the trays that came out of a resident room who was on contact precautions with a plastic bag, but they no longer cover the tray because the temperature of the dishwasher was supposed to completely sanitize the tray and utensils. The CNA confirmed that she carried the tray down the hall uncovered with bare hands. She stated that it was not uncovered because it had a lid. She also said that they were told to sanitize once they put the tray down. An observation on 7/10/19 at 9:31 a.m. revealed that the resident had regular dishes in their room. The CNA donned a gown and gloves to enter the resident room. The meal cart was parked beside the room door for R#57 but facing the hallway. The CNA handed the tray out to Laundry Aide LL who placed the tray on the cart. Laundry Aide LL did not have gloves on and was not observed sanitizing hands after handling the tray. An interview on 7/10/19 at 10:00 a.m. with Laundry Aide LL confirmed that she did carry the tray from the door of the room to the cart. An interview on 7/11/19 at 10:05 a.m. with the Assistant Director of Nursing (ADON) revealed that they do not use disposable dishes for residents on contact precautions to protect the dignity of the resident and because the chemicals/temperature of the dishwasher kill the bacteria. She stated that it was her expectation that when the food tray was picked up from the resident's room and placed on the cart, that the CNAs had already sanitized, donned a gown and gloves prior to entering the room. She stated that the meal cart was to be parked in front of the door and facing the door, the CNA would then place the tray directly on the meal cart from the room and it should be the last tray placed on the cart. She also stated that the meal cart should go directly to dietary. When told about the observations of trays being picked up from the isolation room, she said that was not the facility's process. A post survey telephone interview on 7/23/19 at 3:37 p.m. with the Administrator, Director of Nursing (DON), ADON (also the Infection Control Nurse), and the Dietary Manager revealed that the kitchen staff are trained to treat all trays as infectious. They use disposable aprons and gloves to place all trays into the dishwasher which is a high temp dishwasher that includes sanitization chemicals to kill all organisms. Once the tray carts are empty, they are taken outside the building, decontaminated, then after sitting for the required time, the carts are washed with hot water and allowed to air dry prior to re-use. The ADON revealed that both the CNAs and the staff nurses are trained to pull the meal carts, for resident's on isolation, to the resident's room so that staff can place the isolation trays on the cart without leaving the room. Isolation trays should be the last trays placed in the carts. The ADON revealed that should the meal tray be contaminated by liquids such as vomitus that the CNAs should decontaminate the tray before placing it in the cart. This process is not included in a written policy although she states the staff are trained upon hire for this process. 2. Observation and interview on 7/10/19 at 4:30 p.m. with Licensed Practical Nurse (LPN) PP on 200-hall of FSBS for R#28 revealed that she gathered the glucometer and supplies in her ungloved and unsanitized hand. LPN PP then placed the glucometer and supplies on the resident's bed without placing a barrier, she sanitized her hands, then placed a barrier down, sat the supplies and glucometer on the barrier, donned her gloves, cleaned the resident's finger with alcohol and pricked the resident's finger. LPN PP then sat the glucometer on the medication cart without a barrier, and recorded FSBS, allow she did not clean and/or disinfect the glucometer after use. LPN PP confirmed that she sat the glucometer and supplies down on the resident's bed without a barrier and had not sanitized the glucometer after using it. 3. An observation on 7/10/19 at 1:50 p.m. of the lunch meal tray removal from room [ROOM NUMBER] by CNA HH for a resident in contact isolation. The CNA HH was observed wearing an isolation gown and gloves, placing the tray with standard dishes and utensils on a stand located outside of the room, CNA HH then returned to the room to remove gloves, isolation gown and wash her hands. The CNA HH returned the meal tray to the kitchen transport cart which was located down the hall near the nurse's station. An observation on 7/10/19 at 1:58 p.m. for the lunch meal tray removal from room [ROOM NUMBER] tray by CNA DD, for a resident in contact isolation. The CNA was observed coming out of room [ROOM NUMBER] wearing an isolation gown and gloves, carrying a standard meal tray down the hall to the kitchen transport cart located near the nurse's station, setting the tray on the top of the cart, then returning to the room to remove gloves, gown and use gel hand sanitizer. The CNA then came back down the hall to place that resident's tray into the kitchen transport cart. An observation during a medication pass on 7/9/19 at 4:54 p.m. of an insulin subcutaneous injection conducted by LPN EE for R#22. The nurse removed from the medication cart a multi-dose vial of [MEDICATION NAME] 100/units/ml insulin. The nurse was observed injecting the needle into the vial to aspirate the dose of 10 units out of the vial; however, she did not clean/wipe the top of the vial with an alcohol pad prior to injecting. In addition, R#22 also received Humalog insulin 100 units/ml-7 units by an insulin injection pen. An Observation on 7/9/19 at 4:58 p.m. revealed upon return to the medication cart, LPN EE dropped the Humalog insulin pen to the floor. She was then observed to pick it up from the floor and place it in the medication cart drawer without sanitizing the pen or her hands. An observation on 7/9/19 at 5:25 p.m. revealed upon return to the medication cart, LPN EE was observed obtaining a multi-use glucometer from a case in the medication cart and obtaining a blood sugar sample for glucose testing from R#22. The glucometer was cleaned after use with the facility provided 2-minute anti-microbial wipe although the glucometer was placed on the medication cart to dry without a barrier. LPN EE confirmed she did not clean the glucometer prior to using it and did not think that she had to prior to use although, she always cleans it after use. An interview on 7/10/19 at 3:07 p.m. with LPN FF, Unit III Short-Hall, revealed that each medication cart has one glucometer, the same type of glucometer is on each medication cart, to be used on the residents located on their specific hall. She confirmed several LPNs use the medication cart including agency staff. An observation on 7/10/19 at 4:16 p.m. with LPN GG, Unit 1, revealed glucometer cleaning as follows: LPN GG obtained the multi-use glucometer from a case in the top drawer of the medication cart; was observed wiping off the glucometer with an alcohol prep-pad and placing the glucometer on a paper towel barrier. LPN GG then washed her hands and donned gloves and tested R#39's blood sugar, removed her gloves, washed her hands, then carried the glucometer to the medication cart on the same paper barrier, then donned gloves and cleaned the glucometer with an alcohol prep-pad and when air dried, placed the glucometer in the case and returned it to the drawer. The facility required anti-microbial 2-minute wipe located in the bottom drawer of the medication cart was not used. An interview on 7/11/19 at 5:06 p.m. with the Director of Nursing (DON) confirmed that it was not acceptable for an employee to pick an insulin pen up off the floor without sanitizing before placing it back in the drawer. She also confirmed that it was not acceptable for a nurse to use a multi-dose vial without cleaning it between residents. She confirmed it was not acceptable to put the glucometer or supplies down on a surface without a barrier, and it was not acceptable for the entire glucometer to not be cleaned in a two-step process where it was wiped with alcohol and allowed to dry and then wiped with the sani-wipe and allowed to dry before and after use. The DON confirmed is also not acceptable for a gown and gloves worn in a resident room on precautions to be worn out in the hallway. She stated that education and detailed orientation with check-offs were provided to each staff member including agency staff. A review was conducted of the facility policy titled Transmission-Based Precautions (Contact, Droplet, Airborne), updated (MONTH) 2019, provided on 7/10/19 by the DON. It documents under Contact Precautions that the facility uses Contact Precautions as recommended in Appendix A for residents with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. Policy Section 3. (a) documents to remove gown and observe hand hygiene before leaving the resident care area. (b) After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental services that could result in possible transfer of microorganism to other residents or environmental surfaces. Section 4. (b) documents to use disposable non-critical resident equipment (e.g. blood pressure cuffs) or implement resident-dedicated use of such equipment. If common use of equipment for multiple residents is unavoidable, clean and disinfect such equipment before use on another resident. The policy does not give specific instructions and/or a procedure for handling meal tray delivery and subsequent return to the kitchen transport carts for residents on contact isolation. The policy documents in Section 4. to use disposable non-critical resident equipment. No further policy was provided. A review was conducted of the provided facility policy titled Skilled Inpatient Services-Glucometer Disinfection updated (MONTH) 2019. Documentation reflects in a section titled Intent, that it is the policy of this facility that all glucometers shall be thoroughly cleaned and disinfected between resident uses if individual glucometers are not available. Section titled Diabetes Care Procedures & Techniques No. 6 documents that when a glucometer has been used for one resident, and must be reused for another resident, the device must be cleaned and disinfected.

Based on record review, interview and review of facility policy titled Skilled Inpatient Services- Advance directives, the facility also failed to ensure an accurate code status determination was documented in the record for R#77 and failed to inform and provide written Advance Directive information to one Resident (R) (R#484) or his representative, and ensure a code status was ordered by the Physician upon admission. The sample size was 32 residents. The findings include: 1. Review of the medical record for R#77 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE], documents in Section C- a Brief Interview for Mental Status (BIMS) was not conducted, that resident is rarely or never understood. Review of the resident's care plan documents a care area/problem of Advanced Directive (AD) updated 6/27/19, with a goal that patient and/or responsible party will participate in Advance Directive/Advance Care planning discussion during the review period, dated 6/6/19 onset. Interventions included: ensure AD documents are complete/noted in the medical record dated 6/24/19, Full Code status dated 6/24/19, maintain a copy of AD documents on the chart, dated 6/24/19. Evidence by: Social Worker (SW) has discussed advanced directives and code status with resident and/or resident representative 6/24/19 onset. Review of the Physician's Orders in the electronic medical record for R#77 revealed an order for [REDACTED]. A Physician Orders for Life Sustaining Treatment (POLST) form signed on 6/11/19 by a Physician, and signed but undated by the resident's authorized signature and Power of Attorney (POA), was found in the electronic recorder under scanned documents. The POLST documents to allow natural death and do not attempt resuscitation. Another copy of the original POLST form was provided by the Social Worker (SW) on 7/11/19 that had an additional signature by a concurring Physician, dated 6/28/19. No evidence was found in the record of a care plan update or an order change reflecting the DNR code status to allow natural death-do not attempt resuscitation. An interview was conducted on 7/11/19 at 9:15 a.m. with the SW when she explained that once the POLST form is signed, the nurse can change the care plan. The POLST form then goes to medical records to be scanned in the electronic record. She stated they were initially waiting for the resident's family member to bring in evidence of having POA for the resident. The SW stated that the nurses should have changed the care plan and Physician's Order from a Full Code status to a DNR, saying the Full Code status order should have been lined out. She further explained the 6/11/19 POLST was the first one, then then the 6/28/19 POLST has the two physician signatures for DNR status. The SW explained they have been very busy without an Admission Coordinator (AC), that she is filling in for the Admission Coordinator. She explained their AD process is twofold, in that the AC starts the process and gives AD information to the resident and their representative, then will ask a few questions about their wishes, ask if they know their wishes and have signed an Advance Directive, have a POA, Living Will or evidence of a POLST. If they have any of these, she will obtain it or ask the family/or representative to bring in a copy. She stated this AD information is brought to the initial care plan meeting held with the resident and their representative. The SW stated the second line is for her to review the AD wishes in detail with the resident or their representative to make sure they understand it. If the resident has a POLST, to make sure it is properly signed and given to medical records to scan in the electronic record. The nurses are informed at the care plan meeting the resident's wishes, and are responsible that the Physician's Order and the care plan reflect their wishes. The SW then confirmed that this one slipped though and wasn't changed. 2. Review of the electronic record for R#484 revealed that the resident was admitted [DATE] from an acute hospital with a [DIAGNOSES REDACTED]. Record review revealed there was no AD Physician Order; and there was no AD information or checklist was found. An initial review of the resident's Physician Orders revealed there was no code status order. Review of the resident's current care plan dated 6/26/19, revealed a care area/problem- Advanced Directive, updated 7/9/19. Interventions- full code status 7/9/19 onset. Provide education on Advance Directives and Advance Care Planning, dated 6/26/19. An interview with the SW on 7/11/19 at 9:15 a.m. revealed that she is also the Admission Coordinator as they are in the process of hiring one. She confirmed that there was no code order prior to 7/9/19, explaining that the code status is started in admissions and then goes to her to finish getting information if no decision is made. The admission nurse reviews orders and to put in an order, then Medical Record scans any documents in the electronic record, such as the AD checklist, POLST, POA, or a Living Will. She confirmed they are behind and missed that there was no code status order. She further revealed that the code status information is gotten from several sources and information is brought to the care plan conference and then is put into the care plan. Review of the facility policy titled Skilled Inpatient Services- Advance directives updated (MONTH) 2019. Section 1. Informing Patient and or Representative of Rights/Options: A. (3) Written information will be provided to the patient and a verbal explanation of advanced directives will be given. A. (4) The Advance Directive Check List will be completed and filed on the patient's chart, this form documents that written information was provided. C. (5) Results of advance care planning decisions will be documented in the patient's medical record. This documentation will include identification of new care instructions, clarification or changes in care instructions or whether care instructions remain the same. Based on interview and record review, the resident did not have evidence of Advance Directive planning and/or information in the record and did not have a Physician's code status order until 7/9/19, the resident was admitted [DATE].

Based on interview, observation, and review of training information titled Resident Rights- Dignity, Respect, [MEDICATION NAME] and Communication, the facility failed to ensure resident's dignity was maintained by referring to dependent residents as feeders during meal service on Unit One. This affected one of three Units during hall meal service delivery. Findings include: Observation on 7/8/19 at 1:10 p.m. revealed Certified Nursing Assistant (CNA) AA referred to meal trays for a dependent resident as a feeder. During interview on 7/10/19 at 2:28 p.m. CNA AA referred to dependent residents as feeders when discussing meal tray delivery. During further interview CNA AA acknowledged that she should not have referred to residents as being feeders but should have instead said residents that need assistance. During interview on 7/11/19 at 3:25 p.m. with the Assistant Director of Nursing (ADON) it was reported that staff have been in-serviced related to the dignity of residents. ADON reported that residents should not be referred to as feeders. ADON further reported that this is covered in orientation of new staff. On 7/11/19 at 4:07 p.m. the ADON provided a copy of in-service for dignity and resident's rights. ADON reported that this document is used during orientation. Review of the document Resident rights- dignity, respect, [MEDICATION NAME] and communication revealed residents have the right to: be treated with dignity, respect and consideration at all times. The in-service information also stated to not use the term Feeders. An interview on 7/11/19 at 4:43 p.m. with the Director of Nursing (DON) who reported that patients are to be referred to by their given name or name of choice. She further reported that staff should not refer to patients as feeders but should instead refer to residents as needing assistance with meals.

Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of hospital transfer for one resident (R#23) out of three residents reviewed. Findings include: An interview with R#23 on 7/8/19 at 12:38 p.m. revealed he had a history of [REDACTED]. A review of the Minimum Data Sets revealed a discharge assessment for 4/2/19 and an entry assessment for 4/6/19. The discharge assessment revealed that the resident was discharged to an acute hospital on [DATE]. A review of the Physician order [REDACTED]. A review of the care plan revealed that the resident had [MEDICAL CONDITION] disease related to [MEDICAL CONDITION]. A review of the Nurse's Note dated 4/2/19 revealed that the resident's oxygen saturation was 93% (percent) and oxygen was applied. The resident was requesting to go to the hospital and the facility obtained an order to send him to the hospital. A Nurse's Note dated 4/3/19 revealed that the resident was admitted to the hospital with [REDACTED]. An interview on 7/11/19 at 10:55 a.m. with the Social Service Director MM revealed that she had not been notifying the Ombudsman of residents who were discharged to the hospital. An interview on 7/11/19 at 11:43 a.m. with the Administrator revealed that she expected the Ombudsman to be notified of emergency transfers once a month. An interview on 7/11/19 at 11:54 a.m. with Vice President of Social Activities/Consultant NN stated that she didn't know why the Ombudsman was not been being notified because she had sent out an email notifying the facilities that they needed to be doing this.

Based on observation, record review and staff interview, the facility failed to ensure that the catheter tubing and urine drainage bag for two of four Residents (R) (R#484 and R#46) with indwelling catheters, were positioned to ensure that these items did not meet contact with the floor. The sample size was 32 residents. Findings include: 1. Record review for R#484 revealed that the resident was admitted to the facility on [DATE] from an acute hospital with a [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Review of the resident's current care plan dated 6/26/19, revealed that the resident has a urinary catheter, and will be free of complications of an indwelling catheter through the review period. Interventions include: care/changing of urinary catheter as ordered, encourage adequate fluid intake, offer at frequent interviews, keep catheter tubing placed below level of bladder, maintain a closed, sterile system with tubing free of kinks, monitor urine output, appearance, amount, odor, and clarity, and observe and report any signs and symptoms of urinary tract infection. Observations were conducted of R#484's catheter tubing and urine drainage bag from 7/8/19 to 7/11/19 as follows: Observation on 7/08/19 at 11:12 a.m., at 1:10 p.m. and at 6:00 p.m. revealed that R#484 was observed in bed, with. the bed in a low position, the catheter bag secured to the bed, however, the urine bag half full of dark yellow urine was sitting on the floor, with urine, in the bag, visible from the door. Observation on 7/9/19 at 10:26 a.m. revealed that R#484 was observed in bed, the catheter bag is covered in a privacy pouch, however bag and tubing are both touching the floor. Observation on 7/9/19 at 3:34 p.m. revealed that R#484 was observed sitting in his wheelchair, the urine bag in a privacy pouch cover; however, the bag in the privacy pouch and tubing are lying on the floor under his wheelchair. Observation on 7/10/19 at 7:45 a.m. revealed that R#484 was in bed, and the urine bag was in a privacy pouch type cover, however, the tubing and urine bag in the pouch were lying on the floor. Observation on 7/10/19 at 9:30 a.m. during medication pass with Licensed Practical Nurse/Charge Nurse (LPN) CC revealed the resident's urine bag was lying on the floor, the catheter tubing touching the floor. The LPN CC stated the urine looks good; Certified Nurse Assistant (CNA) CNA DD was present in the room, removing the breakfast tray and both did not remove the urine bag from the floor. An interview on 7/10/19 at 3:30 p.m. with LPN CC revealed that a resident with a Foley catheter should have a privacy bag and the bag and/or tubing should not be on the floor. Review of the provided facility policy titled, Skilled Inpatient Services-Foley Catheter Care, updated (MONTH) 2019, documents the intent is to promote hygiene, comfort and decrease the risk of infection for patients with an indwelling catheter and is performed daily and as needed for soiling. The Guideline Section No. 8 documents- secure the catheter to drainage bag, Section No. 9- secure the catheter with a securement device, and Section No. 10- position the catheter drainage bag below the bladder. 2. Record review revealed that Resident (R)#46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS), Section O-Special Treatments and Programs, dated 5/9/19 revealed the presence of an indwelling (urine) catheter. Review of the care plan, updated 5/21/19, revealed a care plan for the urinary catheter with appropriate goals and interventions. An observation of R#46 in his bed on 7/8/19 at 2:36 p.m. revealed a urine catheter and bag placed in a privacy pouch with the pouch lying on the floor alongside the bed. An observation of R#46 in his bed on 7/9/19 at 9:45 a.m. and at 4:37 p.m. revealed the urine catheter/bag was inside the privacy pouch but the pouch was lying on the floor. An observation of R#46 in his bed on 7/10/19 at 3:45 p.m. revealed the resident's urine bag inside a privacy pouch, the pouch and catheter tubing were attached to his bed, the bed was in a low position; however, the catheter bag and tubing were lying on the floor. An interview with the Assistant Director of Nursing (ADON), who is also the Infection Control Nurse, on 7/11/19 at 3:33 PM, revealed that her expectation was that the catheter bag must be inside a privacy pouch which should not rest on the floor surface.

Based on record review and staff and resident interviews, the facility failed to maintain completed documentation of the [MEDICAL TREATMENT] Pre/Post Communication Report following eight of 16 [MEDICAL TREATMENT] sessions from 6/1/19 through 7/8/19 for one Resident (R)#71 of 32 sampled residents. Findings include: Review of the policy titled, Skilled Inpatient Services: [MEDICAL TREATMENT] Patient, revealed the intent was to assure safe care for the [MEDICAL TREATMENT] Patient. Procedural guidelines included: 1. Weights are obtained according to Physician Order. 2. Observe vascular access site. 3. Coordination with [MEDICAL TREATMENT] Plan of Care. Review of the clinical record revealed that R#71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/7/19, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact, in Section C - Cognitive Patterns and [MEDICAL TREATMENT] while a resident, under Section O-Special Treatments and Programs. Review of the care plan, updated 6/27/19, revealed care plans for [MEDICAL TREATMENT]; risk for abnormal bleeding; potential for abnormal bleeding/bruising; potential for shortness of breath, chest pain, [MEDICAL CONDITION], and hypertension. Review of the physician's orders [REDACTED]. check for Thrill/bruit (vibration/sound which is felt/heard over a blood vessel) every eight hours, and check the [MEDICAL TREATMENT] site every eight hours. Review of the [MEDICAL TREATMENT] Communication Book revealed missing Pre/Post [MEDICAL TREATMENT] Communication Reports for the following dates: 6/7/19, 6/10/19, 6/19/19, 6/26/18, 6/28/19, 7/1/19, 7/3/19, and 7/5/19. An interview with R#71 on 7/10/19 at 11:49 a.m., revealed that he takes the Communication Form with him to [MEDICAL TREATMENT] clinic then the clinic writes something on it when his session is done and gives it back to him to return to the facility. He stated he doesn't know what happens to the forms after that. An interview with the Director of Nursing (DON) on 7/9/19 at 1:10 p.m. she confirmed there were communication reports missing from the [MEDICAL TREATMENT] Communication Book. An interview with the DON on 7/10/19 at 3:15 p.m. revealed that she was unable to explain what happened to the missing Communication Forms although she would expect the staff nurses to complete their portion of the form prior to [MEDICAL TREATMENT] and would ensure the post-[MEDICAL TREATMENT] forms were completed upon the resident's return to the facility. She further revealed that the nursing staff should contact the [MEDICAL TREATMENT] center, if the post form was not complete, and once completed they would put the form in the [MEDICAL TREATMENT] Communication Book.

Based on record review, staff interviews, and policy review titled [MEDICAL CONDITION] Medications the facility failed to consistently document monitoring of side effects for behaviors for two of five residents (R# 60 and R# 68), who were receiving [MEDICAL CONDITION] medications. Findings include: Review of the policy title [MEDICAL CONDITION] Medications documented that when [MEDICAL CONDITION] therapy is initiated, the patient is monitored quantitatively and qualitatively to determine the effectiveness of the medication and the presence of side effects. The policy further indicated that behaviors should be noted using 0, 1, 2,3, or C if continuous episodes per shift per day. It further indicated that side effects should be indicated with a Y for yes and N for no related to side effects noted per shift per day. 1. Review of the clinical record for R#60 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of MAR for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 revealed medications given as ordered except when refused by resident. Review of behavior monitoring for R#60 revealed there was no behavior monitoring each shift for twelve days in (MONTH) 2019. There was no behavior monitoring each shift for twenty-eight days in (MONTH) 2019. There was no behavior monitoring each shift for ten days in (MONTH) 2019. An interview on 7/11/19 at 4:30 p.m. with the Director of Nursing (DON) who reported that when the electronic medical record program only allowed the behavior monitoring tool documenting for day or night. She further reported that with the behavior monitoring tool staff should be completing twice a day. It was also reported that side effects of the medication are documented only if there are behaviors note. The DON confirmed that there were missing days on the tool and reported that she had not previously identified this as a problem. 2. Review of the clinical record for R#68 revealed resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating some cognitive impairment. Section D revealed no down depressed mood, sleeps much of the day and easily annoyed. Section [NAME] revealed no rejection of care or wandering exhibited. Review of resident's care plan initiated 4/12/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, assess for non-drug interventions, document episodes of refusing requested care, monitor behavior as indicated, notify physician as indicated, and observe for possible side effects. Review of Physician order [REDACTED]. Review of Behavioral Monitoring log dated 5/1/19 - 7/11/19 reveals two episodes of abnormal behavior. The Behavioral Monitoring log fails to consistently monitor the behaviors and side effects of medications taken by Resident # 68. In (MONTH) 2019 there were 37 missed monitoring opportunities during the day and seven missed opportunities during the night. In (MONTH) 2019 there were 48 missed opportunities during the day and 25 missed opportunities during the night. In (MONTH) 2019 there were 22 missed opportunities during the day and seven missed opportunities during the night. The behavior monitoring log only showed monitoring of side effects on 5/2/19, 5/15/19, 5/18/19, 5/19/19, and 6/14/19.

Based on observation and staff interviews, the facility failed to assure the nurse staffing information form was fully completed for four of four days during the survey. Findings include: During observation on 7/9/19 at 8:13 a.m. the daily staffing was posted but missing the facility name. During an interview with the Director of Nursing (DON) on 7/11/19 at 8:49 a.m. it was reported that night supervisor is responsible for completing daily staffing form and a copy is left for her to post each day. During an interview with the Administrator on 7/11/19 at 10:26 a.m. who confirmed that the posted staffing information did not have the facility name on it. The Administrator reported that it had not been noticed that the facility name was not on the form.

Based on observation, review of facility, hospital and police records and staff, resident and family interviews, staffing agencies interviews, the facility failed to ensure that staffing agency employees, utilized by the facility, complied with the facility's Abuse policy and the contract between the facility and the staffing agencies, specifically: This failure resulted in actual harm and death for one resident (R) B of 12 sampled residents. Review of the CMS Form-672, Resident Census and Condition of Residents, dated [DATE], the census was eighty five (85) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE], the date of the injury to R B and subsequent death, and was removed on [DATE] which was verified by the surveyor through observation, review of policies and interviews with staff. On [DATE] around 7:30 a.m., during morning care, CNA AA, held R B legs down tightly due to combative behavior of the resident then heard a crack. CNA AA alerted the nurse telling her that he found the resident in this condition. CNA AA did tell the facility what had occurred before lunchtime. R B was transferred to the hospital and it was determined that the resident had a fractured femur requiring surgical repair. During surgery the R B began to bleed excessively and did not respond to interventions. The resident was transferred to the Intensive Care Unit (ICU) and died on [DATE] at 2:12 a.m. The facility was notified on [DATE], by the hospital, that the R B had died as a result of the fracture. The facility then contacted the local police department on [DATE] who contacted the Georgia Bureau of Investigation (GBI) and CNA AA was arrested by the GBI. Review of the local police department's Incident/Investigation Report dated [DATE] at 14:57 (2:57 p.m.) arrived at the facility to begin the investigation of CNA AA and R B. The facility Administrator, Director of Nursing (DON) and the Nurse Consultant were informed on [DATE] at 9:51 a.m. that Immediate Jeopardy exists. The non-compliance related to the immediate jeopardy was identified to exist on [DATE]. The immediate jeopardy continued through [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The facility implemented a Credible Allegation of Compliance alleging the immediate jeopardy was removed as of [DATE]. Based on observation, record reviews, review of the revised policy for background checks for agency staff and agency contracts, staff, residents and family interviews related to the abuse protocol, it was validated in the corrective actions plans that the immediacy of the deficient practice was removed. However, the facility remains out of compliance as they continue to implement systematic changes related to abuse training, screening of employees and agency staff prior to working directly with residents while management level staff continues to oversee and Quality Assurance monitors the effectiveness of the systematic changes. The Scope and Severity (S/S) was lowered as follows: F224: S/S-F, F282: S/S-F, F490: S/S-F. Findings include: Review of the facility's Policy titled Grievances-Abuse Prohibition Screening and Hiring Practices, updated [DATE]: 1. Screening and Hiring Practices: A. The center will conduct a thorough investigation of the histories of individuals being considered for hire, in addition to the inquiry of the State Nurse Aide Registry or licensing authorities. All reasonable efforts will be made to check references and information from previous and/or current employers to uncover information about any past criminal prosecutions. B. The screening of all applicants will involve the following: 1. Background investigations 2. Criminal Records Check for Pre-employment Screening 3. Substance Abuse C. Prior to hiring an employment applicant, the center shall request a criminal record check from Georgia Crime Information Center (GCIC) to determine whether the applicant has a criminal record. A nursing home shall make a written determination for each applicant for whom a criminal record check is performed. A nursing home shall not employ a person with an unsatisfactory determination. Review of the facility [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R B revealed the resident was admitted to the facility [DATE], was cognitively impaired and unable complete interview questions, was assessed for behaviors of hitting, kicking, verbal behaviors and rejection of care on a daily basis. The resident was assessed for extensive assist by one or two persons for Activity of Daily Living (ADL) and was assessed for extensive assist, by one person, for dressing. Review of the care plan for R B revealed a Problems/strengths: Resident resist Activities of Daily Living (ADL) at times evidenced by cursing and hitting at staff with potential to cause harm to self. Intervention dated [DATE]: Two person assist when resident is combative and an intervention dated [DATE]: Allow resident time to calm down and approach again at a later time. Record review of the Physician order [REDACTED].½ tablet at bedtime for GAD, [MEDICATION NAME] 10 mg at bedtime for dementia, [MEDICATION NAME] ,[DATE] mg one tablet twice daily as needed for pain, not to exceed two per day, [MEDICATION NAME] 0.5 mg one tablet daily as needed (prn) for agitation but no blood thinners. Review of the Situation, Background, and Appearance and Review (SBAR) report dated [DATE] at 8:00 a.m. revealed that R B's right thigh was swollen and right foot is turn inward. The resident's vital signs were recorded as follows: Blood Pressure-,[DATE], pulse-112, respirations-20 and temperature-96.0. Resident is shouting more than normal Oh my leg. The resident's Physician was notified with a new order to send to the hospital. Nursing notes: called into the room by the CNA. Patient's right thigh swollen and right foot turned inward. Family notified. Signed by Licensed Practical Nurse (LPN) BB. Review of the facility's Follow-up Entity Report dated [DATE] revealed that during their investigation, staff and the resident's roommate were interviewed. CNA AA provided two written and verbal statements dated [DATE] without times; 1. He was providing care to the resident and observed swelling to the resident's right thigh and immediately called for a charge nurse. 2. The CNA AA, at approximately 11:30 a.m. and 12:00 p.m., provided a verbal and written statement to the Administrator and the Director of Nursing (DON), where he stated that he held the resident's legs down tightly and heard a crack, then immediately notified the nurse but did not tell the nurse what had happened. CNA AA was immediately sent home and staffing agency was notified of the incident and informed that CNA AA could not return to the facility due to the incident. Education of staff has been implemented regarding Abuse, Neglect and Resident Rights. Record review of the Interdisciplinary Progress Notes dated [DATE] at 8:00 a.m. revealed a note by LPN BB that she had been called into R B's room by the CNA. Patient lying in bed, yelling out. Patient's right thigh swollen, tender to touch, right leg turned inward. Patient sent to hospital for evaluation via ambulance. Family member notified. Patient was offered pain medication several times, resident refused and attempted to hit medication out of LPN's hand. Review of the hospital emergency room records dated [DATE] beginning at 9:05 a.m. Registered Nurse (RN) entry: Patient presents to the Emergency Department (ED) via Emergency Management Services (EMS) from facility with complaint (c/o) pain and swelling. Per EMS, patient was found this morning to have obvious deformity to upper right leg. Per facility nobody knows what happened as nothing was reported from night shift. Patient has advanced dementia and is a poor historian. Patient confused but complaining pain to the right leg. Leg noted to be swollen, pedal pulses not found. Will get Doppler for pulses. Physical exam: Blood Pressure (BP) ,[DATE] (low blood pressure), pulse: 85, Temperature 97.7 degrees Fahrenheit (F), respirations: 18. Medical Doctors notes dated [DATE] at 9:36 a.m. revealed the resident is oriented to person, place and time. The resident appears well-developed and well-nourished. Non-toxic appearance. The resident does not have a sickly appearance. She does not appear ill. No distress. Screaming in pain. Systolic BP: 70. Hematoma over right mid-thigh. Complete Blood Count (CBC): Red blood count: 3.43 (low), Hemoglobin 10.2 (low), Hematocrit: 31.8 (low). [MEDICATION NAME] Time (PT): 19 (high), International Normalized Ratio (INR): 1.62 (high). Nursing note dated [DATE] at 9:45 a.m. Patient BP low. Physician ordered bolus of fluids. X-ray of right femur: Confirmed right femur fracture. Consult with Orthopedic Surgeon for surgical repair of fracture. Admit in-patient. An interview with the Director of Nursing (DON) and the Administrator on [DATE] at 6:00 p.m. revealed that CNA AA was an agency employee. The DON explained that when she came into the facility on [DATE] the resident had just left to go to the hospital (after 8:51 a.m.) and therefore did not see the resident that morning herself. The Administrator revealed that she had been alerted by nursing and did see the resident before she left for the hospital. They further revealed that an investigation was started immediately and the State Survey Agency was notified within two hours of an injury of unknown origin for R B. Review of the facility staffing for the last month revealed that the facility used a number of agency staff daily. On [DATE] of 12 Licensed Practical Nurses (LPN's), one agency LPN (Agency #3) worked two shifts and of 26 CNAs, 12 were agency CNAs (11 CNAs from Agency #2 and one CNA from Agency #1) which were consistent with the days reviewed from [DATE] through [DATE]. An interview with the DON on [DATE] at 6:42 p.m. revealed that CNA CC, the staffing coordinator, is responsible for the daily staffing schedule. She is responsible for reviewing the background checks and [MEDICAL CONDITION] test for all agency staff before they work. It is unclear who does this when CNA CC isn't working. Continued interview with the DON revealed that neither she nor the Administrator were aware that the staffing coordinator was not receiving a background check which met the facility's Abuse policy or the contract between the facility and the staffing agencies. Continued interview with the DON revealed that when the DON first interviewed CNA AA, on [DATE] shortly after the DON arrived at the facility and had him write a statement, he stated that the resident was found with a swollen thigh when he was doing care after coming on duty that morning. She contacted the staffing agency in an attempt to speak to the agency CNA who had taken care of the resident on the 11:00 p.m. to 7:00 a.m. shift but was unable to get in touch with the night CNA. She then asked to speak to CNA AA again for more detail but this time CNA AA changed the story somewhat. At this time, the DON became suspicious and asked CNA AA to speak to her and the Administrator around 11:30 a.m. to 12:00 p.m. It was at this time the CNA confessed to holding R B's legs down tightly due to the resident kicking and resisting care, until he heard a crack. The DON revealed at that time the CNA was sent home after this interview. The Administrator was then asked for copies of the contract with the staffing agencies and the background check for CNA AA and all agency staff which were in the building today. An interview with the DON and Administrator on [DATE] at 7:42 p.m. they supplied the background check of CNA AA plus his CNA and CPR certificate and a recent skills check list. The DON stated that when the facility was notified that the resident had died at the hospital on [DATE], at which time, the facility then notified the local police department. They explained that the local police department notified the Georgia Bureau of Investigation (GBI) who immediately began an investigation. She revealed that the GBI agent had been to the facility multiple times and questioned employees, including earlier today. She revealed that the GBI agent had made her aware of a forthcoming press release from the GBI related to the incident. A telephone interview on [DATE] at 1:08 p.m. with the family member of R B revealed that the facility notified the family member timely. The family member reported that R B could be combative at times. The family member reported that on [DATE] the resident was sent to the hospital and found to have a fractured femur which would require surgery to repair. The surgeon had said it would take about one hour but after two hours the surgeon came out and said they were having trouble stopping the bleeding. The resident was sent to ICU and died about 2:00 a.m. on [DATE]. Record review of the agency contracts for the three agencies used by the facility revealed for all agencies: 4. Screening of Employees: The Agency warrant that Temporary Personnel providing services under this agreement have been thoroughly screened by Agency. This screening will include but is not limited to: Verification of current State of Georgia professional license or certification, if applicable, the Office of Inspector General's (OIG) participation exclusion listing, National and Georgia criminal background reports (to include Georgia Crime Information Center (GCIC); and any other screening requirements as set forth under the Georgia Medicaid Provider Manual. The provision to meet Georgia Medicaid Provider screening requirements is required even if Agency is not actively enrolled as a Medicaid provider. Temporary Personnel with a felony conviction within the last ten years and/or listed on the OIG exclusion listing will not provide services to the Nursing Center. Review of the Background checks for 16 agency staff CNAs (CNA II, JJ, KK, LL, MM, NN, OO, PP, QQ, RR, SS, TT, UU, VV and WW), including CNA AA, with the DON, from all three agencies revealed that the background checks did not meet the facility's Abuse policy or the facility's contract with the agencies. An interview with the DON and Administrator on [DATE] at 5:30 p.m. revealed that they could not get an answer regarding whether the agency staff screening complied with the facility's Abuse policy or with the contract between the staffing agencies and the facility until after the holiday weekend. The Administrator and DON were asked if there had ever been a problem with CNA AA or anything that might have indicated there was a concern. They both answered there had not been any problems with CNA AA and that he had been a good employee. The Administrator and the DON did not mention that CNA AA had been part of a facility investigation, at their facility, for an injury of unknown origin, which was not substantiated by the facility, on [DATE]. A news story on the evening of [DATE] indicated that CNA AA had been previously arrested for elder abuse in 2016 which was confirmed by the GBI agent, via telephone, on [DATE] at 9:39 a.m. A second telephone interview with the GBI agent on [DATE] revealed that copies of the police reports would be supplied and were obtained on [DATE] at 3:07 p.m. Review of the police reports revealed that CNA AA had been arrested in 2016 for resident abuse at another facility. A review of reports which named CNA AA revealed seven reports to the State of Georgia, beginning with GA 587 dated [DATE], due to allegation of neglect by CNA AA, which was not substantiated. Review of GA 505 dated [DATE], due to allegation of sexual abuse by CNA AA, resulted in a police report but was unsubstantiated. Review of GA 743 dated [DATE], GA 744 dated [DATE] and GA 746 dated [DATE] by the same facility for three different resident who had reported CNA AA of abusive behavior revealed that CNA AA was terminated and the police notified. Review of GA 495 dated [DATE] due to allegation of abuse by CNA AA, the allegation was unsubstantiated. Review of GA 753 dated [DATE], due to an allegation of sexual abuse by CNA AA, with the CNA being terminated and escorted off the property. Review of GA 610 dated [DATE], at the current facility, due to bruising of unknown origin, was not substantiated which was not disclosed to the surveyor. Review of GA 590 dated [DATE] due to an allegation of abuse by CNA AA. The CNA AA was terminated immediately, the police were called and investigated the incident which resulted in CNA AA being arrested in [DATE]. Review of the police report and investigation, related to GA 590 at another facility, dated [DATE] and the Incident Narrative dated [DATE] with details regarding the incident. A warrant was issued for CNA AA's arrest on [DATE]. CNA AA was arrested on [DATE]. The disposition of this case is unknown. On [DATE] at 9:30 a.m. and an interview with the Administrator, DON and Corporate Regional Nurse BBB on the same day at 9:51 a.m. to inform them that an immediate jeopardy existed due to abuse and improper screening of agency staff that did not comply with the facility's Abuse policy or the contract between the facility and the staffing agencies. The Administrator revealed that she was not aware that the agencies screening did not meet the facility's policy or the contract between the facility and the staffing agencies until the surveyor brought this to her attention and they had not looked closely enough at the background checks. She further revealed that the staffing agency contracts are standard corporate contracts but are entered into by the individual facilities. She agreed that it was assumed the staffing agencies were doing screenings that met the facility's Abuse policy and the contract between them. She had no explanation for this failure. She did confirm that staffing issues had been placed in Quality Assurance (QA) earlier in the year as there is so much competition in this area for staff, it is difficult to get staff. An interview with R F, R B's roommate on [DATE], on [DATE] at 11:30 a.m. revealed the resident in bed and appeared to be alert and oriented at this time. Review of the resident's Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. The resident could not remember any specifics of [DATE] when R B was sent to the hospital. She stated that there had been no problems for her with CNA AA or other staff. On [DATE] at 1:30 p.m. the local police report, dated [DATE] at 14:57 (2:57 p.m.) was obtained from the local police department which provided the same information as the entity five day investigation report. An interview with the DON on [DATE] at 4:00 p.m. revealed that staffing was placed into QA in ,[DATE] and in ,[DATE]. The facility began incentives for referrals from current staff. They increased salaries in [DATE] which brought staff in but once they were trained they left for higher pay at other healthcare facilities in the area. Staffing continues to be a major problem for them. An interview with CNA CC, scheduler, on [DATE] at 10:28 a.m. revealed that she is responsible for ensuring the agency staff have background checks although she was not aware that the agency employee's screening and background checks did not meet the facility's Abuse policy or the contract with the facility. She was not aware until after the surveyor brought this to the Administrator's and DON's attention. An interview with LPN CCC on [DATE] at 11:24 a.m. revealed that she usually works as a charge nurse but is working in a CNA position today. The facility is no longer using agency staff until the screening issue is resolved. She revealed that CNA AA has worked under her several times. She is not aware of any other facilities that he may have worked nor has received any complaints from residents about CNA AA. An interview with LPN BB on [DATE] at 12:52 p.m. revealed that she has been employed at the facility for nine years. She revealed that she gave a written statement about the incident on [DATE]. She revealed that on the morning of [DATE], around 8:00 a.m., that she was passing medications on the 200 hall and heard R B yelling out, which was not usual for the resident during care. She then stated that CNA AA was standing at the resident's door and motioned for her to come. She saw the resident's leg and ask CNA AA what happened to which he replied I found her this way. She states that the resident pants were around her ankles. She revealed that R B's leg was swollen and bruised with her foot turned inward. She called the ambulance service, the doctor and the family member. The resident was transported to the hospital. She stated that when the resident was on the stretcher CNA AA said I'm so nervous and she said why? LPN BB further revealed that she went back to passing medications and CNA AA went to take care of another resident. She states that CNA AA called her to that room and found R I on the floor with a skin tear. She says that CNA AA said the resident just rolled out of bed and onto the floor. LPN BB further revealed that CNA AA was pulled off the floor, by the DON, around lunch time on [DATE]. An interview with the DON on [DATE] at 1:34 p.m. revealed that she arrived at the facility about 8:00 a.m. on [DATE] and was told about the incident with R B although the resident had already gone to the hospital when she arrived. She says that CNA AA was doing care for R F at that time and she called him out to find out what had occurred with R B. She states that LPN BB had made her aware that R I had fallen out of bed during care. The DON revealed that LPN DDD may be able to give more information regarding this incident. An interview with LPN DDD on [DATE] at 1:41 p.m. revealed that she did not work closely with CNA AA but thought that CNA EEE did work with CNA AA frequently and she was working on [DATE]. She only knew that R I had fallen out of bed but did not know the details. An interview with CNA EEE on [DATE] at 1:52 p.m. revealed that she assisted CNA AA to get R I up from the floor and back to bed, after the nurse assessed the resident. She stated the bed was at a high position, the resident was sitting on the floor with towels due to his arms bleeding, when she entered the room. She revealed that the R I had made the statement to her about CNA AA picking the resident up by himself and she asked if the resident remembered me helping, which he did. Continued interview with CNA EEE, at this time, revealed that CNA AA would sometimes tell her that he had just come from another job, working nights at another facility. She revealed that she and CNA AA were providing care to a cognitively impaired resident and that CNA AA stated that he was afraid of what some of the confused residents might say he did to them. She thought this was an odd statement but did not report the comment. An interview on [DATE] at 2:00 p.m. with the Administrator revealed that the facility had stopped using agency staff as of [DATE] until Corporate worked out the screening issues. A telephone interview, post survey Quality Assurance review, on [DATE] at 10:01 a.m. with the Administrator revealed that the previous DON had trained the current DON and CNA CC about the agency book. The Administrator further revealed that she would ask CNA CC if she was keeping up with the agency book but that no one realized the background checks from the agencies did not met the facility's Abuse policy nor the contract between the agencies and the facility. She confirmed that CNA CC, the previous or current DON, had ever seen the contract between the agencies and the facility. The Administrator assumed that the agencies were following the contract but she did not confirm that they were. The Administrator was asked why the facility did not report to the police the day the incident occurred and the Administrator revealed she was in touch with the Corporate Consultants and they did not feel that CNA AA had intended to harm the resident. After hearing that R B had died , it was decided that the police should be called. The Administrator revealed that the responding police officer didn't think it was a criminal act at that point. Post survey review of the Emergency Medical Services (EMS) records and the hospital records for R B, received on [DATE] revealed that the call came in to EMS on [DATE] at 8:10 a.m., they arrived at the facility at 8:25 a.m. and left the facility at 8:51 a.m. then arrived at the hospital emergency room (ER) at 9:01 a.m. The records revealed a Physician's note dated [DATE] at 12:33 p.m. The resident has angular deformity, difficulty moving the leg and was brought to the ER and found to have a mid-shaft oblique femur fracture shortened and angulated. Orthopedic service was called to consult. Review of the Surgeon's Postoperative [DIAGNOSES REDACTED]. Laboratory test were ordered during surgery revealing the resident's INR was at 8 (normal 0XXX,[DATE].12) with a hematocrit of 5.5 (normal 36XXX,[DATE].0). We continued with our resuscitation attempts transfusing two units of packed red cells and two units of Fresh Frozen Plasma (FFP). The resident was transferred to the Intensive Care Unit (ICU) and the Physician notified the family of the events and that it is unlikely the resident will recover from this event. Review of the hospital Demographic Information dated [DATE] revealed that R B died on [DATE] at 2:12 a.m. Review of hospital Final [DIAGNOSES REDACTED]. The autopsy report for R B is pending. A telephone interview with staffing agency #1, on [DATE] at 4:16 p.m. revealed that she employed CNA AA who had worked for her since beginning the business years ago. She stated that she had not received any complaints about CNA AA and was shocked by the news. She confirmed that a background check had been run on CNA AA [DATE] but that she has Public Record Reports run as background checks. She was unaware that Criminal Background checks were needed and was not aware these background checks did not meet the facility's policy or the contract with the facility. She then asked for a copy of the contract as she did not have one. She had never heard of a Georgia Criminal Information Center (GCIC) background check. She revealed that reference checks were not conducted on potential employees. The surveyor requested a list of assignments for CNA AA to include dates and names of facilities which were supplied via email on [DATE]. A telephone interview on [DATE] at 1:19 p.m. with staffing agency #3 Administrator revealed that CNA AA had never worked for their agency. The Administrator revealed that a nationwide background check is done but does not include a GCIC background check. The agency does reference checks and is Joint Commission accredited. A telephone interview on [DATE] at 1:34 p.m. staffing agency #2 revealed that CNA AA had never worked for their agency. They do a background check but it is not the GCIC background check. They are not always able to conduct reference checks as some employees, who are currently employed, do not want their employer to know that are working extra. They do conduct personal references. A telephone interview, during post-survey Quality Assurance review, on [DATE] at 9:35 a.m. revealed that CNA CC had started in this position around [DATE]. She revealed that before she took over keeping up with the Agency book, (which included: background checks, license/certification, TB testing and CPR certification) the previous DON was responsible. The previous DON had worked with her and the current DON as to what was kept in the book although neither the previous or current DON, was aware the background checks did not met the agency/facility contract. CNA CC revealed that she has never seen the contract between the agencies and the facility. CNA CC further revealed that since the agencies basically sent the same people over and over again, who already had a folder in the agency book (including CNA AA), she did not need to recheck the background checks which had already been done and were contained the agency book. The facility implemented the following actions to remove the immediate jeopardy: 1. Beginning on [DATE] 11:45 A.M. the agency CNA that was involved in the incident is no longer providing care in our center. On [DATE] all agency employees utilized from agencies will receive Georgia Criminal Information Center (GCIC) background checks prior to returning to work. 2. All Residents have the potential to be affected. 3. To prevent reoccurrence, the decision was made by management and operations support team to not use agency until agency personnel have abuse training and a GCIC background completed and submitted to the center for review by the Administrator, Director of Nursing or Overhouse Supervisor . The administrator contacted the agencies by telephone on [DATE] to request that backgrounds be rerun on the agency employees that they send to center. A certified return receipt letter was mailed that day requesting same. On [DATE] the administrator emailed the agencies to inform them that the background checks had to include the GCIC as part of the background. The Agency contracts have been revised to include providing the center with a copy of GCIC background check, PPD (TB test), and reference check information for any agency staff used by the center. These requirements also apply to direct hires. In addition the center will provide abuse training for agency and direct hires prior to patient contact. The Administrator, Director of Nursing or Overhouse Supervisor will review the information provided from the nursing agency prior to them working to ensure it meets guidelines. If information provided does not meet the standard or reveals information that prohibits their eligibility to provide service, the individual will not be permitted to work at the center, and the agency will be notified. 4. The policy for background checks for agency staff has been revised to reflect current practice. The agency contract has been revised [DATE] to ensure background checks include GCIC requirements. Our parent company notified the agencies by letter on [DATE] that we are conducting a review of their process and a copy of their screening process was requested. An attestation of compliance will be required of the agencies. 4 of 4 hiring associates and 10 of 10 directors received training on [DATE] on the Agency Personnel Hiring Guidelines. Training for center associates began on [DATE]. As of [DATE] 80 of 90 center associates have received education on abuse. Those that have not been educated are either on FMLA or are temporary associates. Those associates will receive training prior to working. 4 of 4 agency associates

Based on record review and staff interviews the facility failed to ensure that the care plan was followed for one resident (R) B relating to combative behaviors. This failure resulted in actual harm and death for one resident (R) B of twelve sampled residents whose right femur was fractured by CNA AA and the resident died , at the hospital, within 24 hours. Review of the CMS Form-672, Resident Census and Condition of Residents, dated [DATE], the census was eighty five (85) residents. On [DATE] around 7:30 a.m., during morning care, CNA AA, held R B legs down tightly due to combative behavior of the resident then heard a crack. CNA AA alerted the nurse telling her that he found the resident in this condition. CNA AA did eventually confess what had occurred with R B. R B was transferred to the hospital and it was determined that the resident had a fractured femur requiring surgical repair. During surgery R B began to bleed excessively which did not respond to interventions. The resident was transferred to the Intensive Care Unit (ICU) and died on [DATE] at 2:12 a.m. The facility notified the local police on [DATE] who turned the investigation over to the Georgia Bureau of Investigation (GBI). CNA AA was arrested by the GBI. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE], the date of the injury to R B and subsequent death. The facility Administrator, Director of Nursing and the Nurse Consultant were informed on [DATE] at 9:51 a.m. that Immediate Jeopardy was determined to exist. The non-compliance related to the immediate jeopardy was identified to exist on [DATE]. The facility implemented a Credible Allegation of Compliance alleging the immediate jeopardy was removed as of [DATE]. Based on observation, record reviews, review of the revised policy for background checks for agency staff and agency contracts, staff, residents and family interviews related to the abuse protocol, it was validated in the corrective actions plans that the immediacy of the deficient practice was removed. However, the facility remains out of compliance as they continue to implement systematic changes related to abuse training, screening of employees and agency staff prior to working directly with residents while management level staff continues to oversee and Quality Assurance monitors the effectiveness of the systematic changes. The Scope and Severity (S/S) was lowered as follows: F224: S/S-F, F282: S/S-F, F490: S/S-F. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R B revealed the resident was admitted to the facility [DATE], was cognitively impaired and unable to complete interview questions, was assessed for behaviors of hitting, kicking, verbal behaviors and rejection of care on a daily basis. The resident was assessed for extensive assist by one or two persons for Activity of Daily Living (ADL) and was assessed for extensive assist, by one person, for dressing. Review of the care plan for R B revealed a Problems/strengths: Resident resists Activities of Daily Living (ADL) at times evidenced by cursing and hitting at staff with potential to cause harm to self. An intervention date [DATE]: Two person assist when resident is combative. Intervention dated [DATE]: Allow resident time to calm down and approach again at a later time. An interview with the DON on [DATE] at 6:42 p.m. revealed that when the DON first interviewed CNA AA, on [DATE] and had him write a statement, he stated that the resident was found with a swollen thigh when he was doing care after coming on duty. She then asked to speak to CNA AA again for more detail but this time CNA AA changed the story somewhat. At this time, the DON became suspicious and asked the CNA AA to speak to her and the Administrator together. It was at this time the CNA confessed to holding R B's legs down tightly due to the resident kicking and resisting care, until he heard a crack. At that time he called for the nurse although he did not share what had occurred, only that he found the resident in this condition. CNA AA made a second written statement to this fact which is dated [DATE] but does not include a time. The DON revealed that the facility policy and the resident's care plan for a resident who is resisting care, is to walk away and approach the resident later. She agrees that CNA AA did not do this which resulted in the fracture of R B's leg. Cross refer to F224 The facility implemented the following actions to remove the immediate jeopardy: 1. Beginning on [DATE] 11:45 A.M. the agency CNA that was involved in the incident is no longer providing care in our center. On [DATE] all agency employees utilized from agencies will receive Georgia Criminal Information Center (GCIC) background checks prior to returning to work. 2. All Residents have the potential to be affected. 3. To prevent reoccurrence, the decision was made by management and operations support team to not use agency until agency personnel have abuse training and a GCIC background completed and submitted to the center for review by the Administrator, Director of Nursing or Overhouse Supervisor . The administrator contacted the agencies by telephone on [DATE] to request that backgrounds be rerun on the agency employees that they send to center. A certified return receipt letter was mailed that day requesting same. On [DATE] the administrator emailed the agencies to inform them that the background checks had to include the GCIC as part of the background. The Agency contracts have been revised to include providing the center with a copy of GCIC background check, PPD (TB test), and reference check information for any agency staff used by the center. These requirements also apply to direct hires. In addition the center will provide abuse training for agency and direct hires prior to patient contact. The Administrator, Director of Nursing or Overhouse Supervisor will review the information provided from the nursing agency prior to them working to ensure it meets guidelines. If information provided does not meet the standard or reveals information that prohibits their eligibility to provide service, the individual will not be permitted to work at the center, and the agency will be notified. 4. The policy for background checks for agency staff has been revised to reflect current practice. The agency contract has been revised [DATE] to ensure background checks include GCIC requirements. Our parent company notified the agencies by letter on [DATE] that we are conducting a review of their process and a copy of their screening process was requested. An attestation of compliance will be required of the agencies. 4 of 4 hiring associates and 10 of 10 directors received training on [DATE] on the Agency Personnel Hiring Guidelines. Training for center associates began on [DATE]. As of [DATE] 80 of 90 center associates have received education on abuse. Those that have not been educated are either on FMLA or are temporary associates. Those associates will receive training prior to working. 4 of 4 agency associates that meet the requirements have been trained on abuse and have the appropriate background checks to include GCIC. 5. Center QAPI meeting was held on [DATE] to conduct a post event review that included abuse and resident rights. Another Center QAPI meeting was held [DATE] to review the revised guidelines for background screening for agency personnel and details entered into the QAPI meeting minutes. Our Operations Support representatives and Chief Compliance Officer reviewed and approved the updated guidelines on [DATE]. Medical Director notified of incident and the opportunities identified to correct in the future. Administrator or Director of Nursing will monitor for compliance. 6. Human Resources associate audited 100% of current associate files for abuse training and back ground checks to include GCIC on [DATE]. The administrator or Human Resources associate will audit twelve agency or direct hire associates files per week for four weeks to ensure abuse training has been completed prior to patient care and background checks are correct to Include GCIC background. Random audit of six associate files will be completed per month for accuracy for three months. A Quality Improvement Data Collection Grid, titled Associate Abuse Training and Background Checks to include GCIC, will be used to document compliance. All audit reviews will be reviewed in the QAPI meeting to ensure ongoing compliance. We are alleging compliance as of [DATE]. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Removal as follows: 1. Review of the facility's five day investigation and review of the staff schedule from [DATE] through [DATE] revealed that CNA AA was crossed off the schedule and replaced with another CNA. 2. The Administrator has confirmed that interviews with some residents regarding CNA AA were done and have spoken to any residents or family members that have expressed concern regarding the incident and news stories. 3. Review of the staffing schedule from [DATE] through [DATE] revealed that only direct staff were on the schedule and in the building. All staff in the building for [DATE] and [DATE] were verified per the facility schedule for the day and evening shifts. There were no agency staff in the building during the review. 4. The facility policy titled Agency Personnel-Background Screening revealed the policy was update in [DATE] and was reviewed. An in-service conducted on [DATE] on Overview of Meeting Agency personnel hiring requirements revealed that 13 facility employees, and one Corporate Regional Nurse, who are responsible for decisions to call in agency staff participated in the in-service. A form titled Quality Improvement Data Collection Grid to be utilized by the hiring associates and managers to track that all information is available from the agencies before allowing the agency employee to work with residents. An interview with CNA CC, scheduler, on [DATE] at 10:28 a.m. revealed that when she is not working, or on the weekends, the Overhouse nurse would make the decision if staffing agency personnel is needed. She revealed that she had participated in an in-service on [DATE] regarding the new procedure for agency staff. The nurse would be responsible for checking background checks and [MEDICATION NAME] (TB) skin test were completed and negative before agency staff can work with residents. She reveals that now GCIC background checks are required of agency staff before they can work in the facility. 5. The facility and corporate office have reviewed the agency contracts. After further review, it was determined that the contract did not need revision although a process to ensure the contract was followed was put into place. A review of the new attestation form titled Affirmation of Compliance Provisions Background Screening of Agency Personnel revealed that these are signed, in addition to the contract, by the Staffing Agency owner or manager. The Staffing Agency that employed CNA AA is in process of contracting with a background screening service to offer GCIC services but in the meantime the employees will go to the local police department to have the needed background check completed before working. The facility policy titled Agency Personnel-Background Screening revealed the policy was updated in [DATE] and was reviewed. An in-service conducted on [DATE] on Overview of Meeting Agency personnel hiring requirements revealed that 13 facility employees, and one Corporate Regional Nurse, who are responsible for decisions to call in agency staff participated in the in-service. A form titled Quality Improvement Data Collection Grid to be utilized by the hiring associates and managers to track that all information is available from the agencies before allowing the agency employee to work with residents. Review of the facility in-services on Abuse from [DATE] through [DATE] revealed that 80 of the 90 employees had completed the in-service which also included an understanding quiz. Interviews on [DATE] with CNA DD at 11:36 a.m., CNA GG on [DATE] at 2:56 p.m., interviews on [DATE] CNA CC, scheduler, at 10:28 a.m., CNA FFF on [DATE] at 11:00 a.m., CNA EEE on [DATE] at 1:52 p.m. revealed that they had recently participated in in-services on abuse, recognizing abuse and to who they should report any allegation of abuse to at the facility. An interview with the Assistant Director of Nursing (ADON) R.N., on [DATE] at 2:45 p.m. revealed that she had recently had in-services on multiple items including recognizing abuse, what to do if it is reported to her and how to report to the State. Interviews on [DATE] at 11:41 p.m. with Housekeeper EE and on [DATE] with Housekeeper GGG at 11:16 a.m. revealed that they had recently had an in-service on abuse, were aware of what abuse involved. They would report any allegation of abuse to their supervisor or the nurse on the floor. They were aware of the Ombudsman program and the abuse hotline and where the posters were located in the facility. Interviews on [DATE] with LPN HH at 3:01 p.m., on [DATE] with Registered Nurse (RN) FF at 3:23 p.m., LPN CCC at 11:24 a.m., LPN BB at 12:52 p.m., LPN DDD at 1:41 p.m. who revealed they had recently participated in multiple in-services relating to abuse, identifying abuse, who to report abuse to in the facility or how to report abuse to the State. 6. Review of the Quality Assurance Improvement Plan (QAIP) sign in sheets reveal that on [DATE] and [DATE] QAIP meetings were held to discuss the immediate jeopardy issue. A telephone interview with the Medical Director on [DATE] revealed that she is aware that staffing issues are a problem at the facility and has been discussed in the QA meetings that she has attended. She also revealed that the facility made her aware of the incident with R B and CNA AA the day after the incident. She discussed the situation with the DON on the next visit. Review of the facility audit sheet revealed that 100% of direct facility employees have been confirmed as having had abuse training and a background check that includes a GCIC background check.

Based on record review, review of the Administrator job description and interviews including staffing agencies interviews, the facility failed to ensure that staffing agency employees, utilized by the facility, complied with the facility's Abuse policy and the contract between the facility and the staffing agencies, specifically: On [DATE] at approximately 7:30 a.m. Certified Nursing Assistant (CNA) AA (a staff agency CNA) was getting resident (R) B dressed. CNA AA notified Licensed Practical Nurse (LPN) BB that R B had a swollen right thigh and was complaining of pain. LPN BB assessed the resident and it was determined that R B had a swollen right thigh and the right foot was turned inward. LPN BB contacted the Physician and family at 8:00 a.m. and the resident was transported to the hospital for evaluation. Record review of the hospital emergency room notes revealed that R B had a fractured right femur which required surgical intervention to repair. Post-survey review of the Emergency Medical Services (EMS) report, dated [DATE], revealed the call came into EMS at 8:10 a.m., EMS at the scene at 8:25 a.m. and left the facility at 8:51 a.m. arriving at the hospital at 9:01 a.m. The facility was notified on [DATE], by the hospital, that the R B had died as a result of the fracture. The facility then contacted the local police department on [DATE] who contacted the Georgia Bureau of Investigation (GBI) and CNA AA was arrested by the GBI. Review of the local police department's Incident/Investigation Report dated [DATE] at 14:57 (2:57 p.m.) arrived at the facility to begin the investigation of CNA AA and R B. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. Immediate Jeopardy was identified to exist on [DATE], the date of the injury to R B and subsequent death. The facility Administrator, Director of Nursing and the Nurse Consultant were informed on [DATE] at 9:51 a.m. that immediate jeopardy was determined to exist. The non-compliance related to the immediate jeopardy was identified to exist on [DATE]. The facility provided a Credible Allegation of Compliance (AOC) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on [DATE]. Based on the validation of the Credible Allegation of Compliance, the State Survey Agency (SSA) determined the immediate jeopardy was removed. The Scope and Severity were lowered as follows: F224:F, F282:F, F490: F while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance monitors the effectiveness of the systematic changes related to abuse and screening of agency staff prior to working with residents. Review of the CMS Form-672, Resident Census and Condition of Residents, dated [DATE], the census was eighty five (85) residents. Cross refer to F224 Findings include: Review of the Administrator job description revealed: Directs the day to day functions of the Nursing Center in accordance with current federal, state and local regulations that govern long-term care centers, and as may be directed by the Regional Vice President, to provide appropriate care for our patients. Review of the Administrators State license revealed that it is current. An interview with the Administrator on [DATE] at 5:30 p.m. revealed she had been at the facility since 2005. She has never experienced a situation like what happened on [DATE] with R B and CNA AA. She revealed that the incident was first thought to be an injury of unknown origin that was reported to the State within two hours. She revealed that the Director of Nursing (DON) had interviewed CNA AA and had him write a statement which described that he found the resident with a swollen thigh and yelling in pain which was reported to the nurse. After asking additional information from CNA AA, by the DON, the story changed somewhat at which time it was decided to interview him together. CNA AA confessed that he had held the resident's legs down tightly, due to the resident being combative and kicking at him, then heard a crack. The resident immediately started yelling that her leg hurt and was swollen. CNA AA provided another statement, which is dated but does not have a time, to these facts. At that time the CNA was sent home and the staffing agency was notified and that CNA AA could not come back to the facility. An interview with the Administrator and the DON on [DATE] at 7:42 p.m. revealed that the facility was notified on [DATE] that the resident had died , at which time, they contacted the local police who came to the facility to take the report on [DATE] at 2:57 p.m. (14:57). The case was turned over to the Georgia Bureau of Investigation (GBI) who began an investigation immediately. The GBI agent interviewed the Administrator and staff at the facility and CNA AA was arrested by the GBI for elderly abuse. The Administrator supplied a copy of the background report for CNA AA and the facility contracts with three staffing agencies utilized by the facility. All background checks were requested for agency staff in the building today. Review of the facility's Policy titled Grievances-Abuse Prohibition Screening and Hiring Practices, updated [DATE]: 1. Screening and Hiring Practices: A. The center will conduct a thorough investigation of the histories of individuals being considered for hire, in addition to the inquiry of the State Nurse Aide Registery or licensing authorities. All reasonable efforts will be made to check references and information from previous and/or current employers to uncover information about any past criminal prosecutions. B. The screening of all applicants will involve the following: 1. Background investigations 2. Criminal Records Check for Pre-employment Screening 3. Substance Abuse C. Prior to hiring an employment applicant, the center shall request a criminal record check from GCIC to determine whether the applicant has a criminal record. A nursing home shall make a written determination for each applicant for whom a criminal record check is performed. A nursing home shall not employ a person with an unsatisfactory determination. Record review of the agency contracts for the three agencies used by the facility revealed for all agencies: 4. Screening of Employees: The Agency warrant that Temporary Personnel providing services under this agreement have been thoroughly screened by Agency. This screening will include but is not limited to: Verification of current State of Georgia professional license or certification, if applicable, the Office of Inspector General's (OIG) participation exclusion listing, National and Georgia criminal background reports (to include Georgia Crime Information Center (GCIC); and any other screening requirements as set forth under the Georgia Medicaid Provider Manual. The provision to meet Georgia Medicaid Provider screening requirements is required even if Agency is not actively enrolled as a Medicaid provider. Temporary Personnel with a felony conviction within the last ten years and/or listed on the OIG exclusion listing will not provide services to the Nursing Center. Review of the facility staffing for the last month revealed that the facility used a number of agency staff daily. On [DATE] of 12 Licensed Practical Nurses (LPN's), one agency LPN (Agency #3) worked two shifts and of 26 CNAs, 12 were agency CNAs (11 CNAs from Agency #2 and one CNA from Agency #1) which were consistent with the days reviewed from [DATE] through [DATE]. An interview with the DON and Administrator on [DATE] at 5:30 p.m. revealed that they could not get an answer regarding whether the agency staff screening complied with the facility's Abuse policy or with the contract between the staffing agencies and the facility until after the holiday weekend. The Administrator and DON were asked if there had ever been a problem with CNA AA or anything that might have indicated there was a concern. They both answered there had not been any problems with CNA AA and that he had been a good employee. The Administrator and the DON did not mention that CNA AA had been part of a facility investigation for an injury of unknown origin, which was not substantiated by the facility, on [DATE]. A news story on the evening of [DATE] indicated that CNA AA had been previously arrested for elder abuse in 2016 which was confirmed by the GBI agent, via telephone, on [DATE] at 9:39 a.m. A second telephone interview with the GBI agent on [DATE] revealed that copies of the police reports would be supplied and were obtained on [DATE]. A review of reports which named CNA AA revealed seven reports to the State of Georgia, beginning with GA 587 dated [DATE], due to allegation of neglect by CNA AA, which was not substantiated. Review of GA 505 dated [DATE], due to allegation of sexual abuse by CNA AA, resulted in a police report but was unsubstantiated. Review of GA 743 dated [DATE], GA 744 dated [DATE] and GA 746 dated [DATE] by the same facility for three different resident who had reported CNA AA of abusive behavior revealed that CNA AA was terminated and the police notified. Review of GA 495 dated [DATE] due to allegation of abuse by CNA AA, the allegation was unsubstantiated. Review of GA 753 dated [DATE], due to an allegation of sexual abuse by CNA AA, with the CNA being terminated and escorted off the property. Review of GA 610 dated [DATE], at the current facility, due to bruising of unknown origin, was not substantiated which was not disclosed to the surveyor. Review of GA 590 dated [DATE] due to an allegation of abuse by CNA AA. The CNA AA was terminated immediately, the police were called and investigated the incident which resulted in CNA AA being arrested in [DATE]. Review of the police report and investigation, related to another facility, dated [DATE] and the Incident Narrative dated [DATE] with details regarding the incident. A warrant was issued for CNA AA's arrest on [DATE]. CNA AA was arrested on [DATE]. The disposition of this case is unknown. A telephone interview with staffing agency #1, on [DATE] at 4:16 p.m. revealed that she employed CNA AA who had worked for her since beginning the business years ago. She stated that she had not received any complaints about the CNA and was shocked by the news. She confirmed that a background check had been run on CNA AA on [DATE] but that she has Public Record Reports run as background checks. She was unaware that Criminal Background checks were needed and thought that the background checks she does covers everything needed. She had never heard of a GCIC background check. She revealed that reference checks were not conducted on employees. The surveyor requested a list of assignments for CNA AA to include dates and names of facilities which were supplied via email on [DATE]. An interview with the Administrator on [DATE] at 9:51 a.m. revealed that she had no idea the background checks did not meet facility's Abuse policy requirements or the contract requirement with the staffing agencies until the surveyor brought it to her attention. She revealed that the contracts are standard corporate contracts but are entered into by the individual facilities. She agreed that it was assumed the staffing agencies were meeting the facility's Abuse policy for screening their employees and per the contract between the staffing agencies and the facility. She had no explanation for this failure. A telephone interview, post survey Quality Assurance review, on [DATE] at 10:01 a.m. with the Administrator revealed that she had been in this position since 2005. She revealed that CNA AA had been sent to this facility around the first of 2016. She further stated that the previous DON had trained the current DON and CNA CC about what to keep in the agency book although they were unaware of the background check requirements. The Administrator further revealed that she would ask CNA CC if she was keeping up with the agency book but that no one realized the background checks from the agencies did not meet the facility's Abuse policy nor the contract between the agencies and the facility. She confirmed that CNA CC, the previous or current DON, had ever seen the contract between the agencies and the facility. The Administrator assumed that the background checks the agencies were sending met the contract although the facility was accepting what the agencies sent to the facility without checking them. The facility implemented the following actions to remove the immediate jeopardy: 1. Beginning on [DATE] 11:45 A.M. the agency CNA that was involved in the incident is no longer providing care in our center. On [DATE] all agency employees utilized from agencies will receive Georgia Criminal Information Center (GCIC} background checks prior to returning to work. 2. All Residents have the potential to be affected. 3. To prevent reoccurrence, the decision was made by management and operations support team to not use agency until agency personnel have abuse training and a GCIC background completed and submitted to the center for review by the Administrator, Director of Nursing or Overhouse Supervisor . The administrator contacted the agencies by telephone on [DATE] to request that backgrounds be rerun on the agency employees that they send to center. A certified return receipt letter was mailed that day requesting same. On [DATE] the administrator emailed the agencies to inform them that the background checks had to include the GCIC as part of the background. The Agency contracts have been revised to include providing the center with a copy of GCIC background check, PPD (TB test), and reference check information for any agency staff used by the center. These requirements also apply to direct hires. In addition the center will provide abuse training for agency and direct hires prior to patient contact. The Administrator, Director of Nursing or Overhouse Supervisor will review the information provided from the nursing agency prior to them working to ensure it meets guidelines. If information provided does not meet the standard or reveals information that prohibits their eligibility to provide service, the individual will not be permitted to work at the center, and the agency will be notified. 4. The policy for background checks for agency staff has been revised to reflect current practice. The agency contract has been revised [DATE] to ensure background checks include GCIC requirements. Our parent company notified the agencies by letter on [DATE] that we are conducting a review of their process and a copy of their screening process was requested. An attestation of compliance will be required of the agencies. 4 of 4 hiring associates and 10 of 10 directors received training on [DATE] on the Agency Personnel Hiring Guidelines. Training for center associates began on [DATE]. As of [DATE] 80 of 90 center associates have received education on abuse. Those that have not been educated are either on FMLA or are temporary associates. Those associates will receive training prior to working. 4 of 4 agency associates that meet the requirements have been trained on abuse and have the appropriate background checks to include GCIC. 5. Center QAPI meeting was held on [DATE] to conduct a post event review that included abuse and resident rights. Another Center QAPI meeting was held [DATE] to review the revised guidelines for background screening for agency personnel and details entered into the QAPI meeting minutes. Our Operations Support representatives and Chief Compliance Officer reviewed and approved the updated guidelines on [DATE]. Medical Director notified of incident and the opportunities identified to correct in the future. Administrator or Director of Nursing will monitor for compliance. 6. Human Resources associate audited 100% of current associate files for abuse training and back ground checks to include GCIC on [DATE]. The administrator or Human Resources associate will audit twelve agency or direct hire associates files per week for four weeks to ensure abuse training has been completed prior to patient care and background checks are correct to Include GCIC background. Random audit of six associate files will be completed per month for accuracy for three months. A Quality Improvement Data Collection Grid, titled Associate Abuse Training and Background Checks to include GCIC, will be used to document compliance. All audit reviews will be reviewed in the QAPI meeting to ensure ongoing compliance. We are alleging compliance as of [DATE]. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Removal as follows: 1. Review of the facility's five day investigation and review of the staff schedule from [DATE] through [DATE] revealed that CNA AA was crossed off the schedule and replaced with another CNA. 2. The Administrator has confirmed that interviews with some residents regarding CNA AA were done and have spoken to any residents or family members that have expressed concern regarding the incident and news stories. 3. Review of the staffing schedule from [DATE] through [DATE] revealed that only direct staff were on the schedule and in the building. All staff in the building for [DATE] and [DATE] were verified per the facility schedule for the day and evening shifts. There were no agency staff in the building during the review. 4. The facility policy titled Agency Personnel-Background Screening revealed the policy was update in [DATE] and was reviewed. An in-service conducted on [DATE] on Overview of Meeting Agency personnel hiring requirements revealed that 13 facility employees, and one Corporate Regional Nurse, who are responsible for decisions to call in agency staff participated in the in-service. A form titled Quality Improvement Data Collection Grid to be utilized by the hiring associates and managers to track that all information is available from the agencies before allowing the agency employee to work with residents. 5. The facility and corporate office have reviewed the agency contracts. After further review, it was determined that the contract did not need revision although a process to ensure the contract was followed was put into place. A review of the new attestation form titled Affirmation of Compliance Provisions Background Screening of Agency Personnel revealed that these are signed, in addition to the contract, by the Staffing Agency owner or manager. The Staffing Agency that employed CNA AA is in process of contracting with a background screening service to offer compliant screenings but in the meantime the employees will go to the local police department to have the needed background check completed before working. An interview with CNA CC, scheduler, on [DATE] at 10:28 a.m. revealed that when she is not working, or on the weekends, the Overhouse nurse would make the decision if staffing agency personnel is needed. She revealed that she had participated in an in-service on [DATE] regarding the new procedure for agency staff. The nurse would be responsible for checking background checks and [MEDICATION NAME] (TB) skin test were completed and negative before agency staff can work with residents. She reveals that now GCIC background checks are required of agency staff before they can work in the facility. Review of the facility in-services on Abuse from [DATE] through [DATE] revealed that 80 of the 90 employees had completed the in-service which also included an understanding quiz. Interviews on [DATE] with CNA DD at 11:36 a.m., CNA GG on [DATE] at 2:56 p.m., interviews on [DATE] CNA CC, scheduler, at 10:28 a.m., CNA FFF on [DATE] at 11:00 a.m., CNA EEE on [DATE] at 1:52 p.m. revealed that they had recently participated in in-services on abuse, recognizing abuse and to who they should report any allegation of abuse to at the facility. An interview with the Assistant Director of Nursing (ADON) R.N., on [DATE] at 2:45 p.m. revealed that she had recently had in-services on multiple items including recognizing abuse, what to do if it is reported to her and how to report to the State. She further revealed that she had been in-serviced on what was needed prior to agency staff being allow to work in the facility. Interviews on [DATE] at 11:41 p.m. with Housekeeper EE and on [DATE] with Housekeeper GGG at 11:16 a.m. revealed that they had recently had an in-service on abuse, were aware of what abuse involved. They would report any allegation of abuse to their supervisor or the nurse on the floor. They were aware of the Ombudsman program and the abuse hotline and where the posters were located in the facility. Interviews on [DATE] with LPN HH at 3:01 p.m., on [DATE] with Registered Nurse (RN) FF at 3:23 p.m., LPN CCC at 11:24 a.m., LPN BB at 12:52 p.m., LPN DDD at 1:41 p.m. who revealed they had recently participated in multiple in-services relating to abuse, identifying abuse, who to report abuse to in the facility or how to report abuse to the State. 6. Review of the Quality Assurance Improvement Plan (QAIP) sign in sheets reveal that on [DATE] and [DATE] QAIP meetings were held to discuss the immediate jeopardy issue. A telephone interview with the Medical Director on [DATE] revealed that she is aware that staffing issues are a problem at the facility and has been discussed in the QA meetings that she has attended. She also revealed that the facility made her aware of the incident with R B and CNA AA the day after the incident. She discussed the situation with the DON on the next visit. Review of the facility audit sheet revealed that 100% of direct facility employees have been confirmed as having had abuse training and a background check that includes a GCIC background check.