Every finding on record at Northgate Health and Rehabilitation Center

Based on interviews, resident record review, and review of a facility policy titled Behavioral Health Care Services, the facility failed to ensure residents with behaviors were managed and addressed to protect other residents from abuse, and to ensure other residents' safety and privacy was protected from residents with combative, aggressive, and sexual behaviors. Specifically, 1.) The facility failed to ensure staff documented the presence of or absence of target behaviors that were identified in Resident Identifier (RI) #1's Care Plan to ensure RI #1's behaviors were managed. RI #1 had diagnoses of Schizophrenia and Bipolar Disorder and a history of sexually inappropriate behavior. On 09/12/2024 RI #1 was found by staff in the Activity Room unsupervised with RI #49 and RI #1 had his/her hand on RI #49's breast. The facility failed to accurately document changes in occurrences of behaviors including the frequency. The facility failed to establish and communicate the level of supervision and monitoring required when a Gradual Dose Reduction (GDR) attempt was made on 08/28/2024. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.40 Behavioral Health Services. On 05/06/2025 at 6:45 PM, the Administrator, Director of Nursing (DON), [NAME] President of Clinical Reimbursement, [NAME] President of Clinical Operations, Regional Director of Clinical Operations, and Senior Regional Director of Clinical Operations were provided a copy of the IJ template and notified of the findings of immediate jeopardy in the area of Behavioral Health at 740-Behavioral Health Services. The IJ began on 09/12/2024 and continued until 05/09/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/09/2025 the immediate jeopardy was removed, F740 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of Facility Reported Incident (FRI)/complaint /report number AL00048797. The following deficiency did not rise to the level of IJ. 2) The facility failed to manage RI #2's behavior on 10/15/2024 when RI #2 hit RI #11 in the arm. These deficiencies were cited as a result of the investigation of complaint/report number AL00049328. These failures affected RI #1, RI #49, RI #2, and RI #11 four of 27 sampled residents. Findings include: A facility policy titled Behavioral Health Care and Services with an implemented date of 05/20/2022 and a revised date of 05/04/2025 documented: Policy: It is the policy of this facility to ensure all residents receive necessary behavioral health services to assist them in reaching and maintaining their highest level of mental and psychosocial functioning and well-being . Policy Explanation and Compliance Guideline: 1. Behavioral health encompasses a resident's whole emotional and mental well-being, . 3. The facility will ensure the necessary behavioral health care services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety . 7. The facility utilizes the comprehensive assessment process for identifying and assessing a resident's mental and psychosocial status and providing person-centered care. The assessment and care plan will include goals that are person-centered and individualized to reflect and maximize the resident's dignity, autonomy, socialization, independence, choice, and safety. Staff will: . b. Obtain history from medical records, the resident, and as appropriate the resident's family and friends regarding mental, psychosocial, and emotional health. f. Assess and develop a person-centered care plan for concerns identified in the resident's assessment. g. Share concerns with the interdisciplinary team (IDT) to determine underlying causes of mood and behavior changes . h. Accurately document the changes, including frequency of occurrence and potential triggers in the resident's record. i. Ensure appropriate follow-up as needed. j. Discuss potential modifications to the care plan. k. Evaluate resident and care plan routinely to ensure the approaches are meeting the needs of the resident. 10. All facility staff, including contracted staff and volunteers, shall receive education to ensure appropriate competencies and skill sets for meeting the behavioral health needs of residents. Behavioral health training as determined by the facility assessment will include, but is not limited to, the competencies and skills necessary to provide the following: a. Person-centered care and services that reflect the resident's goals for care. 11. Facility staff will implement person-centered care approaches designed to meet the individual goals and needs of each resident . 1) RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Paranoid Schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. A review of PASARR Level I Screening & Results dated 10/04/2019 documented . 5. Does the individual's current behavior or recent history within 1 year indicate that they are a danger to self or other . Yes history of sexual inappropriate behaviors . A review of RI #1's comprehensive care plan titled Care Plan Report revealed: Focus Behaviors r/t [related to] bipolar do [disorder], personality do, paranoid do and dementia with behaviors of hallucinations and inappropriate social behaviors AEB [as evidenced by] . cursing, threatening and criticizing others, taunting and provoking others, name calling and demeaning names . sexual remarks and slurs and inappropriate behaviors such as sexually inappropriate and social behaviors of sexual and vulgar remarks, impulsive episodes and cursing out others. Date initiated: 06/02/2022 Revision on 09/06/2022 . Interventions . Counsel concerning invading others personal space and sexual boundaries as needed . Observe for effectiveness of current medication regimen . Observe for episodes of behaviors and response to interventions . RI #1's Care Plan Report further revealed: Focus The resident uses antipsychotic and antidepressant medications daily r/t [related to] [his/her] dx [diagnosis] of intermittent explosive disorder, dementia with behavioral disturbances, major depressive disorder and bipolar 2 Date initiated: 05/02/2022 Revision on 05/23/2024 . Interventions . Monitor for change in mood and behaviors . A review of RI #1's Progress Notes revealed a Nursing Progress Note dated 03/15/2023 that documented: . Resident verbally aggressive and offering sex to staff . A review of Certified Nursing Assistant (CNA) mood documentation for RI #1 from August 2024 to October 2024 was conducted. The document directed staff to document specific behaviors each day as either cooperative, passive, agitated, or depressed/withdrawn. A review of the documents revealed this was not completed each shift. A review of Certified Nursing Assistant (CNA) behavior documentation revealed an X was documented 19 of 30 shifts in September 2024. The document instructed staff to document numbers 0-12 to correspond to different behaviors including . 10-Sexually Inappropriate . 12- None of the above observed. The instructions key did not include an X or provide the meaning of an X. A review of RI #1's Electronic Medication Record (EMAR) behavior documentation from August 2024 to October 2024 revealed the monitoring was not completed per instructions. A review of RI #1's Behavior Monitoring notes in 2024 revealed no Behaviors Monitoring notes were documented except on 07/04/2024 which documented refusal of a vaccination and that the resident was combative with the writer of the note. An interview was held with the Social Service Designee (SSD) on 05/03/2025 at 11:40 AM. During the interview, the SSD was questioned regarding the behaviors of RI #1. The SSD reported that RI #1 exhibited verbally aggressive behavior, including cursing at staff and residents, refusing care and treatment, and engaging in arguments. She noted that RI #1's care plan addressed that RI #1 had behaviors that include sexually inappropriate behaviors. The SSD said that she had overheard RI #1 complimenting staff by stating they are attractive or nice looking. Furthermore, the SSD indicated that these behaviors are recorded in the nurses' notes and on the EMAR. An interview was conducted with CNA #14 on 05/03/2025 at 12:04 PM. During the interview, CNA #14 was questioned regarding the behaviors of RI #1. CNA #14 reported that she had observed RI #1 become loud and refusing care. She indicated that she had not observed any instances of sexual inappropriate behavior from RI #1 towards either staff or residents. An interview was conducted with CNA #22 on 05/04/2025 at 11:50 AM. During the interview, CNA #22 was questioned regarding the incident involving RI #1 and RI #49 that took place on 09/12/2024. CNA #22 stated that she was on duty that day but did not observe the incident. She said unsupervised residents in the Activity Room could potentially engage in arguments or altercations. When asked about RI #1's behaviors, CNA #22 reported that he/she would use profanity toward staff regarding cigarettes and would make comments about staff members appearances and expressed a desire to marry them. CNA #22 said that those behaviors were reported to the nurse. A follow-up interview took place with CNA #22 on 05/05/2025 at 11:51 AM. During this interview, CNA #22 was questioned regarding RI #1's comments, including phrases like hey honey and will you marry me, and whether these comments had been reported. CNA #22 indicated that she would at times report those behaviors or comments to the nurse or she would redirect RI #1. She noted that these behaviors began approximately two years prior, and she had not witnessed any such behaviors from RI #1 in the last three to six months. An interview was conducted with Former Administrator (FA) #10 on 05/05/2025 at 3:55 PM. During the interview, the FA described RI #1 as someone who would flirt with staff by attempting to make them laugh and singing to them. The FA said that RI #1 had a care plan addressing a history of inappropriate sexual behavior, which should have been monitored by the nursing staff and documented in the MAR. An interview was held with the Administrator on 05/06/2025 at 12:15 PM. During the interview, the Administrator was questioned regarding the procedures for documenting and reporting behaviors. The Administrator said that any resident behavior directed towards staff must be documented and included in the care plan. When asked about strategies to prevent behaviors directed at staff from escalating to residents, the Administrator suggested that proper care planning and a referral to psychiatric services could help mitigate such escalations. ************************************************ On 05/09/2025, the facility submitted an acceptable removal plan, which documented: F 740 Removal Plan 05/09/2025 1.Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure target behaviors were identified, managed, and addressed for RI #1, a resident with Schizophrenia and Bipolar Disorder, to prevent and protect other residents from being abused by RI #1, a resident with a history of sexually inappropriate behavior, when on 09/12/2024 RI #1 was found by staff in the activity room at the facility alone and unsupervised with RI #49 and RI #1 had his/her hand on RI #49's breast. b. CNA #15 witnessed RI #1 touch RI #49 on the right breast upon entering the activities room. CNA #15 instructed RI #1 to stop touching RI #49 as she entered the room and approached the residents to separate them. CNA #15 called out for assistance and LPN #13 was present in the hallway outside of the activities room door passing medications and entered the activities room and witnessed RI #1 touch RI #49 on the right breast. Residents were immediately separated. RI #1 on was immediately taken to his room and placed on 1:1 observation. c. Resident #49 was assessed by RN #16 on 9/12/24 at approximately 1700. d. Provider was contacted and resident was assessed on 9/13/24 - Recommendation was to discontinue 1:1 sitter and to provide close monitoring while resident out of bed in common areas. 1:1 observations were maintained for five days as a follow-up provider visit was scheduled for Monday 9/16/2024. NP assessed RI #1 on 9/16/2024 and resident continued to have no further behaviors so 1:1 monitoring was stopped the following day on day 5, 9/17/24. The assigned staff were to complete the documentation flow sheet. Charge nurses verified staff were 1:1 with RI #1 during the above noted dates, and staff submitted the flow sheet to the DON for review when completed. No behaviors were observed during that time. 1:1 observation were in place from 9/12/24 to 9/17/24. RI #1 is unable to transfer out of bed without the assistance of the staff. CNAs assigned to RI #1 were verbally instructed by charge nurses at the start of each shift to notify nurse once resident is assisted out of bed so he/she can be monitored. This directive was also noted on the CNA's care Kardex. This directive was put into effect following the completion of the 1:1 observation. e. RI #1 is now included in our list of residents located within the Nursing Communications binders at each desk. Residents on this list are not to be in common areas with other residents unsupervised. All staff have been in-serviced on this directive. This intervention has also been added to the residents' care plan, behavior monitoring order, and Kardex. f. On 05/07/2025, the Regional Director of Clinical Operations conducted an in-service for the Administrator and Director of Nursing covering all types of abuse and the facility's responsibility to ensure resident safety. 2. Identification of other residents having the potential to be affected: a. Any other residents with inappropriate sexual behaviors in the center have the potential to be affected. b. All residents' PASRRs in the center were audited by the DON/designee on 05/07/2025 for history of sexually inappropriate behaviors. On 5/07/2025, The Clinical Reimbursement Specialist reviewed all residents' care plans for any residents identified with known history of sexually inappropriate behaviors. Two additional residents were identified to have a history of sexually inappropriate behaviors. Each of these 3 residents have individualized interventions in their care plans, with specific targeted behaviors to prevent the occurrence of abuse. All three residents noted with history of sexually inappropriate behaviors have intervention to prevent abuse. None of these residents are physically capable of transferring out of bed unassisted. They are to be always monitored while in common areas with other residents. They will not be in common areas unsupervised. All three residents have been placed on every 15-minute observations while out of bed, to be signed off by the observing staff member every 15 minutes. If in activities, the Activities Director will sign the observation. If in the dining room, the CNA and/or charge nurse assigned to the dining room with sign the observation. If near or at nurses' station, the nurse will sign the observations. The charge nurse is responsible for ensuring the observation monitoring sheet is signed off at the end of the shift. The DON is responsible for collecting the observation sheets and the Administrator is responsible for maintaining the records. 63 of 65 staff trained (two staff members on FMLA). c. The Regional Nurse consultant/Designee reviewed resident progress notes from 4/01/2025-current reviewing for sexually inappropriate behaviors none noted. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: a. On 5/07/25 the Regional Nurse Consultant provided in-service for the Administrator and Director of Nursing training on the facility's Behavioral Health Services Policy and facility's Abuse Policy to include management of sexually inappropriate behaviors and behaviors that that increase residents risk of abuse such as masturbation, unwanted touching of sexual organs by another resident, cursing, shadowing, calling out, and disrobing. b. Facility-wide staff training was initiated on 05/07/2025, by the Director of Nursing/ designee. No staff are permitted to work until this training is completed. The training covered: i. The abuse policy. This policy emphasizes that all residents have the right to be free from sexual abuse, outlines how to identify abuse, and mandates immediate residents when abuse is suspected or observed, by physically moving the resident and the aggressor away from each other. When abuse is suspected or observed report to abuse coordinator once residents have been provided safety. An incident report is completed, and reports are reviewed by the DON and Administrator. ii. Prevention of Abuse, Neglect and Exploitation. a. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually intimate relationship; B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment; D. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; E. Ensuring the health and safety of each resident with regard to visitors such as family members or resident representatives, friends, or other individuals subject to the resident's right to deny or withdraw consent at any time and to reasonable clinical and safety restrictions. (See Resident Right to Access and Visitation Policy); F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; G. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and iii. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. iv. When any staff observe behaviors, staff should report behaviors to charge nurse for documentation in the medical record. Behaviors are reported during shift-to-shift reports by charge nurses. IDT team reviews documentation in clinical meetings weekly during clinical risk meeting and daily during morning clinical meeting for interventions/follow up. During morning clinical meeting, all of this information is read aloud by the DON to the IDT team members present during each meeting and assigns follow-up to the designated team member responsible for the item needing follow-up. As part of the weekly risk meeting, behaviors, psychotropic medications, and monitoring orders are reviewed and documented by the IDT team members during the meeting as needed. Staff identify these target behaviors through a structured, person-centered approach that emphasizes observation, communication, and individualized care planning. The residents' target behaviors are identified in their care plans and in their behavior monitoring order. v. On 5/7/25, DON/Designee conducted an in-service with all staff that included the process for monitoring target behaviors. The in-service included how these behaviors are identified and the process for reporting behaviors. a. Residents identified with a potential for exhibiting inappropriate sexual behaviors reviewed during weekly risk meetings, by the interdisciplinary team. Residents identified with a potential for/history of exhibiting inappropriate sexual behaviors, individualized, person-centered care plans will be developed by the MDS coordinator/Designee, implemented by all staff providing care to the residents. Each nurse assigned to the identified residents each day will observe to ensure care planned interventions that are listed on the care Kardex for the CNA are in place and effective. The charge nurses will communicate with the IDT team as needed if care planned interventions are ineffective, and the MDS Coordinator/Designee will revise CP as necessary. All three residents have been placed on every 15-minute observations while out of bed, to be signed off by the observing staff member every 15 minutes. If in activities, the Activities Director will visually observe the resident and sign the observation. If in the dining room, the CNA and/or charge nurse assigned to the dining room will visually observe the resident and sign the observation. If near or at nurses' station, the nurse will visually observe the resident and sign the observations. The charge nurse is responsible for ensuring the observations are made and that the observation monitoring sheet is signed off at the end of the shift. The DON is responsible for collecting the observation sheets and the Administrator is responsible for maintaining the records. b. 63 of 65 staff trained (two staff members on FMLA). c. DON/designee will monitor the schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. 63 of 65 staff trained (two staff members on FMLA). vi. An audit was completed on 5/7/25 by the Clinical Reimbursement Specialist. Care plans of the three residents identified to have a history of sexually inappropriate behaviors including RI #1 were reviewed to ensure they were appropriate, person centered and that they considered pertinent history of the residents. All three residents had revisions made to their care plans to include the added directive that those residents will not be in common areas unsupervised with other residents. The revisions were made by the Director of Nursing and by the Clinical Operations Support nurse on 5/7/25 and 5/8/25. vii. On 5/7/2025 by DON/Designee, all residents identified with a history of sexually inappropriate behaviors had an audit completed to ensure behavior monitoring orders are appropriately entered to include specific target behaviors and appropriate supporting documentation attached to the order. Staff identify these target behaviors through a structured, person-centered approach that emphasizes observation, communication, and individualized care planning. The residents' target behaviors are identified in their care plans and in their behavior monitoring order. f. On 5/7/25, An in-service with all staff included the process for monitoring target behaviors. The in-service included how these behaviors are identified and the process for reporting behaviors. CNAs document these behaviors on an as needed basis in their POC. Nurses document the behaviors in the eMAR and then if occurred, charted in the nurses' notes as directed by the monitoring order. The nursing progress notes and POC alerts are read aloud in morning clinical meetings Monday thru Friday. The in-services on monitoring target behaviors, monitoring residents on psychotropic medications/GDR Monitoring process and the in-service on monitoring target behaviors are all also located in the nursing communications binder for nurses and CNAs to reference as needed. 63 of 65 staff trained (two staff members on FMLA). g. QAPI Committee meeting was held 05/07/2025 to review allegations involving sexually inappropriate behaviors, including nonconsensual touching of sexual organs of other residents, to include incidents originating 12/2/24 - current Investigations. The Interdisciplinary Team (IDT) identified 3 residents requiring care plan reviews that were completed related to sexually inappropriate behaviors. The Quality Assurance and Performance Improvement (QAPI) team initiated a review to identify trends in sexual behaviors and behaviors associated with GDRs, assess potential behavioral triggers, and ensure that appropriate, individualized interventions were implemented and documented in the care plans. Any trends will be communicated to the Medical Director. 9 department head members attended QAPI meeting. h. On 5/9/2025, an additional in-service began, by the Regional Director of Clinical Operations to train all staff (CNAs, Nurses, Nurse Managers, Administrator, Dietary staff, Housekeeping Staff, administrative staff) that the three residents identified will remain on every 15-minute observations while out of bed. Staff has been educated to continue the process noted on their Kardex that as soon as any of these residents are out of bed, the charge nurse is notified who will then initiate the observation sheet for that day and ensure the observations are continued and signed for the entirety that these residents are out of bed to prevent the risk of occurrence of abuse. On 5/9/25, all Nurses, CNAs and housekeepers scheduled to work 5/10/25, 5/11/25 and 5/12/25 have been in-serviced on the process for the every 15 minute observations for the identified residents. DON/designee will monitor the schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. i. This directive of maintaining these observations will continue for each of the identified residents on an individual basis based upon their behaviors observed. The observations will be discussed daily, Monday thru Friday in the morning clinical meeting. The IDT team will discuss these observations during the weekly clinical risk meeting. It will be a collaborative effort and decision of the interdisciplinary team when these observations can be reduced or discontinued based on those findings. j. The regional nurse consultant in-serviced the DON 5/7/25 regarding the process to follow with monitoring specific target behaviors with an increase in monitoring during the 30-day period following a GDR. Monitoring orders will list target behaviors specific to each resident identified with sexually inappropriate behaviors. Monitoring orders with be reviewed for accuracy on initiation of order and daily in morning clinical meeting weekly in clinical risk meeting. Facility requests IJ removal plan to be effective on 05-09-2025. **************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 05/09/2025. ************************************************************** 2) RI #2 was admitted to the facility on [DATE] and had diagnoses to include: Psychotic Disturbance, Mood Disturbance, Anxiety Disorder, and Major Depressive Disorder. RI #2's quarterly MDS assessment with an ARD of 09/13/2024 documented a BIMS score of 8 of 15, which indicated that RI #2 had moderate cognitive impairment. A review of RI #2's comprehensive care plan revealed RI #2 may exhibit outbursts toward staff and may become combative, striking out by hitting and/or kicking. This care plan was initiated on 06/28/2022 and revised on 07/29/2024. The care plan did not provide direction to staff regarding the level of supervision required to protect residents and ensure safety. A review of a Progress Note for RI #2, dated 07/19/2024, indicated the following behaviors: During an onsite psychological visit, RI #2 was observed to ball up his/her fist and attempted to strike another resident while passing through the door. A verbal intervention was conducted, during which RI #2 was informed that such actions would not be allowed, and the potential consequences of retaliation and injury were explained. RI #2 reacted with anger and directed profanity towards the writer. The inappropriate nature of his/her behavior and language was addressed, along with the associated risk of injury stemming from such conduct. A review of the Progress Note for RI #2, dated 07/24/2024, indicated that the appointment was a follow-up to the visit to the 07/19/2024 visit. During this session, RI #2 denied feelings of anger and was advised against hitting others and using derogatory language towards others. RI #2 did not want to talk with the provider, leading to the termination of the interview. Staff were directed to observe and intervene in any behavioral disturbances as necessary. An interview with Social Services Designee (SSD) was conducted on 05/03/2025, at 4:17 PM. The SSD was questioned regarding the behaviors of RI #2. She indicated that RI #2 had exhibited verbal aggression towards both staff and other residents and had made attempts to physically strike staff. When asked about strategies for managing RI #2's behaviors, the SSD said that if the aggression was directed at a staff member, they should leave when safe and return later. If the aggression was directed at other residents, staff should intervene and remove RI #2 from the situation. A telephone interview with FA #10 took place on 05/05/2025 at 4:20 PM. The FA reported that RI #2 had instances of verbal outbursts, including the use of racial slurs, and a refusal to accept care. She said that staff should not compel a resident to receive care but should pause and attempt again later. In cases of verbal altercations between residents, staff should intervene, remove the resident, and de-escalate the situation. When asked about the management of RI #2's behavior on 10/15/2024, she confirmed that staff was present in the room and did intervene. When questioned about the possibility of preventing the incident, she suggested that if the situation had been identified earlier, RI #2 could have been removed and the incident could have been prevented. On 10/16/2024 at 10:39 AM the State Agency received a FRI alleging that RI #2 struck RI #11 on the arm.

Based on interviews, record review, and review of a facility policy titled Unnecessary Drugs the facility failed to ensure adequate monitoring for behaviors was completed accurately, properly, and consistently while a Gradual Dose Reduction (GDR) for a psychotropic medication was being attempted. Specifically, RI #1 had a dose reduction of Seroquel on 08/28/2024 and the facility did not have a documented system to include timeframe and instructions to staff on monitoring for behaviors while a GDR attempt was in progress. The Certified Nursing Assistant (CNA) and the nurses' behavior monitoring documentation on the Electronic Medication Record (EMAR) was not completed accurately and in a manner to validate whether RI #1 had behaviors or escalation of behaviors. RI #1 had a history of sexually inappropriate behaviors and on 09/12/2024 RI #1 sexually abused RI #49, 15 days after the dose reduction. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from abuse, neglect and exploitation. On 05/06/2025 at 6:45 PM, the Administrator, Director of Nursing (DON), [NAME] President of Clinical Reimbursement, [NAME] President of Clinical Operations, Regional Director of Clinical Operations, and Senior Regional Director of Clinical Operations were provided a copy of the IJ template and notified of the findings of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F605-Free from Chemical Restraints . The IJ began on 09/12/2024 and continued until 05/09/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/09/2025 the immediate jeopardy was removed, F605 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint /report number AL00048797. Findings Include: Cross-Reference F600 and F740. Review of the facility's undated policy titled, Unnecessary Drugs, revealed: Policy: It is the facility's policy that each resident's entire drug/medication regimen is managed and monitored to promote or maintain the resident's highest practicable mental, physical and psychosocial well-being free from unnecessary drugs. Policy Explanation and Compliance Guidelines: . 3. The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents and/or representatives, other professionals and the interdisciplinary team . d. Adequate monitoring for efficacy and adverse consequences; . 8. Information gathered during the initial and ongoing evaluations will be incorporated into the resident's comprehensive care plan that reflects the person-centered medication related goals and parameters for monitoring the resident's condition . RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Paranoid schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. RI #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/03/2024 documented a Brief Interview for Mental Status (BIMS) score of 7 of 15, which indicated RI #1 had severe cognitive impairment. A review of RI #1's comprehensive care plan titled Care Plan Report revealed: Focus The resident uses antipsychotic and antidepressant medications daily r/t [related to] [his/her] dx [diagnosis] of intermittent explosive disorder, dementia with behavioral disturbances, major depressive disorder and bipolar 2 Date initiated: 05/02/2022 Revision on 05/23/2024 . Interventions . Monitor for change in mood and behaviors . The care plan did not include parameters for monitoring the resident's condition. Continued review of RI #1's Care Plan Report revealed: Focus The resident is resistive to care and has hallucinations r/t schizophrenia, Dementia and history of non-compliance with medication regimen. Date initiated: 01/04/2023 Revision on: 01/03/2023 Interventions . Observe for effectiveness of current medication regimen . A review of RI #1's Physician's Orders revealed RI #1 had an order for: . QUEtiapine Fumarate [Seroquel] oral tablet 150 MG . Give 150 mg [milligram] by mouth at bedtime . Start Date . 10/19/2023 . End Date . 08/28/2024 . A review of Consultant Pharmacist Medication Regimen Review dated 08/19/2024 documented: . Quetiapine 150 mg HS started 10/2023. If no present behaviors noted from 150 mg, please consider another dose reduction to find lowest effective dose . AGREE: Please write order . A review of RI #1's Progress Notes reveal an onsite note documented by Certified Registered Nurse Practioner (CRNP) #24 dated 08/28/2024 documented: . Spoke with resident regarding reduction of quetiapine and patient states it was fine . GDR [gradual dose reduction] made and quetiapine reduced to 100 mg . Further review of RI #1's Physician's Orders documented the following: . QUEtiapine Fumarate Oral Tablet 100 MG . Give 1 tablet by mouth at bedtime . Start Date . 08/28/2024 . End Date . 10/23/2024 . A review of Certified Nursing Assistant (CNA) mood documentation for RI #1 from August 2024 to October 2024 was conducted. The document directed staff to document the resident's mood each shift with a corresponding code related to the resident's mood. A review of the documents revealed this was not completed each shift. Seven of 12 shifts from August 28th to August 31 were blank and not completed. 32 of 60 shifts in September 2024 were blank and not completed including 13 of 24 shifts from September 1st to September 12th. A review of CNA behavior documentation revealed an X was documented 19 of 30 shifts in September 2024. The document instructed staff to document numbers 0-12 to correspond to different behaviors including . 10- Sexually Inappropriate . 12- None of the above observed. The instruction's key did not include an X or provide the meaning of an X. A review of nurses' behavior monitoring task on RI #1's EMAR revealed check marks were documented each shift in August 2024 and each shift in September 2024 except one shift on 09/27/2024 which was blank. The instructions for the behavior monitoring documentation on the EMAR was: Anti-Psychotic Monitor for any behaviors (Harassing disruptive loud behaviors, cursing, sexual slurs and remarks) Document: 'Y' if behavior IS noted during the shift 'N' if NO behavior noted during the shift Use chart code 9 and 'Other/See Nurses Notes' putting in specific progress note findings Document TOTAL # [number] of episodes per shift, Non-Pharmacological Interventions Attempted and Outcomes every shift related to PARANOID SCHIZOPHRENIA . Start Date 09/18/2022 . D/C [discontinued] Date 02/04/2025 1407. There was no instruction to document a check mark. The behavior monitoring task had a start date of 08/18/2022. A review of RI #1's Progress Notes and Nursing Notes revealed no Behavior Monitoring notes were documented from 08/28/2024 through 09/11/2024. An interview was completed with the Director of Nursing (DON) on 05/06/2025 at 5:28 PM. During this interview, the DON was asked to examine the Medication Administration Record (MAR) for RI #1 from September 2024 and the CNA documentation for September to October 2024. The DON stated that she could not provide an opinion whether the forms were completed accurately because she was not employed at the facility at the time the forms were filled out. An interview was held with the Social Services Designee (SSD) on 05/06/2025 at 2:57 PM. During the interview, the SSD was asked about the procedure for communicating GDRs to direct care personnel, including nurses, CNAs, and activities staff. The SSD explained that when a GDR was attempted nursing staff or she would verbally alert all staff members to be alert for any increased resident behaviors and were instructed to report back to either the SSD or the nursing staff. The SSD said the importance of monitoring residents following a GDR was to ensure they received the appropriate dosage for effectiveness and to prevent any escalation in behaviors. The SSD said that enhanced monitoring of residents exhibiting behaviors after a GDR could safeguard other residents from potential abuse by enabling staff to recognize problematic behaviors before they escalated into conflicts. An interview was conducted with the Medical Director (MD) on 05/06/2025 at 3:36 PM. During the interview, the MD was questioned regarding the GDR for RI #1 that took place on 08/28/2024. The MD indicated that residents with a history of behavioral issues should be closely monitored following a GDR to prevent the emergence of new behaviors. He noted that while there was no established standard for the duration of monitoring. The MD emphasized that the purpose of monitoring was to ensure that any changes in a resident's condition were not attributable to the medication adjustment. He also mentioned that heightened observation of residents with behavioral issues after a GDR could safeguard other residents by identifying subtle behavioral changes at an early stage. ************************************************ On 05/09/2025, the facility submitted an acceptable removal plan, which documented: F 605 Removal Plan 05/09/2025 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure monitoring for behaviors after a psychotropic/antipsychotic GDR, was completed accurately, properly, and consistently for RI #1 who had a dose reduction of Seroquel on 8/28/2024. b. On 05/07/2025, the Regional Nurse Consultant conducted an in-service with the Director of Nursing addressing the proper procedure for monitoring behaviors after a psychotropic/antipsychotic dose reduction is initiated and the proper procedure for order entry for all monitoring orders. 2. Identification of other residents having the potential to be affected: a. This had the potential to affect all residents prescribed a recommended GDR during the last 30 days. On 5/7/25, A comprehensive audit was completed on all residents with a GDR during that period to ensure proper monitoring order procedure followed. Two residents were identified on this audit as having a GDR in the last 30 days. All current behavior monitoring orders for the two residents identified and for RI #1 were audited for accurate order entry. This was completed on 5/07/25 by DON/Designee. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: a. On 5/7/25, The Regional Nurse Consultant in-serviced the DON regarding the process to follow with monitoring specific target behaviors with an increase in monitoring during the 30-day period following a GDR. The process included: i. Upon receiving the recommendation of GDR, the DON/designee reviews the recommendations, contacts the physician prior to implementation. If the physician does not approve, they will provide rational and document it in the progress notes or the DON/designee will document it in the progress notes. If the resident has a prior history of a failed GDR, this should be documented in the residents' CP by the MDS Coordinator/Designee and nurse's notes. If approved the charge nurse will initiate the order in the resident's record. ii. The monitoring order will be entered into EMR by the charge nurse entering the prescribed psychotropic/antipsychotic order or GDR. All components including special documentation parameters for accurate and complete documentation/assessment to be recorded as written in the order. iii. All physicians' orders are reviewed each morning in the morning clinical meeting for accuracy of order entry as well as during the weekly clinical risk meetings. iv. The 30 days following the start date of the GDR, the monitoring frequency will be increased to twice per shift. iv. If during that period any increase in targeted behaviors or any new behaviors are observed, the provider will be notified by the charge nurse immediately and address accordingly. v. The GDRs will be reviewed weekly during clinical risk meetings during the first 30 days of initiation of GDR. vi. A GDR audit tool was implemented 5/7/25 by the Regional Nurse Consultant/Designee. B. The DON was in-serviced on process for utilizing GDR Monitoring Tool and proper monitoring order entry on 5/7/25 by the Regional Nurse Consultant. C. On 5/7/25, the DON and Regional Nurse Consultant conducted in-services with all staff on the above process for monitoring residents when GDR attempted. Staff identify these target behaviors through a structured, person-centered approach that emphasizes observation, communication, and individualized care planning. The residents' target behaviors are identified in their care plans and in their behavior monitoring order. 63 of 65 staff trained (two staff members on FMLA). D. On 5/7/25, DON/Designee conducted an in-service with all staff that included the process for monitoring target behaviors. The in-service included how these behaviors are identified and the process for reporting behaviors. The in-service included; New GDRs will be monitored twice per shift by documentation within Behavior Monitoring Orders in the MAR for the first 30 days that a GDR is attempted. GDR attempts will be tracked via GDR Monitoring Tool and reviewed weekly during clinical risk meetings during those first 30 days to monitor for changes in behaviors associated with the attempted GDR. Medication Monitoring Orders Batch Order Set will be utilized for all behavior and medication monitoring orders. The Behavior Monitoring Order will be edited/updated to note the specific targeted behaviors for that resident as listed in their CP. The Monitoring Order will have all components including special requirement documentation parameters attached within the order in the MAR. Orders will be documented accurately according to the directions noted within the order text. (IE: Chart Y/N for yes or no if noted behavior or side effect occurred. Order document number associated with list of targeted behaviors within the order text.) The nurse assigned documents the behavior on the eMAR and then as directed in the monitoring order, the nurse will then make a progress note detailing the behavior. The in-service on targeted behaviors included identifying, reporting and documentation. All LPNs/RNs have been educated and the education is located in the Nursing Communications Binder for nurses to reference. 63 of 65 staff trained (two staff members on FMLA). E. The DON included this process in the in-service provided to all staff on 5/7/2025. The monitoring order will be entered into EMR by the charge nurse entering the prescribed psychotropic/antipsychotic order or GDR. All components including special documentation parameters for accurate and complete documentation/assessment to be recorded as written in the order. All physicians' orders are reviewed each morning in the morning clinical meeting for accuracy of order entry as well as during the weekly clinical risk meetings. The 30 days following the start date of the GDR, the monitoring frequency will be increased to twice per shift. If during that period any increase in targeted behaviors or any new behaviors are observed, the provider will be notified by the charge nurse immediately. This process is also noted in the Nursing Communications binders. 63 of 65 staff trained (two staff members on FMLA). Facility requests for IJ removal plan to be effective on 05/09/25 **************************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 05/09/2025.

Based on interviews, resident record reviews, review of a facility policy titled Abuse, Neglect and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the residents' rights to be free from sexual and physical abuse perpetrated by residents. Specifically: 1.) The facility failed to ensure Resident Identifier (RI) #49 was free from sexual abuse perpetrated by RI #1, a resident with a history of sexually inappropriate behavior to include vulgar comments and obscene language. On 09/12/2024 RI #1was found unsupervised in the Activity Room with his/her hand on RI #49's breast. The facility had not developed and implemented interventions to ensure RI #1 was supervised in a manner to protect other residents and monitored appropriately for behaviors that could affect residents' safety. On 08/28/2024 RI #1's dosage of Seroquel (an antipsychotic medication ordered to treat RI #1's Schizophrenia) was decreased. The facility did not ensure the staff were providing enhanced supervision or monitoring and documenting RI #1's behaviors to ensure residents' safety following the Gradual Dose Reduction (GDR) of Seroquel. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was cited in reference to 483.12 Freedom from Abuse, Neglect and Exploitation. On 05/06/2025 at 6:45 PM, the Administrator, Director of Nursing (DON), [NAME] President of Clinical Reimbursement, [NAME] President of Clinical Operations, Regional Director of Clinical Operations, and Senior Regional Director of Clinical Operations were provided a copy of the IJ template and notified of the findings of immediate jeopardy and substandard quality of care in the area of Freedom from Abuse, Neglect, and Exploitation at F600- Free from Abuse and Neglect. The IJ began on 09/12/2024 and continued until 05/09/2025 when the survey team verified onsite that corrective actions had been implemented. On 05/09/2025 the immediate jeopardy was removed, F600 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as the result of the investigation of complaint /report number AL00048797. The facility further failed to ensure RI #11 and RI #1 were protected from physical abuse that did not rise to the jeopardy level. 2.) On 10/04/2023, the facility failed to protect RI #1 from physical abuse when RI #262 hit RI #1 in the face. 3.) On 10/15/2024 the facility failed to protect RI #11 from physical abuse when RI #2, a resident with a history of behaviors, hit RI #11 on the arm. These deficient practices affected three of eight residents sampled for abuse. These deficient practices were cited as a result of the investigations of facility reported incident/complaint/report numbers AL00048797, AL00049328, and AL00045759. Findings include: Cross-Reference F605 and F740. Review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implemented date of 05/20/2022, and a revised date of 09/12/2024, revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations . It includes verbal abuse, sexual abuse, physical abuse, . Physical Abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment . Sexual Abuse is non-consensual sexual contact of any type with a resident . Verbal Abuse means the use of oral, written or gestured communication sounds that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance regardless of their age, ability to comprehend, or disability . Policy Explanation and Compliance Guidelines: . 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The components of the facility abuse prohibition plan are discussed herein: . III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect . that achieves: . B. Identifying, correcting and intervening in situations in which abuse . is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; . D. The identification, ongoing assessment, and care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict . 1) On 09/12/2024 at 5:35 PM the State Agency received a FRI alleging that RI #1 was observed touching RI #49's breast in the activity room. RI #49 was admitted to the facility on [DATE]. RI #49's quarterly MDS assessment with an ARD of 07/07/2024 documented a BIMS score of 10 of 15 which indicated moderate cognitive impairment. RI #1 was admitted to the facility on [DATE] and had diagnoses to include: Paranoid Schizophrenia, Vascular Dementia, Bipolar II Disorder, and Borderline Personality Disorder. A review of RI #1's PASRR Level I Screening & Results dated 10/04/2019 documented . 5. Does the individual's current behavior or recent history within 1 year indicate that they are a danger to self or other . Yes history of sexual inappropriate behaviors . A review of RI #1's comprehensive care plan titled Care Plan Report revealed: Focus Behaviors . AEB [as evidenced by] . cursing, threatening and criticizing others, taunting and provoking others, name calling and demeaning names . sexual remarks and slurs and inappropriate behaviors such as sexually inappropriate and social behaviors of sexual and vulgar remarks, impulsive episodes and cursing out others. Date initiated: 06/02/2022 Revision on 09/06/2022 . Interventions . Counsel concerning invading others personal space and sexual boundaries as needed . Observe for effectiveness of current medication regimen . Observe for episodes of behaviors and response to interventions . The care plan did not provide direction to staff regarding how or when RI #1 needed to be supervised. A review of RI #1's Progress Notes revealed a Nursing Progress Note dated 03/15/2023 that documented: . Resident verbally aggressive and offering sex to staff . RI #1's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 08/03/2024 documented a Brief Interview for Mental Status (BIMS) score of 7 of 15, which indicated the RI #1 had severe cognitive impairment. A review of Certified Nursing Assistant (CNA) mood and behavior documentation for RI #1 from August 2024 to October 2024 was conducted. The review of the documents revealed the monitoring was not completed each shift per the instructions. No behaviors were documented on 09/12/2024. A review of RI #1's Electronic Medication Record (EMAR) for August and September 2024 revealed a task to monitor for behaviors each shift with start date of 08/18/2022. The review of the documents revealed the monitoring was not completed each shift per the instructions. No behaviors were documented on 09/12/2024. A review of RI #1's Behavior Monitoring notes in 2024 revealed no behaviors were documented except a note on 07/04/2024 which documented refusal of a vaccination and that the resident was combative with the writer of the note. Surveyors attempted and were unable to view video footage during the survey. An interview was conducted with RI #49 on 04/30/2025 at 10:07 AM. RI #49 was asked about the incident involving RI #1 on 09/12/2024. RI #49 indicated he/she knew RI #1 due to their shared residence at the facility, but he/she did not recall the incident. On 05/01/2025 at 10:25 AM, an interview was held with Certified Nursing Assistant (CNA) #15 regarding the incident that occurred on 09/12/2024, involving RI #1 and RI #49. CNA #15 reported that while passing by the Activity Room around 4:00 PM, she observed RI #1 touching RI #49's breast. She said that both residents were seated at a table in the Activity Room and that RI #1's hand was on the RI #49's breast and not under the shirt. CNA #15 said she intervened by separating the residents, remaining in the room, and calling for the nurse who was outside the door. She said no staff members were present in the room during the incident. CNA #15 said the Activity Director finished her shift at 4:00 PM. CNA #15 said the presence of staff in the Activity Room might have prevented the incident. CNA #15 said she this incident was sexual abuse and that RI #49 likely felt violated. On 05/01/2025 at 4:17 PM, an interview was held with LPN #13 regarding the incident involving RI #1 and RI #49 that occurred on 09/12/2024. LPN #13 reported that while she was outside the Activity Room, she heard CNA #15 calling for assistance. Upon entering the room, LPN #13 observed RI #1 with his/her hand on RI #49's breast. LPN #13 stated that she helped to separate the residents and took RI #1 to his/her room. LPN #13 said that the incident was sexual abuse and that RI #49 did not want for RI #1 to touch him/her. An interview was held with CNA #22 on 05/04/2025 at 11:50 AM. CNA #22 said that residents were prohibited from being in the Activity Room without supervision and that a staff member should have been present during the incident. She said unsupervised residents in the Activity Room could engage in arguments or altercations. An interview was conducted with the Activity Director (AD) on 05/03/2025 at 12:17 PM. The AD was questioned regarding the incident that took place on 09/12/2024 involving RI #1 and RI #49. The AD acknowledged that she was aware of the incident but did not witness it firsthand. When asked whether residents were permitted to be in the Activity Room unsupervised, she did not know. The AD said not providing supervision in the Activity Room could lead to resident altercations. She said that the incident involving RI #1 and RI #49 might have been prevented had staff been present, as RI #1 would not have touched RI #49 in front of staff. An interview was conducted with Former Administrator (FA) #10 on 05/05/2025 at 3:55 PM. During the interview, the FA was questioned regarding the incident involving RI #1 and RI #49 that occurred on 09/12/2024. According to the FA, LPN #13 informed her that RI #1 had touched RI #49's breast. The FA said she did not know how long the residents were in the Activity Room unsupervised. She said residents were typically not permitted to be in the Activity Room without supervision, which was usually provided by the AD. The FA said the incident involving RI #1 and RI #49 was sexual abuse and that RI #49 would have likely felt violated. On 05/06/2025 at 2:03 PM, an interview was held with the Director of Nursing (DON) regarding the level of supervision for RI #1. The DON indicated that she was not aware of any specific supervision requirements for RI #1. The DON stated that the RI #1 needed standard supervision, which included monitoring every two hours, as well as during activities, dining, and smoking. When asked about the interventions in RI #1's care plan at the time of the incident could have safeguarded RI #49 and other residents from potential abuse by RI #1. The DON said that the interventions explaining to RI #1 the reasons for not engaging in sexually inappropriate behavior, interacting with RI #1, and redirecting or removing the resident from situations when they became disruptive or agitated. ************************************************ On 05/09/2025, the facility submitted an acceptable removal plan, which documented: F600 Removal Plan 05/09/2025 1. Immediate action(s) taken for the resident(s) found to have been potentially affected include: a. The facility failed to ensure RI #49 was free from sexual abuse perpetrated by RI #1, when RI #1, a resident with a history of sexually inappropriate behavior to include vulgar comments and obscene language, was found alone in the activity room at the facility, with his/her hand on RI #49's breast. b. CNA #15 witnessed RI #1 touch RI #49 on the right breast upon entering the activities room. CNA #15 instructed RI #1 to stop touching RI #49 as she entered the room and approached the residents to separate them. CNA #15 called out for assistance and LPN #13 was present in the hallway outside of the activities room door passing medications and entered the activities room and witnessed RI #1 touch RI #49 on the right breast. Residents were immediately separated. RI #1 was immediately taken to his room and placed on 1:1 observation. c. Resident #49 was assessed by RN #16 on 9/12/24 at approximately 1700. d. 1:1 observation was initiated on 9/12/24 immediately following the occurrence of the incident. Provider was contacted, and resident was assessed on 9/13/24 - Recommendation was to discontinue 1:1 sitter and to provide close monitoring while resident out of bed in common areas. 1:1 observation was maintained for five days as a follow-up provider visit was scheduled for Monday 9/16/2024. NP assessed RI #1 on 9/16/2024 and resident continued to have no further behaviors so 1:1 monitoring was stopped the following day on day 5, 9/17/24. The assigned staff were to complete the documentation flow sheet. Charge nurses verified staff were 1:1 with RI #1 during the above noted dates, and staff submitted the flow sheet to the DON for review when completed. No behaviors were observed during that time. 1:1 observation was in place from 9/12/24 to 9/17/24. RI #1 was unable to transfer out of bed without the assistance of the staff. CNAs assigned to RI #1 were verbally instructed by charge nurses at the start of each shift to notify nurse once resident is assisted out of bed so he can be monitored. This directive was also noted on the CNA's care Kardex. This directive was put into effect following the completion of the 1:1 observation. e. On 05/07/2025, the Regional Director of Clinical Operations conducted an in-service for the Administrator and Director of Nursing covering all types of abuse and the facility's responsibility to ensure resident safety. 2. Identification of Other Residents Having the Potential to Be Affected a. This incident had the potential to affect vulnerable residents, that are unable to consent, residing in the facility. 29 residents with BIMS of 10 or greater were interviewed by Care Manager/designee on 5/07/25 using the Abuse screening interview form, if BIMS less than 10 form allows for staff observation with no abuse findings. b. On 5/07/2025, DON/Designees conducted a comprehensive audit of all PASRR forms of all residents in facility to identify all residents with a history of potentially inappropriate sexual behaviors. 0 additional residents were identified upon completion of the audit. RI #1 is the only resident will this history noted on his PASARR. c. On 5/07/2025, The Clinical Reimbursement Specialist reviewed all residents' care plans for any residents identified with known history of sexually inappropriate behaviors. Two additional residents were identified to have a history of sexually inappropriate behaviors. The 2 additional residents were identified by reviewing all residents' care plans to determine if any other resident was care planned for a history of inappropriate sexual behavior or comments. 3. Actions Taken / Systems to Be Put into Place to Reduce the Risk of Future Occurrences a. On 05/7/2025, the Regional Nurse Consultant/Designees provided one-on-one in-service training to the Administrator and Director of Nursing on the facility's Abuse Policy. b. Three residents are identified with a known history of sexually inappropriate behaviors and have interventions identified in their comprehensive person-centered care plan with individualized interventions in place to prevent the occurrence of abuse. These interventions include that each resident will not be in common areas with other residents unsupervised at any time as none of the three residents identified are physically able to transfer out of bed without the assistance of the staff. Interventions were added by the DON and Clinical support specialist on 05-07-2025. The two common areas located within the center are the dining room and the activities room. No residents are unsupervised in the dining room as the dining room is locked when meal service is complete. Meal services are supervised by the charge nurse and CNA assigned to the dining room that shift. The activities room is always supervised by a staff member. The identified Residents will be kept in highly visible areas when not in a common area. Nurse, CNAs, housekeepers, dietary staff, administrative staff and therapy staff have been in-serviced and will assist in monitoring these individuals. All staff have been in-serviced that the individuals identified in the communications book cannot be left alone in common areas with other people. The CNA assigned to the identified individuals will notify their charge nurse as directed by their care Kardex when these residents are out of bed as none of these residents are physically capable of transferring out of bed unassisted. If any of the identified residents are in the activities room, the activity director or designee hosting the activity will monitor them. If any of the identified residents are in the dining room the CNAs and nurses assigned to assist in the dining room that shift would be responsible for monitoring these residents in the dining room. All staff have been in-serviced to monitor these residents while in any common areas including the hallways of the facility to maintain every 15-minute observations. All three residents have been placed on every 15-minute observations while out of bed, to be signed off by the observing staff member every 15 minutes. If in activities, the Activities Director will visually observe the resident and sign the observation. If in the dining room, the CNA and/or charge nurse assigned to the dining room will visually observe the resident and sign the observation. If near or at nurses' station, the nurse will visually observe the resident and sign the observations. The charge nurse is responsible for ensuring the observations are made and that the observation monitoring sheet is signed off at the end of the shift. The DON is responsible for collecting the observation sheets and the Administrator is responsible for maintaining these records. Care Plans will be monitored and revised with comprehensive assessments and for any changes by the MDS Coordinator/IDT team during their care plan meetings. c. On 5/9/25, the Dietary Dept. has been in-serviced by the Regional Director of Clinical Operations on the process for ensuring the dining room remains locked between meal services to ensure no resident is unsupervised in the dining room. d. On 5/07/2025 All staff were provided training on the process to ensure that any residents identified with a known history of sexually inappropriate behaviors will not be alone/unsupervised in common areas with other residents. No residents are unsupervised in the dining room as the dining room is locked by the dietary aid when meal service is complete. Meal services are supervised by the charge nurse and CNA assigned to the dining room that shift. The activities room is always supervised by a staff member. If the activities director is not present, the activities room will be locked. The identified Residents will be kept in highly visible areas when not in a common area. Nurse, CNAs, housekeepers, dietary staff, administrative staff and therapy staff have been in-serviced and will assist in monitoring these individuals. All staff have been in-serviced that the individuals identified in the communications book cannot be left alone in common areas with other people. The CNA assigned to the identified individuals will notify their charge nurse as directed by their care Kardex when these residents are out of bed. If any of the three residents identified as having history of sexually inappropriate behaviors is in the activities room, the activity director or designee hosting the activity would be monitoring him/her; if in the dining room the CNAs and nurses assigned to assist in the dining room that shift would be responsible for monitoring these residents in the dining room. All staff have been in-serviced to monitor these residents while in any common areas including the hallways of the facility. Training included that these residents will be listed in the nursing communication binders located at each nurse's station and interventions were added to the Kardex of each identified individual instructing that these identified individuals must be supervised in common areas and in highly visible areas when out of room. DON/designee will monitor the schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. Facility-wide staff training completed. 63 of 65 staff trained (two staff members on FMLA). e. On 5/9/2025, an additional in-service began, by the Regional Director of Clinical Operations, to train all staff (CNAs, Nurses, Nurse Managers, Administrator, activity staff) that the three residents identified will remain on every 15-minute observations while out of bed. Staff has been educated to continue the process noted on their Kardex that as soon as any of these residents are out of bed, the charge nurse is notified who will then initiate the observation sheet for that day and ensure the observations are continued and signed for the entirety that these residents are out of bed to prevent the risk of occurrence of abuse. f. The Resident Care Manager is responsible for monitoring the list of residents located within the Nursing Communications binders located at each nurse's station and updating the list for any changes due to admissions, discharges, and changes noted on comprehensive assessments. On 5/08/2024, Resident Care Manager, RN #16 was in-serviced by Clinical Operations Support Nurse on her specific responsibilities in updating and maintaining the list of residents located in the Nursing Communications binders. 1 of 1 staff member in-serviced. g. Facility-wide staff training began on 05/07/2025, by the Director of Nursing/ designee covering abuse policy. This policy emphasizes that all residents have the right to be free from sexual abuse, outlines how to identify abuse, and mandates immediate protection when abuse is suspected or observed. h. The in-service provided also included the process for when any staff observe behaviors. Staff should report behaviors to their charge nurse immediately for documentation in the medical record in the nursing progress notes and document the behavior in the PRN option of the CNAs POC charting. Behaviors are reported during shift-to-shift reports by charge nurses. IDT team reviews documentation in daily (Monday-Friday) clinical meetings, including review of behavior monitoring alerts, all nurses progress notes and nursing summaries for interventions/follow up. All of this information is read aloud by the DON to the IDT team members present during each meeting and assigns follow-up to the designated team member responsible for the item needing follow-up. Staff were educated during this in-service as well as during the Abuse Policy in-service on the process for behaviors that require immediate intervention. ii. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. 63 of 65 staff trained (two staff members on FMLA). iii. DON/designee will monitor each department's schedule for staff who have not completed the training. DON/designee will provide training prior to the start of the shift. Staff not physically present were in-serviced via phone. No staff are permitted to work until this training is completed. 63 of 65 staff trained (two staff members on FMLA). i. On 5/9/25, all Nurses, CNAs and housekeepers scheduled to work 5/10/25, 5/11/25 and 5/12/25 have been in-serviced on the process for every 15 minute observations for the identified residents or will be contacted via telephone prior to be able to clock in for their scheduled shift. j. The observations will be discussed daily, Monday thru Friday in the morning clinical meeting. The IDT team will discuss these observations during the weekly clinical risk meeting. k. Ad hoc QAPI meetings were held on 05/07/2025 and 05/08/2025 with key facility personnel, including the Administrator, Director of Nursing, maintenance director, Human resources, Dietary manager, activities director, Clinical Operations Support and the Regional Nurse Consultant. The meetings focused on ensuring all residents are protected from all forms of abuse, the importance of close supervision for residents identified to have a history of inappropriate sexual behaviors. Removal plans were reviewed by all team members present and approved at that time. 9 department head members attended QAPI meeting on 5/7/25. 10 department head members attended QAPI meeting on 5/8/25. QAPI Committee meeting was held 05/07/2025 to review allegations involving sexually inappropriate behaviors, including nonconsensual touching of sexual organs of other residents, to include incidents originating 12/2/24 - current Investigations. The Interdisciplinary Team (IDT) identified 3 residents requiring care plan reviews that were completed related to sexually inappropriate behaviors. The Quality Assurance and Performance Improvement (QAPI) team initiated a review to identify trends in sexual behaviors and behaviors associated with GDRs, assess potential behavioral triggers, and ensure that appropriate, individualized interventions were implemented and documented in the care plans. One of the two newly identified residents are currently on hospice services and no longer gets up out of bed to common areas. He/She has a history of making verbal sexual remarks with no recent documentation noted. 9 department head members attended QAPI meeting on 5/7/25. Facility requests for IJ removal plan to be effective on 5-09-25. ********************************************************* After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 05/09/2025. ******************************************************** 2.) The facility reported a FRI that alleged that on 10/04/2023 at 10:45 PM RI #262 struck RI #1 in the face. The residents were separated, and Emergency Medical Services (EMS) were requested for transport to the emergency room for psych services, and local law enforcement were notified. RI #262 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Anxiety Disorder, Adjustment Disorder with Depressed Mood and Vascular Dementia, unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. RI #262's quarterly MDS assessment with an ARD of 09/24/2023 documented a BIMS score of 0 of 15 which indicated that RI #262 had severe cognitive impairment. RI #262'S comprehensive care plan titled Care Plan Report revealed: . FOCUS . The resident is resident to care . exhibits aggressive behavior with [his/her] care refusals . Date initiated: 09/26/2023 . Cancelled Date: 03/04/2024 . The care plan did not include what level of supervision RI #262 required to keep residents safe. On 05/05/2025 at 2:50 PM an interview was conducted with Speech Pathologist (SP) said, on 10/04/2023 RI #262 was holding RI #1 from behind and had his/he arms wrapped around the waist of RI #1. The SP further said she yelled for help and did not leave RI #1. On 05/05/2025 at 3:10 PM an interview was conducted with LPN #19, the nurse on duty when the incident occurred. LPN #19 said on 10/04/2023 she heard the SP yelling for help and responded. LPN #19 said upon entering their room she saw RI #1's upper chest on the bed and legs hanging off the bed with the SP supporting RI #1's upper body. LPN #19 said, RI #262 was immediately removed from the room and was placed 1 on 1 observation. LPN #19 said she assessed RI #1 and he/she had a scratch to the forehead and some pain to the lip of RI #1. LPN #19 said, RI #1's forehead was cleansed with wound wash and triple antibiotic appointment applied. On 05/05/2025 at 4:12 PM an interview was conducted with Registered Nurse (RN) #9, the Unit Manager Nurse on duty when the incident occurred. RN #9 said, on 10/04/2023 when she entered the resident room, she did not see the altercation but heard RI #1 and RI #262 fussing over a bedside table. She further said, she saw a small scratch on RI #1's forehead. RN #9 said the incident was physical abuse. When asked how a reasonable person would feel in this situation, she said, it would make them feel bad and scared if they just got jumped. A telephone interview was conducted with the FA #20 on 05/06/2025 at 10:56 AM. During the interview, the FA #20 said, he became aware of the incident involving RI #1 and RI #262 on 10/04/2023. FA #20 said, RI #262 had taken RI #1's over the bed table and words were exchanged, and RI #262 hit RI #1 in the face. FA #20 said it was substantiated due to the injury to the forehead. FA #20 said, RI #262 was sent to the emergency room at local hospital for psychiatric evaluation. The FA #20 said there was sufficient evidence to substantiate physical abuse. The facility investigative file contained a form titled, Follow-up Incident Investigation to Alabama Department of Public Health (ADPH) / Administrative Summary Final Report for RI #1 dated 10/11/2023 which documented that RI #262 struck RI #1 in the face on 10/04/2023. A conclusion to the report was documented as follows: In conclusion, the facility completed an investigation and there is sufficient evidence to substantiate an allegation of physical abuse (Resident to Resident). (RI #262) transferred to the hospital on [DATE] for psych evaluation . (RI #1) is monitored for any psychosocial changes. (RI #262) transferred to two different hospitals on 10/04/2023. After the incident, the residents were separated as roommates. A review of RI #262's hospital medical record indicated he/she was admitted on [DATE] and discharged on 10/12/2023. The hospital medical record document titled Discharge Summary documented: REASON FOR admission (Quoted from H&P): . admitted to geriatric unit for dementia with behavioral disturbances. Per report pt was brought to emergency department for aggressive and combative behavior . 3) On 10/16/2024 at 10:39 AM the State

Based on interview and review of the Dietary Manager's (DM) employee file, the facility failed to have a qualified Dietary Manager. This had the potential to affect 60 of 60 residents receiving meals from the kitchen. Findings include: An undated job offer letter for the position of Dietary Director (Dietary Manager) from the Administrator included: 1.) The date the offer was accepted by the Dietary Manager: 01/21/2025. 2.) The hire date for the Dietary Manager: 02/14/2025. 3.) The start date for the Dietary Manager: 03/11/2025. A job description for Dietary Manager, dated 12/08/2018 and signed by the Dietary Manager on 03/11/2025, included the following: . JOB SUMMARY: The primary purpose of the Dietary Manager position is to oversee in planning, organizing, developing and directing the overall operations of the Dietary Department. JOB REQUIREMENTS: . Education * Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association or a graduate of another course in food service supervision * Must be a Certified Dietary Manager; or * Must be certified Food Service Manager in this state; or * Must have a similar national certification for food services management and safety from a national certifying body; or * Must have an associate's [sic] degree or higher degree in food service management or hospitality, if the course study includes food service or restraint [sic] (restaurant) management, from an accredited institution of higher learning; . During the initial kitchen tour on 04/29/2025 which began at 1:55 PM, the Dietary Manager said, she had been working at the facility for about two months. During the tour the Dietary Manager said, 60 residents were served meals from the kitchen with one additional resident being NPO (nothing by mouth) and receiving a tube feeding. On 04/30/2025 at 5:00 PM, the Dietary Manager was interviewed, with the Registered Dietitian (RD) in attendance, to review the Dietary Manager's experience and training as follows. The Dietary Manager had previously worked three years as the dietary manager of another nursing facility in Alabama. The Dietary Manager had completed some coursework in Food Safety and Management as provided by the University of North Dakota Nutritional and Foodservice Training Program, from 2022 through March 2025. An extension was approved by the University of North Dakota for completion of the coursework. The Dietary Manager was working on completing Module #17 of the seventeen-part module training program. Once Module #17 was complete, the Dietary Manager would be eligible to apply for certified dietary manager status with ANFP (Association of Nutrition & Foodservice Professionals). The RD is a full-time employee of the facility's parent company and visits the facility weekly and as needed to provide support. During a kitchen observation on 05/01/2025 at 10:04 AM, the Dietary Manager said she had stayed late last night to complete Module #17 and now just needed to submit it. The Dietary Manager said once the the course was finalized, she could apply to take the ANFP exam to become a Certified Dietary Manager (CDM). During an interview on 05/01/2025 at 3:59 PM, the RD said the Dietary Manager was hired with the understanding she would complete the dietary manager course and then pass the CDM test. The RD further said the Dietary Manager was three modules away from completing the dietary manager course at the time of her hire. The RD said Long Term Care (LTC) experience was desired and the dietary Manager had 25 years of LTC foodservice experience and dietary manager experience.

Based on observations, interviews, record review and review of a facility policy titled, Safe and Homelike Environment, the facility failed to ensure residents were provided a safe, clean, comfortable, and homelike environment. During the survey the following concerns were observed in Residents' rooms and common areas: 1) Resident Identifier (RI) #2, RI #7, RI #24, RI #25, RI #31, RI #38 and RI #43 had areas of walls and trim in their rooms in need of painting; 2) RI #1, RI #2, and RI #25 had window blinds in their rooms with broken or missing pieces; 3) RI #15 and RI #25 had windowsills in their rooms in need of repair; 4) RI #26 had a dresser with chipped paint; 5) The Unit Two hallway had broken and stained ceiling tiles; 6) RI #31 and the hallway on Unit Two had as wall with detaching trim; 7) RI #43 had a wall with a hole behind the door and missing pieces of floor tiles. These observations were made on two of two units at the facility; and in the rooms of RI #'s 1, 2, 7, 15, 24, 25, 26, 31, 38, and 43. Findings include: Review of a facility policy titled, Safe and Homelike Environment, with a copyright date of 2024, revealed the following; . Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable, and homelike environment, . Definitions: . Environment refers to any environment in the facility that is frequented by the residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby . A homelike environment is one that de-emphasizes the institutional character of the setting, . 9. General Considerations: . e. Report any furniture in disrepair to Maintenance promptly. 1) RI #38 was admitted to the facility on [DATE]. On 04/29/2025 at 2:44 PM during observations to identify environmental concerns, a board was observed on the wall to the left side of RI #38's bed and plastered areas were observed on the wall behind the head of RI #38's bed. On 05/01/2025 at 8:26 AM the unpainted board was observed on the wall to the left side of RI #38's bed and the plastered areas remained on the wall behind the head of RI #38's bed. On 05/05/2025 at 2:56 PM the Maintenance Director (MTD) observed the areas with the surveyor and he described the area on the left wall of RI #38's bed and areas at the head of the bed as needing to be painted. The MTD said, he had not had a chance to paint the areas yet and they had been that way for at least a month. 2) RI #25 was admitted to the facility on [DATE]. On 04/29/2025 at 3:53 PM the surveyor observed plaster on the wall at the head of RI #25's bed and missing pieces of paint on the wall, and a piece of wood was observed missing from the right windowsill. On 05/05/2025 at 2:59 PM the MTD observed the areas with the surveyor and he described the wall at the head of RI #25's bed as needing to be sanded and painted, the window blind had missing pieces and the piece of wood from the window sill needed to be glued back into place. The MTD said, no one had made him aware of the missing pieces on the blinds or the wood from the windowsill. 3) RI #24 was admitted to the facility on [DATE]. On 04/29/2025 at 4:24 PM, the surveyor observed a plastered area on the right wall and at the head of RI #24's bed. RI #24 said, the walls had been that way for a while. On 05/05/2025 at 3:02 PM, the MTD observed the areas with the surveyor, and he described the walls on the right side and at the head of RI #24's bed as needing to be painted. 4) RI #7 was admitted to the facility on [DATE]. On 04/29/2025 at 5:43 PM, the surveyor observed missing pieces of paint on the wall behind the head of RI #7's bed. On 05/05/2025 at 3:08 PM, the MTD observed the areas with the surveyor, and he described the wall at the head of RI #7's bed as needing to be sanded and painted. 5) RI #2 was admitted to the facility on [DATE]. On 04/29/2025 at 3:04 PM, the surveyor observed missing paint on the wall and missing trim behind the head of RI #2's bed, along with broken blinds at both of the windows in RI #2's room. On 05/05/2025 at 3:09 PM, the MTD observed the areas with the surveyor, and he described the area at the head of RI #2's bed as needing to be patched and painted. The MTD said, the blinds needed to be replaced, and no one had told him about the condition of the blinds. 6) RI #26 was admitted to the facility on [DATE]. On 04/29/2025 at 3:19 PM, the surveyor observed chipped paint on top of the dresser in RI #26's room. On 05/05/2025 at 3:13 PM, the MTD observed the area with the surveyor, and he described the top of RI #26's dresser as having chipped paint which needed to be sanded and painted. 7) On 04/30/2025 at 4:14 PM, the surveyor observed broken ceiling tile over the door leading onto the dining room. On 05/05/2025 at 3:18 PM, the MTD observed the area with the surveyor, and he described the ceiling tile going into the dining room as needing to be replaced. 8) RI #31 was admitted to the facility on [DATE]. RI #15 was admitted to the facility on [DATE]. RI #1 was admitted to the facility on [DATE]. On 04/29/2025 at 2:39 PM, the surveyor observed the baseboard leading into the bathroom shared by RI #31, RI #15 and RI #1 was detaching from the wall and there was a damaged windowsill. On 05/05/2025 at 3:25 PM, the MTD observed with the surveyor areas of concern in the room shared by RI #31, RI #15, and RI #1. The MTD described the wall at the head of RI #31's bed as needing to be painted, the blinds at RI #1's window as needing to be replaced, the window sill of RI #15's window as needing to be replaced, the baseboard leading into the bathroom needed to be glued back, and a black substance on the bathroom floor was worn safety strips that needed to be replaced. 9) On 04/29/2025 at 3:55 PM, the surveyor observed the ceiling tiles in the hallway between rooms Room Locator (RL) #1 and RL #6 to be sagging and torn. On 05/05/2025 at 3:33 PM, the MTD observed the area with the surveyor, and he described the ceiling tiles between RL #1 and RL #6 as being torn and ripped and said the tiles needed to be replaced. 10) RI #43 was admitted to the facility on [DATE] and readmitted on [DATE]. On 04/29/2025 at 2:40 PM, the surveyor observed a hole in the wall in RI #43's room. When asked how long the hole had been in the wall, RI #43 said since he/she had been in the room, which was about three months. Chipped paint was also observed on the wall behind RI #43's bed. On 04/30/2025 at 4:00 PM, the surveyor also observed missing pieces of floor tile in RI #43's room. On 05/05/2025 at 3:34 PM, the MTD observed the areas with the surveyor, and he said the hole on the wall behind the door on the right side of the room needed to be patched; and the area at the head of RI #42's bed needed to be painted. On 05/05/2025 at 3:37 PM, the surveyor conducted an interview with the MTD. The MTD said staff were supposed to put needed repairs in TELS (a system for entering and managing work orders) when things needed to be repaired in the facility. The surveyor asked the MTD when he was made aware of the needed repairs, that were just observed by himself and the surveyor. The MTD said most of them just now, when the surveyor showed him. The MTD said he would not consider the resident's rooms/environment to be homelike.

Based on observations and interview, the facility failed to ensure: 1) hand rails in the hallways were not missing plastic end cap pieces, 2) a small handrail was not missing from the wall on the left side of the hall, and there was not a missing handrail on the right side of the hallway on Unit One; and 3) a small hand rail was not missing from the wall next to the nurses station on Unit Two. This deficient practice was identified during observations of the environment and had the potential to affect residents who ambulated in the facility. Findings include: On 04/29/2025 at 4:00 PM, the surveyor observed the hand rail in front of the nurses' station on Unit One was missing the end cap. On 04/29/2025 at 4:16 PM, the surveyor observed the hand rail near the Respiratory Supply Closet was missing the end cap. On 04/29/2025 at 4:17 PM, the surveyor observed a the hand rail near Social Service (SS) office was missing the end cap. On 05/05/2025 at 3:05 PM during observations of areas of concern with the environment in the facility with the Maintenance Director (MTD) he said, end cap pieces were missing from the hand rail by door #4 (the respiratory supply closet), the hand rail outside the SS door, and the hand rail across from the nurses' station on Unit One. On 04/29/2025 at 3:57 PM during observations of the hallways, the surveyor observed a hand rail with a missing end cap piece outside of Room Locator (RL) #1 and the hand rail near RL #2 was broken. On 05/05/2025 at 3:24 PM during observations of the facility with the MTD, he said, the hand rail outside of RL #2 needed to be replaced because there was a crack in the hand rail and the hand rail outside of RL #3 needed the end cap replaced. On 04/29/2025 at 3:28 PM, the surveyor observed a small hand rail was missing from the wall between doors/offices marked with a 9 and 10 on the left side of the hallway and a hand rail was missing between doors/offices marked 11 and 12 on the right side of the hallway on Unit One. On 05/03/2025 at 10:25 AM, the surveyor observed that a small hand rail was missing from the wall next to the nurses station on Unit Two. On 05/04/2025 at 11:16 AM, the surveyor observed with the MTD areas of the facility with missing hand rails. The MTD said, the length of the missing hand rail between offices 9 and 10, on Unit One, would be about 10 inches. When asked how long had it been that there was no hand rail on the wall, the MTD said at least three weeks to a month. On 05/04/2025 at 11:19 AM, the surveyor asked the MTD what he would say was the length of the missing hand rail between RL #4 and RL #5 on the right side of the hall way on Unit One. The MTD said about two or three feet. The MTD said he was also aware of the missing hand rail by the nurses station on Unit Two. When asked why it would be important to have hand rails permanently affixed to the walls in the hallways, the MTD said for the residents that need assistance with walking, this would prevent them from falling. The MTD said the hand rail would be something for the residents to hold onto. On 05/05/2025 at 11:53 AM, an interview was conducted with the Director of Nursing (DON). When asked why it would be important to ensure there were hand rails permanently affixed to the walls in the hallways, the DON said for safety. The DON said most of the residents walk on the side of the hall using the hand rails, especially if the resident did not have a steady gait.

Based on interviews, record review and review of a facility policy titled, Notification of Change, the facility failed to ensure Resident Identifier (RI) #312's sponsor/representative was notified when RI #312 had a room change in the facility on 10/18/2024. This deficient practice affected RI #312, one of 27 sampled residents and was cited as a result of the investigation of complaint/report number AL00049381. Findings include: A review of a facility policy titled, Notification of Changes, dated 2024 revealed: . 1. Competent individuals: a. The facility must still contact the resident's physician and notify resident's representative, if known. RI #312 was readmitted to the facility on [DATE]. On 05/01/2025 at 10:03 AM, an interview was conducted with Social Service Designee (SSD)/Care Manager #9. The SSD stated, RI #312 had a room change in the facility on 10/18/2024. The SSD stated, the facility was responsible for notifying the responsible party, and the resident when moving to another room. The SSD stated, she did not notify RI #312's sponsor of the room change. On 05/01/2025 at 11:50 AM, an interview was conducted with RI #312's sponsor. The sponsor was asked when the facility notified her of RI #312's room change. The sponsor stated, the facility did not notify her of the room change. On 05/01/2025 at 4:56 PM, an interview was conducted with the DON (Director of Nursing). The DON stated, Social Services was responsible for notifying family members of a room change. The DON stated, family members and residents should be notified of room changes before the move. The DON stated, according to the policy, someone should have notified RI #312's family of the room change.

Based on observations and interviews, the facility failed to ensure Resident Identifier (RI) #29's bed was in a safe operating condition at all times. During the dinner meal on 04/29/2025, RI #29's head of bed (HOB) was observed to be in a flat position. Certified Nursing Assistant (CNA) #23 reported the bed had been broken since 04/28/2025. This affected RI #29, one of 27 sampled residents. Findings include: RI #29 was admitted to the facility on [DATE] with diagnoses to include Dementia, Anxiety, Intellectual Disabilities, and Gastrostomy Status. On 04/29/2025 at 6:10 PM, RI #29 was observed on a low bed with the HOB in a flat position while Certified Nursing Assistant (CNA) #23 tried to wake RI #29 up for the dinner meal. CNA #23 said, the HOB was flat due to the bed being broken and maintenance needed to fix the bed. On 04/30/2025 at 7:57 AM, RI #29 was observed in bed and the HOB remained in the flat position. On 05/02/2025 at 8:49 AM, the surveyor conducted an interview with CNA #23. When asked when she noticed the remote on RI #29's bed was not working, CNA #23 said, Monday, 04/28/2025. CNA #23 said, she was not sure when she notified the Maintenance Director (MTD) of RI #29's bed being broken. On 05/05/2025 at 3:38 PM, the surveyor conducted an interview with the MTD. The MTD said the first time he was told something was wrong with RI #29's bed was on Tuesday, 04/29/2025. The surveyor shared with the MTD that the surveyor had been informed RI #29's bed was not functioning on Monday. The MTD said if the bed was not functioning on Monday, he or the Director of Nursing (DON) should have been informed. The MTD said the residents needed a functioning bed at all time so they could get out of the bed without trouble. On 05/04/2025 at 10:26 AM, a follow-up interview was conducted with CNA #23. CNA #23 said it would be important to have a resident's bed operating properly at all times because staff wanted to be able to let the HOB up and down when providing care and the head to be in an upright position when staff were feeding the resident so they would not choke. On 05/05/2025 at 11:53 AM, an interview was conducted with the DON. The DON said she had not been informed RI #29's bed was not functioning properly. The DON said the MTD should have been informed of this as soon as possible. The DON said it would be important to ensure a resident's bed was operating properly for the residents safety. The DON said if staff had a resident who was to be fed, the HOB needed to be elevated so the resident did not aspirate or choke. The DON said staff also needed to be able to let the bed up or down for the resident's safety and to care for the resident.

Based on interviews, medical record review, review of a facility policy titled, Diagnostic Testing Services, and a review of a Facility Incident Report (FRI) received by the State Agency, the facility failed to ensure RI #412's laboratory services were provided timely when an order was received on 07/19/2024 to obtain a Urinalysis (UA) and Culture and Sensitivity (C&S) for RI #412. This deficient practice affected RI #412, one of 27 sampled residents. Findings include: RI #412 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Benign Prostatic Hyperpasia and History of Cystitis. RI #412's July 2024 Physician Orders were reviewed and revealed an order dated 07/19/2024 for a laboratory test of urinalysis and culture and sensitivity. RI #412's medical record contained laboratory results for a Urinalysis that was collected 07/29/2024 and included a final report documenting there was probable urogenital contamination and no further work up would follow. On 05/02/2025 at 11:08 AM Registered Nurse (RN) #9 was asked about a Nursing Progress Note entry she had documented and signed on 07/19/2024 for collection of a clean catch urine specimen for RI #412. RN #9 said, RI #412 was more confused that day, she obtained an order from the doctor to get a urine specimen, and it was collected with no issues. When asked how long it would take for a urine culture report to come back, RN #9 said, a day or two. RN #9 said they completed another UA on 07/29/2024 ten days later. On 05/05/2025 03:59 PM Clinical Laboatory Services (CLS) was contacted and CLS Employee, CLS #21 was asked about RI #412's physician order dated 07/19/2024 for a Urine specimen. CLS #21 said, she saw the order in the system, but they never received the specimen, and the collection was pending.

Based on observations, interviews, resident record review, and review of the Centers for Medicare & (and) Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument 3.0 Manual, the facility failed to ensure Resident Identifier (RI) #21's quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 01/28/2025 was coded to accurately reflect that RI #21 received special treatment of dialysis. This deficient practice had the potential to affect RI #23, one of 27 sampled residents whose MDS assessments were reviewed. Findings include: The review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, section O, revealed: . Intent: the intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods . RI #21 was readmitted to the facility on [DATE] with diagnoses to include: Dependence on Renal Dialysis and Chronic Kidney Disease. RI #21's Physician Orders documented an order dated 01/07/2025 for Renal Dialysis on Tuesday, Thursday, and Saturday. RI #21's quarterly MDS assessment with an ARD of 01/28/2025 was not marked to reflect RI #21 received dialysis. An interview was conducted with the Regional MDS Coordinator (RMDSC) on 05/01/2025 at 3:50 PM. The RMDSC indicated that RI #21 was currently receiving Dialysis. When asked about the quarterly MDS with an ARD of 01/28/2025, the RMDSC said, it had not been recorded that RI #21 received Dialysis. The RMDSC said, the quarterly MDS assessment should have documented RI #21 received Dialysis, which was an oversight, during the completion of the assessment. The RMDSC said, the importance of an accurate MDS assessment was to ensure a true representation of the care being provided.

Based on observations, interview, and review of a facility policy titled, Nurse Staffing Posting Information, the facility failed to ensure the total hours staff actually worked were included on the nurse staff forms posted in the facility on 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, and 05/03/2025. This deficient practice was observed on five of 11 days of the survey, and had the potential to affect all 61 residents residing in the facility. Findings include: Review of a facility policy titled, Nurse Staffing Posting Information, with a copyright date of 2025, revealed the following: . Policy Explanation and Compliance Guidelines: 1. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses [RN] ii. Licensed Practical Nurses [LPN]/Licensed Vocational Nurses iii.Certified Nurse Aides [CNA] . 4. A copy of the schedule will be available to all supervisors to ensure the information posted is up-to-date and current. a. The information shall reflect staff absences on that shift due to call-outs and illness. After the start of each shift, actual hours will be updated to reflect such . On 04/29/2025 at 3:20 PM, the nurse staff posting form for the 7 AM to 7 PM shift was observed on the bulletin board in front of the main dining room. The form listed the number of Registered Nurses (RN), Licensed Practical Nurses (LPN), Medication Assistant Certified (MAC), and Certified Nursing Assistants (CNA) who were to work the shift, but did not include the total hours actually worked. There was not a section on the form to list the hours worked. On 04/30/2025 at 8:24 AM, the nurse staff posting form for the 7 AM to 7 PM shift was observed on the bulletin board in front of the main dining room. The form listed the number of RNs, LPNs, MACs, and CNAs who were to work the shift, but did not include the total hours actually worked. There was not a section on the form to list the hours worked. On 05/01/2025 at 9:38 AM, the nurse staff posting form for the 7 AM to 7 PM shift was observed on the bulletin board in front of the main dining room. The form listed the number of RNs, LPNs, MACs, and CNAs who were to work the shift, but did not include the total hours actually worked. There was not a section on the form to list the hours worked. On 05/02/2025 at 8:12 AM, the nurse staff posting form for the 7 AM to 7 PM shift was observed on the bulletin board in front of the main dining room. The form listed the number of RNs, LPNs, MACs, and CNAs who were to work the shift, but did not include the total hours actually worked. There was not a section on the form to list the hours worked. On 05/03/2025 at 10:31 AM, the nurse staff posting form for the 7 AM to 7 PM shift was observed on the bulletin board in front of the main dining room. The form listed the number of RNs, LPNs, MACs, and CNAs who were to work the shift, but did not include the total hours actually worked. There was not a section on the form to list the hours worked. On 05/05/2025 at 11:53 AM, an interview was conducted with the Director of Nursing (DON). The DON said, according to the facility's nurse staff posting policy, the facility name, the current date, the census, and the total actual hours worked for RNs, LPNs, CNAs should be on the form. The DON said, looking at the nurse staff posting forms for 04/29/2025 to 05/03/2025, the total number of hours staff actually worked was missing. When asked why it would be important to have the actual hours staff worked on the staffing form, the DON said, they would need to know how many staff were actually in the building for a certain timeframe.

Based on observations, interviews, and review of a facility policy titled Code of Dress and Personal Appearance the facility failed to ensure: 1.) the Dietary Manager (DM) wore a beard guard around food while in the kitchen on 01/06/2025 and 01/08/2025; 2.) Residents were served on dinnerware instead of paper plates during the evening dining observation on 01/06/2025 and; 3.) the kitchen stove hood and vents were clean and free of a grease and dust like substance on 01/06/2025 during the initial tour of the kitchen. This had the potential to affect 52 out of 52 residents who received meals from the kitchen. 1.) A review of a facility policy titled Code of Dress and Personal Appearance dated 2020, revealed: . Guideline: All Dining Services employees will comply with printed and posted personal hygiene guidelines, sanitation practice, and dress code of this community. Procedure: . a. Employees will use effective hair restraints, such as hairnets, hair bonnets, and beard guards to prevent contamination of food or food contact surfaces. On 01/06/2025 at 5:11 PM during the initial kitchen tour the DM was observed without a beard guard on. On 01/08/2025 at 4:49 PM the surveyor observed the DM without a beard guard on in the kitchen. On 01/08/2025 at 5:08 PM the DM, without wearing a beard guard, began placing macaroni salad into bowls. On 01/09/2025 at 2:01 PM the DM was asked about the facility policy for beard guards. The DM stated, they have to wear a beard guard in the kitchen. The DM stated, he did serve macaroni salad into bowls without wearing a beard guard. The DM stated, he had not worn a beard guard on Monday, Tuesday, and Wednesday (01//6/2025 - 01/08/2025). The DM stated, it was important to wear a beard guard so hair would not fall into the food. 2.) On 01/06/2025 at 6:22 PM four of nine residents observed in the dining room were eating from blue and white paper plates instead of dinnerware. RI #44 was admitted to the facility on [DATE]. On 01/09/2025 at 10:54 AM RI #44, one of the residents observed on 01/06/2025 who was served on paper plates, was asked what type of plate his/her meal was served on Monday 01/06/2025. RI #44 stated, a paper plate. RI #44 stated, he/she often was served on paper plates. RI #44 said, he/she preferred a nicer plate. RI #44 said, everyone in the facility knew about the use of paper plates but he/she had not talked to the DM about the paper plates. On 01/09/2025 at 11:17 an interview was conducted with a Dietary Aide (DA) #6. DA #6 was asked why were residents eating from paper plates. DA #6 stated, because they ran out of plates. DA #6 was asked how often residents were served on paper plates. DA #6 stated the residents had been eating from paper plates for a week. DA #6 stated that residents were not supposed to be served food from paper plates. On 01/09/2025 at 2:01 PM an interview was conducted with the DM and he was asked why residents were served food on paper plates. The DM stated, maybe all of the dishes not had not come back to the kitchen. The DM stated, it was important that residents were not served food on paper plates and it was the facility policy to only serve residents on paper plates when they were on isolation or sick. The DM stated, there was not a shortage of plates in the kitchen. The DM stated, he was responsible for making sure residents were not served food on paper plates. 3.) On 01/06/2025 at 05:11 PM the surveyor observed the stove vents and light bulbs under the stove hood to be dirty with a grease like and dust like substance on them. On 01/08/2025 at 4:30 PM and observation was made of the stove with the DM. The DM said, there was grease on the back of the stove hood, the vents under the stove hood, and on the hood light bulbs. On 01/09/2025 at 1:01 PM an interview was conducted with the DM. The DM stated, there was grease on the vents under the stove hood and he saw grease on the back of the stove hood. The DM stated, he saw grease on the light bulbs. The DM said, it was there and because it had not been cleaned. The DM stated, it was important for the vents to be cleaned so nothing would drip into the food and to make sure there was proper venting.

Based on observations, interviews, resident record review, and review of a facility policy titled Nebulizer Therapy the facility failed to ensure Resident Identifier (RI) #8's nebulizer mask and tubing was maintained in a manner to prevent contamination on four of four days of the survey from 01/06/2025 through 01/09/2025 when RI #8's nebulizer mask was not stored in a zip lock bag per policy and RI #8's nebulizer mask and tubing had not been changed since 12/22/2024. This deficient practice affected RI #8, one of two residents sampled for Respiratory Care. Findings include: Review of a facility policy titled Nebulizer Therapy with a Copyright date of 2024, revealed the following: . Policy Explanation and Compliance Guidelines: . Care of the Equipment . 7. store . in a zip lock bag . RI #8 was admitted to the facility on [DATE] and had diagnoses to include Chronic Obstructive Pulmonary Disease. Review of RI #8's January 2025 physician orders revealed RI #8 was to be given a vial of Ipratropium-Albuterol Solution for inhalation daily for nebulizer treatment. On 01/06/2025 at 6:45 PM RI #8's nebulizer mask was observed lying on the inside of the nebulizer machine, not stored in a covering. The tubing connected to the mask was dated 12/22/2024. On 01/07/2025 at 12:21 PM, the surveyor observed the nebulizer mask to remain uncovered. On 01/08/2025 at 3:47 PM, RI #8's nebulizer mask remained not stored in a covering. On 01/09/2025 at 8:45 AM, RI #8's nebulizer tubing remained with the date of 12/22/2024. On 01/09/2025 at 08:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) #3. LPN #3 said, RI #8 received nebulizer treatments in the mornings, the nebulizer mask should be stored in a Ziploc bag, and when not stored in that manner there was a potential for infection. LPN #3 said, the tubing on the mask should be changed on Sunday evenings. LPN #3 said, the date on RI #8's tubing was 12/22/2024 (Sunday) and should have already been changed. LPN #3 said, with the tubing not being changed in a timely manner there was a potential for infection. On 01/09/2025 at 2:03 PM, the surveyor conducted an interview with the Infection Preventionist (IP). The IP said, nebulizer masks should be stored in a Ziploc bag. The IP said, when not stored in that manner there was a potential for bacterial growth. The IP said, oxygen/nebulizer tubing should be changed weekly and when not changed as needed, there was also a potential for bacterial growth.

Based on observations, interviews, record review, review of facility policies titled, Pest Control Program and Safe and Homelike Environment, review of complaints received by the Alabama State Survey Agency, the facility failed to ensure: 1) rodent droppings were not observed in the Dietary Manager's (DM) office, dry storage room in the kitchen, and in the nurses medication room, 2) an adhesive strip with multiple size roaches was not in Resident Identifier (RI) #24's bathroom, and adhesive strips with dead roaches were not in the kitchen, 3) an exit door near RI #'s 26 room did not have a gap beneath the door; and 4) there were not numerous complaints from residents about roaches/rodents being in the facility. These deficient practices affected four of 24 sampled residents including RI #3, RI #24, RI #26, and RI #28 and had the potential to affect all 55 residents residing in the facility. Observations were made on 07/29/2024, 07/30/2024, 07/31/2024 and 08/01/2024. These deficiencies were cited as a result of the investigation of complaint/report numbers AL00048404, AL00048134, AL00046118 and AL00045643. Finding Include: Review of a facility policy titled, Pest Control Program, with a Copyright date of 2023, revealed the following: Policy: It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: Effective pest control program is defined as measures to eradicate and contain common household pests (e.g. [for example] . roaches . mice and rats) . Review of another facility policy titled, Safe and Homelike Environment with a Copyright date of 2023, revealed the following: Policy: In accordance with resident's rights, the facility will provide a safe, clean, comfortable homelike environment . Definitions: . Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the resident's rooms, bathrooms, hallways . On 08/14/2023, the Alabama State Survey Agency received an anonymous complaint alleging the facility had a rat infestation. On 10/25/2023, the Alabama State Survey Agency received an anonymous complaint alleging there were rats in the facility. On 05/14/2024, the Alabama State Survey Agency received an anonymous complaint alleging there were rat/mouse feces in the kitchen, hallways and closet areas in the facility. On 07/24/2024, the Alabama State Survey Agency received an anonymous complaint alleging that while working on the night shift there have been plenty times that mice had been seen running up and down the hallways; and there were roaches of all shapes and sizes in the facility. 1) During an observation of the kitchen on 07/29/2024 at 5:20 PM, the surveyor observed a small oval shaped substance in the DM's office. The DM said it looked like a rat dropping. The DM said the concern of there being rat droppings was contamination. The surveyor and DM entered the dry storage room and multiple small oval shaped substances were observed. The DM also identified the substances as being rat droppings and said rat droppings should not be in the dry good area and could cause contamination. On 07/30/2024 at 3:40 PM, the surveyor toured the medication room on Station Two. There was a small oval shaped black substance observed in the storage cabinet in the medication room. The Maintenance Director (MTD) identified the substance as a rodent dropping. On 08/01/2024 at 11:23 AM, the surveyor again toured the kitchen. The small oval shaped black substance remained in the DM's. The DM said the dropping being in the area was not homelike and sanitary. 2) On 07/29/2024 at 4:20 PM, the surveyor observed a large pest adhesive strip on the floor underneath the sink in the bathroom of RI #24. There was a large dead cockroach and multiple small water bugs and slugs on the strip. On 07/29/2024 at 5:30 PM, the surveyor continued the kitchen observation with the DM. There were six adhesive strips under the sink with large dead roaches on the strips. The DM said roaches being in the kitchen would be a concern of contamination. On 07/31/2024 at 6:05 PM, the surveyor observed the bathroom of RI #24 with the MTD. The adhesive strip remained beneath the sink in the bathroom. The MTD said roaches should not be in the resident's bathroom. The MTD said the concern of roaches being in a resident's bathroom would be germs or the roaches could possibly get in the resident's bed or food. 3) RI #26 was admitted to the facility on [DATE]. RI #26's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 06/22/2024, identified RI #26 as scoring 15 of 15 on the Brief Interview for Mental Status (BIMS) indicating RI #26 was cognitively intact. On 07/31/2024 at 6:20 PM, RI #26 said he/she saw two rats in the hallway outside his/her door three nights ago. On 07/31/2024 at 6:25 PM, the surveyor and MTD observed a gap underneath the employee entry/exit door across from RI #26' room. The MTD said rodents could crawl under the gap and this might be where rodents were entering the building. 4) On 08/02/2024 at 10:00 AM, the surveyor conducted a Resident Council Group Meeting with residents at the facility. The group said they had seen mice/rats off and on over the past six months and they were not completely gone. The group said they had seen mice/rats in their rooms, bathrooms, and hallways; and multiple residents said they had seen roaches or bugs in their rooms. RI #28 was admitted to the facility on [DATE]. RI #28's Annual MDS assessment with an ARD of 06/07/2024, identified RI #28 as scoring 12 of 15 on the BIMS indicating RI #28 had moderately impaired cognition. During the Resident Group Council Meeting on 08/01/2024, RI #28 said he/she saw a big roach on yesterday. RI #3 was admitted to the facility on [DATE] and readmitted on [DATE]. RI #3's Annual MDS assessment with an ARD of 06/30/2024, identified RI #3 as scoring 13 of 15 on the BIMS indicating RI #3 was cognitively intact. During the Resident Group Council Meeting on 08/01/2024, RI #3 said he/she saw a huge live roach in his/her bathroom last night.

Based on observations, interviews, record review and review of a facility policy titled, Safe and Homelike Environment, the facility failed to ensure: 1) the privacy curtain in Resident Identifier (RI) #14's room was not stained and dirty, 2) the smoke detector in RI #25's room was not detaching from the ceiling, 3) there was not a hole in the wall on Station II adjacent to RI #24's room, 4) two tiles were not missing from the floor outside of RI #25's room. These deficient practices affected RI #14, RI #24, and RI #25, three of 26 sampled residents: one of one medication room and one of two units at the facility. This deficiency was cited as a result of the investigation of complaint/report numbers AL00048404 and AL00048134. Finding Include: Review of a facility policy titled, Safe and Homelike Environment, with a Copyright date of 2024, revealed the following: Policy: In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . Definitions: . Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, . Policy Explanation and Compliance Guidelines: 3. Housekeeping and maintenance services will provide as necessary to maintain a sanitary, orderly and comfortable environment . 1) On 07/30/2024 at 11:35 AM, the surveyor observed the privacy curtain in RI #14's room to have a stain and a brown substance on the curtain. Surveyor asked Licensed Practical Nurse (LPN) #10 what the substance was, and she stated she was not sure. On 07/31/2024 at 12:35 PM, the surveyor again observed the privacy curtain and the stain, and the brown substance remained on the curtain. On 07/31/2024 at 5:38 PM, the surveyor was accompanied by the Housekeeping Supervisor (HSK) to RI #14's room. When asked what the stain and brown substance looked like the HKS said bowel movement. The HSK said the stain should not be on the curtain; it should be clean and unstained. The HSK said the stained curtain could cause contamination. 2) RI #25 was admitted to the facility on [DATE] and readmitted on [DATE]. On 07/30/2024 at 5:15 PM, the surveyor made an observation in RI #25's room. The smoke detector was noted detaching from the ceiling. On 07/31/2024 at 8:37 AM, the surveyor made observation and noted the smoke detector remained detaching from the ceiling. On 07/31/2024 at 6:15 PM, the MTD stated a resident could get shocked due to the detaching smoke detector. 3) On 07/28/2024 at 5:36 PM surveyor observed a hole the size of a baseball in the hallway outside of RI #24's room next to a couch in the hallway. On 07/31/2024 at 6:00 PM, the hole was observed with the MTD. The MTD said there should not be a hole in the wall. When asked how the wall should be, the MTD replied smooth and painted. The MTD said the appearance was not homelike. 4) On 07/31/2024 at 8:37 AM, surveyor observed the floor outside RI #25's room and noted two (2) pieces of tile missing. On 07/31/2024 at 5:52 PM, the surveyor and the MTD observed the floor with two missing tiles. Surveyor asked the MTD should the tiles be missing, and MTD replied, No. The MTD stated the tile should be secured. The MTD stated that someone could trip if their shoe got caught in an empty slot.

Based on observation, interviews, record review and review of a facility policy titled, Hand Hygiene, the facility failed to ensure Certified Nursing Assistant (CNA) #7 performed hand hygiene after removing her gloves after feeding Resident Identifier (RI) #6 the lunch meal and leaving RI #6's room on 07/30/2024. This deficient practice affected CNA #7; one of three staff observed for infection control practices. Findings Include: Review of a facility policy titled, Hand Hygiene, with a Copyright date of 2023, revealed the following: Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working within the facility. Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: . 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . RI #6 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of Dysphagia and Need for Assistance with Personal Care. Review of RI #6's Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 07/06/2024, identified RI #6 needed Substantial/maximal assistance with eating. On 07/30/2024 at 12:30 PM, CNA #7 was observed wearing gloves while feeding RI #6 the lunch meal. After feeding RI #6, CNA #7 removed her gloves, and exited RI #6's room without performing hand hygiene. On 08/02/2024 at 9:25 AM, an interview was conducted with CNA #7. When asked what she should have done after removing her gloves after she fed RI #6 the lunch meal on 07/30/2024, CNA #7 said she should have sanitized her hands. CNA #7 said the concern of not sanitizing her hands after removing her gloves would be cross contamination. On 08/03/2024 at 1:55 PM, the surveyor conducted an interview with the Director of Nursing (DON). The DON said staff should immediately sanitize their hands after removing their gloves. The DON said the concern with staff not sanitizing their hands after removing their gloves would be infection and cross contamination. On 08/03/2024 at 2:20 PM, an interview was conducted with the Regional Director of Clinical Operations (RDCO)/Infection Control Nurse. The RDCO said staff should sanitize their hand after removing their gloves. The RDCO said the concern with staff not sanitizing their hands after removing their gloves would be contamination.

Based on interviews, record review and review of facility policies titled, Fall Prevention Program, and Safe and Homelike Environment, the facility failed to ensure Resident Identifier (RI) #7 did not have a fall due to water being on the floor from a leaking air conditioner (AC) unit in RI #7's room. This deficient practice affected RI #7, one of five residents sampled for Falls. This deficiency was cited as a result of the investigation of complaint/report number AL00048404. Findings Include: Review of a facility policy titled, Fall Prevention Program, with a Copyright date of 2023, revealed the following: . A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level . The event may be witnessed, reported, or presumed when a resident is found on the floor or ground, and can occur anywhere . Review of another facility policy titled, Safe and Homelike Environment, with a Copyright date of 2023, revealed the following: Policy: In accordance with resident's rights, the facility will provide a safe . environment . Definitions: . Environment refers to an environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms . RI #7 was admitted to the facility on [DATE], with diagnoses to include Other Reduced Mobility, Muscle Weakness and Unspecified Abnormality of Gait and Mobility. Review of a facility form (Incident Report) titled Un-witnessed Fall, dated 06/24/2024, documented: Resident: (RI #7's name) Incident Location: Resident's Room . Incident Description Nursing Description: This RN (Registered Nurse) called to resident's room for a fall. Resident seen on floor beside bed. Code purple called immediately. Resident lifted back to wheelchair by nursing staff. Resident denies hitting (his/her) head. (He/She) said (he/she) slipped on water on the floor from water leaking from AC unit. (He/She) denies hitting (his/her) head. (He/She) endorses soreness to (his/her) bottom and redness to left elbow. Resident does not have any broken skin areas . Resident Description: I slipped on water and fell . Predisposing Environmental Factors . (Wet Floor was checked) . On 08/01/2024 at 7:20 PM, a telephone interview was conducted with Certified Nursing Assistant (CNA) #23, the CNA assigned to care for RI #7 on 06/24/2024 when RI #7 fell . CNA #23 said she went to RI #7's room after the nurse called her. CNA #23 said RI #7 was on the floor next to the bed and there was a sheet on the floor to catch the water that was leaking from the AC in RI #7's room. CNA #23 said when RI #7 was lifted from the floor you could see water on the floor. When asked should there have been water on the floor, CNA #23 said no. CNA #23 said the water was on the floor because RI #7's AC had been leaking. On 08/02/2024 at 2:10 PM, a telephone interview was conducted with RN #24, the former RN supervisor who prepared the incident report. RN #24 said when she entered RI #7's room RI #7 was on the floor and there was water on the floor due to RI #7's AC leaking. RN #24 said RI #7's fall was avoidable because if water had not been on the floor, RI #7 might not have fallen.

Based on observation, interviews, record review and review of a facility policy titled, Pressure Injury Prevention Guidelines, the facility failed to ensure there was not an unidentified Stage II pressure injury to the back of Resident Identifier (RI) #12's right leg when the Treatment Nurse completed a body audit for RI #12 on 08/01/2024 with the surveyor. This deficient practice affected RI #12, one of five residents sampled for pressure injury. This deficiency was cited as a result of the investigation of complaint/report #AL00048404. Findings Include: Review of a facility policy titled, Pressure Injury Prevention Guidelines, with a copyright date of 2023, revealed the following: Policy: To prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or have pressure injury present . Preventive Skin Care: 1. Inspect skin while providing care . RI #12 was admitted to the facility on [DATE]. RI #12's Quarterly Minimum Data Set assessment with an Assessment Reference Date of 07/02/2024, assessed RI #12 as being at risk for developing pressure ulcers. A review of RI #12's Shower Audit/Skin Assessment forms revealed a form dated 07/29/2024 which did not document any injury or area of concern to the back of RI #12's right leg during this shower audit/skin assessment. On 08/03/2024 at 4:33 PM, a telephone interview was conducted with CNA #22, the CNA assigned to care for RI #12 on 07/31/2024 on the 11 PM to 7 AM shift. CNA #22 said she would have inspected RI #12's skin whenever she checked RI #12 to see if he/she was soiled. CNA #22 said she did not recall looking at the back of RI #12's right leg when she provided care for RI #12 on her shift. On 08/01/2024 at 12:05 PM, an observation of Licensed Practical Nurse (LPN) #10/Treatment Nurse and LPN #11 performing a body audit on RI #12. LPN #11 was the nurse assigned to provide care to RI #12 for the 7 AM to 3 PM shift. LPN #10 identified a Stage II to the back of RI #12's right leg. Both LPN #10 and LPN #11 said they had not been informed of the open area but should have been. Review of a Progress Note completed by the Certified Registered Nurse Practitioner (CRNP), dated 08/01/2024, documented the following: . I was asked to see patient for new wound assessment . According to staff, patient has a new wound to leg and some redness to buttocks. Upon assessment open area with redness noted to back of leg which appears to be a stage II pressure ulcer . wound care orders were given . A Physicians Order dated 08/01/2024, documented the following: . wound care: Right lower outer leg clean area with wound cleanser, pat dry, apply calcium alginate to wound bed, cover with 4x4 gauze and border dressing every day as needed . On 08/01/2024 at 6:16 PM, an interview was conducted with Registered Nurse (RN) #21, the RN supervisor. RN #21 said the Certified Nursing Assistants (CNAs) should be inspecting the resident's skin during care. RN #21 said the evidence this was being done would be on the resident's shower sheets. RN #21 said she was not aware the treatment nurse had identified new skin concerns on RI #12, and the CNAs should have identified the areas before the treatment nurse did. On 08/03/2024 at 2:20 PM, the surveyor conducted an interview with the Director of Nursing (DON). The DON said the CNAs should be inspecting or observing the resident's skin when they are providing peri-care and when taking the resident to the shower. The DON said the CNAs should be inspecting all areas on the resident's body including arms, legs, buttocks, back, etcetera. The DON said there should never be an unidentified pressure ulcer on a resident if the CNAs were inspecting the resident's skin as they should be.

Based on interview, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure Resident Identifier (RI) #12's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date of 07/02/2024, was coded to reflect RI #12 receive an anticoagulant medication during the assessment period. This deficient practice affected RI #12, one of 26 sampled residents whose MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated 10/2019, revealed the following: . SECTION N: MEDICATIONS . Coding Instructions . N0410E, Anticoagulant . Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period . RI #12 was admitted to the facility on [DATE]. RI #12 had a diagnosis of Pulmonary Embolism without Acute Cor Pulmonale. An Order Summary Report (Physician's Order) for RI #12, Eliquis (an anticoagulant) Oral Tablet 5 mg (milligrams) two times a day for atria fibrillation had been ordered for RI #12 to receive since 03/25/2024. RI #12's June and July 2024 Medication Administration Record revealed the resident had received the anticoagulant, Eliquis twice daily as ordered. RI #12's Quarterly MDS assessment, with an ARD of 07/02/2024, revealed RI #12 was not coded for receiving an anticoagulant medication during this assessment period. On 08/03/2024 at 5:37 PM, an interview was conducted with the MDS Coordinator (MDSC). The MDSC said according to RI #12's Physician Orders RI #12 was receiving RI #12 was receiving an anticoagulant medication which was Eliquis. The MDSC said the Eliquis should have been coded on RI #12's Quarterly MDS assessment dated [DATE], but it was not coded accurately. The MDSC said the lookback period for coding mediations was seven days and RI #12 was receiving an anticoagulant medication during the lookback period. The MDSC said it was important for the MDS to be coded accurately so everyone would know the medication the resident received. The MDSC said the anticoagulant not being coded was an oversite.

Based on observation, interviews, record review and review of a facility policy titled, Promoting/Maintaining Resident Dignity, the facility failed to ensure Certified Nursing Assistant (CNA) #7 did not stand while feeding Resident Identifier (RI) #6 the lunch meal on 07/30/2024. This deficient practice affected RI #6; one of one resident observed being fed by facility staff. Findings Include: Review of a facility policy titled, Promoting/Maintaining Resident Dignity, with a Copyright date of 2023, revealed the following: Policy: It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity . RI #6 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Cognitive Communication Deficit, Dysphagia, Need for Assistance with Personal Care and Contracture, Unspecified Joint. Review of RI #6's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date of 07/06/2024, identified RI #6's Brief Interview for Mental Status (BIMS) was 00 of 15 which indicated that RI #6 had severely impaired cognition. The MDS also indicated that RI #6 had impairment of the upper extremities, and needed substantial/maximal assistance with eating. On 07/30/2024 at 12:30 PM, CNA #7 was observed standing while feeding RI #6 the lunch meal. On 08/02/2024 at 9:25 AM, an interview was conducted with CNA #7. When asked what position she should be in when feeding the resident, CNA #7 said sitting. CNA #7 said when she fed RI #6 the lunch meal on 07/30/2024, she should have been seated and was not. CNA #7 said standing over a resident while feeding the resident could cause the resident to feel rushed. CNA #7 said when assisting a resident with a meal, staff should be seated at the level of the resident. On 08/03/2024 at 1:55 PM, an interview was conducted with the Director of Nursing (DON). The DON said staff should not stand when feeding the resident because that was a dignity issue. On 08/03/2024 at 2:20 PM, an interview was conducted with the Regional Director of Clinical Operations (RDCO)/Infection Control Nurse. The RDCO said staff should not stand while feeding the resident and should be positioned at the eye level of the resident. The RDCO said the concern of staff standing while feeding the resident could signal to the resident that staff are not taking their time and are in a hurry.

Based on interviews, record review, review of the facility's policy titled, Elopements and Wandering Residents, and review of the facility's investigation regarding Resident Identifier (RI) #1's elopement, facility staff failed to implement the elopement policy after a door alarmed on 09/15/2022, when RI #1 exited a facility door and left the premises. Per facility video footage, on 09/15/2022 at approximately 8:02 PM, RI #1 exited the facility and proceeded to leave the property and was out of view at approximately 8:05 PM. Facility staff did not respond to the alarm until approximately 8:06 PM, when Employee Identifier (EI) #5, Certified Nursing Assistant (CNA), walked to the front entrance door, looked outside through the door window, did not see anyone, turned off the door alarm and went back to work on the unit. No one else responded to the door alarm. It was not until approximately 8:46 PM, according to the facility's investigation, that EI #3, Licensed Practical Nurse (LPN)/Charge Nurse, noticed RI #1 was not in his/her room for medication administration. It was not until this time that a search began for RI #1 and a head count of residents was initiated. CNAs, EI #7 and EI #8, then searched outside, but they did not see anyone. At approximately 8:50 PM, they got in their car and drove down the road. They saw emergency vehicle lights and found RI #1 at a strip mall 0.4 miles away from the facility and noted dirt on the back of RI #1's shirt. The CNAs returned RI #1 to the facility at approximately 9:11 PM. Upon assessment at the facility, RI #1 was found to have abrasions to the left shoulder, left knee and left forearm and complained of left shoulder pain. This deficient practice placed RI #1, one of three sampled residents, as well as any other residents in the facility at risk for elopement, in immediate jeopardy, as it was likely to result in serious injury, serious harm, serious impairment or death. On 09/23/2022 at 12:23 PM, the Administrator and the Director of Nursing were given a copy of the immediate jeopardy template and notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F689 Free of Accident Hazards/Supervision/Devices. Findings Include: On 09/15/2022 at 11:07 PM, the facility self-reported an incident of elopement to the Alabama State Survey Agency. According to the initial report, RI #1 eloped from the facility but was found at the nearby convenience store. Upon return to the facility, an assessment of RI #1 was conducted. The resident was noted to have pain in the left shoulder and left knee. The resident was unable to explain how he/she got the injury and why he/she wandered from the facility. Review of a facility policy titled, Elopements and Wandering Residents, with an implementation date of 5/01/2022, revealed: . Policy: This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. Definitions: .Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or necessary supervision to do so. . Policy Explanation and Compliance Guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. RI #1 was admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia. Review of RI #1's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/24/2022 revealed RI #1 had a Brief Interview for Mental Status (BIMS) score of 02, indicating severe cognitive impairment. Review of RI #1's Comprehensive Care Plans revealed the facility identified and care planned RI #1 on 09/12/2022 as an elopement risk/wanderer related to resident wanders into others' rooms and towards exits. Review of RI #1's handwritten Physician's Order Form revealed an order dated 09/15/2022 at 11:30 AM for the use of a wander guard. During an interview on 09/20/2022 at 1:56 PM, EI #9, the dayshift nurse on 09/15/2022, reported she was the one obtain the order for the wander guard, and applied it to RI #1's left ankle during her shift on 09/15/2022. EI #9 said the wander guard she applied was brand new and provided to her by EI #10, LPN/Charge Nurse. On 09/20/2022 at 3:53 PM, EI #10 stated they obtained a wander guard for RI #1 on 09/15/2022 because he/she was wandering around and going towards exit doors. EI #10 confirmed she tested RI #1's wander guard for proper functioning prior to EI #9 applying it to RI #1's left ankle. EI #10 explained that if a resident wearing a wander guard gets close to an exit door, it will first alarm, and then it will make a loud noise, before the door releases and opens (break-away door). EI #10 said staff should be able to redirect a resident away from an exit door before it opens. When asked what staff should do if a door alarm sounds, EI #10 said look to see which door is alarming, go to the door to see who is there, and open the door to see if anyone is outside. EI #10 further explained if no one is seen, staff should go outside to look around, check inside to see where everyone is located, and conduct a head count. On 09/21/2022 at 8:56 AM, a friend of RI #1 was interviewed. This friend indicated he/she had gone to the facility on [DATE] to sit and visit with RI #1. This friend confirmed staff had applied a wander guard to RI #1's ankle while he/she was visiting that should have alerted staff if RI #1 was trying to leave the facility. This friend also indicated when he/she left the facility for the day, RI #1 had calmed down and was relaxed on the bed. The facility's Follow-up Incident Investigation to ADPH (Alabama Department of Public Health)/Administrative Summary Final Report dated 09/22/2022, documented the facility's investigation into RI #1's elopement. A review of this document revealed the following: . 3. Conclusion . It appears at approximately 8:00pm . (RI #1) began to wander down unit 2 and walked to the front door where . (he/she) pushed on it for the allotted 10 seconds. Once the door is pushed for that period of time the alarm sounds and the door unlocks. Once . (RI #1) was able to open the door, . (he/she) went down the front 3 steps and proceeded to walk down the sidewalk into the parking lot. Once . (he/she) reached the end of the driveway . (he/she) went to the right which would follow Highway 11 North. The outdoor surveillance shows . (RI #1) off the property at approximately 8:05pm. There is not footage of the main interior entrance, but it appears that CNA . (EI #5) does go in the direction of the main entrance to disarm the alarm at approximately 8:06pm which would be based on her interview. The administrator was able to interview the manager, . (of the store), and she stated that the resident did not make it up to the store location. It was reported that the . (store) shares a parking lot with an adjacent strip mall where . (the resident) had a fall in the parking lot . (local police) responded, along with Fire rescue. The dispatcher stated that there were no recorded events for that day, at that time, or at that location. At approximately 8:46pm Charge Nurse . (EI #3) walks into . (RI #1)'s room and finds that . (he/she) is not in . (his/her) bed. She does a brief survey on the unit and discovers that .(he/she) is not on the unit. (EI #3) then notifies all staff that . (RI #1) is missing, and they begin a facility-wide search. After the staff complete a search of the facility CNA . (EI #5), and CNA . (EI #6) begin searching outside the facility. At Approximately 8:50pm CNA . (EI #8) and CNA . (EI #7) decide to jump in the car to see if they can find . (him/her) down the road. Once they turned out of the parking lot they discovered the flashing lights in the next-door parking lot and turned in. The two facility employees arrived and explained to the responders that . (RI #1) was a resident at a nearby nursing home and that they were tasked with bringing . (him/her) back. The responding officer allowed the CNAs to put . (him/her) in the car and followed them to the entrance where the staff members pulled into the parking lot with the resident, and the police officer continued south on Highway 11. The resident was returned to the facility at approximately 9:11pm. Unit 2 charge nurse began her assessment of the resident at that time and returned . (him/her) to . (his/her) room. Resident was voicing pain to left shoulder and decreased range of motion. (EI #3) notified MD and x-ray order was given along with U/A (urinalysis). Resident sponsor notified. In Summary, after the resident had opened the door and the alarm was actively sounding at 8:02pm, there were approximately 4 minutes in which it took a staff member to respond. it appears that the staff during the incident failed to follow the elopement policy and failed to realize that the alarm coming from the main entrance was an active wandering resident. The failure to respond timely in this specific situation is what led to this incident. On 09/21/2022 at 4:09 PM, the surveyor reviewed the facility's video footage from 09/15/2022 of RI #1 leaving the facility, staff responding to the door alarm, and of RI #1 returning to the facility at approximately 9:11 PM. This footage confirmed the series of events and timeline outlined above in the facility's investigative summary. Review of RI #1's Shower Sheet dated 09/15/2022 from after RI #1's return to the facility indicated the resident was assessed by EI #3, LPN, and noted to have abrasions to his/her left shoulder, left knee and left forearm. This form also reflected a pain scale of six out of ten at the time of the assessment. Review of EI #5's Incident Witness Statement, dated 09/15/2022, revealed the alarm went off and EI #5 went to the front door and turned it off. EI #5 stated she looked out the door but she did not see anyone. EI #5 stated EI #3 asked her later if she had seen RI #1. EI #5 told EI #3 that she had not seen the resident. EI #5 stated she and EI #6 then went outside to look for the resident. In an interview on 09/20/2022 at 6:13 PM, EI #5, CNA, reported she heard a door alarm during her shift on 09/15/2022. EI #5 stated she went to the front door, which she described as a little ajar, and pulled it closed. EI #5 stated she looked out the window by shielding her eyes with her hands so she could see out, and did not see anything. EI #5 stated she then turned the alarm off and walked back down the hall. EI #5 was asked what she was supposed to do when she heard a door alarm. EI #5 stated when she heard a door alarm, she was supposed to stop what she was doing and go check on the alarm and make sure no one was outside, even if that meant going outside to check. EI #5 stated on 09/15/2022 when she responded to the door alarm she did not go outside to make sure all residents were safe. When asked about the concern with RI #1 being outside the facility, EI #5 stated the resident could get hurt. In an interview on 09/20/2022 at 6:49 PM, EI #3, LPN, reported she realized RI #1 was not in his/her bed on 09/15/2022 when she went to his/her room to check on him/her. EI #3 did not know the time. EI #3 stated she looked for the resident and notified the other staff of the active search. EI #3 stated two staff members (EI #7 and EI #8, both CNAs) left the facility property and were able to locate RI #1. EI #3 estimated RI #1 was gone from the facility 45 minutes to an hour based on vital sign times, medication pass times, and the other residents she was also providing care to that night. When asked about the door alarm sounding on the evening/night of 09/15/2022, EI #3 said she knew she heard something because she recalled scooting back in her chair to see what it was, but then the sound stopped. EI #3 said she only heard it once, and someone must have turned it off, because the sound stopped. When asked what staff should do when they hear a door alarm, EI #3 said they should get up and search to make sure everyone is safe; however, EI #3 indicated that was not done on the evening/night of 09/15/2022. When asked why not, EI #3 said the alarm she heard was not on her hall, and someone cut it off. EI #3 was asked to explain what happens if a resident wearing a wander guard gets close to an exit door. EI #3 indicated the doors will initially lock and alarm, but if held down/pushed, the door will eventually open (break away door). When asked about the concern with RI #1 leaving the facility property, EI #3 stated possible injury or not being able to find the resident. During an interview with EI #4, another LPN, on 09/21/2022 at 10:51 AM, EI #4 said the purpose of door alarms is to alert staff to someone leaving the building. When asked what should be done when a door alarm goes off, EI #4 said staff should look out to see if they see anyone, do a headcount, and if someone is found to be missing, announce a Dr. Wander over the intercom to alert everyone that someone is missing. EI #4 said this did not happen on 09/15/2022 because when EI #5 responded to the door alarm, she did not see anything and turned the alarm off. EI #8, CNA, was interviewed on 09/21/2022 at 9:30 AM. EI #8 said when they were notified on 09/15/2022 that RI #1 was not in the facility, she and EI #7 drove down the road and saw police and fire lights in the parking lot of a nearby shopping center. EI #8 said when she and EI #7 got there, they realized it was RI #1, and were able to return him/her to the facility. In an interview on 09/21/2022 at 11:31 AM, EI #7, CNA, said when she found out that RI #1 was missing on 09/15/2022, she road with EI #8 down the road and saw emergency lights at a nearby shopping center parking lot, where they located RI #1. EI #7 said they were able to get RI #1 into EI #8's car and return him/her to the facility. When asked what staff could have done differently to prevent RI #1 from leaving the facility or to reduce the amount of time RI #1 was gone from the facility unsupervised, EI #7 said they could have paid more attention to the resident and to the alarms. Google Maps indicated a distance of 0.4 miles from the facility to where EI #7 and EI #8 located RI #1 on 09/15/2022. In an interview on 09/22/2022 at 9:41 AM, EI #2, DON, was asked about how the facility's door alarms work. EI #2 explained when the door handle is pushed, the alarm sounds, and then when held for 15 seconds, the door opens (break away door). EI #2 said the alarm would sound until someone turned it off. EI #2 said on 09/15/2022 at 9:00 PM or just before, she received a call from EI #3, LPN, letting her know they were looking for RI #1. EI #2 said she instructed staff, at this time, to page Dr. Wander, start room checks to make sure no one else was missing, and to check the outside perimeter of the facility. EI #2 said following RI #1's return to the facility, the facility tested to ensure the door alarms were working properly and they were. EI #2 said they determined their staff had not responded timely when the door alarm was sounding. When asked how staff had responded to the door alarm, EI #2 stated staff responded to the alarm untimely. EI #2 said they had no sound on their video footage, but EI #5 was seen on camera walking towards the front door. EI #2 said, based on the video footage, the alarm sounded three to four minutes from the time RI #1 pushed on the door when he/she left the facility until EI #5 disarmed the alarm. When asked how staff should have responded to the door alarm, EI #2 stated staff should have immediately responded to the alarm system by reporting to the alarming door, opening the door, assessing the perimeter inside and outside for any residents, before disarming the alarm. When asked about the facility's policy, EI #2 stated when a door alarm sounded, staff were to safely stop what they were doing and respond to the door alarm at all times. EI #2 stated staff did not respond with a sense of urgency to the alarm when RI #1 pushed the front door open and left the facility. EI #2 stated staff should have initiated elopement protocol, including a head count, when the alarm went off. EI #2 stated if elopement protocol was initiated then, RI #1 could have had decreased risk of harm and a quicker return time to the facility. EI #2 stated the elopement could have been prevented and the resident could have possibly been returned to the safety of the inside of the facility while still on facility property if staff had followed protocol. In an interview on 09/22/2022 at 11:43 AM, EI #1, Administrator and Abuse Coordinator, stated staff were not vigilant in responding to the door alarm timely on 09/15/2022. When asked about the expectations of staff in the event a door alarm is sounding, EI #1 said he expects all staff to move in the direction of the alarm when they hear the alarm. EI #1 stated if no one is at the door that could have caused the alarm, staff should do a head count of all residents in the facility. EI #1 stated staff did not initially conduct the head count on 09/15/2022 when the door alarm sounded. EI #1 stated he expected staff to approach every alarm as an active resident out of the building until confirmed otherwise. EI #1 stated if staff had followed facility protocol correctly, staff could have known RI #1 was outside the building sooner than they knew. EI #1 stated RI #1 left the facility at 08:02 PM and was returned inside the facility at 09:11 PM. This deficiency was cited as a result of the investigation of complaint/report number AL 056. On 09/23/2022 at 9:16 PM, the facility submitted an acceptable Removal Plan for F689 which documented: 1. On 9/15/2022 at 9:11pm the Resident returned to the facility and a head-to-toe assessment was completed by the Charge Nurse. Injuries noted were pain to left shoulder, scratches on left forearm, and abrasion on left knee. Wander-guard was intact and functioning properly. Notifications were made to administrator and DON by Charge Nurse at 9:00pm. MD notified of injuries and x-ray and U/A were ordered at 9:30pm. Resident sponsor was notified at 10:00pm. 1-on-1 was implemented for the remainder of that night and in place until 9/19/2022. Administrator reported incident to ADPH at 11:07pm on 9/15/2022. Investigation initiated, witness statements collected, and interviews conducted on 9/16/2022. Maintenance Director inspected Wander-guard system on 9/16/2022 and found that the systems were working properly. We reviewed the Elopements and Wandering Residents policy on 9/16/2022. The facility completed the 5-day investigation and submitted the final report to ADPH on 9/22/2022. 2. On 9/20/2022 the facility suspended 2 LPN charge nurses, and 1 CNA due to failure to monitor resident actively exit-seeking and failure to respond to door alarm. On 9/21/22 the facility suspended another CNA as she was the one who silenced the alarm and did not initiate a head count. On 9/22/22 we terminated 2 LPN Charge nurses, and a CNA for failure to follow the elopement policy and failing to protect the safety of a wandering resident. 3. The facility initiated an all-staff in-service on 9/16/2022 and completed the training on 9/17/2022 which explained the elopement policy. The training explained that all staff are to respond to any door alarm, and to treat that alarm as if there is an elopement in progress. This in-service was completed by 69/69 staff members and instructed by the DON and RN Supervisor. 4. The facility conducted code alert response drills which are defined by intentionally triggering the alarm by a member of management on various shifts and at various times to gauge response times of staff. These drills were completed on 9/16/22 during 1st shift at 11:36am, 9/20/22 during 1st shift at 3:00pm by DON, 9/21/22 on 2nd shift at 7:45pm by DON, on 9/21/22 during 3rd shift at 3:00am by administrator, and on 9/22/22 during 2nd shift at 3:32pm by DON. Sign-in sheets show the staff response time, the specifics of who responded, and when the drill was completed. Staff members are expected to appropriately respond to alarm and assess whether a resident was cause of alarm. If reason is unknown a facility-wide head count should be initiated and all clear given if all residents have been confirmed to be in the building. Drills will be conducted randomly during the week for various shifts and at various times. ******************************************************************* After reviewing the facility's information provided in their Removal Plan and verifying the immediate actions had been implemented, the scope/severity level of F689 was lowered to a D level as of 09/22/2022, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

Based on staff and resident interviews, review of Resident Identifier (RI) #1 and RI #2's medical record, the facility's policies titled Medication Administration General Guidelines and Standing Orders and a complaint received by the Alabama State Survey Agency, the facility failed to ensure pain medication ordered for RI #1 and RI #2 was administered as ordered by the physician. RI #1, a resident assessed as having frequent pain, was ordered [MEDICATION NAME] ER (Extended Release) to be administered every eight hours at 6:00 AM, 2:00 PM and 10:00 PM for a [DIAGNOSES REDACTED].#1 was not administered this medication as it was not available in the facility; RI #1 missed 11 doses of routine pain medication. During this time, RI #1 exhibited signs/symptoms of [MEDICATION NAME] withdrawal, to include: complaints of muscle pain, shakiness, nervousness, [MEDICAL CONDITION]/ inability to sleep, and restlessness. RI #2, a cognitively intact resident, assessed as having occasional pain, was ordered [MEDICATION NAME] 10 one tablet by mouth every six hours PRN (as needed) for pain. RI #2 stated in an interview, the facility ran out of his/her pain medication one time last week for about four to five days. Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN) acknowledged in an interview, that RI #2 requested pain medication once during her shift. EI #11 stated she administered RI #2's last [MEDICATION NAME] 10 on 9/1/2017 and when she returned to work on 9/4/2017, RI #2 did not have any pain medication available for administration. These deficient practices affected RI #1 and RI #2, two of three sampled residents reviewed for pain medication, and placed RI #1 and RI #2 in immediate jeopardy of serious injury, harm or death. On 9/9/2017 at 6:50 PM, the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Clinical Services and Chief Operating Officer were notified of the findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 309. Findings include: On 9/1/2017, the State Survey Agency received a compliant which alleged RI #1 went without pain medication, [MEDICATION NAME], for five days because a staff member forgot to reorder the medication. The complainant stated during this five day time frame, without pain medication, RI #1 experienced a severe detox as the resident paced, was observed shaking, had bouts of [MEDICAL CONDITION] and desired to leave the facility. On 9/6/2017, the State Survey Agency received a complaint which alleged RI #2 was also out of his/her pain medication, [MEDICATION NAME]. The complainant stated RI #2's pain medication was ordered to be administered every four hours. The facility's policy titled, Standing Orders, signed and dated 3/21/2006, revealed POLICY: Nursing Administration Routine Standing Orders Procedure: . 2) Mild Pain A. [MEDICATION NAME] 650 mg (milligram) by mouth, per tube or rectal suppository every four hours PRN (as needed) for up to 24 hours. B. Notify physician if pain is not relieved, becomes severe or persists longer than 24 hours . The facility's policy titled, Medication Administration General Guidelines, dated May 2016, revealed . POLICY Medications are administered as prescribed . PR(NAME)EDURES . Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber . Documentation: . 2. If two consecutive doses of a vital medication are withheld or refused, the physician is notified . 1) RI #1 was admitted to the facility on [DATE] with a medical history to include: Hepatic Failure and Chronic Pain. RI #1's Quarterly Minimum Data Set (MDS) with an assessment reference date of 7/12/2017, revealed RI #1 was moderately impaired in cognitive skills, with a Brief Interview for Mental Status (BIMS) score of 8. The MDS indicated RI #1 was on a scheduled pain regimen and received PRN pain medication. RI #1 was assessed as having frequent pain that made it hard to sleep, with an intensity rating of seven. RI #1's care plan titled Potential for pain r/t (related to) general aches and pains, slightly decreased mobility, hepatic [MEDICAL CONDITION] . with a problem onset date of 1/16/2014 and last reviewed 7/13/2017 had an approach of . Administer pain meds (medication) per MD (Medical Doctor) orders . RI #1's physician orders [REDACTED]. On 9/9/2017 at 9:32 AM, a telephone interview was conducted with Employee Identifier (EI) #7, a Licensed Practical Nurse (LPN) assigned to care for RI #1 during the 11PM -7AM shift. EI #7 was asked was she familiar with RI #1 receiving [MEDICATION NAME] for pain. EI #7 responded yes. According to EI #7, on 8/22/2017 she asked EI #6, a LPN, about RI #1's [MEDICATION NAME] prescription and EI #6 told her (EI #7) that the Director of Nursing (DON) had been made aware. EI #7 stated the nursing staff was to report to the DON when prescriptions were running low. Then on 8/23/2017, EI #7 stated when she came in she noticed RI #1 still did not have a [MEDICATION NAME] prescription, so she charted on the 24-hour report that RI #1 had only four [MEDICATION NAME] tablets left and needed a prescription. EI #7 stated when she returned she saw it documented that RI #1 had been administered his/her last [MEDICATION NAME] tablet. The facility's 24-HOUR REPORT/CHANGE OF CONDITION REPORT for Station 2, written by EI #7 dated 8/23/2017, documented . (RI #1) needs [MEDICATION NAME] script only #4 left . On 9/6/2017 at 7:55 PM, an interview was conducted with EI #4, a LPN who works the 3PM - 11PM shift on Station 2. EI #4 was asked if she ever cared for RI #1. EI #4 replied, yes. When asked if RI #1 received routine pain medication, EI #4 said yes, RI #1 received [MEDICATION NAME]([MEDICATION NAME]) 30mg at 6AM, 2PM and 10PM. EI #4 was asked if there ever was a time, the resident had been out of pain medication. EI #4 replied, yes. EI #4 said she worked a double shift (3PM -11PM and 11PM -7AM) on 8/24/2017 and she gave RI #1 the last pain pill at 6AM on 8/25/2017. EI #4 said she reported to the morning nurse, EI #6, that she had given the last pain pill. EI #4 was asked if she remembered how long RI #1 was out of pain medication. EI #4 replied she was off for the weekend and when she returned on Monday (8/28/2017) RI #1 did not have any [MEDICATION NAME]. When asked what she did, EI #4 stated she asked EI #6, a LPN, about the [MEDICATION NAME] and was told the medication had been ordered and it should come in that evening when pharmacy delivered. In an interview on 9/9/2017 at 10:35 AM, EI #6, a LPN acknowledged she was assigned to care for RI #1 during the 7AM - 3PM shift on 8/25/2017, 8/28/2017 and 8/29/2017, when RI #1 was out of pain medication. EI #6 stated she tried to get with the pharmacy to get RI #1's pain medication. EI #6 explained she faxed the reorder request to the pharmacy on 8/20/2017 and 8/25/2017. According to EI #6, it was during her 2PM medication pass on 8/25/2017, RI #1 did not have any pain medication available for administration. When asked what she did, EI #6 stated she reported to the DON that she had faxed everything to pharmacy. EI #6 was asked if she contacted the physician and she said no. When asked why not, EI #6 said because she thought the pharmacy needed a new script. EI #6 then stated on 8/28/2017, she realized RI #1 still had not gotten the ordered pain medication, [MEDICATION NAME]. The backside of page 2 of 4 of RI #1's MEDICATION RECORD for August 2017, documented .NURSE'S MEDICATION NOTES . 8/25/17 [MEDICATION NAME] Pharmacy notified script sent to MD . During a telephone interview on 9/8/2017 at 8:05 PM, EI #8, a LPN Charge Nurse who works 7AM - 7PM shift on the weekend on Station 2, stated she was told by EI #4 (LPN) that RI #1 was out of pain medication. EI #8 stated on Saturday (8/26/2017) she called the pharmacy and was told there was no prescription. Then on Sunday (8/27/2017), EI #8 stated she called and texted the physician but received no response. In a telephone interview on 9/9/2017 at 4:45 PM, EI #14, the 7PM -7AM LPN on the weekend, was asked if she contacted the physician when RI #1's pain medication, [MEDICATION NAME], was not available. EI #14 said no. EI #14 explained she had been told the medication had been ordered, so she was waiting for it to come from the pharmacy. The backside of page 2 of 4 of RI #1's MEDICATION RECORD for August 2017, documented . NURSE'S MEDICATION NOTES . 8/26/17 6a [MEDICATION NAME] mg Awaiting pharmacy delivery 8-26-17 10p [MEDICATION NAME] script 8-27-17 6a [MEDICATION NAME] script . The backside of page 3 of 4 of RI #1's MEDICATION RECORD for August 2017, documented . NURSE'S MEDICATION NOTES . 8-26-17 2pm [MEDICATION NAME] did not give . In a follow-up interview on 9/8/2017 at 8:30 PM, EI #4, a LPN was asked when she returned to work on 8/28/2017, did RI #1 have pain medication, [MEDICATION NAME], available for administration. EI #4 replied, no. According to EI #4, she was told by EI #6, a LPN, that a new script had been faxed to the pharmacy, so she (EI #4) was waiting for the delivery. When asked what happened during the 10PM medication pass on 8/28/2017, EI #4 stated she thought the pharmacy would come. EI #4 was asked if she notified the physician and she said no. EI #4 explained that she notified the oncoming nurse that RI #1's [MEDICATION NAME] was not in the facility, it had been ordered and the staff was waiting on the pharmacy to deliver it. On 9/6/2017 at 9:03 PM, an interview with EI #5, a Registered Nurse (RN) assigned to care for RI #1 during the 3PM - 11PM shift was conducted. EI #5 was asked if she was aware that RI #1 was out of pain medication from 8/25/2017 to 8/29/2017. EI #5 replied, yes. When asked what type of harm could be caused from not receiving ordered pain medication, EI #5 said it could cause withdrawal from the medication. EI #5 explained there could be behaviors, anxiety and distress. In a follow-up interview on 9/8/17 at 8:40 PM, EI #5, a RN was asked if she notified the physician that RI #1 was out of pain medication. EI #5 said, no. In an interview with the Director of Nursing, EI #2 on 9/8/2017 at 2:45 PM, she was asked if she knew RI #1's pain medication, [MEDICATION NAME], was not in the facility and available for administration. EI #2 replied, yes. When asked once the medication was not available, what should the licensed nursing staff have done, EI #2 stated the pharmacy should have been notified that there was no medication available and the physician should have been notified for further orders. During an interview on 9/9/2017 at 9:32 AM, EI #7, a LPN assigned to care for RI #1 during the 11PM -7AM shift stated when she returned to work on 8/28/2017 on the 11PM - 7AM shift around 3AM, RI #1 came to her shaking and asked could she give him/her something because he/she was about to jump out of his/her skin. EI #7 said she told RI #1 she would get something to help. According to EI #7, there is a standing order for Tylenol 650 mg, so she administered it to RI #1 and the resident went to bed. Then about an hour later, RI #1 came back to her and said she had to do something or he/she was going to leave the facility. EI #7 said RI #1 was a smoker so she allowed RI #1 to smoke and that took the edge off. EI #7 said she informed RI #1 that she had texted the physician. EI #7 said the physician responded to her about RI #1's symptoms and she requested something to help with RI #1's anxiety, muscle pain, hands shaking and [MEDICAL CONDITION]. EI #7 said the physician ordered a one-time dose of [MEDICATION NAME]. Also the physician, gave EI #7 orders to call the pharmacy and have the pharmacy call him for a verbal order of [MEDICATION NAME]. Afterwards, EI #7 stated the pharmacist gave her verbal permission to remove four doses of [MEDICATION NAME] 15mg from the emergency kit to administer to RI #1. According to EI #7, at 6AM (on 8/29/2017) she administered the first dose to RI #1 and informed the oncoming nurse there was another dose of [MEDICATION NAME] in the narcotic drawer labeled for RI #1. RI #1's MEDICATION RECORD for August 2017 indicated during the 11PM - 7AM shift on 8/28/2017, RI #1's pain was assessed by the licensed nursing staff as being a 10. RI #1's Departmental Notes dated 8/29/2017 3:16 AM, written by EI #7, documented . Resident exhibiting s/s (signs/symptoms) of [MEDICATION NAME] withdrawal. Resident c/o (complained of) muscle pain, shakiness, nervousness, [MEDICAL CONDITION]/ inability to sleep, and restlessness. All PRN pain meds and benedryl ([MEDICATION NAME]) discontinued on 8/21/2017. Standing orders for Tyl (Tylenol) 650mg PO Q4H (every four hours) PRN for 24 hours started. Resident returned to bed after Tyl administration. Will cont (continue) to observe and with P(NAME) (plan of care). RI #1's Departmental Notes dated 8/29/2017 7:57 AM, written by EI #7, documented Dr. (EI #10) phone regarding resident's s/s. Resident is pacing and threatening to leave facility. New orders as follows: [MEDICATION NAME] 1mg IM (intramuscularly) x 1 now for increased anxiety, [MEDICATION NAME] ER 15mg (2) PO Q8H (every eight hours) until 30 mg arrive (may pull 4 from back up) . Orders noted and transcribed. Meds administered as ordered. Resident resting quietly in bed at this time. Reported all findings to oncoming nurse. Will cont to observe and with P(NAME). RI #1's Departmental Notes dated 8/29/2017 11:04 AM, documented . Alert, with some confusion. States (he/she) feel, some what better. Appears relaxed and denies any pain at this time. Will continue to follow P(NAME). During a telephone interview on 9/7/2017 at 11:26 AM, EI #10, the facility's Medical Director and RI #1's primary physician acknowledged that he did get a phone call regarding RI #1. EI #10 stated he was driving, so he asked the facility to have the pharmacy call him. EI #10 stated he gave a verbal order to the pharmacy for RI #1 to have the pain medication, [MEDICATION NAME]. When asked if he could recall when this occurred, EI #10 stated he could not, he just remembered RI #1 ran out of the medication because of the attention that was given to it. EI #10 was asked, what attention. According to EI #10, RI #1 had withdrawals, nausea/vomiting and abdominal pain. EI #10 stated he was told the resident had nausea and vomiting. EI #10 stated he was not aware the resident did not have any pain medication. In an interview on 9/7/2017 at 3:19 PM, RI #1 was asked, if he/she recall being without pain medication. RI #1 said it was less than a month ago, the facility did not reorder, so he/she went without pain medication for about six days. RI #1 explained that during this time, he/she went through withdrawals, where he/she was hurting and had nausea and vomiting. According to RI #1, he/she was as sick as a dog, a nervous wreck and couldn't sleep. RI #1 said he/she finally got over the suffering now that he/she had been receiving his/her pain medication. Page 811 of Mosby's 2017 NURSING DRUG REFERENCE with a copyright date of 2017, indicated [MEDICATION NAME] is a Schedule II controlled substance used to treat moderate to severe pain. According to page 815 . NURSING CONSIDERATIONS . *Abrupt discontinuation: gradually tamper to prevent withdrawal symptoms; . Teach patient/family: . *That withdrawal symptoms may occur: nausea, vomiting, cramps, fever, faintness, anorexia . 2) RI #2 was readmitted to the facility on [DATE] with a medical history to include: Acquired absence of left leg above knee, [DIAGNOSES REDACTED], and End Stage [MEDICAL CONDITION]. RI #2's MDS with an assessment reference date of 8/29/2017, revealed RI #2 was cognitively intact, with a BIMS score of 13. The MDS indicated RI #2 received PRN pain medication. RI #2 was assessed as having occasional pain with an intensity rating of five. RI #2's physician's orders [REDACTED].#2 was ordered [MEDICATION NAME] 10/325mg one tablet by mouth every six hours as needed for pain. Page 894 of Mosby's 2017 NURSING DRUG REFERENCE with a copyright date of 2017, indicated [MEDICATION NAME] is a Schedule II controlled substance used to treat moderate to severe pain. In an interview on 9/6/2017 at 4:10 PM, RI #2 was asked about pain. RI #2 stated he/she was not in pain; however, the facility did run out of his/her pain medication one time last week. RI #2 stated the medication is back now. When asked how long he/she was out of pain medication, RI #2 said for about four to five days. RI #2 stated during that time, he/she was administered Tylenol for pain once. During an interview on 9/6/2017 at 8:41 PM, EI #11, the 3PM - 11PM LPN, was asked if RI #2 received pain medication. EI #11 replied, yes it was PRN (as needed). When asked how often the resident requested the PRN pain medication, EI #11 stated once during her shift. EI #11 acknowledged that she was assigned to care for RI #2 on 9/1/2017, 9/4/2017, 9/5/2017 and 9/6/2017. EI #11 stated during her shift on 9/1/2017, she administered the last [MEDICATION NAME] 10mg tablet in stock to RI #2. EI #11 further stated that when she returned to work on Monday, 9/4/2017, she noticed there were no available [MEDICATION NAME] 10mg tablets to administer to RI #2. According to EI #11, the day shift LPN told her that she had faxed the order to pharmacy. EI #11 was asked when she came back to work on 9/4/2017, and RI #2 did not have any [MEDICATION NAME], did she notify the physician. EI #11 said she did not, but she did inform her supervisor, EI #5. In an interview on 9/7/2017 at 5:00 PM, EI #5, a RN was asked what she did when she was made aware that RI #2 did not have any [MEDICATION NAME] in stock. EI #5 stated when she made rounds with the physician on Tuesday, 9/5/2017, she got the physician to sign the order and she faxed it to the pharmacy. The facility's pharmacy CONSOLIDATED DELIVERY SHEETS revealed on 9/6/2017, the facility received from the pharmacy 30 [MEDICATION NAME]-APAP ([MEDICATION NAME]) 10-325mg tablets for RI #2. ************************* On 9/10/2017 at 4:45 PM, the facility submitted an Allegation of Credible Compliance which documented: F 309 1) RI #1 and RI #2 had no permanent adverse effects from not receiving prescribed narcotics. 2) All residents who receive narcotics have the potential to be affected. A medication availability audit tool was initiated on 8/29/2017 to randomly monitor residents receiving narcotics. On 9/6/2017 every resident receiving narcotics was audited by the Director of Nursing and the Vice President of Clinical Services for medication availability to ensure all residents had their prescribed narcotics available. Director of Nursing or Assistant Director of Nursing will monitor every resident weekly for narcotic medication availability by reviewing physician orders, reviewing Medication Administration Record [REDACTED]. 3) All baylor, full-time, and PRN status nursing staff was in-serviced on the Policy and Procedure of Ordering and Receiving Controlled Medications on 8/29/2017, 9/6/2017, 9/8/2017 by Staff Development Coordinator and 9/6/2017 by Vice President of Clinical Services. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 309 was lowered to an E level on 9/10/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 320.

Based on interview with Employee Identifier (EI) #2, the Director of Nursing, and review of the facility's policy titled Assurance and Performance Improvement (QAPI) Committee, the facility failed to implement an action plan when it was determined routine pain medication ordered for Resident Identifier (RI) #1 was not available in the facility for administration. From 8/25/2017 beginning at 2:00 PM until 8/28/2017 10:00 PM, RI #1 was not administered the ordered pain medication, [MEDICATION NAME], as it was not available; RI #1 missed 11 doses. After EI #2, the DON became aware, she stated she implemented an action plan; however, on 9/1/2017, another resident, RI #2's PRN (as needed) pain medication was not available in the facility for administration when requested. According to EI #2, when the initial action plan was developed, she only spot checked residents ordered pain medication instead of reviewing all residents to determine if all residents' pain medication was available in the facility for administration. This failure to develop and implement a comprehensive action plan to address all failures identified resulted in another resident, RI #2, not having pain medication in the facility for administration when requested. This deficient practice affected RI #1 and RI #2, two of three sampled residents reviewed for availability of pain medication, and placed RI #1 and RI #2 in immediate jeopardy of serious injury, harm or death. On 9/9/2017 at 6:50 PM, the Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Clinical Services and Chief Operating Officer were notified of immediate jeopardy level in the area of Administration, F 520. Findings include: Refer to F 309, F 425 and F 490 The facility's policy titled Assurance and Performance Improvement (QAPI) Committee with an effective date of 4/1/2017, documented Policy Statement This facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program. Policy Interpretation and Implementation 1. The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program . Goals of the Committee The primary goals of the QAPI Committee are to: 1. Establish, maintain and oversee facility systems and processes to support the delivery of quality of care and services; 2. Promote the consistent use of facility systems and processes during provision of care and services; 3. Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; 4. Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems; . During an interview on 9/9/2017 beginning at 10:55 AM, EI #2, the Director of Nursing stated she started an action plan on 8/29/2017 when she became aware that RI #1's pain medication has run out. EI #2 stated she inserviced the licensed nursing staff on the proper way to reorder narcotics, use of the emergency kit and implemented a narcotic coordinator. When asked if the action plan was implemented, how did another resident, RI #2, run out of pain medication on 9/1/2017. EI #2 stated, she had not inserviced the Baylor shift nurses, nurses assigned to work 7AM to 7PM and 7PM to 7AM on the weekends. When it was clarified that 9/1/2017 was a Friday and the Baylor shift nursing staff was not in the facility, EI #2 stated the nursing staff failed to follow the protocol. EI #2 explained that she did not question the staff about how RI #1 ran out of pain medication until 9/7/2017. EI #2 stated she was not aware that RI #2 also ran out pain medication until being questioned by the State Surveyor. When asked what happened with the monitoring of the action plan put in place on 8/29/2017, EI #2 stated she only spot checked. EI #2 further explained that there had been a fall out with her monitoring of the action plan. ************************* On 9/10/2017 at 4:45 PM, the facility submitted an Allegation of Credible Compliance which documented: F 520 1) RI #1 and RI #2 had no permanent adverse effects from not receiving prescribed narcotics. 2) All residents who receive narcotics have the potential to be affected. A medication availability audit tool was initiated on 8/29/2017 to randomly monitor residents receiving narcotics. On 9/6/2017 every resident receiving narcotics was audited by the Director of Nursing and the Vice President of Clinical Services for medication availability to ensure all residents had their prescribed narcotics available. Director of Nursing or Assistant Director of Nursing or RN Designee will monitor every resident weekly for narcotic medication availability. 3) Vice President of Clinical Services will monitor narcotic availability weekly on Narcotic Availability Audit Tool. A QAPI meeting was held on 9/10/2017 to review the Credible Allegation of Compliance including Medical Director. The next meeting date to review the status of the Credible Allegation of Compliance will be held on Tuesday, 9/12/17, and weekly thereafter until substantial compliance is achieved. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 520 was lowered to an E level on 9/10/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 320.

Based on interview with the Director of Nursing (DON) and review of the facility's . Job Description Director of Nursing, the DON, responsible for the overall operation of the Nursing Service Department, failed to ensure the licensed nursing staff implemented the facility's policies so that pain medication was available in the facility for administration to Resident Identifier (RI) #1 and RI #2, when ordered and requested by the resident. RI #1, a resident assessed as having frequent pain, was ordered [MEDICATION NAME] ER (Extended Release) to be administered every eight hours at 6:00 AM, 2:00 PM and 10:00 PM for a [DIAGNOSES REDACTED].#1 was not administered this medication as it was not available in the facility; RI #1 missed 11 doses of routine pain medication. During this time, RI #1 exhibited signs/symptoms of [MEDICATION NAME] withdrawal, to include: complaints of muscle pain, shakiness, nervousness, [MEDICAL CONDITION]/ inability to sleep, and restlessness. RI #2, a cognitively intact resident, assessed as having occasional pain, was ordered [MEDICATION NAME] 10 one tablet by mouth every six hours as needed for pain. RI #2 stated in an interview, the facility ran out of his/her pain medication one time last week for about four to five days. Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN) acknowledged in an interview, that RI #2 requested pain medication once during her shift. EI #11 stated she administered RI #2's last [MEDICATION NAME] 10 on 9/1/2017 and when she returned to work on 9/4/2017, RI #2 did not have any pain medication available for administration. These deficient practices affected RI #1 and RI #2, two of three sampled residents reviewed for pain medication and pharmacy services, and placed RI #1 and RI #2 in immediate jeopardy of serious injury, harm or death. On 9/9/2017 at 6:50 PM, the Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Clinical Services and Chief Operating Officer were notified of immediate jeopardy level in the area of Administration, F 490. Findings include: Refer to F 309, F 425 and F 520 The facility's . Job Description Director of Nursing revised 5/29/2014, documented . Basic Job Responsibility . To assure that the Nursing Service Department is in compliance with rules and regulations of Federal, State and local authorities. The primary purpose of the position is to plan, organize, develop and direct the overall operation of the Nursing Service Department to ensure the highest degree of quality care is maintained at all times. As the Director of Nursing, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. You are responsible for carrying out the resident care policies established by the Corporation . In an interview of 9/8/2017 at 2:45 PM, EI #2, the Director of Nursing (DON) stated she was aware that RI #1 was out pain medication on 8/28/2017 but she was not aware RI #2 was out of pain medication. According to EI #2, EI #6, a LPN notified her on 8/28/2017 that RI #1's pain medication was still not in the facility. When asked how she communicated with the nursing staff, EI #2 stated she read the 24-hour report and nurses' notes daily. EI #2 was asked if there were any 24-hour reports regarding RI #1's pain medication. EI #2 replied, no. (The facility's 24-HOUR REPORT/CHANGE OF CONDITION REPORT for Station 2, written by EI #7 dated 8/23/2017, documented . (RI #1) needs [MEDICATION NAME] script only #4 left .) When asked what should be the nursing staff next steps once a resident has run out of pain medication, EI #2 answered, notify the pharmacist that the resident is out of medication and notify the physician for further orders. In a follow-up interview on 9/9/2017 beginning at 10:55 AM, EI #2, the DON was asked why did she not know prior to 8/28/2017 that RI #1 was out of pain medication when it was documented on the 24-hour report dated 8/23/2017. EI #2 stated that she was away from the facility on 8/24/2017 at an inservice and she did not come in or contact the facility. EI #2 was asked whose responsibility was it to ensure residents received care and treatment to include medications as ordered by the physician. EI #2 replied, it was ultimately her responsibility, along with the licensed nursing staff. According to EI #2, she started an action plan on 8/29/2017 when she became aware that RI #1's pain medication has run out. EI #2 stated she inserviced the licensed nursing staff on the proper way to reorder narcotics, use of the emergency kit and implemented a narcotic coordinator. When asked if the action plan was implemented, how did another resident, RI #2, run out of pain medication on 9/1/2017. EI #2 stated, she had not inserviced the Baylor shift nurses, nurses assigned to work 7AM to 7PM and 7PM to 7AM on the weekends. When it was clarified that 9/1/2017 was a Friday and the Baylor shift nursing staff was not in the facility, EI #2 stated the nursing staff failed to follow the protocol. EI #2 explained that she did not question the staff about how RI #1 ran out of pain medication until 9/7/2017. EI #2 stated she was not aware that RI #2 also ran out pain medication until being questioned by the State Surveyor. When asked what happened with the monitoring of the action plan put in place on 8/29/2017, EI #2 stated she only spot checked. EI #2 further explained that there had been a fall out with her monitoring of the action plan. EI #2 was asked if she read the 24-hour report for 8/23/2017 when she returned to work on 8/25/2017. EI #2 replied that she had only read the 24-hour report for 8/24/2017. EI #2 explained that she should have looked at everything when she returned. According to EI #2, on Tuesday, 8/29/2017 around 2:00 PM, she read the nurses' notes for RI #1. It was then EI #2 stated she realized the resident did not have a prescription and that's why the pharmacy did not send the medication. When asked what she did at that time, EI #2 stated she didn't do anything right then because she didn't know the severity of the situation. EI #2 was asked, what happened as to why RI #2 also ran out of pain medication. EI #2 replied, the policy was not followed. When asked what potential harm RI #2 could have for not receiving pain medication when requested, EI #2 stated the resident could be in pain. When asked what potential harm RI #1 could have for not receiving pain medication as ordered, EI #2 stated Suffering of being in pain, withdrawal, depressed. A lot of things that could have happen (happened) due to (him/her) not receiving (his/her) medication. ************************* On 9/10/2017 at 4:45 PM, the facility submitted an Allegation of Credible Compliance which documented: F 490 1) RI #1 and RI #2 had no permanent adverse effects from not receiving prescribed narcotics. 2) All residents who receive narcotics have the potential to be affected. Director of Nursing was in-serviced by the Vice President of Clinical Services on the Policy and Procedure on Ordering and Receiving Controlled Medications and including standing orders, pain assessment, and MD notification on 9/6/17. 3) Vice President of Clinical Services or Pharmacy Consultant will monitor narcotic availability weekly on Narcotic Availability Audit Tool by reviewing physician orders, reviewing Medication Administration Record [REDACTED]. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to an E level on 9/10/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 320.

Based on staff interviews, review of Resident Identifier (RI) #1 and RI #2's medical record, and the facility's policy titled Medication Ordering and Receiving From Pharmacy Provider Ordering and Receiving Controlled Medication the facility failed to ensure routine and PRN (as needed) pain medication was available in the facility for administration. RI #1, a resident assessed as having frequent pain, was ordered Morphine Sulfate ER (Extended Release) to be administered every eight hours at 6:00 AM, 2:00 PM and 10:00 PM for a [DIAGNOSES REDACTED].#1 was not administered this medication as it was not available in the facility; RI #1 missed 11 doses of routine pain medication. During this time, RI #1 exhibited signs/symptoms of Morphine withdrawal, to include: complaints of muscle pain, shakiness, nervousness, insomnia/ inability to sleep, and restlessness. RI #2, a cognitively intact resident, assessed as having occasional pain, was ordered Percocet 10 one tablet by mouth every six hours as needed for pain. RI #2 stated in an interview, the facility ran out of his/her pain medication one time last week for about four to five days. Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN) acknowledged in an interview, that RI #2 requested pain medication once during her shift. EI #11 stated she administered RI #2's last Percocet 10 on 9/1/2017 and when she returned to work on 9/4/2017, RI #2 did not have any pain medication available for administration. These deficient practices affected RI #1 and RI #2, two of three sampled residents reviewed for pharmacy services, and placed RI #1 and RI #2 in immediate jeopardy of serious injury, harm or death. On 9/10/2017 at 6:50 PM, the facility's Administrator, Director of Nursing, Assistant Director of Nursing, Vice President of Clinical Services and Chief Operating Officer were notified of the findings of immediate jeopardy in the area of Pharmacy Services, F 425. Findings include: Refer to F 309 The facility's policy titled, Medication Ordering and Receiving From Pharmacy Provider Ordering and Receiving Controlled Medication, dated May 2016, revealed . ORDERING AND RECEIVING CONTROLLED MEDICATIONS . PR(NAME)EDURES . 5. Refill Requests . and Partial Fill Requests . a. If one or more refills or a partial fill quantity remains: *Written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose, and requested from the pharmacy a minimum of 3 days in advance of need to assure an adequate supply is on hand. *If only one refill remains or only a partial fill quantity remains the pharmacy will simultaneously dispense the remaining fill, and, if necessary proactively seek out a new, complete prescription from the prescriber for further use. If a new prescription is not obtained by the pharmacy before the medication would be due again, the facility is notified. In this situation, the facility may be asked to contact the prescriber for a new prescription prior to the medication running out. In an interview on 9/6/2017 at 7:55 PM, EI #4, a LPN was asked what the facility's process for reordering medication was. EI #4 stated, the label is pulled on the medication and faxed to pharmacy. If there are no issues, the medication would be received from pharmacy that same day. According to EI #4, the pharmacy would notify the facility if a prescription was needed. Once the physician was notified, he would sign a prescription and fax it to the pharmacy. When asked what was the process for notifying the physician that a new prescription was needed, EI #4 stated the nurse who received the communication from pharmacy usually notified the physician. EI #4 explained that if the medication did not come from the pharmacy, the physician should be notified that the pain medication had not arrived. During an interview on 9/6/2017 at 8:41 PM, EI #11, a LPN was asked what the facility's policy for ordering medication was. EI #11 stated, the sticker on the medication was pulled when there are seven pills left and faxed to pharmacy. EI #11 stated after that the medication usually arrived during the next pharmacy delivery. When asked what happens when the medication does not come in, EI #11 replied, the pharmacy will notify the facility that a script is needed. EI #11 was asked, who got the notice from the pharmacy that a script was needed. EI #11 answered, the Registered Nurse Supervisor, EI #5, and she usually took care of it after that. In an interview on 9/6/2017 at 9:03 PM, EI #5, a RN was asked what the facility's process for reordering medication was. EI #5 stated the hard script was faxed to pharmacy and when that script ran out, a new one had to be sent to pharmacy. When asked who was responsible for getting a new prescription (script) to the pharmacy, EI #5 stated all of the nurses. EI #5 stated if a nurse told her a medication had not come from pharmacy, she would call the pharmacy to find out what was going on with the medication order. If a new script was needed, pharmacy would fax it to the physician and the physician would fax the signed script back to the pharmacy. In an interview on 9/7/2017 at 12:25 PM, EI #6, a LPN was asked what the facility's process for reordering medication was. EI #6 stated, she pulled the sticker off when the medication had about 14 pills left and sends it to pharmacy. EI #6 stated in RI #1's case, the facility was waiting for the medication to come in. EI #6 stated that when the medication didn't come from pharmacy, she called the pharmacy to see if she could get the medication from the backup pharmacy. EI #6 stated she was told no because RI #1 needed a new prescription, signed by the physician. According to EI #6, she faxed the pharmacy, the physician's fax number so they could send the script to the physician. When asked what happened after that, EI #6 stated she was not sure. In a follow-up interview on 9/9/2017 at 10:35 AM, EI #6, a LPN stated she pulled the tab on RI #1's pain medication on 8/20/2017 and faxed it to pharmacy. The MEDICATION REFILL REQUEST FORM indicated on 8/20/2017, EI #6 faxed a request to the pharmacy to refill RI #1's pain medication, Morphine Sulfate Extended Release 30 milligram tablets. The form also indicated on 8/21/2017, the pharmacy indicated NO REFILL, FAXED MD. In a telephone interview on 9/8/2017 at 9:20 PM, EI #16, the weekend RN Supervisor was asked what the facility's procedure for ordering medication was. EI #16 stated we first notify the pharmacy. If the pharmacy did not have a script, the nursing staff had to notify the physician to get a script. During an interview on 9/7/2017 beginning at 11:26 AM, EI #10, the facility's Medical Director was asked, what the facility's process for ordering pain medication was. EI #10 stated the medication is ordered when the resident is admitted and then renewed monthly by a formal order sheet. EI #10 stated if the medication was a narcotic, a prescription was written and faxed to the pharmacy. According to EI #10, when RI #1 runs out of pain medication, a renewal prescription is faxed to his office by the pharmacy. The prescription is then signed and faxed back to the pharmacy. EI #10 stated he doesn't know when a prescription is needed until pharmacy faxed. EI #10 stated they don't pick up the phone to let him know that a resident is out of medication. EI #10 explained that his fax machine is checked daily Monday thru Friday. EI #10 stated that was plenty of time to be notified by pharmacy that a prescription is needed, to prevent a resident from running out of medications. EI #10 further stated the only way he had to monitor this was then the fax comes through but stated another way was by a telephone call. EI #10 stated when a resident runs out of medication, either the pharmacy or the facility should notify him. When asked about RI #2, EI #10 stated he spoke with the pharmacy and was informed a fax was sent on 9/1/2017 and no response was received. Then another fax was sent on 9/5/2017 and a prescription was sent and filled by pharmacy. EI #10 stated 9/1/2017 was on a Friday and then the weekend was a holiday weekend, so his office could have closed at 3PM. According to EI #10, there should be some type of system in place between the facility and pharmacy to ensure residents don't run out of medication. There should be a way for the physician to be notified. EI #10 stated there is a physician on-call every day, 24 hours a day, seven days a week. In a telephone interview on 9/7/2017 at 10:04 AM, EI #9, the Pharmacist was asked what the facility's process for ordering pain medication was. EI #9 stated, the pharmacy faxes the prescription to the physician for him to sign and fax back to either the facility or the pharmacy. EI #9 stated he prefers the physician to fax it back to the pharmacy. When asked about RI #1, EI #9 stated the most recent order was faxed on 8/29/2017 and it was dispensed that same day. EI #9 stated prior to 8/29/2017, the last request was received from the facility was on 7/20/2017 and a 30-day supply was dispensed. When asked how long does it take for the facility to receive medications, EI #9 stated there is a delivery every day. EI #9 was then asked how often the pharmacy had received a request form the facility to refill RI #2's pain medication, Percocet. According to EI #9, 10 tablets were dispensed on 8/16/2017. On 9/1/2017 and then again on 9/5/2017, the pharmacy faxed the physician. A signed prescription was received in the pharmacy on 9/5/2017 and 30 tablets were dispensed to the facility on [DATE]. In a follow-up interview on 9/8/2017 at 5:54 PM, EI #9, the Pharmacist was asked why there were two faxes to the physician, one on 9/1/2017 and then again on 9/ for RI #2. EI #9 stated maybe the nurse called the pharmacy to say the medication had not been received and therefore, it was faxed again to the physician. According to EI #9, the physician doesn't want multiple faxes constantly for the same medication request. During an interview on 9/9/2017 at 3:00 PM, EI #13, the Pharmacy Technician reported they faxed to the physician on 8/21/2017 and 8/29/2017 that RI #1 needed a new prescription for the Morphine Sulfate; however, the signed new script was not received until 8/29/2017. ************************* On 9/10/2017 at 4:45 PM, the facility submitted an Allegation of Credible Compliance which documented: F 425 1) RI #1 and RI #2 had no permanent adverse effects from not receiving prescribed narcotics. 2) All residents who receive narcotics have the potential to be affected. The Assistant Director of Nursing will act as Narcotic Coordinator to proactively follow-up on communication between pharmacy and Medical Director to ensure that refill prescriptions are available timely. A Narcotic Medication Review log and protocol was implemented on 9/6/2017 to be completed by the Assistant Director of Nursing/Narcotic Coordinator weekly for ensuring narcotics are available. Assistant Director of Nursing will use pharmacy refill report weekly to assist with early identification of prescription refill dates. 3) In-service on medication availability and ordering of medications to all full-time, baylor, and PRN Registered Nurses and Licensed Practical Nurses was conducted on 8/29/2017, 9/6/2017, 9/8/2017 by Staff Development Coordinator and 9/6/2017 by Vice President of Clinical Services. ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 425 was lowered to an E level on 9/10/2017, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 320.

Based on interviews and record review, Employee Identifier (EI) #13, the Vice President of Clinical Services (VPCS), who is responsible to provide and/or coordinate services that will assist the facility to promote programs in accordance with current federal, state, and local guidelines, regulations and standards, failed to ensure the facility had a policy/procedure in place which directed the staff how to respond when they found a resident without a pulse or respirations. During the third shift (11:00 PM - 7:00 AM) on [DATE], Employee Identifier (EI) #1, a Licensed Practical Nurse determined that Resident Identifier (RI) #1, did not have a pulse or respiration. Instead of immediately initiating CPR and directing the staff present in the resident's room to activate the emergency response system, EI #1 instructed the staff to perform incontinence care on RI #1, then left the resident's room to call 911. EI #13 further failed to ensure the facility's Cardiopulmonary Resuscitation (CPR) policy was updated with the 2010 American Heart Association (AHA) Standards for CPR, and in keeping with the Alabama Board of Nursing (ABN) standards. The facility's policy allowed licensed staff to use their judgment in determining whether or not to initiate CPR on a resident with Full Code Status. These deficient practices affected RI #1, one of four sampled residents reviewed for emergency response, with the potential to affect the remaining 48 Full Code status residents who reside in the facility. These deficient practices placed RI #1 in immediate jeopardy because it was likely to cause serious injury, harm or death. The facility's "RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated [DATE], indicated the facility had a total of 62 residents. On [DATE] at 9:45 AM, the facility's Administrator, Director of Nursing, Staff Development Coordinator, and Vice President of Clinical Services were notified of the finding of substandard quality of care at the immediate jeopardy level of "K" in the area of Governing Body, F 493. The immediate jeopardy began [DATE] and was relieved onsite on [DATE]. Findings include: Cross reference F 309 and F 490. EI #13, the Vice President of Clinical Services' job description revised [DATE], documented " ... Summary of Responsibilities To provide and/or coordinate services that will assist facilities to promote, to the highest degree, programs in accordance with current applicable federal, state, and local guidelines, regulations and standards to provide quality resident care at all times ... 5. Assists facility management with development of appropriate resident care policies and procedures. 6. Conducts facility reviews to assess compliance with Federal and State regulations ... 12. Remains current on State and Federal regulations, assisting with interpretation as needed ... ." The facility's policy titled, "Cardio [MEDICAL CONDITION] Resuscitation (CPR) NP.VII-4" with an effective date of [DATE], documented " ... STANDARD: ... The licensed nurse makes his/her best judgement (judgment), based upon the time passing and the clinical symptoms of the resident, whether to initiate CPR on a resident ... PROCESS: 1. Begin compressions and assisted ventilation within four minutes immediately after the following symptoms occur: *No pulse *No respirations *No heartbeat *Unconsciousness ... ." The "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" with a copyright date of 2010 documented " ... Part 4: CPR Overview ... The Universal Adult Basic Life Support (BLS) Algorithm is a conceptual framework for all levels of rescuers in all settings. It emphasizes the key components that any rescuer can and should perform. When encountering a victim of sudden adult [MEDICAL CONDITION], the lone rescuer must first recognize that the victim has experienced a [MEDICAL CONDITION], based on unresponsiveness and lack of normal breathing. After recognition, the rescuer should immediately activate the emergency response system, get an AED/defibrillator, if available, and start CPR with chest compressions. If an AED is not close by, the rescuer should proceed directly to CPR. If other rescuers are present, the first rescuer should direct them to activate the emergency response system and get the AED/defibrillator; the first rescuer should start CPR immediately ... If an AED/defibrillator is not available, continue CPR without interruptions until more experienced rescuers assume care ... rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally ... CPR improves the victim's chance of survival by providing heart and brain circulation. Rescuers should perform chest compressions for all victims in [MEDICAL CONDITION], regardless of rescuer skill level, victim characteristics, or available resources ... ." According to the Alabama Board of Nursing, Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice " ... 610-X-6-.03 Conduct and Accountability. The registered nurse and licensed practical nurse shall: (1) Have knowledge and understanding of the laws and rules regulating nursing. (2) Function within the legal scope of nursing practice ... (7) Accept individual responsibility and accountability for judgments, actions and nursing competency, remaining current with technology and [MEDICATION NAME] consistent with facility policies and procedures ... 610-X-6-.04 Practice of Professional Nursing (Registered Nurse Practice (1) The practice of professional nursing includes, but is not limited to: ... (b) Provision of care supportive to or restorative of life and well-being ... ." The Centers for Medicare & Medicaid Services (CMS) Center for Clinical Standards and Quality/Survey & Certification Group memorandum issued [DATE] and revised [DATE], with a subject of "Cardiopulmonary Resuscitation (CPR) in Nursing Homes, documented " ... Initiation of CPR - Prior to the arrival of emergency medical services (EMS), nursing home must provide basic life support, including initiation of CPR, to a resident who experiences [MEDICAL CONDITION] (cessation of respirations and/or pulse) in accordance with that resident's advance directives or in the absence of advance directives or a Do Not Resuscitate (DNR) order ... A. Background ... The American Heart Association (AHA) publishes guidelines every five years for CPR and Emergency Cardiovascular Care (ECC). ... According to the AHA, reversal of clinical death is among the goals of ECC since brain damage begins four to six minutes following [MEDICAL CONDITION] if CPR is not administered during that time ... AHA guidelines for CPR provide the standard for the American Red Cross, state EMS agencies, health providers, and the general public ... D. Survey Implications When reviewing facility policies and procedures related to emergency response, surveyors should ascertain that facility policy, at a minimum, directs staff to initiate CPR as appropriate. Facility policy should specifically direct staff to initiate CPR when [MEDICAL CONDITION] occurs for residents who have requested CPR in their advance directives, who have not formulated an advance directive, who do not have a valid DNR order, or who do not show AHA signs of clinical death as defined in the AHA Guidelines for CPR and Emergency Cardiovascular Care (ECC) ... ." On [DATE] at 1:50 AM, EI #3, a Certified Nursing Assistant (CNA) noticed that RI #1 was breathing funny and alerted the nurse, EI #1. EI #1 went into RI #1's room, cleaned the resident's mouth of a white foamy substance and noted RI #1 had shallow breathing. EI #1 left the resident's room to obtain an oxygen saturation monitor located at the nurses' station approximately 56 feet from RI #1's room. When EI #1 returned to the resident's room, EI #3, the CNA told EI #1 that she thought RI #1 was gone (no longer alive). EI #1 went back into RI #1's room to assess the resident's vital signs. After EI #1 could not obtain a pulse or respirations on RI #1, she instructed the CNA staff (EI #3 and EI #4) to change RI #1's incontinence brief (diaper). Instead of initiating CPR and directing the CNA staff to activate the emergency response system, EI #1 left the resident's room to call 911. After the CNA staff completed incontinence care, which took approximately five to 10 minutes, on RI #1, who had no pulse, CPR was initiated. When emergency medical services (EMS) arrived on the scene, they found RI #1 unresponsive, pupils fixed and dilated, without breath, or a pulse. RI #1 was pronounced dead at 2:14 AM on [DATE]. In an interview on [DATE] at 4:15 PM, EI #6, the Assistant Director of Nursing (ADON), was asked, what was the facility's policy for calling codes? EI #6 explained since the facility was small, they just overhead paged that a nurse was needed to a room stat (immediately) or sometimes the staff would just run and get a nurse. In an interview on [DATE] at 8:20 AM, EI #7, the Director of Nursing (DON), was asked, what was the facility's policy on calling a code, EI #7 stated it depends and explained if the staff was in the hallway, they would just holler; if no staff were in the hallway, they would overhead page. During an interview on [DATE] at 9:35 AM, EI #8, the Administrator was asked if the facility's CPR policy was current with the American Heart Association (AHA) guidelines. EI #8 replied that she assumed it was and explained that EI #13, the Vice President of Clinical Services (VPCS), handled that. An interview was conducted with EI #13, the Vice President of Clinical Services on [DATE] at 11:25 AM. The surveyor asked EI #13 if the facility's CPR policy that indicated a nurse could make a judgment whether or not to initiate CPR was based on the AHA guidelines or the Alabama Board of Nursing. EI #13 replied, she didn't think so. EI #13 explained that if a nurse found a resident without vital signs, they should determine the resident's code status, initiate CPR and contact 911. When asked, what the facility's CPR was based on, EI #13 stated she couldn't answer that because she didn't develop the policy. EI #13 was asked, if the facility had a policy on how to respond when a resident was found without a pulse or respiration and she said no. ****************************** On [DATE] at 4:00 PM, the facility submitted an acceptable Allegation of Credible Compliance, which documented " F493 Governing Body Policy entitled "Cardio [MEDICAL CONDITION] Resuscitation" was revised on [DATE] by the Vice President of Clinical Services to include staff directions on what to do if a resident stops breathing per AHA, ABN, and CMS guidelines. The Medical Director approved the policy entitled "Cardio [MEDICAL CONDITION] Resuscitation" on [DATE]. Licensed staff have been in-serviced on the revised policy entitled "Cardio [MEDICAL CONDITION] Resuscitation" by RN/Staff Development Coordinator or Designee on [DATE] through [DATE]." ***************************** After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 493 was lowered to an "E" level on [DATE] at 4:30 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 151.

Based on observation, interviews and record review, Employee Identifier (EI) #8, the Administrator, who was responsible for directing the overall operation of the facility and EI #7, the Director of Nursing, who was responsible for the overall operation of the nursing service department, failed to ensure a system was in place for all staff to readily identify a resident's code status. The resident's code status was documented on the physician's orders [REDACTED]. Furthermore, EI #7 and EI #8 failed to ensure licensed nurses maintained current Cardiopulmonary Resuscitation (CPR) certification. These deficient practices affected RI #1, one of four sampled residents reviewed for emergency response, with the potential to affect the remaining 48 Full Code status residents who reside in the facility. These deficient practices placed RI #1 in immediate jeopardy because it was likely to cause serious injury, harm or death. The facility's "RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated [DATE], indicated the facility had a total of 62 residents. On [DATE] at 9:45 AM, the facility's Administrator, Director of Nursing, Staff Development Coordinator, and Vice President of Clinical Services were notified of the finding of substandard quality of care at the immediate jeopardy level of "K" in the area of Administration, F 490. The immediate jeopardy began [DATE] and was relieved onsite on [DATE]. Findings include: Cross reference F 309 and F 493. The Director of Nursing, EI #7's, job description revised [DATE], documented " ... Basic Job Responsibility ... To assure that the Nursing Service Department is in compliance with rules and regulations of Federal, State and local authorities. The primary purpose of the position is to plan, organize, develop and direct the overall operation of the Nursing Service Department to ensure the highest degree of quality care is maintained at all times. As the Director of Nursing, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties ... ." The Administrator, EI #8's, undated job description documented " ... BASIC FUNCTION Responsible for directing the overall operation of the facility's activities in accordance with current applicable federal, state and local standards, guidelines and regulations and as directed by the governing board and for ensuring that the highest degree of quality patient/resident care is maintained at all times ... ESSENTIAL FUNCTIONS 1. Establish and direct the implementation of written policies and procedures that reflect the goals and objectives of the facility ... 2. Assist in the development and implementation of departmental policies and procedures ... ." 1) On [DATE] at 3:00 PM, a tour of the facility was completed. The facility had no system in place to readily access a resident's code status. In a telephone interview on [DATE] at 1:25 PM, EI #4, a CNA was asked, how he knew the code status of a resident. EI #4 replied, the charge nurse. In a telephone interview on [DATE] at 2:20 PM, EI #1, an LPN was asked, how she knew the code status of a resident. EI #1 replied, the resident's medical record. In a telephone interview on [DATE] at 3:40 PM, EI #3, a CNA was asked, how she knew the code status of a resident. EI #3 replied that she didn't. In a telephone interview on [DATE] at 4:00 PM, EI #2, an LPN was asked, how she knew the code status of a resident. EI #2 replied it was in the front of the resident's medical record. In an interview on [DATE] at 4:15 PM, EI #6, the Assistant Director of Nursing (ADON), was asked, where the residents' code status was documented. EI #6 stated, in the residents' medical record. During an interview on [DATE] at 8:20 AM, EI #7, the Director of Nursing (DON), was asked, where was the code status of a resident documented. EI #7 stated, in the resident's medical record and Medication Administration Record [REDACTED]. In a follow-up interview on [DATE] at 2:00 PM, EI #7 was asked if the staff found a resident without a pulse or respiration, how would they know to start CPR without going and looking at the resident's medical record, located at the nurses' station. EI #7 stated, in the front of the Medication Administration Record [REDACTED]. 2) According to a typed list dated [DATE], the facility employs 18 licensed nurses. After a review of CPR certification records, it was determined EI #2, the LPN who brought the crash cart into RI #1's room on [DATE], was not CPR certified. EI #2's certification expired [DATE]. EI #10, another licensed nurse's CPR certification expired February 2015 and EI #11, an LPN, was not certified by an approved CPR course. In an interview on [DATE] at 8:05 AM, EI #12, the Staff Development Coordinator, was asked who monitored to ensure the licensed nursing staff maintained current CPR certification. EI #12 stated, the Director of Nursing, EI #7. In an interview on [DATE] at 8:20 AM, EI #7, the DON, stated he was unaware that EI #2's CPR certification had expired when she responded to RI #1 being found without pulse or respirations on [DATE]. In an interview on [DATE] at 3:30 PM, EI #8, the Administrator, was asked who was responsible for monitoring CPR certification for licensed nurses. EI #8 stated that EI #7, the DON was but EI #12, the Staff Development Coordinator was taking over this responsibility. ****************************** On [DATE] at 4:00 PM, the facility submitted an acceptable Allegation of Credible Compliance, which documented "F 490-Administration The facility immediately implemented a color code system on [DATE] on care cards located in each resident room to readily identify code status of residents. The color code system is called the CPR identification Protocol and was competed on [DATE] with each resident's care card being marked with an orange "DNR" sticker or a green "Full Code" sticker. The facility currently identifies code status in two ways as follows: under Physicians Order tab in resident's chart and a current list of DNR residents is kept in the front of the MAR indicated [REDACTED]. No one without proof of current CPR certification has worked since [DATE]. Any licensed nursing staff without proof of current CPR certification will be removed from the nursing schedule and will not work until proof of current CPR certification is received. One licensed nurse remains that has not provided proof of current CPR certification, and she has been removed from the schedule until it is obtained. Licensed and non-licensed staff will be in-serviced by Social Worker or RN/Staff Coordinator or Designee on the new CPR Identification Protocol on [DATE] through [DATE]. Staff development coordinator was in-serviced on [DATE] by Administrator to obtain CPR certification cards upon hire and to maintain current CPR certifications for licensed staff." ****************************** After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 490 was lowered to a "E" level on [DATE] at 4:30 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 151.

Based on interviews, review of Resident Identifier (RI) #1's medical record, the facility's admission packet, the facility's investigative file and the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, the facility failed to ensure Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), promptly provided Cardiopulmonary Resuscitation (CPR), to RI #1, a resident with Full Code status. Code status describes what type of intervention a health care facility will conduct should a resident stop breathing and/or heart stops beating. Full Code status means when a resident stops breathing and/or heart stops beating, staff are to immediately initiate emergency medical services, Cardiopulmonary Resuscitation (CPR), in an attempt to revive the resident. On [DATE] at 1:50 AM, EI #3, a Certified Nursing Assistant (CNA) noticed RI #1 was breathing funny and alerted the nurse, EI #1. EI #1 went into RI #1's room, cleaned the resident's mouth of a white foamy substance and noted RI #1 had shallow breathing. EI #1 left the resident's room to obtain an oxygen saturation monitor located at the nurses' station approximately 56 feet from RI #1's room. When EI #1 returned to the resident's room, EI #3, the CNA told EI #1 that she thought RI #1 was gone (no longer alive). EI #1 went back into RI #1's room to assess the resident's vital signs. After EI #1 could not obtain a pulse or respirations on RI #1, she instructed the CNA staff (EI #3 and EI #4) to change RI #1's incontinence brief (diaper). Instead of initiating CPR and directing the CNA staff to activate the emergency response system, EI #1 left the resident's room to call 911. After the CNA staff completed incontinence care, which took approximately five to 10 minutes, on RI #1, who had no pulse, CPR was initiated. When emergency medical services (EMS) arrived on the scene, they found RI #1 unresponsive, pupils fixed and dilated, without breath, or a pulse. RI #1 was pronounced dead at 2:14 AM on [DATE]. This deficient practice affected RI #1; one of four sampled residents reviewed for emergency response, and placed RI #1 in immediate jeopardy because it was likely to cause serious injury, harm or death. On [DATE] at 9:45 AM, the facility's Administrator, Director of Nursing, Staff Development Coordinator, and Vice President of Clinical Services were notified of the finding of substandard quality of care at the immediate jeopardy level of "J" in the area of Quality of Care, F 309. The immediate jeopardy began [DATE] and was relieved onsite on [DATE]. Findings include: The "2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" with a copyright date of 2010 documented " ... Part 4: CPR Overview ... The Universal Adult Basic Life Support (BLS) Algorithm is a conceptual framework for all levels of rescuers in all settings. It emphasizes the key components that any rescuer can and should perform. When encountering a victim of sudden adult [MEDICAL CONDITION], the lone rescuer must first recognize that the victim has experienced a [MEDICAL CONDITION], based on unresponsiveness and lack of normal breathing. After recognition, the rescuer should immediately activate the emergency response system, get an AED/defibrillator, if available, and start CPR with chest compressions. If an AED is not close by, the rescuer should proceed directly to CPR. If other rescuers are present, the first rescuer should direct them to activate the emergency response system and get the AED/defibrillator; the first rescuer should start CPR immediately ... If an AED/defibrillator is not available, continue CPR without interruptions until more experienced rescuers assume care ... rescuers should start CPR immediately if the adult victim is unresponsive and not breathing or not breathing normally ... CPR improves the victim's chance of survival by providing heart and brain circulation. Rescuers should perform chest compressions for all victims in [MEDICAL CONDITION], regardless of rescuer skill level, victim characteristics, or available resources ... ." RI #1 was admitted to the facility on [DATE] from a local hospital with a primary admit [DIAGNOSES REDACTED]. RI #1's "ADM--Admission Nursing Assessment" dated [DATE] indicated RI #1 was a Full Code. RI #1's "history and physical examination [REDACTED]." Within the facility's admission packet was a document titled "TERRACE OAKS CARE AND REHABILITATION CENTER ADVANCED DIRECTIVES" which indicated all measures of resuscitation will be taken including: CPR, calling 911 and emergency IVs or medication when a resident has Full Code status. RI #1's undated care plan titled "Advanced care planning ... " had a goal of "Resident/Healthcare Decision Maker current wishes will be honored regarding advanced directives" On [DATE], the State Agency received a complaint alleging the charge nurse responsible for RI #1 delayed initiating CPR on two occasions: 1) The charge nurse waited outside RI #1's room for the staff to bring the crash cart before proceeding into the room to initiate CPR; and 2) Once in the room, the charge nurse directed the CNA staff to change the resident's incontinence brief (diaper) before initiating CPR. A telephone interview was conducted on [DATE] at 3:40 PM, with EI #3, the 11:00 PM - 7:00 AM CNA assigned to care for RI #1 on [DATE]. EI #3 stated during her 12:00 AM rounds (on [DATE]), RI #1 was fine. Then a little before 2:00 AM, EI #3 noticed RI #1 was breathing funny, so she went to find the nurse, EI #1. According to EI #3, EI #1 came immediately to RI #1's room, then left to go and get an oxygen (O2) saturation (sat) monitor. EI #3 stated once EI #1 came back to RI #1's room, she could not get the O2 monitor to read. EI #3 stated once RI #1 was cleaned up (incontinence care provided), EI #1 started chest compressions on RI #1. A telephone interview was conducted on [DATE] at 2:20 PM, with EI #1, the 11:00 PM - 7:00 AM LPN assigned to care for RI #1 on [DATE]. According to EI #1, the CNA (EI #3) noticed foam coming out of RI #1's mouth around 1:50 AM and she (CNA) came and got her (LPN) to look at the resident. EI #1 stated she went to RI #1's room, cleaned the resident's mouth and noticed RI #1 had shallow breathing. EI #1 left the resident's room to get her oxygen saturation monitor from the medication cart, located at the nurses' station. After returning to RI #1's room, the CNA (EI #3) told her she thought RI #1 was gone. EI #1 went into RI #1's room in an attempt to get RI #1's vital signs, but the O2 monitor would not register. EI #1 then left RI #1's room and went to the nurses' station to call the other nurse on duty (EI #2) and 911. Once the other nurse (EI #2) made it to the nurses' station and while on the phone with 911, EI #1 asked EI #2 to go and get the crash cart. After calling 911, EI #1 instructed another CNA (EI #4) to assist EI #3 in changing RI #1's incontinence brief. After incontinence care was provided, EI #1 stated she began chest compressions, EI #4 did the Ambu bag and EI #3 just watched. EI #1 explained that EI #2, the other LPN, left RI #1's room after she bought the crash cart, and she saw the CNA staff had to finish providing incontinence care. According to EI #1, while EI #2 waited on the CNA staff to finish, another resident began to holler out for help, so EI #2 left RI #1's room to tend to the resident who was hollering out for help. RI #1's "Departmental Notes" written by EI #1, dated [DATE] 6:30 AM, documented " ... 1:50 AM Called to room per CNA and noted resident foaming @ (at) the mouth and having shadow (shallow) breathing. Went to desk to get O2 sat monitor and CNA called me back to room. Could not get O2 Sat on resident nor vital signs. 1:55 AM Call 911 and code in facility went back to resident room and preceded (proceeded) CPR until first responders arrived. First responders and police arrived @ 2:07 AM. They took over and pronounced ... expired @ 2:14 AM ... ." Within the facility's investigative file was a handwritten document signed by EI #1, the 11:00 PM - 7:-00 AM LPN assigned to care for RI #1 on [DATE], which read "[DATE] At 1:50 AM a code was called ... ." In a follow-up interview on [DATE] at 1:00 PM, EI #1 stated, at 1:50 AM the CNA (EI #3) came and got her; that's when white foam was observed in the resident's mouth. EI #1 stated she could not get a pulse and she couldn't recall if she tried to get a carotid (neck) pulse or radial (wrist) pulse. When asked, if she checked RI #1's vital signs before or after she instructed the CNAs to change RI #1's incontinence brief, EI #1 stated she already had checked RI #1's vital signs, when she asked EI #4 to assist EI #3 in changing RI #1's incontinence brief. EI #1 stated as she was talking to the CNAs about changing RI #1's incontinence brief, she left RI #1's room to call 911. On [DATE] at 4:05 PM, EI #9, the Maintenance Director, was asked to measure the distance from station two nurses' station to RI #1's room. EI #9 stated it was 56 feet from the nurses' station to RI #1's room. Within the facility's investigation file was a handwritten note from EI #4, a CNA, which documented "[DATE] Incident Report At about 1:50, AM, I was changing Resident in Room # ..., I was called by (EI #1) to assist in (RI #1's room) ... we were asked to change the resident diaper ... ." During a telephone interview on [DATE] at 1:25 PM, EI #4, a CNA, stated EI #1 (LPN) asked him to change RI #1's incontinence brief (diaper). According to EI #4, CPR was not started until after he and EI #3 changed RI #1's incontinence brief. In a follow-up interview on [DATE] at 2:15 PM, EI #4 was asked if he thought RI #1 was deceased when the resident's incontinence brief was changed. EI #4 stated yes, but he was not authorized to confirm it. When asked, how long it took to change RI #1's incontinence brief, EI #4 stated RI #1 was a large person, so about ,[DATE] minutes. During a telephone interview on [DATE] at 4:00 PM, EI #2, (the LPN who brought the crash cart to RI #1's room) was asked to recall the events that occurred on [DATE]. According to EI #2, she was on Station I when she heard EI #1 call her name on the intercom system. EI #2 stated she immediately went to Station II, where she observed EI #1 and EI #3 standing at the nurses' station. EI #2 stated EI #1 was not on the phone; EI #1 asked EI #2 to bring the crash cart. EI #2 stated after she was told the crash cart was needed, she ran back to Station I to get the crash cart. When EI #2 returned to Station II, she saw EI #1 and EI #3 still standing in the hallway. EI #2 then explained how all three (EI #1, EI #2 and EI #3) went to RI #1's room. EI #2 stated when she went into RI #1's room, she observed that the resident was not breathing. According to EI #2, as she began to pull the plastic off the Ambu bag (a hand-held device commonly used to provide ventilation to patients who are not breathing or not breathing adequately), EI #1 told the CNA staff to change RI #1's diaper (incontinence brief). EI #2 explained that she was trying to get ready to start CPR but EI #1 instructed the CNA staff to change RI #1's incontinence brief. EI #2 stated as she backed away from RI #1's bed with the crash cart, she heard another resident yell out in help, so she left the room to assist the other resident. EI #2 stated she never returned to RI #1's room because as she was assisting the other resident and she observed EMS coming down the hall. In a follow-up interview on [DATE] at 8:20 AM, EI #2 was asked, why she didn't start CPR. EI #2 replied that when she walked in RI #1's room, her intention was to start CPR; however, EI #1, the nurse assigned to care for RI #1, was adamant that the CNA staff change RI #1's incontinence brief. EI #2 further stated that EI #1 delayed initiation of CPR. During an interview on [DATE] at 4:15 PM, EI #6, the Assistant Director of Nursing (ADON), acknowledged RI #1 had Full Code status. When asked, when CPR should be initiated, EI #6 stated, as soon as you find a resident unresponsive, no pulse and not breathing. The local EMS report indicated 911 was notified on [DATE] at 1:55 AM, with a dispatch complaint of [MEDICAL CONDITION] for RI #1. At 2:01 AM, EMS arrived on the scene and found RI #1 unresponsive, apneic (absence of breathing), pulseless, pupils fixed and dilated, with asystole (absence of heartbeat) on all three leads. According to RI #1's "ALABAMA Certificate of Death", RI #1's time of death was [DATE] 2:14 AM. ************************* On [DATE] at 4:00 PM, the facility submitted an acceptable Allegation of Credible Compliance, which documented "F 309-Quality of Care Two licensed nurses were terminated on [DATE] for allegedly failing to provide timely CPR. The two licensed nurses who were terminated will be reported to the ABN (Alabama Board of Nursing) by [DATE]. Licensed staff were in-serviced and took a post-test on revised policy entitled "Cardio [MEDICAL CONDITION] Resuscitation" on [DATE] and [DATE] by an RN/Staff Development Coordinator. The in-service included a review of the revised policy and procedure, what to do if someone is found not breathing, how to call a code, and to perform CPR until EMS arrives and takes over ... ." ************************* After reviewing the facility's information provided in their Allegation of Credible Compliance and verifying the immediate actions had been implemented, the scope/severity level of F 309 was lowered to a "D" level on [DATE] at 4:30 PM, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This deficiency was cited as a result of the investigation of complaint/report number AL 151.