Every finding on record at Pruitthealth - Crestwood, LLC

Based on observation, staff interview, and Review of the facility's policies titled, Pot/Pan Washing and Sanitation and Dishwashing, the facility failed to ensure kitchen staff thoroughly cleaned and air-dried plates and pans prior to storage. This failure had the potential to increase the risk of foodborne illness and had the potential to affect 61 of 66 residents who received dietary services. Findings include: Review of the facility's policy titled, Pot/Pan Washing and Sanitation, dated 11/16/2020 revealed, Policy Statement: It is the policy if PruittHealth that equipment and utensils are cleaned and sanitized appropriately after use to maintain a clean and sanitary environment for food preparation. Scope: This applies to all dietary partners employed by PruittHealth. Procedure: . Air dry pots and pans on the drain board. Never use a dish towel. Inspect for cleanliness and store pots and pans inverted in a clean, dry, protected area . Review of the facility's policy titled, Dishwashing dated 8/3/2017, revealed, Policy Statement: It is the policy of PruittHealth that all utensils, dishes, glassware and trays will be cleaned and sanitized. Scope: This policy applies to all dietary partners employed by PruittHealth. Procedure: . 8. Allow all items to thoroughly air dry before unloading racks or storing items. During an observation and interview on 6/23/2025 at 10:15 am, the Food Service Manager (FSM) confirmed five six-inch plates were found to have been stacked for use and were still wet and had not properly been allowed to air-dry. Interview with the FSM at this time, stated, the dishes should be dry before being stacked. During an observation and interview on 6/23/2025 at 10:2025 am, the FSM confirmed two pans, 6 inches by 12 inches by 3 inches deep, two pans 12 inches by 18 inches by 3 inches deep, and three pans 12 inches by 18 inches by 6 inches deep that had been cleaned and stacked for use and were still wet when they were stacked. The pans were found to have been stacked wet and not allowed to air dry. Interview with the FSM at this time, stated, they should be dry before being put away, they weren't allowed to properly dry.

Based on observations, interviews, record reviews, and a review of the policy titled, Abuse Identification the facility failed to maintain an environment that was free from sexual abuse by another resident for one of three residents (R1) sampled for abuse. Findings include: Review of the policy titled Abuse Identification, last reviewed on 1/11/2024 revealed the following: Policy Statement 3. Patients/residents in a Health Care Center should not be subjected to abuse or neglect by anyone (including but not limited to: staff, other patients/residents, consultants, volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals). Review of the medical record for R1 revealed diagnosis that included but was not limited to unspecified dementia, unspecified severity, with psychotic disturbance, cerebral infarction. Review of the Admission Minimum Data Set (MDS) dated [DATE] with a Brief Interview for Mental Status (BIMS) score that was not indicated Review of Progress Notes dated 4/11/2024 revealed R53 was sexually inappropriate towards a female resident. He was rubbing her in inappropriate places. Review of Progress Notes dated 4/13/2024 indicated inappropriate sexual behavior was noted towards another resident by R53. Review of Progress Notes dated 4/21/2024 indicated, male resident entered R1's room and was seen by staff inappropriately touching her breast. Facility administrator and DON notified. During an interview on 4/25/2024 at 3:15 pm with Registered Nurse (RN) AA it was revealed R1 was admitted to the facility with only the clothes she had on and clothing had to be utilized from the Lost and Found items. It is reported that R1 pulled up her shirt exposing her breast. R53 is reported as seeing R1 exposing herself and he began to follow her. RN AA further reported that R1 has not exposed herself since that initial incident because her family brought her clothing in the next day. RN AA also reported there was an incident in which R53 was observed rubbing on R1's legs when they were sitting outside. R53 was told not to touch R1. During an interview on 4/25/2024 at 3:15 pm with Licensed Practical Nurse (LPN) BB it was revealed, R1 frequently walked and R53 would follow her. LPN BB further reported that staff would monitor R53's behavior by making sure he was not near R1. During an interview on 4/25/2024 at 4:15 pm with Certified Nursing Assistant (CNA) CC it was revealed R53 was in R1's room sitting on the side of the bed touching her breast. CNA CC reported that she told R53 to stop touching R1 and to get out of the room. R53 then walked out of the room and went to stand near the back door. During an interview on 4/25/2024 at 3:40 pm with RN DD, it was revealed R53 exhibited inappropriate behavior towards R1. It was explained that R53 reached for R1 and pulled her to his chest, her shoulder was touching his chest. RN DD reported that she separated the two residents and R53 went outside. During an interview on 4/25/2024 at 4:45 pm with the Social Service Director (SSD), it was revealed that R53 was sent out to a psychiatric facility because of his inappropriate sexual behavior toward R1 on 4/21/2024. During an interview on 4/25/2024 at 5:00 pm with LPN EE it was revealed on 4/21/2024 she was called to the room of R1 and the staff in the room told her R53 was observed touching R1's breast. When LPN EE got to the room, R53 was no longer touching R1 but remained in the room. During an interview on 4/25/2024 at 5:15 pm with the Administrator she revealed she was notified on 4/21/2024 of inappropriate sexual behavior exhibited by R53 towards R1. She reported that she instructed staff to provide 15-minute checks of R53 until he could be transferred out of the facility the next day.

Based on observations, interviews, record reviews, and review of the policy titled, Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to timely report an allegation of sexual abuse to the State Agency (SA) for one resident of three residents (R1) sampled for abuse. Findings include: Review of the policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, last reviewed 1/11/2024, under the Policy Statement: It is the policy of (named facility) and its affiliated entities (collectively, the Organization) to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property. Under the Procedures section: Any allegation, suspicion, or identified occurrence is identified involving, patient abuse, neglect, exploitation, mistreatment, and misappropriation of property, including injuries of an unknown source, should be immediately reported to the Administrator of the provider entity. In accordance with applicable laws and regulations, the Administrator or his or her designee should notify the appropriate state agency (or agencies), the patient's attending physician, and the patient's designated representative of any allegation or incident described above and of the pending investigation. Review of the medical record for R1 revealed, a Brief Interview for Mental Status (BIMS) score was not indicated. R1 diagnosis included unspecified dementia, unspecified severity, with psychotic disturbance, and cerebral infarction. Review of Progress Notes dated 4/11/2024 revealed R53 was sexually inappropriate towards a female resident. He was rubbing her in inappropriate places. Review of Progress Notes dated 4/13/2024 indicated inappropriate sexual behavior, by R53, was noted towards another resident. Review of Progress Notes dated 4/21/2024 indicated, R53 resident entered R1's room and was seen by staff inappropriately touching her breast. Facility administrator and DON notified. There was no evidence to support that the incidents on 4/11/2024 and 4/13/2024 were reported to the SA. During an interview on 4/25/2024 at 4:45 pm with the Social Service Director (SSD), it was revealed that R53 was sent out to a psychiatric facility because of his inappropriate sexual behavior toward R1 on 4/21/2024. She did not know about any allegation of sexual abuse documented by the staff on 4/11/2024. During an interview on 4/25/2024 at 5:15 pm with the Administrator she revealed she was notified on 4/21/2024 of inappropriate sexual behavior exhibited by R53 towards R1. She stated that staff were then instructed to provide 15-minute checks of R53 until he could be transferred out of the facility the next day. During a post survey interview on 5/9/2024 at 9:29 am, the Administrator reported that she was not aware of any incidents between R53 and R1 before 4/21/2024. The Administrator further stated that the supervisor should have reported any incidents to her, and the staff who witnessed any incidents should have reported them to their supervisor.

Based on observations, staff interviews, record review, and review of the facility's policies titled Coronavirus (COVID-19) Infection Prevention and Control Practices Policy and COVID-19 Isolation and Cohorting Process, the facility failed to ensure notification of the facility's current active COVID-19 status was posted on the front exterior doors of the facility as recommended by the Centers for Disease Control (CDC). In addition, the facility failed to follow infection control procedures of applying and removing Personal Protective Equipment (PPE) during treatment services for one of 17 Residents (R) (R12). Findings include: Observations on 2/20/2024 at 8:35 AM, 2/21/2024 at 8:30 AM, and 2/22/2024 at 8:40AM revealed there were no COVID -19 status signs on the front entrance doors of the facility to provide notification of active COVID-19 in the building. Interview on 2/22/2024 at 10:35 AM with the Administrator and the Infection Control Preventionist (ICP) regarding the lack of notification of the facility's current COVID -19 status on the front entrance doors of the facility revealed that both parties confirmed that the notification signs were not posted. During the interview with the ICP she confirmed that the facility had one active case of Covid-19 in the building. The ICP also reported being aware of the policy regarding notification of Covid-19 in the building but was unaware of the missing notification signs that should have been posted on the facility's front entrance doors. The Administrator reported that this was an error by the facility and all facility staff should have ensured the Covid-19 signs were posted. The Administrator reported that the importance of having the sign notification was to make sure that everyone including family members, staff, and the residents were protected and aware. A policy was requested by the survey team regarding Covid-19 notification signage posting and the facility failed to provide a policy. 45811 2.Findings include. Review of the facility policy titled, Coronavirus (COVID-19) Infection Prevention and Control Practices revision date of 1/25/2024, revealed under section VI (Isolation) During the care of any HCC or ALF patient/resident with known or suspected COVID-19, healthcare personnel should do the following: Wear a N95 mask and appropriate PPE upon entering the exposed or confirmed positive patient/resident's room or when working within three feet of the patient/resident. Remove the mask when leaving the patient/resident's room and dispose of the mask in a waste container outside the patient/resident room. If appropriate, don a procedure mask after exiting the resident room. Wear goggles or face shield, waterproof gowns and gloves with Contact and Droplet isolation of these patients/residents. Review of the policy titled, COVID-19 Isolation and Cohorting Process revised date 11/13/2023; under section III, number 9. (Entering or Exiting Confirmed Positive or suspected of COVI-19 Infection room) 2. PPE will be used in each Transmission Based Precautions Room and changed accordingly. a) N95 mask (N95 mask that the staff was fitted for). b) Eye protection must be wiped clean with a disinfectant wipe or changed before entering a positive or suspected resident room. During an observation and interview on 2/21/2024 at 11:55 am, Registered Nurse (RN) AA gathered supplies to administer insulin to R12 who was on droplet precautions for COVID-19. The nurse had on a surgical mask and gloves only. The nurse was asked what the appropriate PPE was to use for a resident who was COVID positive; she went to the cart outside of the room and opened each drawer and stated the supplies in the drawer included the N95 mask, gowns, and gloves. The nurse was asked why she only wore a surgical mask and gloves to enter the room and she stated she had been working with the resident and just wanted to get in the room and give her the medicine. The nurse admitted she should have worn the N95 mask and gown. The nurse states the appropriate PPE to wear in a COVID positive room is a gown, mask, and face shield. Staff should wear an N95 mask. The nurse stated there have been in-services on the type of PPE to wear when providing care for a COVID-19 positive resident, but she had not attended any of the classes. Review of the facility in-service education provided to the staff revealed the following classes: on 6/2/2023 Infection Prevention; Topic: Personal Protective Equipment (PPE) - there were 22 attendees including RN AA; 2/22/2024 - PPE for COVID Positive Residents - 4 attendees. Interview on 2/22/2024 at 10:00 am, with the Infection Control Nurse (ICP) it was revealed staff are to wear N95 mask, eye protection, gloves, and gown when going into a room to care for a resident who is COVID positive; the contents of the PPE supply cart in front of the resident's room was reviewed with the ICP nurse which included N95 mask, face shields, gloves, gown, shoe covers that were available for staff use. Interview on 2/22/2024 at 10:15 am with the DON revealed; staff should wear gown, mask (N95), gloves, and shoe covers (optional) when entering a room that has a COVID positive resident.

Based on staff interview and record review, the facility failed to maintain bookkeeping techniques for one of four private pay residents (R) (R1) reflecting discrepancies with the daily rates and billing. The facility census was 62 residents. Findings include: Review of the record revealed that Resident 1(R1) was admitted to the facility as a private pay resident. The admission agreement contract revealed a rate of $288 per day or $8,805 per month. Review of the Resident Account Detail dated [DATE] through [DATE] revealed that R1 was initially charged a daily rate of $284.03 for the month of [DATE]. The responsible party paid the facility a cashier check dated [DATE] for $8,500. R1 had a carryover credit of $831.19 from daily rate calculation. In [DATE], the responsible party submitted a cashier check dated [DATE] in the amount of $8,257.90 for [DATE] through [DATE] at a calculated daily rate of $284.03. R1 had a carryover credit of $568.19. In [DATE], the responsible party submitted a cashier check dated in the amount of $9,243.00 for [DATE] through [DATE]. The July month had two sets of calculations of daily rate which was not reflected on the statement. [DATE] through [DATE] revealed a daily rate of $284.03. However, the rate for [DATE] through [DATE] reflected a rate of $302.645. R1 had a carryover credit of $722.23 (rate at $284.03) or $349.86 (rate at $302.645). In [DATE], the responsible party submitted a cashier check dated [DATE] in the amount of $2,920.00. R1 daily rate of $302.645 was calculated for [DATE] through [DATE] reflected a balance of $605.29. R1 was discharged to a behavior facility on [DATE]. She was readmitted to the facility on [DATE] through [DATE] at a daily rate of $249.23 to reflect a room charge of $2,741.53. R1 had carryover credit of $332.64 (rate at $249.23) or a negative balance of $76.96 (rate at $302.645). In [DATE], the responsible party submitted a cashier check dated [DATE] in the amount of $4,000 dollars. R1 daily rate of $249.23 for [DATE] through [DATE] total to $7,476.90. Therefore, the responsible party was $3,144.26 or $3,553.84 in the arrear and with or without the carryover credit consecutive order. In [DATE], R1 daily rate was $245.86 for [DATE] through [DATE]. She expired on [DATE] with arrears of $737.58 . R1 arrears total to $3881.82 or $4,291.42 . The pharmacy bill was included in the calculations. Review of the Resident Statement dated [DATE] revealed a billing for [DATE] through [DATE] for charges dated /credit dated [DATE] through [DATE]. The bill dated [DATE] revealed [DATE] through [DATE] did not list the daily rate for charges. Review of the Progress Notes dated [DATE] through [DATE] revealed that R1 had multiple behaviors directed toward other residents that R1 was moved to a private room. Review of the Notice of Decision (Medicaid) dated [DATE] revealed R1 was denied medical assistance for refused or failed to verify required information. An interview on [DATE] at 10:30 am, with the Financial Office Manager AA revealed that she does not process any checks received. And that all checks are processed by corporate. An interview on [DATE] at 11:00 am, with Corporate Financial CC revealed that if a resident overpays, they get the overpayment as credit. The $4,706.55 she explained that the resident was a private pay pending Medicaid approval for room and board estimated liability. R1 was paying her estimated liability. A subsequent interview at 4:03 pm, to clarify the room rate before a Medicaid application is approved. She stated that R1 rate on admission was 293.50 dollars through [DATE]. When she returned on [DATE] through [DATE], her rate was $249.23 dollars per day. The rate for [DATE] through [DATE] was $249.23. And for [DATE] through [DATE] her rate was $245.86. However, she could not explain the discrepancy for the actual daily rate charged.

Based on observations and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to ensure residents rooms were in good repair on two of seven halls 200 Hall and 300 Hall that were occupied by residents. These areas contained a loose appendage on the floor, jagged edges at bathroom threshold, cracks in floor tile, rust on doorframe, missing baseboard, and dirt buildup on floor. The facility census was 69. Findings include: 1. An observation on 5/3/22 at 10:40 a.m. of resident room 252 revealed bathroom thresh hold is jagged with missing pieces. An observation on 5/4/22 at 11:03 a.m. of 200 Hall revealed there was a silver metal stripping in the hallway that was secured with black electrical tape that was coming lose from the floor. On 5/5/22 at 9:07 a.m. Environmental rounds were conducted with Administrator, Maintenance Director, and Housekeeping Supervisor who confirmed the repairs needed for 200 Hall and room 252 bathroom thresh hold that was observed during the three-day survey process. On 5/5/22 at 9:27 a.m. Interview with Maintenance Director revealed the staff reports any maintenance issues to the department by logging the concern in electronic program that can be accessed from any computer in the facility. The Maintenance Director revealed that he was already aware of confirmed observations on 200 Hall but did not have a time frame of when repairs would be completed. On 5/5/22 at 9:47 a.m. Interview with Administrator revealed the expectation is for the facility to be always in good repair. Further interview also revealed there are no policy or procedures pertaining to maintenance. There is a quarterly maintenance process that is followed by maintenance that alerts them to what areas to check for repairs. 2. During observations of the environment on the 300-hall on 5/3/22, beginning at 9:00 a.m. and concluding at 9:50 a.m., the following concerns were noted: In Room 303 there were several visible cracks in the floor tile, and the floor near the air conditioner had dirt buildup. In the shared bathroom for Rooms 303 and 305 (shared by four residents): the door frame was noted with rust. In Room 305 the floor near the air conditioner unit had dirt buildup and missing a piece of the baseboard. In Room 307 and 309 there were several visible cracks in the floor tile. In Room 311 there were several visible cracks in the floor tile and the floor near the air conditioner had dirt buildup. An Environmental round was initiated on 5/5/22 beginning at 9:07 a.m. with the Administrator, Maintenance Director, and Housekeeping Supervisor. The Administrator, Maintenance Director, and the Housekeeping Supervisor confirmed the room concerns related to cracked floor tile, rust on doorframe, dirt buildup on floor by air conditioning units, missing baseboard, and rusty doorframe. During an interview with the Maintenance Director on 5/5/22 at 9:30 a.m. revealed that maintenance concerns are reviewed in the facility's online maintenance reporting program daily. He further stated daily room rounds are also conducted. Maintenance Director expressed that there are monthly maintenance tasks that must be completed that is generated by the online maintenance program that he follows. He stated he prioritizes and works on what is most severe first.

Based on interview, observations, and review of policy titled, Policy Food ordering, receiving, and storage the facility failed to label and date food items stored in walk in cooler, failed to discard items after expiration date in refrigerator, and failed to monitor freezer temperatures in one of two resident refrigerators at the nurse stations. The facility census was 74 residents. Findings include: Observations: Observation on 1/28/19 at 11:40 a.m. during the brief kitchen tour with the Dietary Manager revealed the following: 1. In the reach in refrigerator in the dining room there was one 46 fluid ounce (oz) container of Lyons Thickened Water with a use by date of 6/18/19 but there was not an open date. 2. In the reach in refrigerator there were two apple sauce cups with a date of 1/15/19 and four apple sauce cups with a 1/20/19 date on them. There was no use by date on the apple sauce. 3. In the reach in refrigerator there was also one bowl of raisin bran cereal that was not labeled or dated. 4. In the kitchen there were bins with labels for flour, sugar, meal, rice, and thickener but there were no in dates or use by dates on either. 5. In a storage area there were five loaves of 12 count hot dog buns that did not have a use by or in date. 6. In the walk in cooler revealed temperature of 37 degrees Fahrenheit (F). In the walk in cooler there were two bags of cole slaw with a use by date of 1/27/19. 7. In the walk in cooler there was a container with sandwiches in it that was not labeled or dated. Observation on 1/29/19 at 4:57 p.m. of the Resident refrigerator in the front nurse station revealed the following: 1. There were 13 single serve ice cream cups that were visibly separated and soft to the touch. 2. There was a plastic bag with a pear and orange in it but did not have a name or in date or use by date. 3. The temperature log did not reflect monitoring of the freezer temperatures. The DHS, at this time, reported that night shift checks refrigerator nightly. Initially stated that thermometer in refrigerator was for the freezer. During second tour of kitchen on 1/30/19 at 1:20 p.m. the following was observed: 1. In the dry storage area there was a half bag of raisin bran that was removed from it's original box and wrapped but did not have an open or use by date. It was further reported that nursing is responsible for resident refrigerators on the unit. Interview on 1/28/19 at 11:45 a.m. with the Dietary Manager (DM) revealed that the date on the apple sauce was the preparation date and it should have been used within seven days beyond that date. She confirmed that the apple sauce was beyond it's use by date. The DM further reported that the sandwiches in the walk in cooler should have been labeled with a date that they were prepared and that it was the responsibility of whoever prepared the sandwiches to label them. Interview on 1/29/19 at 4:57 p.m. with Licensed Practical Nurse (LPN) FF confirmed that the ice cream in freezer was soft to touch and LPN FF reported the ice cream should be more firm. In addition, at this time, the DHS reported that the ice cream belongs to all residents and also confirmed the ice cream soft to touch. During an interview on 1/30/19 at 1:15 p.m. with the Dietary Consultant confirmed that the containers with flour, meal, sugar, rice, thickener should be labeled with name and dates. The Dietary Consultant further reported that the date is usually written on these containers. During the interview with the Dietary Manager on 1/30/19 at 4:30 p.m. revealed that typically when bins are washed and filled the date is placed on the container and that whoever washes and refills the bins is responsible for labeling and dating. Policy Food ordering, receiving, and storage reviewed: 8/3/17 storage and rotation guidelines *date all stock items with delivery date labeling, dating, and storage 1. food and/or beverage items will be properly labeled with the name of the item, and a use by date. 5. all items sent to the floors and taken out of original containers, will have a use by dated based on the USDA quick reference shelf life list. USDA - food safety information Basics for Handling Food Safely The refrigerator should be at 40 degrees F or below and the freezer at 0 degrees F or below.

Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, for a total of three of fifteen rooms on the Memory Support Unit (MSU). The facility census was 74 residents. Findings include: The Environmental tour began on 1/31/19 at 10:16 a.m. with the Maintenance Director, Director of Health Services, Assistant Director of Health Services, Nurse Consultant, Housekeeping Supervisor, and Registered Nurse (RN) BB. Observation revealed resident privacy curtains with a width space/gap of approximately 56.5 inches which did not ensure full visual privacy during patient care for rooms 351, 355, 357. In room [ROOM NUMBER] there was no privacy curtain at the foot of the bed for the Bed B and there was a 56.5 inch space/gap from the wall for Bed A in room [ROOM NUMBER]. During an interview on 1/31/19 at 10:16 a.m. with the DHS revealed that her expectation is that staff will pull curtains up to assure privacy when providing care to residents and that going forward there will be an audit of all rooms to assure 100% privacy and if short curtains are identified they will be replaced. Interview on 1/31/19 at 10:21 a.m. with Housekeeping Supervisor revealed that privacy curtains are removed and rehung monthly. The Housekeeping Supervisor also revealed that if short curtains are identified by staff they are taken down and replaced. However, the Housekeeping Supervisor denied being aware of any short privacy curtains prior to today.

Based on staff interview, record review, and review of the policy titled Advanced Directives: Georgia, the facility failed to ensure that documentation for two residents (R#38 and R#2) had matching information on both the Physician order [REDACTED].#39, R#40,and R#74) had two physician signatures on their POLST form. The sample size was 28 residents. Findings include: 1. Review of the POLST form for R#38 revealed documentation that the resident wished to allow natural death and the form was signed as of [DATE]. Review of Physician order [REDACTED]. Review of monthly Physician order [REDACTED]. Review of phone orders from (MONTH) (YEAR) through present revealed no change in code status. Review of the care plan for R#38 revealed that the resident had an advanced directive of DNR. Interview on [DATE] at 3:10 p.m. with Licensed Practical Nurse (LPN) DD revealed that she would look at the POLST or the Physician order [REDACTED]. The LPN confirmed that there was a conflict between what was on the POLST and what the physician's orders [REDACTED]. She stated that due to the conflicting information that if the resident experienced respiratory and/or [MEDICAL CONDITION] she would have to start cardiopulmonary resuscitation (CPR). 2. Review of the POLST for R#2 signed on [DATE] documented to allow natural death. Review of the monthly Physician order [REDACTED].#2 was a full code. Review of monthly Physician order [REDACTED]. Review of phone orders back to [DATE] revealed no change in the residents code status. Review of the care plan revealed that R#2 had an Advanced Directive for a DNR. Interview on [DATE] at 3:08 p.m. with LPN DD confirmed that there was a conflict between what was on the POLST and what the physician's orders [REDACTED]. Interview on [DATE] at 3:20 p.m. with Social Service Director revealed that she or the Admissions Director obtained the physician signed POLST. Social Services would fax the POLST form to the physician for it to be signed. She confirmed that there was a conflict with current monthly Physician order [REDACTED]. 3. Review of medical record for R# 39 revealed a physician's orders [REDACTED]. Further review of the medical record revealed a POLST signed by resident's daughter and there was one physician signature on the form. There was no documentation in the resident's record to show that there was an identified health care agent. Review of Advanced Directive checklist indicated that the resident did not have an advanced directive but would like more information. 4. Review of medical record for R# 40 revealed a POLST signed on [DATE] by spouse with one physician signature. Further review of the medical record revealed that there was no indication that the spouse was the healthcare agent. During an interview with Registered Nurse BB on [DATE] at 12:37 p.m. revealed that she looks to the POLST in the resident record to determine the residents code status. During interview with the Social Services Director (SSD) on [DATE] at 3:16 p.m. it was reported that the POLST is signed on admission. The POLST form is then faxed to the resident's physician to get signed. SSD then confirmed that there is no health care agent info in the medical record for R#39. Further interview with the SSD revealed that the SSD reviewed the POLST form and confirmed that a concurring physician signature was needed for R#39. The SSD further reported that other than herself the admissions director and medical records staff also assist with getting POLST's signed and send them to the physician for signatures. SSD denied having provided any education to medical records staff related to how the POLST should be completed to assure appropriate physician signatures. Further interview with the SSD confirmed that R# 40 did not have a health care agent and two physician signatures. 5. Record review revealed that R#74 was an [AGE] year old man that had experienced a cebreal vascular accident ([MEDICAL CONDITION]) with a deficit of range of motion (ROM) on his right side. He required extensive assistance from the staff to meet his Activities of Daily Living (ADL) and had [MEDICAL CONDITION] making it difficult for him to express his needs and desires. During a review of the Physician order [REDACTED].#74's daughter and one physician. There is a General Power of Attorney in the clinical records but it does not give authority over health care for this resident. This POLST form indicates the need for two physician signatures when the resident is unable to sign for themselves or the responsible party does not have Power of Attorney for Health Care.

Based on Resident Interview, staff interview, and review of the facility policy titled, Printing and Distribution of Resident Quarterly Statements, the facility failed to ensure that one cognitively intact resident (R#26) received a quarterly statement of her personal fund account on a routine basis. The sample size was 28 residents. Findings include: Review of the resident's Quarterly Minimum Data Sets dated 11/23/18 revealed a Brief Interview for Mental Status score of 15 indicating that she was cognitively intact. Interview on 1/28/19 at 12:41 p.m. with R#26 revealed that she doesn't receive a quarterly statement of her personal funds account. Interview on 1/30/19 at 8:54 a.m. with the Financial Counsellor/Business Office Manager revealed that the residents' quarterly statements were mailed out by corporate to the responsible party but not to the resident. The Financial Counsellor/Business Office Manager stated that corporate sends the quarterly statements to the Financial Counsellor/Business Office Manager twice a year and had instructed her to keep them on file. If a resident's responsible party or a resident comes to the Financial Counsellor/Business Office Manager and wanted to know how much money the resident had in their account, the Financial Counsellor/Business Office Manager stated that she printed out a statement for them. She also stated that the residents do not routinely receive a quarterly statement. The Financial Counsellor stated that R#26 would periodically ask for a copy of her statement and she would take a copy to her and answer any questions. She stated that after reviewing the statement the resident would then ask the Financial Counsellor/Business Office Manager to shred the statement. She does not have a copy of a statement that the resident had signed or any other documentation that the resident received a quarterly statement. The Financial Counsellor/Business Office Manager confirmed that statements were not given out quarterly to cognitive residents on a routine basis. Review of the Facility Policy for Printing and Distribution of Resident Quarterly Statements revealed that the Business Office Coordinator will distribute quarterly statements and will provide one copy to each cognizant resident, mail all others to authorized representatives and file the Quarterly Survey Report.

Based on observations and staff interviews the facility failed to assure that hot water temperatures were less than 110 degrees Fahrenheit (F) in three of 15 rooms (264, 351, and 357) on the Memory Support Unit (MSU). The facility census was 74 residents. Findings include: During a tour of the MSU on 1/28/29 from 1:14 p.m. to 1:57 p.m. the hot water was observed to be hot to the touch for rooms [ROOM NUMBER]. Observation on 1/28/19 at 2:04 p.m. revealed that the Maintenance Supervisor identified the following temperatures in the following rooms: room [ROOM NUMBER] the hot water temperature was 127.4 degrees F. room [ROOM NUMBER] at 2:09 p.m. the hot water temperature was 127.5 degrees F. room [ROOM NUMBER] at 2:11 p.m. the hot water temperature was 127.1 degrees F. During an interview on 1/28/19 at 2:04 p.m. with the Maintenance Supervisor revealed that hot water temperatures are checked weekly. It was further reported that the water temperature was turned up a few days ago due to complaints that the water was not getting hot enough.

Based on record review and interview it was determined the facility failed to follow the care plan interventions for two residents (R#39 and R#92) of 28 residents sampled. R#39 was care planed for respiratory problems, the care plan interventions included the nurse to perform respiratory assessments, administer nebulizer treatments and notification of physician if the resident developed respiratory problems. R#92 was care planned for removal of bilateral leg immobilizers and skin checks twice daily. There was no evidence the twice daily skin checks were done. R #92 sustained pressure ulcers under both right and left leg immobilizers. This standard is cited at harm level. Findings include: 1. Record review revealed Resident (R) 39 was admitted with [DIAGNOSES REDACTED]. Review of the R#39's respiratory care plan revealed the potential for respiratory complications r/t [DIAGNOSES REDACTED].will not experience any complications r/t respiratory problems .Respiratory distress will be minimized and maintained at patient's acceptable level of no shortness of breath (SOB) or distress, .Approaches: .Notify resident's physician of conditions .observe resident's vital signs per protocol, Evaluate resident for excessive fluid retention, Listen to resident's lung sounds per protocol, Oxygen (O2) at two liters (L) continuously, Check O2 saturation (sats) every shift, . This care plan did not have any new goals nor approaches with the 12/2/16 review. Review of physician's orders [REDACTED]. For SOB give two liters (L) via nasal cannula immediately (STAT) and notify the physician. Nebulizer treatment every four hours as needed for [MEDICAL CONDITION]/SOB Nurse notes dated 4/3/16 at 2:50 p.m., for R#39 revealed Resident noted c (with) slight SOB (shortness of breath) .placed on 3 day charting for observation. Will cont. (continue) to observe. There were no documentation indicating LPN HH notified the doctor, monitored oxygen level due to the SOB, nor administered nebulizer treatment as indicated in the care plan. From the first observation of R#39 at 2:50 p.m., LPN HH entered and exit R#39's room three times without initiating the approaches/interventions according to the respiratory care plan. Nurse notes for R #39 on 4/3/16 at 4:45 p.m., revealed R #39 was still unresponsive with an oxygen saturation level of 88% on three L of oxygen. The physician's orders [REDACTED]. LPN HH stated she did not place R#39 on three L of oxygen. There was no documentation of when R#39 was placed on three L of oxygen. On 3/2/17 at 2:22 p.m., an interview with the Director of Health Service (DHS) in her office stated LPN HH did not follow the care plan. LPN HH should have initiated the approaches listed on the care plan along with nursing judgement. On 3/2/17 at 2:56 p.m., an interview with LPN HH in the DHS office with the DHS present revealed I thought she (R #39) was having a deep sleep episode. I did not call the physician. I felt comfortable because her daughter was with her. The facility failed to ensure interventions/approaches were followed for a resident who had a [DIAGNOSES REDACTED]. Cross Refer to F309 2. Closed record review of the Face sheet for R#92 indicated an admission into the facility in September 2015. R#92's [DIAGNOSES REDACTED]. Review of the Care Plan for R#92 revealed plans that included but were not limited to: 9/28/15 resident was admitted with pressure area to right heel and sacrum. Updated 12/2/15 sacral area has healed. Updated 4/8/16 right heel has healed. Updated 7/27/16 admitted to (Named hospital). Updated 7/29/16 return to facility. Updated 8/5/16 immobilizers to both legs. Check under immobilizers for skin issues. Updated 8/16/16 abrasion left lateral, 8/16/16 darken area right posterior leg, darken area left posterior leg, Updated 9/2/16 open abrasion right posterior leg and open abrasion left posterior leg. Treatment orders received. Approaches to the fall care plan included but not limited to: 7/29/16 apply immobilizer and check skin BID (twice a day). Review of the Discharge Orders for Extended Care Facility dated 7/29/16 revealed instructions for no weight bearing, skin precaution, fall precaution, immobilizer to bil legs remove and check skin BID and PRN call office for follow up. Review of the Admission/Nursing Observation Form dated 7/29/16 indicated R#92 had: Bilateral femur fractures with bilateral knee immobilizers. Braden Scale for Predicting Pressure Sore Risk score of nine which indicated R#92 was at severe risk for pressure sore development. Review of the Skilled Daily Nurses Notes dated 7/31/16 through 9/8/16 for R#92 revealed seven entries that documented removal of the immobilizers from both legs and skin checks which were dated: 8/1/16, 8/24/16, 8/29/16 (documentation that nurse could not check resident skin due to agitation), 9/1/16, 9/5/16, 9/6/16 (left knee noted with hard area on top of left knee. Unknown if this is hardware or bone. Appointment set up for tomorrow at 1:45 p.m. with (physician named). 9/7/16 9:50 a.m. Noted with [MEDICAL CONDITION] bilateral (bilat.) knees. Unable to get a ride for today for Orthopedic appointment. Appointment made for 9/8/16. 9/8/16 R #92 was directly admitted into acute hospital. There was no documentation of twice daily removal of the leg immobilizers and skin checks in the Nurses' Notes, Medication Records, Treatment Records or Wound Observation and Treatment records for R #92 as indicated in the Care Plan for falls and pressure areas. Interview with the Nurse Consultant and the Administrator on 3/1/17 at 12:25 p.m. in the Administrator's office revealed that the resident was not a candidate for surgery when first admitted into the hospital. The resident came back to the facility and was readmitted into the hospital and the bone was displaced, the resident was wiggling, the bone did not heal. The facility purchased three different immobilizers for the resident. Interview with the Corporate Nurse Consultant on 03/02/17 at 12:09 p.m. in the Administrator's office revealed that she could not locate the documentation in the health record of the twice a day removal of the immobilizer and checks of R#92's skin by the nurses. There were intermittent notes of the skin checks in the Nurses' notes. Cross Refer to F314

Based on record review and interview it was determined the facility failed to provide care and services in a timely manner for one resident of 28 sampled residents. Resident (R) #39 was found unresponsive to voice and touch on 4/4/16. The nurse failed to assess and provide treatment to the resident. R#39 was transported to the hospital via ambulance four hours after the initial nursing assessment. This standard was cited at harm level. Findings include: R #39 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/28/17 at 11:35 a.m., an interview with complainant in R#39 room stated My sister received a call to come see about our mother. I was just coming to visit and she (R#39) was non- responsive in her room in the bed. Pushed the call light and no one responded. Told a CNA (Certified Nursing Assistant) to go get LPN HH. She never came. I went to go find LPN HH. LPN HH tried to wake her up and I insisted that she call 911. Someone finally called 911. One of the hospital nurses said that she (R#39) had been given too much medicine. They gave her [MEDICATION NAME] (treats narcotic overdose) more than once to bring her back. Review of R#39's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed R#39 had [DIAGNOSES REDACTED]. physician's orders [REDACTED].#39 was a full code, and for SOB give two L via nasal cannula immediately (STAT) and notify the physician. Nebulizer treatment every four hours as needed for [MEDICAL CONDITION]/SOB Review of the resident's care plan revealed potential for respiratory complications related to [DIAGNOSES REDACTED].will not experience any complications r/t respiratory problems .Respiratory distress will be minimized and maintained at patient's acceptable level of no SOB or distress, .Approaches: Nebulizer treatments .observe resident's vital signs per protocol, Evaluate resident for excessive fluid retention, Listen to resident's lung sounds per protocol, Oxygen (O2) at 2 L (liter) continuously, Check O2 sats (saturation) every shift, . There was no indication to what was updated on 9/20/16. Review of nurse's notes dated 4/3/16 at 2:50 p.m., for R #39 revealed Resident noted c (with) slight SOB (shortness of breath) .placed on 3 (three) day charting for observation. Will cont. (continue) to observe. There was no documentation indicating LPN HH assessed nor provided recommended interventions for R #39 at that time. Nurse's notes dated 4/3/16 at 4:30 p.m., revealed Blood sugar 238, resident non-responsive to physical or verbal stimuli, 10 units [MEDICATION NAME] (insulin) given .Family at bed side. The nurse's note lacked documentation indicating R#39's oxygen level was being monitored due to the display of SOB. The following events were documented on 4/3/16: At 4:45 p.m., R#39 remains unresponsive O2 sat @ (at) 88% on 3L (three) O2. (The physician's orders [REDACTED]. 5:30 p.m., Daughter called this nurse into see resident. Unable to arouse resident. Family concerned, request resident be sent out to hospital. 6:45 p.m., 911 called, resident transferred to (Name of local hospital) ER (emergency room ) for eval. (evaluation) There was approximately four hours from LPN HH initial observation of R#39 having SOB to the time 911 was called. There was no documentation of the physician being contacted. Review of history and physical dated 4/4/16 revealed .Today . patient . was unresponsive for an uncertain amount of time at the nursing home.In the emergency room the patient did receive from the ER doctor Narran x (times) two . Review of hospital discharge summary dated 4/14/16, revealed .The patient .who apparently passed out at the nursing home and was unresponsive for an uncertain amount of time.came in anemic with hemoglobin of 7.3. (normal range was 13.5-17.5) R #39 received blood transfusion. R #39 went into respiratory distress while in the hospital. On 3/2/17 at 2:22 p.m., an interview with the Director of Health Service (DHS) in her office revealed, the facility had a pathway which the nurse should have followed. The DHS also stated there were facility protocols and guideline in place. Staff should never leave the resident in any type of change in condition. It should not take an hour to contact the doctor or do anything. The pathway was requested but not provided during the survey. On 3/2/17 at 2:56 p.m., an interview with LPN HH in the DHS office with the DHS present revealed, I know the resident has episodes of deep sleep and hard to arouse. I moved her head around and she was resistant. So the sternum rub was not done. She like to sleep with a down comforter and was diaphoretic (heavy sweating). I should not have left her (R #39). LPN HH stated she was not aware of a facility policy on what to do when you find an unresponsive resident. LPN HH also stated she should have sent her (R #39) out sooner. I thought she (R #39) was having a deep sleep episode. I did not call the physician. I felt comfortable because her daughter was with her. When asked what she was doing each time she left R #39's room, LPN HH stated she was checking on her other residents. The DHS stated after reviewing nurse's notes dated 4/3/16, stated, That was not following protocol. The DHS also stated the facility had guidelines to follow in an emergency situation but nursing judgement should have been used. Review of the facility's guidelines were requested but not provided during this survey. On 3/2/17 at 3:49 p.m., an interview with the Senior Nurse Consultant in the Administrator's office stated, there was no policy/procedure for assessing residents with oxygen use nor when to call the doctor. The facility failed to assess and provide suggested interventions in a timely manner for a resident who had SOB and was found unresponsive on several observations by the nurse.

Based on closed record review and interview it was determined the facility failed to follow Physician's Orders for the removal of bilateral leg immobilizers and to check the skin under the immobilizers for one resident (R#92) in a total sample of 28 residents. This failure to comply with the order to remove the immobilizers and check R#92's skin led to the development of pressure ulcers on the left ankle and right knee and ankle as well as right flank. This standard is cited at harm level. Findings include: Interview with the Corporate Nurse Consultant and Administrator on 3/2/17 at 11:42 a.m. in the Administrator's office revealed that the facility does not have a lot of policies. The facility had gotten away from using so many policies. The Corporate Nurse Consultant explained that the leg wound changed somewhat, they were intact and at that time they didn't believe that pressure caused the wounds. The facility was unable to provide a pressure ulcer policy. Closed record review of the health record for R#92 indicated admission into the facility in November 2015. R#92 [DIAGNOSES REDACTED]. Review of the Discharge Recapitulation of Stay Form dated 10/27/16 revealed that R #92 was transferred to another facility after her 9/20/16 hospital return. hospitalization s documented 7/27/16-7/29/16 bilateral distal femur fracture. 9/8/16-9/20/16 open femur fracture with wound infection of open wound fracture site, decubitus ulcer of ankle. Family asked for transfer to another facility after 9/20/16 hospital return. discharged to another skilled nursing facility Health record review revealed that R #92 sustained a fall from a chair on 7/20/16. An assessment was performed by RN MM that included full range of motion to the lower extremities. R#92 did not indicate during the assessment that she had pain in her lower extremities. R #92 complained of hitting her head. Neurological checks were conducted after the fall. The Physician and responsible party were notified of the fall the next morning. Review of the Physician's Interim Orders dated 7/26/16 indicated an order for [REDACTED]. Review of the Radiology Report dated 7/26/16 for R #92 revealed there was a fracture involving right distal femur with posterior displacement. The joint showed no dislocation. There was associated joint effusion. Conclusion: Recent displaced right knee fracture as described above. Knee prosthesis noted. R#92 was examined by an orthopedic specialist on 7/27/16 and sent directly to the hospital for admission. Review of the Discharge Orders for Extended Care Facility dated 7/29/16 for R #92 revealed instructions for no weight bearing, skin precautions, fall precautions, immobilizer to bilateral legs remove and check skin twice a day (BID) and as needed (PRN) call office for follow up. Review of the Braden Scale for Predicting Pressure Sore Risk dated 7/29/16 indicate R #92 scored nine, indicating the resident was a severe risk for pressure sore development. Review of the Skilled Daily Nurses Notes dated 7/31/16 through 9/8/16 for R#92 revealed seven entries that documented removal of the immobilizers from both legs and skin checks dated: 8/1/16, 8/24/16, 8/29/16 included documentation that nurse could not check R#92's skin due to agitation, 9/1/16, 9/5/16, 9/6/16 noted left knee noted with hard area on top of left knee. Unknown if this is hardware or bone. Review of the Wound Observation and Assessment Form dated 8/16/16 3:20 p.m. revealed that the certified nursing assistant notified the nurse of dark, dry discoloration to bilateral (bilat.) posterior lower legs. Both areas on bilateral lower extremities (BLE) moisturized and stockinettes applied to both extremities for protection from the immobilizers. Resident has an abrasion noted to the right (Rt) lateral back, [MEDICATION NAME] applied. Responsible party (RP) notified via phone concerning findings and treatment (tx) provided. Review of the Nurse's Notes dated 8/23/16 at 6:30 p.m. indicated that R#92 returned from an Orthopedic physician visit with new orders to keep both braces up to groin, check four times a day and reposition as needed. Keep non-weight bearing (NWB). Check for circulation every eight hours. Protect lower and upper legs for pressure. Review of the Wound Observation and Assessment Form dated 8/24/16 2:30 p.m. revealed that the immobilizers to BLE were opened up(sic), stockinettes removed-BLE assessed per DHS (Director of Health Services) and nurse. Darkened dry discolorations remains, will cont. stockingnettes and add to clean L and Rt posterior legs with normal saline (NS) blot dry, apply foam adhesive dressing (drsg) q five day and prn for protection. Abrasion to Rt lateral back requires further tx every other day (qod) by cleaning with NS, blot dry, apply small amount of [MEDICATION NAME] and cover with border gauze. Closed record review of R#92's the health records including Nurses' Notes, Wound Observation and Assessment Forms, Medication Administration Records and Treatment Records revealed no documentation of twice daily removal of the immobilizers and skin assessments. There were no Physician's Orders for the treatments to R#92's skin under the immobilizers that were performed by the nursing staff. Review of the Treatment Record for R#92 dated 9/1/16 through 9/8/16 indicated that care continued to the abrasion on her right lateral back. The darkened areas on her right and left posterior legs worsened into open abrasions. The treatment changed to: Clean with NS , apply small amount [MEDICATION NAME] cover with four by fours, rolled gauze and secure with tape every other day. Treatments were documented until R#92 was hosptalized on [DATE]. Review of the Orthopedic Encounter Summary-Progress Note dated 9/8/16 indicated R#92 had knee pain, draining sinus over the fracture site of the left knee. Appears to have an infection in the left knee due to the drainage. On 9/8/16 R#92 was directly admitted into acute hospital by the Orthopedic Physician. Per the hospital Focus Notes dated 9/9/16 R#92 had pressure ulcers to: 1. Left Achilles with red granulation tissue, 50% eschar, 5% yellow slough measuring 4 x 7 x 0.2 cm. 2. Right medial knee with 0.5 x 0.5 cm open area with sanguineous fluid draining. 3. Right Achilles with red granulation tissue, 10% stable eschar measuring 8 x 1 x 0.1 cm. 4. Right flank with superficial tissue loss. On 03/02/17 11:42 a.m.an interview (also referenced above) with the Administrator and Corporate Nurse Consultant revealed that: one person was doing the documentation for the treatment nurse because she could not do her own documentation. The ADHS (Assistant Director of Health Services) who did the documentation is no longer employed by the facility. On 8/23/16 There should have been documentation of R #92's skin condition each time the immobilizers were removed twice daily. R#92 was seen at the Orthopedic Physician's. The first observation of the wounds on R #92's skin was documented in the health record on 8/24/16 as darkened areas to bilateral lower legs from the immobilizer rubbing. Protective dressings were applied to the two areas right posterior leg and left posterior leg. Right lateral back had abrasions also that were dressed every other day. There was a Licensed Practical Nurse (LPN) treatment nurse at that time. Now there is a Registered Nurse that does wound care. The Corporate Nurse Consultant explained that the leg wound changed somewhat, they were intact and at that time they didn't believe that pressure caused the wounds. Open abrasion to left lower leg started on 9/2/16 and was treated every other day. R#92 returned to the hospital on [DATE] and was hospitalized until 9/20/16. Interview with the Corporate Nurse Consultant on 03/02/17 at 12:09 p.m. in the Administrator's office revealed that she could not locate the documentation in the health record of the twice a day removal of the immobilizer and checks of R#92's skin by the nurses. There were intermittent notes of the skin checks in the Nurses' notes. The facility failed to follow the Physician's Orders dated 7/29/16 for removal of the immobilizers from both legs and inspect R #92's skin twice a day. R #92 was treated by the Orthopedic surgeon on 8/23/16. The Orthopedic Physician ordered to keep both braces up to groin, check four times a day and reposition as needed. Keep non-weight bearing. Check for circulation every eight hours. Protect lower and upper legs for pressure. The facility staff failed to document the removal of immobilizers and skin check twice a day or four times a day. Additionally, there were no Physician's Orders in the health record for the treatments to R #92's legs that were documented 8/16/16 through 9/7/16. R #92 developed pressure ulcers on both legs that required surgical intervention.

Based on interview and record review, the facility failed to immediately notify the medical doctor of a significant change in a resident's condition of unresponsiveness for one resident (R#39) in a sample of 35 residents. Findings include: During an interview in the resident's room on 2/28/17 at 11:35 a.m., R#39's family member stated, My sister received a call on 4/3/16, to come see about our mother. I was just coming to visit and she (R#39) was non- responsive in her room in the bed. I pushed the call light and no one responded. I told a Certified Nursing Assistant (CNA) to go get License Practical Nurse (LPN) HH. She never came. I went to go find LPN HH. LPN HH tried to wake her up (R#39). I had to insist that she call 911. Someone finally called 911. The family member stated it took a while before someone called 911. R#39 was admitted the facility on 12/26/14. She was re-admitted [DATE] with [DIAGNOSES REDACTED]. Review or the resident's care plan revealed the resident had the potential for respiratory complications related to (r/t) [DIAGNOSES REDACTED].Approaches: .Notify resident's physician of changes in condition . There was no indication of any new interventions being added since the original onset date. Review of the nurse's notes revealed the following: 4/3/16 at 2:50 p.m., Resident noted with (c) slight SOB .placed on three day charting for observation. Will continue (cont.) to observe. 4/3/16 at 4:30 p.m., Blood sugar 238, resident non-responsive to physical or verbal stimuli, 10 units [MEDICATION NAME] (insulin) given .Family at bed side. 4/3/16 at 4:45 p.m., Resident remains unresponsive Oxygen (O2) saturation (sat) at (@) 88% on three liters (L) O2. (The physician's orders [REDACTED].No visible distress noted. 4/3/16 at 5:30 p.m., Daughter called this nurse into see resident. Unable to arouse resident. Family concerned, request resident be sent out to hospital. 4/3/16 at 6:45 p.m., 911 called, resident transferred to (local hospital) emergency room (ER) for evaluation (eval). There was another entry noted at 7:15 p.m., stating the Physician Assistant (PA) was notified of resident's transfer. This entry was not documented prior to the request for a copy. An interview on 3/2/17 at 2:22 p.m., with the Director of Health Service (DHS) in her office revealed We do have pathways that we follow. The nurse need to follow the guide or protocol. Staff should never leave the resident in any type of change in condition. It should not take an hour to contact the doctor or do anything. During an interview on 3/2/17 at 2:56 p.m., LPN HH in the DHS office with the DHS present stated, I know the resident has episodes of deep sleep and hard to arouse. I moved her head around and she was resistant. So the sternum rub was not done. She likes to sleep with a down comforter and was diaphoretic (heavy sweating). LPN HH also stated she was not aware of a facility policy on what to do when you find an unresponsive resident. LPN HH further stated she should have sent her (R #39) out sooner. I thought she (R #39) was having a deep sleep episode. I did not call the physician. The DHS stated after reviewing the nurse notes dated 4/3/16 stated the nurse was not following the protocol. The DHS stated the facility had guidelines to follow in an emergency situation but nursing judgement should have been used. On 3/2/17 at 3:49 p.m., an interview with the Senior Nurse Consultant in the Administrator's office revealed there was no policy/procedure for assessing residents with oxygen use and when to call the doctor. The facility failed to immediately notify the physician of a significant change in a resident's condition as indicated in the residents care plan.

Based on observations and staff interviews, the facility failed to maintain a clean and comfortable environment in six (6) rooms ( #100,102,103,104,105, and 316) of thirty-eight (38) rooms. Findings include: Observations on 5/18/15 at 10.52 a.m., 5/19/15 at 12.15 p.m., 5/20/15 at 7.30 a.m., and 5/21/15 at 8.55 a.m. revealed the hot water faucet in the bathroom sink of room 316 to be inoperable. The room was occupied by two (2) residents. Tour of room 316 with the Maintenance Director on 5/21/15 at 9.05 a.m. confirmed the faucet was inoperable. The Maintenance Director further revealed he had no knowledge of the faucet needing repair. Observations on 05/18/15 at 10:50 a.m. revealed that the toilet in the bathroom in room 100 had a black buildup around the inside of the toilet bowl. Observation of room 102 revealed a heavy build up of dust and debris on the air vent in the bathroom ceiling. It was also observed that the shower wall and floor was noted to have a large area of soap scum type buildup around the shower wall approximately two (2) foot up from the floor. The grab bar, made of galvanized steel, in the shower was noted to have a large build up of soap scum with a small area of rust noted at the end of the grab bar closest to the wall. The shower in room 103 was noted to have black buildup around the bottom wall of the shower approximately two (2) foot up from the floor around the shower wall. The shower grab bar was observed to have a build up of soap scum and the grab bar had a small area of rust on the bar closest to the wall. Further observation revealed that the wooden entrance door, going into the shower, would not close. In room 104, the shower was noted to have large area of debris and black buildup around the perimeter of the floor and around the perimeter of the shower wall approximately two (2) foot high from the floor. The toilet was noted to have a black buildup around the inside of the toilet bowl. The shower had a heavy buildup of scum on the floor and a small area of rust was noted on the shower grab bars closest to the wall. Observation of the shower in room 105 revealed the shower wall had a large area of scum buildup approximately two (2) feet up from the floor going around the perimeter of the shower wall and the bathroom floor was noted to have large buildup of dirt and debris around the perimeter of the bathroom floor. Tour of rooms 100,102,103,104,and 105 with the Housekeeping Director on 5/21/15 at 8.45 a.m. verified the showers were in need of cleaning and repair. The Housekeeping Director further stated the shower room door in room 103 needed to be replaced.

Based on clinical record review, facility document review, and staff interview, the facility failed to ensure the involvement of the Quality Assurance (QA) Committee in the development of a corrective action plan formulated in response to 11/02/2014 and 11/11/2014 altercations between Resident #1 and Resident #2. Resident #1 had [DIAGNOSES REDACTED].#2. However, the facility failed to notify Resident #1's physician of this 11/02/2014 incident when Resident #1 experienced a change in behavior by making these verbal threats against Resident #2. The facility failed to ensure close monitoring of Resident #1 and failed to place Resident #1 in the Behavior Management Program per facility Policy after this incident, and also failed to evaluate Resident #1 for the need for a psychiatric consultation. On 11/11/2014, Resident #2 was discovered not breathing, having no pulse, and having an electric cord around her neck. Resident #1 was documented as reporting to facility staff that she had "killed" Resident #2, and Resident #1 was later arrested and charged with felony murder and aggravated assault. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Corporate Consultant were informed of the immediate jeopardy on November 19, 2014 at 3:36 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on November 11, 2014, the date Resident #1 was documented as stating she had "killed" her roommate, Resident #2, after Resident #2 was found to have no respirations, no pulse, and with an electric cord around her neck, and nine (9) days after November 2, 2014, when the facility failed to enact interventions in response to Resident #1's verbal threats against Resident #2. The immediate jeopardy continued through November 20, 2014, and was removed on November 21, 2014. The facility implemented a credible allegation of jeopardy removal (CAJR) related to the immediate jeopardy on November 20, 2014. During an interview conducted on 11/21/2014 at 11:20 a.m., the Administrator stated that a QA Sub-Committee had met to discuss the issues involved in the 11/02/2014 and 11/11/2014 incidents involving Resident #1 and Resident #2, and to discuss the corrective action plan formulated related to these incidents. However, the Administrator acknowledged that a formal QA Committee meeting had not been held to review and discuss these identified quality deficiencies. The Administrator further acknowledged that, while all members of the QA Committee had reviewed and approved the CAJR, this review was not completed until 11/21/2014, the exit date of this abbreviated survey, and provided no evidence to indicate that the QA Committee had been involved in the formulation of this CAJR. An allegation of jeopardy removal was received on November 20, 2014. Based on the corrective plans which had been developed and implemented by the facility via a credible allegation of jeopardy removal on November 20, 2014, the immediacy of the deficient practice was determined to have been removed on November 21, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of staffs' monitoring of resident behaviors, resident screening and placement in the Behavior Management Program as indicated, resident Care Plan updating and implementation regarding resident behaviors, and physician notification of resident behavioral changes, in accordance with facility policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility policies and procedures governing resident monitoring and the reporting of resident behavioral changes to supervisors and the physician, to therefore ensure resident safety. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the current status of residents, including the development and implementation of interventions to address aggressive behaviors. Findings include: Cross refer to F323. Based on record review, facility document review, facility Policy review, and staff interview, the facility failed to supervise one (1) resident (Resident #1) to ensure the safety of her roommate (Resident #2), toward whom Resident #1 had made verbal threats. The total survey sample was eleven (11) residents. Resident #1 had [DIAGNOSES REDACTED]. Nursing documentation indicated Resident #1 had no observed/reported behaviors from 10/01/2014 through 10/21/2014, and she was discontinued from Behavior Management. Resident #1 was then reported to make verbal threats against Resident #2 on 11/02/2014, including "If you don't get her, I am going to get her", and "I'm going to get that b---h". However, the facility developed and implemented no interventions for monitoring Resident #1 in response to this incident, did not place Resident #1 in the Behavior Management Program as the Program Policy specified, and did not notify Resident #1's physician of this change in behavior. On 11/11/2014, Resident #2 was found not breathing, with no pulse, and with an electric cord around her neck. Resident #1 stated to staff that she had "killed" Resident #2 and was arrested and charged with felony murder and aggravated assault. During an interview with the Administrator conducted on 11/21/2014 at 11:20 a.m., the Administrator was questioned about the facility's Quality Assurance (QA) Committee Process. During this interview, the Administrator was asked if the facility had identified a problem related to resident altercations or the Behavior Management Program prior to the 11/11/2014 incident involving Resident #1 and Resident #2. During this interview, the Administrator stated that prior to the 11/11/2014 altercation between Resident #1 and Resident #2, the facility had identified no problems or quality deficiencies related to resident-to-resident incidents or related to the facility's Behavior Management Program. During the 11/21/2014, 11:20 a.m. interview referenced above, the Administrator was also questioned about the QA Committee's review of the 11/02/2014 incident of Resident #1 voicing verbal threats toward Resident #2 and the 11/11/2014 incident involving Resident #2 being found not breathing and with no pulse, after which Resident #1 acknowledged to staff that she had "killed" Resident #2. In addition, during this interview, the Administrator was asked about the QA Committee's involvement in the development of the corrective action plan which was formulated and implemented by the facility (and subsequently submitted on 11/20/2014 as the CAJR) in response to the 11/02/2014 and 11/11/2014 altercations between Resident #1 and #2. The Administrator stated that a QA Sub-Committee (which, as documented in the CAJR, would have included the Administrator, DHS, Assistant DHS, MDS staff, Activities Director, Social Worker, Senior Care Partner, Maintenance Director, Financial Counselor, Medical Records personnel, Dietary Manager, Admissions Coordinator, Licensed Practical Nurse Supervisor, and Housekeeping Supervisor) had met to discuss the issues involved in the 11/02/2014 and 11/11/2014 incidents which resulted in immediate jeopardy. The Administrator stated that the QA Sub-Committee had also discussed the corrective action plan which was submitted by the facility as the CAJR related to the immediate jeopardy. The Administrator further stated, however, that the formal QA Committee had not yet met to review and discuss the identified quality deficiencies related to the 11/02/2014 and 11/11/2014 altercations involving Resident #1 and Resident #2. Rather, a date had been set for the QA Committee to meet the first week of December 2014 to begin that process. During the 11/21/2014, 11:20 a.m. interview with the Administrator referenced above, the Administrator was also asked whether, in the absence of any actual QA Committee meeting, all members of the QA Committee had reviewed and approved the CAJR, and if so, when this review had been completed. In an 11/21/2014, 12:11 P.M. follow-up interview with the Administrator, the Administrator again stated that the QA Committee had not met as a whole group as of that time, but that all QA Committee members had reviewed and approved the CAJR as of that morning of 11/21/2014. Additionally, although the Administrator indicated in the 11/21/2014, 12:11 p.m. interview referenced above that the QA Committee had, as of the morning of 11/21/2/14, reviewed and approved the CAJR formulated in response to the immediate jeopardy related to the 11/02/2014 and 11/11/2014 incidents, no evidence was presented to indicate that the QA Committee had been involved in the formulation of this CAJR. This was despite facility staff having developed and implemented, as documented in the CAJR, corrective actions which included: the 11/13/2014 behavioral screenings of all residents for inclusion in the Behavior Monitoring Program; the 11/13/2014 Care Plan review of all residents having physical/verbal behaviors in the past month to determine to need for revision; the 11/20/2014 initiation of a process involving a 10 percent minimum monthly audit by the Administrator of resident behavior screens, Behavior Management Documentation Forms, and Care Plans utilizing the Behavior Management Log Form; and the completion, by 11/20/2014, of in-service training of the majority of the facility's staff (as documented in the CAJR) regarding dealing with residents having behavior, the reporting of resident altercations, and physician notification of changes in condition and new resident behaviors. In addition, the facility presented no evidence to indicate that the QA Committee had evaluated and analyzed the facility's systems (which had been in effect prior to the 11/02/2014 and 11/11/2014 incidents referenced above) regarding resident monitoring/supervision of residents having behaviors to ensure resident safety, facility response to significant changes in resident behaviors, Behavior Monitoring Program referral, and facility staff response to resident-to-resident incidents. This was despite quality deficiencies having been identified regarding the 11/02/2014 incident when Resident #1 verbally threatened Resident #2, related to the facility's failure to: implement immediate interventions to ensure resident monitoring/supervision to protect resident safety; ensure the referral and inclusion of residents in a Behavior Monitoring Program, per facility policy; ensure physician consultation for resident changes in status, including behavior changes. This was also despite the incident of 11/11/2014, when Resident #2 was found with no respirations or pulse, after which Resident #1 was documented as admitting to "killing" Resident #2. Based on the above, on 11/02/2014, Resident #1 verbally threatened Resident #2 (a new behavior for Resident #1), but the facility failed to implement immediate interventions to ensure resident monitoring/supervision and resident safety; failed to consult with the physician regarding Resident #1's verbally threatening behavior toward Resident #2; and failed to refer Resident #1 to the Behavior Monitoring Program, per facility policy. Then, on 11/11/2014, Resident #2 was found with no respirations or pulse and with an electric cord around her neck, and Resident #1 stated to staff she had "killed" Resident #2. In response to Resident #2's 11/11/2014 death, the facility identified quality deficiencies and developed and implemented new procedures, reflected on a corrective action plan, which included: behavioral screenings of all residents for inclusion in the Behavior Monitoring Program; Care Plan review and revision; a monthly audit by the Administrator of resident behavior screens, Behavior Management Documentation Forms, and Care Plans; and staff training. However, even though these new procedures were developed and implemented, and even though the facility conducted staff in-service training, beginning on 11/14/2014, there was no evidence to indicate that the QA Committee had been involved in the formulation of this CAJR developed in response to the 11/11/2014 incident resulting in Resident #2's death. There was also no evidence of QA Committee evaluation and analysis of facility systems in effect prior to the 11/11/2014 incident related to resident monitoring/supervision, response to significant changes in behaviors, Behavior Monitoring Program referral, and response to resident-to-resident altercations. The facility presented a CAJR on 11/20/2014, and it was determined that the immediate jeopardy was removed on 11/21/2014, at which time the facility had implemented the following interventions: 1. On 11/11/2014, upon the discovery of the incident of that date, Resident #1 was immediately placed on one-to-one staff observation until she was later transferred out of the facility. 2. On 11/13/2014, the facility's Interdisciplinary Team (consisting of the Administrator, DON, ADON, Admissions Personnel, LPN Supervisor, and Social Services Director) completed Behavioral Symptom Screening Forms on every facility resident. This process of resident behavior screening had been initiated on 11/12/2014. All residents screened during this process and identified as having had physical or verbal behaviors in the previous month were placed on the Behavior Monitoring Program, to ensure the monitoring of these residents and to ensure that no further behavioral interventions were necessary. All residents will have a behavior screen done upon facility admission, quarterly, upon significant change in status, and with any new behavior. 3. On 11/13/2014, the facility's Interdisciplinary Team completed a review, initially begun on 11/12/2014, of the Care Plans of all residents having any physical or verbal behaviors in the previous month. These Care Plans were revised as needed, based on these reviews. Resident Care Plans will be reviewed quarterly, annually, with a significant change in condition, and with any new behavior. 4. On 11/14/2014, the facility's Medical Director reviewed Resident #1's medical record, making no recommendations. 5. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team would screen and review all new resident admissions. This screening process would apply to all new resident admissions, and no resident would be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool, which documents: the date; the resident's name; the History and Physical; PASRR Level II; Nurse' Notes/MR notation; any Consultation Information; and a signature of the reviewer. 6. On 11/20/2014, the facility implemented a new procedure by which the Administrator would conduct a monthly audit of a minimum of 10 percent of the Resident Behavioral Symptom Screening forms and resident Care Plans for residents in behavioral management, to ensure the accuracy and completion of these documents. The Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Documentation Form for residents in behavioral management, to ensure the accuracy and completion of this Form. This Form (a previously existing form) allows for the weekly documentation of residents in the Behavior Management Program, the tracking of the effectiveness of existing behavioral interventions, and the documentation of any newly developed interventions. In addition, the Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Log Forms (a previously existing form) for all residents in a Behavior Management Program, to ensure accuracy and completion of this Form. This Form serves to document any observed behaviors, including agitated or combative behaviors, per day and per shift. These monthly form audits referenced above will be documented by the Administrator dating and signing the review of each of the referenced forms. 7. On 11/20/2014, the facility implemented a procedure by which a designated CNA was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. This Behavior Monitoring Form allows for the documentation of resident behaviors, interventions, the reporting of the behavior(s) to the Charge Nurse and the identity of the staff member reporting the behavior, and a signature of the nurse of verification. If, during these continuous rounds conducted on the Memory Support Unit, behaviors were observed, this staff member was to intervene as necessary to de-escalate the behavior, and also to report the resident behavior to the Charge Nurse. This monitoring was actually initiated on 11/11/2014, when the staff member was immediately assigned to the Memory Support Unit to begin the continuous rounds. 8. On 11/20/2014, the facility's Interdisciplinary Team continued the process of reviewing resident Preadmission Screening and Resident Review (PASRR) Level II Assessments. This review revealed three (3) residents having PASRR Level II assessments with a recommendation for a psychiatric consultation. One (1) of these residents was seen by a psychiatrist on a regular basis. Appointments were made on 11/20/2014 for the remaining two (2) residents, identified with recommendations for a psychiatric consultation, to have a consultation with a psychiatrist. On 11/20/2014, the facility implemented a procedure by which the Administrator or Social Service Director will make a copy of each resident's PASRR, and initial and date that copy, which will then be kept in the resident's medical record. 9. On 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training related to a number of areas. In-service training was provided to staff to educate them in ways to prevent abuse, including behaviors what to report, and to whom to report observations of resident abuse. This included both physical and verbal resident behaviors. This in-service training also addressed how to identify abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. Staff were informed that any resident suspected of any alleged abuse would be protected from any further abuse by the removal of the alleged perpetrator from the facility, as deemed appropriate. Staff were advised of reporting any alleged abuse immediately to their supervisor, leading up to the Administrator, who would then report the allegation of abuse to the appropriate State and corporate agencies. In-service training was also provided regarding employment screening, via criminal background checks, reference checks, and licensure/certification verification. As of 11/20/2014, eighty-nine (89) of one-hundred-and-two (102) staff had received this in-service training. This number included thirty-three (33) of thirty-seven (37) CNA staff; thirteen (13) of fourteen (14) LPN staff; nine (9) of eleven (11) housekeepers; four (4) of five (5) laundry workers; seventeen (17) of twenty (20) dietary workers; seven (7) of eight (8) Registered Nurses; seven (7) of seven (7) department heads (not including the DON, ADON, LPN Supervisor, Senior Care Partner, and MDS Nurse) that did not include nurses, including the Activities Director, Social Worker, Maintenance Director, Financial Counselor, Medical Records, Admissions Coordinator, and Housekeeping Supervisor. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. Additionally, going forward, all employees will receive training upon hire during the orientation process, and quarterly, related to resident abuse, resident neglect, and the procedures by which to deal with residents having verbal or physical behaviors. 10. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training, originally initiated on 11/14/2014, specifically intended for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 11. On 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors. As of 11/20/2014, eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses had received this training. The remaining three (3) LPN staff and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 12. On 11/20/2014, the facility implemented a new procedure by which the results of Administrator and/or Social Service Director audits of the Admission Audit Tool, Behavior Monitoring Form, Behavior Management Documentation Form, Behavior Symptom Screening Form, Management Log Form, and Care Plan and PASRR Assessment reviews would be presented to the QA Sub-Committee each week for four (4) weeks, then monthly by the Administrator or Director of Health Services. This process will allow the QA Sub-Committee to monitor staff compliance with the facility's policies and procedures regarding residents having verbal and/or physically aggressive behaviors which could have the potential to lead to resident abuse. Audit results will also be presented to the facility's QA Committee quarterly for the Committee's review and oversight of facility staff conformance with facility policies and procedures related to the management of resident behaviors, the screening of resident behaviors, physician notification, and resident monitoring. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 11/21/2014, a review of facility investigative documents, including the facility IS, confirmed that Resident #1 was immediately placed on one-to-one observation on 11/11/2014 immediately after the incident involving Resident #1 and Resident #2, as indicated in Step #1 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records completed on that date, but which had been ongoing throughout the abbreviated survey, revealed that the Interdisciplinary Team had conducted behavioral screenings on residents for the purpose of ensuring appropriate resident placement in the Behavioral Monitoring Program, as indicated in Step #2 of the CAJR referenced above. - On 11/21/2014, a sampled review of multiple resident records, but which had been ongoing throughout the abbreviated survey, was completed and verified that resident Care Plans had been reviewed and updated by the Interdisciplinary Team, as related to physically/verbally aggressive behaviors. This was in accordance with Step #3 of the CAJR referenced above. - On 11/21/2014, review of facility investigative documents confirmed that the Medical Director had reviewed Resident #1's medical record and submitted a written summary of this information to the facility on [DATE]. This was in accordance with Step #4 of the CAJR referenced above. (Of note, on 11/20/2014 at 11:12 a.m., a telephone call had been placed to Resident #1's physician, but the physician declined interview.) - On 11/21/2014, interview with the Administrator at 11:20 a.m. confirmed that the Interdisciplinary Team will screen and review all new resident admissions, with no resident being admitted until a review of the resident's medical condition and potential for aggressive behaviors can be assessed. This review will be documented using the Admission Audit Tool. This Team will include the Administrator, DON, ADON, Admissions Personnel, an LPN Supervisor, and the Social Services Director. This was in accordance with Step #5 of the CAJR referenced above. - On 11/21/2014, facility document review and interview with the Administrator confirmed that the Administrator will be conducting monthly audits of the Resident Behavioral Symptom Screening forms, the Behavior Management Documentation Forms, the Behavior Management Log Forms, and resident Care Plans for resident requiring behavioral management services. This was in accordance with Step #6 of the CAJR referenced above. - On 11/21/2014, a 9:55 a.m. observation on the Secured Unit confirmed the presence of an assigned staff member to conduct ongoing and continuous rounds for the purpose of observing for any resident aggressive behaviors. These rounds were documented on the Behavior Monitoring Form. In addition, it was confirmed by interview with the Administrator that this process of ongoing, continuous rounds will be a permanent intervention. This was in accordance with Step #7 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records, which had been ongoing throughout the abbreviated survey, was completed and verified that the Interdisciplinary Team had reviewed all resident PASRR Level II Assessments, with the appropriate follow-up for residents needing additional psychiatric services. This action was also confirmed during an 11/21/2014, 10:45 interview with a Corporate Nursing Consultant. This was in accordance with Step #8 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted staff in-service training for staff, including (but not limited to) licensed nursing staff, CNA staff, Social Services staff, MDS staff, Medical Records staff, the Maintenance Director, and the Admissions Coordinator, regarding resident abuse and the Behavior Management Policy. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #9 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff and CNA staff, regarding resident behavior management policies and the documentation of resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #10 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff, regarding the notification of the physician for changes in condition and new resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #11 of the CAJR referenced above. - On 11/21/2014, an 11:20 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing management level oversight of the assessment, planning of care, and provision of care to residents having behavioral problems, will be reviewed by the QA Committee to provide ongoing QA Committee oversight of this care. This was in accordance with Step #12 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice had been removed on 11/21/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team will screen and review all new resident admissions, and no resident will be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool. This was, however, a new procedure, having been implemented on 11/19/2014, only two (2) days prior to the 11/21/2014 exit date of this abbreviated survey; therefore, the Interdisciplinary Team's ongoing compliance with this newly-implemented procedure could not be fully evaluated at the time of survey exit, and will need further review on a future date. On 11/20/2014, the facility implemented a new procedure by which designated staff was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. The use of this Behavior Monitoring Form was, however, only implemented as of 11/20/2014, one (1) day prior to the 11/21/2014 date of survey exit, thereby preventing the evaluation of facility staffs' ongoing compliance with the use of this Form and concomitant monitoring of aggressive resident behaviors. Such compliance will require further review on a future date. In addition, on 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training which included abuse prevention and reporting, and the identification of abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. As of 11/20/2014, thirty-three (33) of thirty-seven (37) CNA staff, thirteen (13) of fourteen (14) LPN staff, nine (9) of eleven (11) housekeepers, four (4) of five (5) laundry workers, seventeen (17) of twenty (20) dietary workers, and seven (7) of eight (8) Registered Nurses had received this in-service training. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff will need to receive this in-service training upon their return to work. Also, on 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors for eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses, but the remaining three (3) LPN staff and one (1) Registered Nurse will receive this in-service training upon their return to work. Therefore, due to multiple licensed and certified staff members yet remaining to receive in-service training at the time of survey exit, their completion of this required training could not be assessed at the time of survey exit, and wil

Based on clinical record review, facility document review, and staff interview, facility administration failed to ensure intervention and supervision in response to verbal threats and aggression exhibited by one (1) resident (Resident #1) toward another resident (Resident #2), on the total survey sample of eleven (11) residents. Resident #1, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was then discontinued from the Behavior Management Program on 10/21/2014, and the physician documented in a 10/28/2014 Physician's Progress Notes entry that the resident's mood, [MEDICAL CONDITION] Disorder, and [MEDICAL CONDITION] were stable. However, the facility failed to notify Resident #1's physician of the resident's ongoing refusal of drug therapy during October of 2014, and failed to notify the physician of an incident of 11/02/2014 when Resident #1 experienced a change in behavior and was reported to have made multiple verbal threats against Resident #2. The facility failed to put measures into place to ensure close monitoring of Resident #1 and failed to place Resident #1 in the Behavior Management Program, as specified by facility Policy, after this 11/02/2014 incident. The facility also failed to evaluate Resident #1 regarding the need for a psychiatric consultation. On 11/11/2014, Resident #2 was discovered not breathing, having no pulse, and having an electric cord around her neck. Resident #1 stated to facility staff that she had "killed" Resident #2, and Resident #1 was later arrested and charged with felony murder and aggravated assault. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Corporate Consultant were informed of the immediate jeopardy on November 19, 2014 at 3:36 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on November 11, 2014, the date Resident #1 was documented as stating she "killed" her roommate, Resident #2, after Resident #2 was found to have no respirations, no pulse, and with an electric cord around her neck, and nine (9) days after November 2, 2014, when the facility failed to enact interventions in response to Resident #1's verbal threats against Resident #2. The immediate jeopardy continued through November 20, 2014, and was removed on November 21, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on November 20, 2014. During an interview conducted on 11/19/2014 at 12:20 p.m., the Administrator acknowledged the 11/02/2014 incident involving Resident #1's verbal threat toward Resident #2, and stated that Resident #1's verbally threatening behavior was discussed in the facility's morning meeting on 11/03/2014. However, during a later 11/19/2014, 2:30 p.m. interview, the Administrator acknowledged that no new interventions were developed and implemented in response to Resident #1's verbal threats against Resident #2 on 11/02/2014. An allegation of jeopardy removal was received on November 20, 2014. Based on the corrective plans which had been developed and implemented by the facility via a credible allegation of jeopardy removal on November 20, 2014, the immediacy of the deficient practice was determined to have been removed on November 21, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of staffs' monitoring of resident behaviors, resident screening and placement in the Behavior Management Program as indicated, resident Care Plan updating and implementation regarding resident behaviors, and physician notification of resident behavioral changes, in accordance with facility policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility policies and procedures governing resident monitoring and the reporting of resident behavioral changes to supervisors and the physician, to therefore ensure resident safety. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the current status of residents, including the development and implementation of interventions to address aggressive behaviors. Findings include: Cross refer to F323. Based on clinical record review, facility document review, facility Policy review, and staff interview, the facility failed to provide supervision in response to the verbal threats/aggression of one (1) resident (Resident #1), who made verbal threats toward Resident #2, to ensure the safety of Resident #2, from a total survey sample of eleven (11) residents. Resident #1, who had [DIAGNOSES REDACTED]. Evidence indicated that Resident #1 had no observed/reported behaviors from 10/01/2014 through 10/21/2014, and was discontinued from Behavior Management. On 11/02/2014, Resident #1 was reported to make verbal threats against Resident #2 (Resident #1's roommate), including "If you don't get her, I am going to get her", and "I'm going to get that b---h"; however, the facility failed to develop and implement interventions for monitoring of Resident #1 related to her verbally threatening behavior, failed to place Resident #1 in the Behavior Management Program per Policy, and failed to notify Resident #1's physician regarding this change in behavior for Resident #1. On 11/11/2014, facility staff discovered Resident #2 not breathing, having no pulse, and with an electric cord around her neck. Resident #1 stated to facility staff that she had "killed" Resident #2, and Resident #1 was arrested and charged with felony murder and aggravated assault. During an interview with the Administrator conducted on 11/19/2014 at 12:20 p.m., the 11/02/2014 incident during which Resident #1 made verbal threats against Resident #2 was discussed. Additionally, the Administrator was asked about the 11/11/2014 altercation between Resident #1 and Resident #2, after which Resident #2 was discovered having no respiration and no pulse, and after which Resident #1 stated to facility staff that she had "killed" Resident #2. In relation to the 11/02/2014 incident involving Resident #1's verbal threat toward Resident #2, the Administrator acknowledged awareness the incident, stating that this incident had been discussed in the morning staff meeting of 11/03/2014, which she had attended. During a subsequent interview with the Administrator conducted on 11/19/2014 at 2:30 p.m., the Administrator was again questioned about the 11/02/2014 incident when Resident #1 expressed verbal threats toward Resident #2, and was asked about what specific action or actions were taken after the 11/02/2014 incident to address Resident #1's verbal threats against Resident #2. The Administrator stated that after Resident #1 verbally threatened Resident #2 on 11/02/2014, facility staff staff administered intramuscular [MEDICATION NAME] to Resident #1, and also redirected the residents. However, the Administrator acknowledged that the administration of the antianxiety medication [MEDICATION NAME] to Resident #1 and the redirection of the residents were interventions which had been in place prior to the 11/02/2014 incident. The Administrator further acknowledged that no new interventions had been developed, or actions taken, after Resident #1 verbally threatened Resident #2 on 11/02/2014. The Administrator could provide no evidence of any new interventions that she had put into place, or actions she had taken, in response to Resident #1's 11/02/2014 threatening behavior toward Resident #2, even though she had been made aware of the incident during the morning staff meeting of 11/03/2014. Subsequent to the 11/02/2014 incident of Resident #1 verbally threatening Resident #2, and to the 11/03/2014 morning staff meeting during which this incident was discussed, Resident #2 was found not breathing, having no pulse, and with an electric cord around her neck on 11/11/2014. Resident #1 later acknowledged to facility staff she had "killed" Resident #2, and was arrested and charged with felony murder and aggravated assault. The facility presented a credible allegation of jeopardy removal (CAJR) on 11/20/2014, and it was determined that the immediate jeopardy was removed on 11/21/2014, at which time the facility had implemented the following interventions: 1. On 11/11/2014, upon the discovery of the incident of that date, Resident #1 was immediately placed on one-to-one staff observation until she was later transferred out of the facility. 2. On 11/13/2014, the facility's Interdisciplinary Team (consisting of the Administrator, DON, ADON, Admissions Personnel, LPN Supervisor, and Social Services Director) completed Behavioral Symptom Screening Forms on every facility resident. This process of resident behavior screening had been initiated on 11/12/2014. All residents screened during this process and identified as having had physical or verbal behaviors in the previous month were placed on the Behavior Monitoring Program, to ensure the monitoring of these residents and to ensure that no further behavioral interventions were necessary. All residents will have a behavior screen done upon facility admission, quarterly, upon significant change in status, and with any new behavior. 3. On 11/13/2014, the facility's Interdisciplinary Team completed a review, initially begun on 11/12/2014, of the Care Plans of all residents having any physical or verbal behaviors in the previous month. These Care Plans were revised as needed, based on these reviews. Resident Care Plans will be reviewed quarterly, annually, with a significant change in condition, and with any new behavior. 4. On 11/14/2014, the facility's Medical Director reviewed Resident #1's medical record, making no recommendations. 5. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team would screen and review all new resident admissions. This screening process would apply to all new resident admissions, and no resident would be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool, which documents: the date; the resident's name; the History and Physical; PASRR Level II; Nurse' Notes/MR notation; any Consultation Information; and a signature of the reviewer. 6. On 11/20/2014, the facility implemented a new procedure by which the Administrator would conduct a monthly audit of a minimum of 10 percent of the Resident Behavioral Symptom Screening forms and resident Care Plans for residents in behavioral management, to ensure the accuracy and completion of these documents. The Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Documentation Form for residents in behavioral management, to ensure the accuracy and completion of this Form. This Form (a previously existing form) allows for the weekly documentation of residents in the Behavior Management Program, the tracking of the effectiveness of existing behavioral interventions, and the documentation of any newly developed interventions. In addition, the Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Log Forms (a previously existing form) for all residents in a Behavior Management Program, to ensure accuracy and completion of this Form. This Form serves to document any observed behaviors, including agitated or combative behaviors, per day and per shift. These monthly form audits referenced above will be documented by the Administrator dating and signing the review of each of the referenced forms. 7. On 11/20/2014, the facility implemented a procedure by which a designated CNA was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. This Behavior Monitoring Form allows for the documentation of resident behaviors, interventions, the reporting of the behavior(s) to the Charge Nurse and the identity of the staff member reporting the behavior, and a signature of the nurse of verification. If, during these continuous rounds conducted on the Memory Support Unit, behaviors were observed, this staff member was to intervene as necessary to de-escalate the behavior, and also to report the resident behavior to the Charge Nurse. This monitoring was actually initiated on 11/11/2014, when the staff member was immediately assigned to the Memory Support Unit to begin the continuous rounds. 8. On 11/20/2014, the facility's Interdisciplinary Team continued the process of reviewing resident Preadmission Screening and Resident Review (PASRR) Level II Assessments. This review revealed three (3) residents having PASRR Level II assessments with a recommendation for a psychiatric consultation. One (1) of these residents was seen by a psychiatrist on a regular basis. Appointments were made on 11/20/2014 for the remaining two (2) residents, identified with recommendations for a psychiatric consultation, to have a consultation with a psychiatrist. On 11/20/2014, the facility implemented a procedure by which the Administrator or Social Service Director will make a copy of each resident's PASRR, and initial and date that copy, which will then be kept in the resident's medical record. 9. On 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training related to a number of areas. In-service training was provided to staff to educate them in ways to prevent abuse, including behaviors what to report, and to whom to report observations of resident abuse. This included both physical and verbal resident behaviors. This in-service training also addressed how to identify abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. Staff were informed that any resident suspected of any alleged abuse would be protected from any further abuse by the removal of the alleged perpetrator from the facility, as deemed appropriate. Staff were advised of reporting any alleged abuse immediately to their supervisor, leading up to the Administrator, who would then report the allegation of abuse to the appropriate State and corporate agencies. In-service training was also provided regarding employment screening, via criminal background checks, reference checks, and licensure/certification verification. As of 11/20/2014, eighty-nine (89) of one-hundred-and-two (102) staff had received this in-service training. This number included thirty-three (33) of thirty-seven (37) CNA staff; thirteen (13) of fourteen (14) LPN staff; nine (9) of eleven (11) housekeepers; four (4) of five (5) laundry workers; seventeen (17) of twenty (20) dietary workers; seven (7) of eight (8) Registered Nurses; seven (7) of seven (7) department heads (not including the DON, ADON, LPN Supervisor, Senior Care Partner, and MDS Nurse) that did not include nurses, including the Activities Director, Social Worker, Maintenance Director, Financial Counselor, Medical Records, Admissions Coordinator, and Housekeeping Supervisor. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. Additionally, going forward, all employees will receive training upon hire during the orientation process, and quarterly, related to resident abuse, resident neglect, and the procedures by which to deal with residents having verbal or physical behaviors. 10. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training, originally initiated on 11/14/2014, specifically intended for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 11. On 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors. As of 11/20/2014, eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses had received this training. The remaining three (3) LPN staff and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 12. On 11/20/2014, the facility implemented a new procedure by which the results of Administrator and/or Social Service Director audits of the Admission Audit Tool, Behavior Monitoring Form, Behavior Management Documentation Form, Behavior Symptom Screening Form, Management Log Form, and Care Plan and PASRR Assessment reviews would be presented to the QA Sub-Committee each week for four (4) weeks, then monthly by the Administrator or Director of Health Services. This process will allow the QA Sub-Committee to monitor staff compliance with the facility's policies and procedures regarding residents having verbal and/or physically aggressive behaviors which could have the potential to lead to resident abuse. Audit results will also be presented to the facility's QA Committee quarterly for the Committee's review and oversight of facility staff conformance with facility policies and procedures related to the management of resident behaviors, the screening of resident behaviors, physician notification, and resident monitoring. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 11/21/2014, a review of facility investigative documents, including the facility IS, confirmed that Resident #1 was immediately placed on one-to-one observation on 11/11/2014 immediately after the incident involving Resident #1 and Resident #2, as indicated in Step #1 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records completed on that date, but which had been ongoing throughout the abbreviated survey, revealed that the Interdisciplinary Team had conducted behavioral screenings on residents for the purpose of ensuring appropriate resident placement in the Behavioral Monitoring Program, as indicated in Step #2 of the CAJR referenced above. - On 11/21/2014, a sampled review of multiple resident records, but which had been ongoing throughout the abbreviated survey, was completed and verified that resident Care Plans had been reviewed and updated by the Interdisciplinary Team, as related to physically/verbally aggressive behaviors. This was in accordance with Step #3 of the CAJR referenced above. - On 11/21/2014, review of facility investigative documents confirmed that the Medical Director had reviewed Resident #1's medical record and submitted a written summary of this information to the facility on [DATE]. This was in accordance with Step #4 of the CAJR referenced above. (Of note, on 11/20/2014 at 11:12 a.m., a telephone call had been placed to Resident #1's physician, but the physician declined interview.) - On 11/21/2014, interview with the Administrator at 11:20 a.m. confirmed that the Interdisciplinary Team will screen and review all new resident admissions, with no resident being admitted until a review of the resident's medical condition and potential for aggressive behaviors can be assessed. This review will be documented using the Admission Audit Tool. This Team will include the Administrator, DON, ADON, Admissions Personnel, an LPN Supervisor, and the Social Services Director. This was in accordance with Step #5 of the CAJR referenced above. - On 11/21/2014, facility document review and interview with the Administrator confirmed that the Administrator will be conducting monthly audits of the Resident Behavioral Symptom Screening forms, the Behavior Management Documentation Forms, the Behavior Management Log Forms, and resident Care Plans for resident requiring behavioral management services. This was in accordance with Step #6 of the CAJR referenced above. - On 11/21/2014, a 9:55 a.m. observation on the Secured Unit confirmed the presence of an assigned staff member to conduct ongoing and continuous rounds for the purpose of observing for any resident aggressive behaviors. These rounds were documented on the Behavior Monitoring Form. In addition, it was confirmed by interview with the Administrator that this process of ongoing, continuous rounds will be a permanent intervention. This was in accordance with Step #7 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records, which had been ongoing throughout the abbreviated survey, was completed and verified that the Interdisciplinary Team had reviewed all resident PASRR Level II Assessments, with the appropriate follow-up for residents needing additional psychiatric services. This action was also confirmed during an 11/21/2014, 10:45 interview with a Corporate Nursing Consultant. This was in accordance with Step #8 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted staff in-service training for staff, including (but not limited to) licensed nursing staff, CNA staff, Social Services staff, MDS staff, Medical Records staff, the Maintenance Director, and the Admissions Coordinator, regarding resident abuse and the Behavior Management Policy. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #9 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff and CNA staff, regarding resident behavior management policies and the documentation of resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #10 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff, regarding the notification of the physician for changes in condition and new resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #11 of the CAJR referenced above. - On 11/21/2014, an 11:20 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing management level oversight of the assessment, planning of care, and provision of care to residents having behavioral problems, will be reviewed by the QA Committee to provide ongoing QA Committee oversight of this care. This was in accordance with Step #12 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice had been removed on 11/21/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team will screen and review all new resident admissions, and no resident will be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool. This was, however, a new procedure, having been implemented on 11/19/2014, only two (2) days prior to the 11/21/2014 exit date of this abbreviated survey; therefore, the Interdisciplinary Team's ongoing compliance with this newly-implemented procedure could not be fully evaluated at the time of survey exit, and will need further review on a future date. On 11/20/2014, the facility implemented a new procedure by which designated staff was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. The use of this Behavior Monitoring Form was, however, only implemented as of 11/20/2014, one (1) day prior to the 11/21/2014 date of survey exit, thereby preventing the evaluation of facility staffs' ongoing compliance with the use of this Form and concomitant monitoring of aggressive resident behaviors. Such compliance will require further review on a future date. In addition, on 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training which included abuse prevention and reporting, and the identification of abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. As of 11/20/2014, thirty-three (33) of thirty-seven (37) CNA staff, thirteen (13) of fourteen (14) LPN staff, nine (9) of eleven (11) housekeepers, four (4) of five (5) laundry workers, seventeen (17) of twenty (20) dietary workers, and seven (7) of eight (8) Registered Nurses had received this in-service training. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff will need to receive this in-service training upon their return to work. Also, on 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors for eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses, but the remaining three (3) LPN staff and one (1) Registered Nurse will receive this in-service training upon their return to work. Therefore, due to multiple licensed and certified staff members yet remaining to receive in-service training at the time of survey exit, their completion of this required training could not be assessed at the time of survey exit, and will need to be evaluated at a future time. Therefore, due to the need for future evaluation and assessment of the facility's ongoing compliance with newly-implemented procedures regarding the assessment, supervision, and monitoring of residents having aggressive behaviors, to include pending staff in-service training regarding these issues, the noncompliance continues, with the scope and severity of the deficiency reduced to the "D" level.

Based on clinical record review, facility investigation summary review, Behavior Management Documentation Form review, Preadmission Screening and Resident Review (PASRR) Level I Application - Resident Identification Screening Instrument Form review, PASRR Review Outcome Notification form review, PASRR Psychiatric and MR/RC Evaluation and Medical History form review, and staff interview, the facility failed to provide specialized services, related to a psychiatric consultation/evaluation, for one (1) resident (Resident #1) as recommended by the PASRR Assessment, even though Resident #1 had a history of [REDACTED].#2). The total survey sample was eleven (11) residents. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1's PASRR Psychiatric and MR/RC Evaluation and Medical History form recommended a psychiatric consultation/evaluation by a psychiatrist. After facility admission, Resident #1 exhibited aggressive behaviors toward staff, including hitting staff and pulling staffs' hair. There was no evidence, however, to indicate that the facility provided Resident #1 with a psychiatric consultation/evaluation, or assessed the resident for the need for this psychiatric consultation/evaluation, even after Resident #1 was reported by facility staff to make verbal threats on 11/02/2014 against Resident #2. Resident #1's verbal threats toward Resident #2 were reported to include "If you don't get her, I am going to get her", and "I'm going to get that b---h." Then, on 11/11/2014, Resident #2 was discovered on the floor and was not breathing, had no pulse, and had an electric bed cord around her neck. Resident #1 was documented as stating to facility staff that she had "killed" Resident #2, and Resident #1 was later arrested and charged with felony murder and aggravated assault. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Corporate Consultant were informed of the immediate jeopardy on November 19, 2014 at 3:36 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on November 11, 2014, the date Resident #1 was documented as stating she "killed" her roommate, Resident #2, after Resident #2 was found to have no respirations, no pulse, and with an electric cord around her neck, and nine (9) days after November 2, 2014, when the facility failed to enact interventions in response to Resident #1's verbal threats against Resident #2. The immediate jeopardy continued through November 20, 2014, and was removed on November 21, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on November 20, 2014. During interviews with the Administrator conducted on 11/19/2014 at 2:05 p.m. and the Director of Nursing (DON) on 11/19/2014, at 2:45 p.m., these facility staff provided no information to indicate that Resident #1 had received a psychiatric consultation/evaluation, as per the PASRR recommendation. An allegation of jeopardy removal was received on November 20, 2014. Based on the corrective plans which had been developed and implemented by the facility via a credible allegation of jeopardy removal on November 20, 2014, the immediacy of the deficient practice was determined to have been removed on November 21, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of staffs' monitoring of resident behaviors, resident screening and placement in the Behavior Management Program as indicated, resident Care Plan updating and implementation regarding resident behaviors, and physician notification of resident behavioral changes, in accordance with facility policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility policies and procedures governing resident monitoring and the reporting of resident behavioral changes to supervisors and the physician, to therefore ensure resident safety. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the current status of residents, including the development and implementation of interventions to address aggressive behaviors. Findings include: Resident #1's Admission Minimum Data Set of 09/10/2014 documented an admission date of [DATE], and Section I - Active [DIAGNOSES REDACTED]. Section E-Behavior documented Resident #1 had physical behavioral symptoms toward others 1 to 3 days during the look-back period. A 09/03/2014, 4:10 p.m. Daily Skilled Nurses Notes (DSNN) entry documented Resident #1's facility admission from an Intensive Treatment center, and documented additional [DIAGNOSES REDACTED]. Admission physician's orders [REDACTED].#1 receive the antipsychotic [MEDICATION NAME] two (2) milligrams (mgs) by mouth at bedtime and the antianxiety drug [MEDICATION NAME] ([MEDICATION NAME]) one (1) mg, either by mouth or intramuscularly (IM), every six (6) hours as needed for agitation. Further record review for Resident #1 revealed a Preadmission Screening and Resident Review (PASRR) Level I Application, Resident Identification Screening Instrument Form which was signed by a physician and dated 09/03/2014, the date of Resident #1's nursing facility admission. This PASRR Level I Application documented, in Section 2, that Resident #1 had the mental illness of [MEDICAL CONDITION] - Residual Type as a primary (Axis 1) diagnosis, and Section 3 of this Level I Application documented that the resident did not have an Axis II [DIAGNOSES REDACTED]. A related PASRR Review Outcome Notification form dated 09/18/2012 documented that Resident #1's Level II PASRR review found Resident #1 to meet a nursing facility level of care and to be eligible to receive additional specialized services according to a plan of care to treat the resident's serious mental illness. This PASRR Review Outcome Notification form further indicated that a copy of the PASRR Medical Assessment form, which included treatment recommendations, was enclosed. Review of this attached PASRR Psychiatric and MR/RC Evaluation and Medical History form for Resident #1 revealed Section X(1.1) documented approval of nursing facility services due to a serious mental illness and specialized services. Section XI, Service Planning Recommendations of this form for Resident #1 documented a recommendation for a psychiatric consultation/evaluation by a psychiatrist for reasons including, but not limited to, management of [MEDICAL CONDITION] medications and an extensive history of "cheeking" medications. A facsimile date of 09/03/2014 was stamped at the top of the PASRR Review Outcome Notification and Psychiatric and MR/RC Evaluation and Medical History forms, thus documenting the facility's receipt of these documents on Resident #1's 09/03/2014 date of facility admission. However, further review of Resident #1's medical record revealed that, even though Resident #1's PASRR Review Outcome Notification and Psychiatric and MR/RC Evaluation and Medical History forms referenced above had recommend that Resident #1 receive a psychiatric consultation/evaluation by a psychiatrist, there was no evidence to indicate that Resident #1 had been evaluated by a psychiatrist, or assessed for the need to be examined by a psychiatrist, upon or after her 09/03/2014 facility admission. During an interview with the Director of Nursing (DON) conducted on 11/19/2014 at 2:45 p.m., the DON was asked about the process by which resident PASRR recommendations were addressed upon a resident's admission to the facility. The DON stated she would inquire as to this process and would provide additional information. During a subsequent interview with the DON conducted on 11/19/2014 at 3:00 p.m., the DON stated that when residents were admitted to the facility, the admission packet documents were sent by facility Admission Department personnel to the physician for his review. The DON further stated that the admission packet documents would include PASRR Level II documents, which the physician would review and give orders for treatment. However, even though the DON indicated in the 11/19/2014, 3:00 p.m. interview referenced above that Resident #1's admission documents (including the PASRR Level II forms recommending a psychiatric consultation/evaluation) should have been provided to the attending physician upon the resident's 09/30/2014 facility admission, record review revealed no evidence, nor did the facility provide evidence, to indicate the PASRR documents, including the recommendation for a psychiatric consultation/evaluation, were reviewed by the physician when Resident #1 was admitted . A Behavior Management Documentation Form for Resident #1 indicated that on 09/09/2014, approximately one (1) week after facility admission, Resident #1 was placed in a Behavioral Management Program. A related Behavioral Symptom Screening Form of 09/10/2014 documented Resident 1's [MEDICAL CONDITION], Dementia with Behavioral Disturbances, and [MEDICAL CONDITION], and documented a history of physical aggression towards staff, refusing medications, and pocketing ("cheeking") medications. A 09/18/2014, 7:00 a.m. DSNN entry documented Resident #1's physician had bee notified of continued escalating behaviors, and the physician ordered the addition of [MEDICATION NAME] one (1) mg each morning. A 09/20/2014, 7:14 a.m. DSNN then documented Resident #1 had hit a certified nursing assistant (CNA), and a 09/28/2014, 1:40 p.m. DSNN documented that Resident #1 received a dose of IM [MEDICATION NAME] for increased agitation after slapping staff and pulling staffs' hair out. Review of Resident #1's Care Plan, dated as originating on 09/18/2014, revealed the Care Plan documented [DIAGNOSES REDACTED]. However, further record review for Resident #1 revealed no evidence of, or assessment for the need for, a psychiatric consultation/evaluation, as recommended on Resident #1's PASRR Psychiatric and MR/RC Evaluation and Medical History form referenced above, upon the resident's 09/09/2014 inclusion in a Behavior Management Program, or after the resident's placement in the Behavior Management Program. This was despite the fact that, as documented in the 09/20/2014, 7:14 a.m. and 09/28/2014, 1:40 p.m. DSNN entries referenced above, Resident #1 continued to show agitated behaviors of slapping staff and pulling staffs' hair. This was also despite the fact that Resident #1's Care Plan, as referenced above, specified that Resident #1 would receive a psychiatric consultation as needed, and despite Resident #1's PASRR Review Outcome Notification form indicating Resident #1 to be eligible to receive specialized services (psychiatric consultation/evaluation) according to the plan of care (Care Plan) to treat serious mental illness. Then, further record review for Resident #1 revealed an 11/02/2014, 11:00 a.m. Nurse's Notes (NN) entry which documented Resident #1 to have made verbal threats against another resident (Resident #2, who was the roommate of Resident #1), and that Resident #1 had received an IM dose of [MEDICATION NAME]. A subsequent NN entry for Resident #1 dated 11/11/2014 at 7:00 a.m. (nine days after Resident #1's documented verbal threats against Resident #2, per the 11/02/2014, 11:00 a.m. NN above) documented nursing staff had found Resident #2 not breathing and having no pulse, and with an electric cord around her neck. In an investigation summary (IS) completed by the facility as part of an investigation of the 11/11/2014 incident involving Resident #2 described in the 11/11/2014, 7:00 a.m. NN referenced above, the facility also documented the earlier, 11/02/2014 altercation which involved Resident #2 and her roommate, Resident #1. This IS documented that on 11/02/2014, staff observed Resident #1 carrying a family picture which she put in the face of Resident #2. As staff redirected Resident #1 and Resident #2, this facility IS documented that Resident #1 stated to staff "I am going to get you", and then told staff, "If you don't get her, I am going to get her." This IS documented that later, Resident #1 stated to the CNA "I'm going to get that b---h", referring to Resident #2. During an interview with License Practical Nurse (LPN) "DD" conducted on 11/18/2014 at 12:45 p.m., LPN "DD" acknowledged that on 11/02/2014, Resident #1 had threatened Resident #2 and held a picture in Resident #2's face. LPN "DD" also stated that Resident #1's behavior of threatening another resident on 11/02/2014 was new behavior. However, further record review for Resident #1 revealed no evidence to indicate that, even after Resident #1 exhibited aggressive behavior by verbally threatening Resident #2, as documented in Resident #1's 11/02/2014, 11:00 a.m. NN entry referenced above, and even though this was a new form of aggressive behavior for Resident #1, as indicated in LPN "DD"'s 11/18/2014, 12:45 p.m. interview referenced above, there was no evidence to indicate that Resident #1 received, or was assessed for the need for, a psychiatric consultation/evaluation, as recommended by the PASRR Review Outcome Notification/Psychiatric and MR/RC Evaluation and Medical History forms referenced above. During an interview with the Administrator conducted on 11/19/2014 at 2:05 p.m., the Administrator was questioned regarding the process by which PASRR recommendations, such as Resident #1's PASRR recommendation for a psychiatric consultation/evaluation, would be obtained. During this interview, the Administrator provided no information to indicate that Resident #1's psychiatric consultation/evaluation had been obtained, per the PASRR recommendation. During a subsequent interview with the Director of Nursing (DON) conducted on 11/19/2014 at 2:45 p.m., when asked about a psychiatric consultation/recommendation for Resident #1 as recommended on the resident's PASRR Assessment, the DON provided no evidence of Resident #1 having received a psychiatric consultation/evaluation. Further review of the facility's IS referenced above related Resident #2's 11/11/2014 death revealed the IS to document that, based on verbal reports from sources "close to" the police department, Resident #2's autopsy report concluded Resident #2's trachea was crushed, with a determination that Resident #1 used her hands. This facility IS documented that Resident #1 told a nurse consultant that she "killed" Resident #2, and further documented that Resident #1 had been arrested on 11/13/2014 and charged with felony murder and aggravated assault. Based on the above, Resident #1's [DIAGNOSES REDACTED]. Resident #1 received [MEDICAL CONDITION] medications and was admitted to the facility on [DATE] having a PASRR recommendation for a psychiatric evaluation/consultation. However, despite Resident #1 continuing to exhibit aggressive behaviors, to include hitting staff and verbally threatening Resident #2, the facility failed to provide a psychiatric consultation/evaluation for Resident #1. Then, on 11/11/2014, Resident #2 was found on the floor in her room with an electric cord around her neck, not breathing and having no pulse. Resident #1 later stated to facility staff that she had "killed" Resident #2, was arrested, and was charged with felony murder and aggravated assault. Cross refer to F323 for more information regarding Resident #1. The facility presented a credible allegation of jeopardy removal (CAJR) on 11/20/2014, and it was determined that the immediate jeopardy was removed on 11/21/2014, at which time the facility had implemented the following interventions: 1. On 11/11/2014, upon the discovery of the incident of that date, Resident #1 was immediately placed on one-to-one staff observation until she was later transferred out of the facility. 2. On 11/13/2014, the facility's Interdisciplinary Team (consisting of the Administrator, DON, ADON, Admissions Personnel, LPN Supervisor, and Social Services Director) completed Behavioral Symptom Screening Forms on every facility resident. This process of resident behavior screening had been initiated on 11/12/2014. All residents screened during this process and identified as having had physical or verbal behaviors in the previous month were placed on the Behavior Monitoring Program, to ensure the monitoring of these residents and to ensure that no further behavioral interventions were necessary. All residents will have a behavior screen done upon facility admission, quarterly, upon significant change in status, and with any new behavior. 3. On 11/13/2014, the facility's Interdisciplinary Team completed a review, initially begun on 11/12/2014, of the Care Plans of all residents having any physical or verbal behaviors in the previous month. These Care Plans were revised as needed, based on these reviews. Resident Care Plans will be reviewed quarterly, annually, with a significant change in condition, and with any new behavior. 4. On 11/14/2014, the facility's Medical Director reviewed Resident #1's medical record, making no recommendations. 5. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team would screen and review all new resident admissions. This screening process would apply to all new resident admissions, and no resident would be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool, which documents: the date; the resident's name; the History and Physical; PASRR Level II; Nurse' Notes/MR notation; any Consultation Information; and a signature of the reviewer. 6. On 11/20/2014, the facility implemented a new procedure by which the Administrator would conduct a monthly audit of a minimum of 10 percent of the Resident Behavioral Symptom Screening forms and resident Care Plans for residents in behavioral management, to ensure the accuracy and completion of these documents. The Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Documentation Form for residents in behavioral management, to ensure the accuracy and completion of this Form. This Form (a previously existing form) allows for the weekly documentation of residents in the Behavior Management Program, the tracking of the effectiveness of existing behavioral interventions, and the documentation of any newly developed interventions. In addition, the Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Log Forms (a previously existing form) for all residents in a Behavior Management Program, to ensure accuracy and completion of this Form. This Form serves to document any observed behaviors, including agitated or combative behaviors, per day and per shift. These monthly form audits referenced above will be documented by the Administrator dating and signing the review of each of the referenced forms. 7. On 11/20/2014, the facility implemented a procedure by which a designated CNA was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. This Behavior Monitoring Form allows for the documentation of resident behaviors, interventions, the reporting of the behavior(s) to the Charge Nurse and the identity of the staff member reporting the behavior, and a signature of the nurse of verification. If, during these continuous rounds conducted on the Memory Support Unit, behaviors were observed, this staff member was to intervene as necessary to de-escalate the behavior, and also to report the resident behavior to the Charge Nurse. This monitoring was actually initiated on 11/11/2014, when the staff member was immediately assigned to the Memory Support Unit to begin the continuous rounds. 8. On 11/20/2014, the facility's Interdisciplinary Team continued the process of reviewing resident Preadmission Screening and Resident Review (PASRR) Level II Assessments. This review revealed three (3) residents having PASRR Level II assessments with a recommendation for a psychiatric consultation. One (1) of these residents was seen by a psychiatrist on a regular basis. Appointments were made on 11/20/2014 for the remaining two (2) residents, identified with recommendations for a psychiatric consultation, to have a consultation with a psychiatrist. On 11/20/2014, the facility implemented a procedure by which the Administrator or Social Service Director will make a copy of each resident's PASRR, and initial and date that copy, which will then be kept in the resident's medical record. 9. On 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training related to a number of areas. In-service training was provided to staff to educate them in ways to prevent abuse, including behaviors what to report, and to whom to report observations of resident abuse. This included both physical and verbal resident behaviors. This in-service training also addressed how to identify abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. Staff were informed that any resident suspected of any alleged abuse would be protected from any further abuse by the removal of the alleged perpetrator from the facility, as deemed appropriate. Staff were advised of reporting any alleged abuse immediately to their supervisor, leading up to the Administrator, who would then report the allegation of abuse to the appropriate State and corporate agencies. In-service training was also provided regarding employment screening, via criminal background checks, reference checks, and licensure/certification verification. As of 11/20/2014, eighty-nine (89) of one-hundred-and-two (102) staff had received this in-service training. This number included thirty-three (33) of thirty-seven (37) CNA staff; thirteen (13) of fourteen (14) LPN staff; nine (9) of eleven (11) housekeepers; four (4) of five (5) laundry workers; seventeen (17) of twenty (20) dietary workers; seven (7) of eight (8) Registered Nurses; seven (7) of seven (7) department heads (not including the DON, ADON, LPN Supervisor, Senior Care Partner, and MDS Nurse) that did not include nurses, including the Activities Director, Social Worker, Maintenance Director, Financial Counselor, Medical Records, Admissions Coordinator, and Housekeeping Supervisor. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. Additionally, going forward, all employees will receive training upon hire during the orientation process, and quarterly, related to resident abuse, resident neglect, and the procedures by which to deal with residents having verbal or physical behaviors. 10. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training, originally initiated on 11/14/2014, specifically intended for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 11. On 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors. As of 11/20/2014, eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses had received this training. The remaining three (3) LPN staff and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 12. On 11/20/2014, the facility implemented a new procedure by which the results of Administrator and/or Social Service Director audits of the Admission Audit Tool, Behavior Monitoring Form, Behavior Management Documentation Form, Behavior Symptom Screening Form, Management Log Form, and Care Plan and PASRR Assessment reviews would be presented to the QA Sub-Committee each week for four (4) weeks, then monthly by the Administrator or Director of Health Services. This process will allow the QA Sub-Committee to monitor staff compliance with the facility's policies and procedures regarding residents having verbal and/or physically aggressive behaviors which could have the potential to lead to resident abuse. Audit results will also be presented to the facility's QA Committee quarterly for the Committee's review and oversight of facility staff conformance with facility policies and procedures related to the management of resident behaviors, the screening of resident behaviors, physician notification, and resident monitoring. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 11/21/2014, a review of facility investigative documents, including the facility IS, confirmed that Resident #1 was immediately placed on one-to-one observation on 11/11/2014 immediately after the incident involving Resident #1 and Resident #2, as indicated in Step #1 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records completed on that date, but which had been ongoing throughout the abbreviated survey, revealed that the Interdisciplinary Team had conducted behavioral screenings on residents for the purpose of ensuring appropriate resident placement in the Behavioral Monitoring Program, as indicated in Step #2 of the CAJR referenced above. - On 11/21/2014, a sampled review of multiple resident records, but which had been ongoing throughout the abbreviated survey, was completed and verified that resident Care Plans had been reviewed and updated by the Interdisciplinary Team, as related to physically/verbally aggressive behaviors. This was in accordance with Step #3 of the CAJR referenced above. - On 11/21/2014, review of facility investigative documents confirmed that the Medical Director had reviewed Resident #1's medical record and submitted a written summary of this information to the facility on [DATE]. This was in accordance with Step #4 of the CAJR referenced above. (Of note, on 11/20/2014 at 11:12 a.m., a telephone call had been placed to Resident #1's physician, but the physician declined interview.) - On 11/21/2014, interview with the Administrator at 11:20 a.m. confirmed that the Interdisciplinary Team will screen and review all new resident admissions, with no resident being admitted until a review of the resident's medical condition and potential for aggressive behaviors can be assessed. This review will be documented using the Admission Audit Tool. This Team will include the Administrator, DON, ADON, Admissions Personnel, an LPN Supervisor, and the Social Services Director. This was in accordance with Step #5 of the CAJR referenced above. - On 11/21/2014, facility document review and interview with the Administrator confirmed that the Administrator will be conducting monthly audits of the Resident Behavioral Symptom Screening forms, the Behavior Management Documentation Forms, the Behavior Management Log Forms, and resident Care Plans for resident requiring behavioral management services. This was in accordance with Step #6 of the CAJR referenced above. - On 11/21/2014, a 9:55 a.m. observation on the Secured Unit confirmed the presence of an assigned staff member to conduct ongoing and continuous rounds for the purpose of observing for any resident aggressive behaviors. These rounds were documented on the Behavior Monitoring Form. In addition, it was confirmed by interview with the Administrator that this process of ongoing, continuous rounds will be a permanent intervention. This was in accordance with Step #7 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records, which had been ongoing throughout the abbreviated survey, was completed and verified that the Interdisciplinary Team had reviewed all resident PASRR Level II Assessments, with the appropriate follow-up for residents needing additional psychiatric services. This action was also confirmed during an 11/21/2014, 10:45 interview with a Corporate Nursing Consultant. This was in accordance with Step #8 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted staff in-service training for staff, including (but not limited to) licensed nursing staff, CNA staff, Social Services staff, MDS staff, Medical Records staff, the Maintenance Director, and the Admissions Coordinator, regarding resident abuse and the Behavior Management Policy. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #9 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff and CNA staff, regarding resident behavior management policies and the documentation of resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #10 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff, regarding the notification of the physician for changes in condition and new resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #11 of the CAJR referenced above. - On 11/21/2014, an 11:20 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing management level oversight of the assessment, planning of care, and provision of care to residents having behavioral problems, will be reviewed by the QA Committee to provide ongoing QA Committee oversight of this care. This was in accordance with Step #12 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice had been removed on 11/21/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 11/19/2014, the facility implemented

Based on clinical record review, facility investigation summary review, facility Entity Reported Incident Intake review, facility Behavior Management Program Policy review, facility Behavior Management Documentation Form review, staff written statement review, and staff interview, the facility failed to provide supervision in response to verbal threats and aggression exhibited by one (1) resident (Resident #1), who made multiple verbal threats of harm against another resident (Resident #2), to thus ensure the safety of Resident #2. The total survey sample was eleven (11) residents. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. After facility admission, Resident #1 exhibited aggressive behaviors toward staff, including hitting staff and pulling staffs' hair. Interventions were developed to address Resident #1's behavior, and the resident was placed on a Behavior Management Program on 09/09/2014. Documented evidence then indicated that Resident #1 had no behaviors observed/reported daily from 10/01/2014 through 10/21/2014, at which time she was discontinued from the Behavior Management Program. The physician documented in a Physician's Progress Note of 10/28/2014 that Resident #1's mood, Bipolar Disorder, and Schizophrenia were stable. The facility, however, failed to notify Resident #1's physician of the resident's ongoing refusal of drug therapy, including her Risperidone antipsychotic drug therapy, during October of 2014. On 11/02/2014, Resident #1 experienced a change in behavior and was reported by facility staff to have made multiple verbal threats against Resident #2, including "If you don't get her, I am going to get her", and "I'm going to get that b---h." However, even though these verbal threats against Resident #2 represented a change in behavior for Resident #1, the facility failed to put measures into place to ensure close monitoring of Resident #1, failed to place Resident #1 in the Behavior Management Program as specified by facility Policy, and failed to notify Resident #1's physician of the aggressive behavior and verbal threats. Then, on 11/11/2014, facility staff discovered Resident #2 not breathing and having no pulse, and with an electric bed cord around her neck. Resident #1 was documented as stating to facility staff that she had "killed" Resident #2, and Resident #1 was later arrested and charged with felony murder and aggravated assault. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Corporate Consultant were informed of the immediate jeopardy on November 19, 2014 at 3:36 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on November 11, 2014, the date Resident #1 was documented as stating she had "killed" her roommate, Resident #2, after Resident #2 was found to have no respirations, no pulse, and with an electric cord around her neck, and nine (9) days after November 2, 2014, when the facility failed to enact interventions in response to Resident #1's verbal threats against Resident #2. The immediate jeopardy continued through November 20, 2014, and was removed on November 21, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on November 20, 2014. During an interview with the Administrator conducted on 11/19/2014 at 2:30 p.m., the Administrator acknowledged the 11/02/2014 incidents during which Resident #1 made verbal threats against Resident #2, further stating that as a result of Resident #1's 11/02/2014 verbal threats toward Resident #2, staff administered (the antianxiety drug) Ativan intramuscularly to Resident #1, and also redirected the two residents. The Administrator acknowledged, however, that the administration of Ativan to Resident #1 and the redirection of these residents were interventions in place prior to the 11/02/2014 incidents involving Resident #1 making verbal threats against Resident #2, and further acknowledged that no new measures had been developed in response to Resident #1's aggressive behavior involving verbal threats on 11/02/2014. An allegation of jeopardy removal was received on November 20, 2014. Based on the corrective plans which had been developed and implemented by the facility via a credible allegation of jeopardy removal on November 20, 2014, the immediacy of the deficient practice was determined to have been removed on November 21, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of staffs' monitoring of resident behaviors, resident screening and placement in the Behavior Management Program as indicated, resident Care Plan updating and implementation regarding resident behaviors, and physician notification of resident behavioral changes, in accordance with facility policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility policies and procedures governing resident monitoring and the reporting of resident behavioral changes to supervisors and the physician, to therefore ensure resident safety. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the current status of residents, including the development and implementation of interventions to address aggressive behaviors. Findings include: Facility Entity Reported Incident Intake (ERII) Number GA 575 dated 11/12/2014 documented the facility's report to the State Survey Agency of an incident involving two (2) facility residents (Resident #1 and Resident #2). This ERII documented that on 11/11/2014, facility staff noted Resident #2 on the floor and unconscious, with a cord around her neck. The ERII further documented that Resident #1 stated she had an altercation with Resident #2, her roommate, and that she had "killed" Resident #2. In an investigation summary (IS) submitted by the facility to the State Survey Agency on 11/17/2014 as a follow-up report to the ERII, the facility documented that on 11/13/2014, Resident #1 was arrested and charged with felony murder and aggravated assault. Record review for Resident #1 (one of the residents reported by the facility to have been involved in the incident of 11/11/2014, as documented in facility ERII Number GA 575 referenced above) revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 09/10/2014 which documented the resident's admission Entry Date of 09/03/2014. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident #1 had a Brief Interview for Mental Status (BIMS) Summary Score of 8, indicating that the resident had moderate cognitive impairment, and Section E - Behavior documented she had exhibited physical behavioral symptoms toward others on one (1) to three (3) days during the look-back period. A Daily Skilled Nurses Notes (DSNN) entry of 09/03/2014 timed at 4:10 p.m. for Resident #1 documented the resident's arrival at the nursing facility from an Intensive Treatment Board center. This DSNN entry documented that Resident #1 had [DIAGNOSES REDACTED]. This DSNN entry further documented that upon admission, Resident #1 was placed in resident room 260A. The admission physician's orders [REDACTED].#1 specified orders of 09/03/2014 for the resident to receive the antipsychotic medication Risperidone two (2) milligrams (mgs) by mouth at bedtime, the antianxiety medication Lorazepam (Ativan) one (1) mg by mouth every six (6) hours as needed for agitation, and Lorazepam Injection, 0.5 milliliter (1 mg) intramuscularly (IM) every six (6) hours as needed for agitation if unable to take oral Lorazepam. A DSNN entry of 09/06/2014 timed at 5:30 a.m. for Resident #1 documented that the nurse had gone into the resident's room to ask the resident to get up for breakfast, but the resident sat up in the the bed, hit the nurse across the left side of the face, and stated "I am not doing anything and get out." This DSNN further documented that Resident #1 refused to take any of her medications. A DSNN entry of 09/07/2014 timed at 8:00 a.m. for Resident #1 documented that the nurse went to check the status of the resident and began to ask the resident questions, but the resident closed her eyes, pulled the cover over her, would not respond to the nurse, and refused her medications. A Behavior Management Documentation Form for Resident #1 indicated that on 09/09/2014, the resident was placed in the facility's Behavior Management Program. Review of the Behavior Management Program Policy revealed that all residents would be evaluated upon admission/readmission, and with new behaviors or a change in existing behaviors, for placement in the Behavior Management Program, and would have interventions, per the Care Plan and additional interventions if necessary, to eliminate or reduce behaviors. This Policy further indicated that residents placed in the Behavior Management Program would be evaluated by the Behavior Management Team at weekly Behavior Management Meetings for purposes which included brainstorming/assessing for potential causes and risks of behaviors, developing interventions as indicated, and reassessing and revising the behavior reduction interventions if indicated. The Policy further required that each resident in the Behavior Management Program would remain in the Program until behavior-free for 30 days or until deemed appropriate to discontinue by the Behavior Management Committee. The Behavior Management Documentation Form of 09/09/2014 referenced above for Resident #1 documented that the decision to place Resident #1 in the Behavior Management Program was based on the resident's physically aggressive behaviors. A Behavioral Symptom Screening Form for Resident #1, completed on 09/10/2014 upon the resident's inclusion in the Behavior Management Program, documented the resident's history of Manic Depression, Dementia with Behavioral Disturbances, and Schizophrenia - Residual Type, and also documented a history of the resident being physically aggressive towards staff, refusing medications, refusing to eat sporadically, and pocketing ("cheeking") medications. The 09/09/2014 Behavior Management Documentation Form for Resident #1, as referenced above, documented that once enrolled in the Behavioral Management Program on that date, the Behavior Management Team reviewed the resident's behavior and behavioral interventions weekly, as outlined in the Behavior Management Policy, on the dates of 09/16/2014, 09/23/2014, 09/30/2014, 10/07/2014, and 10/14/2014. Further review of Resident #1's clinical record revealed DSNN entries of 09/14/2014 timed at 10:30 a.m. and 9:00 p.m. which documented the resident continued to refuse medications, and a DSNN entry of 09/16/2014 timed at 11:30 a.m. documented that Resident #1 had balled up her fist and swung at the nurse, then grabbed at another staff member. A 09/18/2014, 7:00 a.m. DSNN entry for Resident #1 documented the resident continued refusing care, and documented that when notified of her escalating behaviors, the physician ordered for the resident to receive Risperidone one (1) mg each morning (in addition to the nightly Risperidone two (2) mg dose already being administered at bedtime, as indicated above). A DSNN entry of 09/20/2014 timed at 7:14 a.m. for Resident #1 then documented the resident was still uncooperative and struck out and hit a certified nursing assistant (CNA). Resident #1's September 2014 Medication Record (MR) and Nurse's Medication Notes documented, per licensed nursing staff entries, that on 09/20/2014, Resident #1 had refused medications, including the daily Risperidone 2 mg dose ordered and scheduled at 8:00 p.m.. This September MR further documented, per licensed nursing staff entries, that on 09/19/2014, 09/20/2014, and 09/23/2014, Resident #1 refused all of her medications, including the daily Risperidone 1 mg dose ordered and scheduled at 8:00 a.m. A DSNN entry of 09/28/2014 timed at 1:40 p.m. for Resident #1 documented that Resident #1 had received a 0.5 mg dose of intramuscular Ativan for increased agitation after having slapped staff and pulled staffs' hair out as they were attempting to assist the resident to dress and ambulate. A 09/29/2014 Physician's Progress Notes entry for Resident #1 signed by the attending physician documented the physician examined the resident on that date. In this 09/29/2014 Physician's Progress Notes entry, the physician documented that Resident #1 was combative and that the resident was not taking her medications, thus documenting the physician's awareness on that date of the resident's behavioral issues and refusal to take medications. Review of Resident #1's October 2014 nursing notes entries revealed DSNN entries of 10/03/2014 timed at 9:00 p.m. and 10/04/2014 timed at 8:00 a.m. which documented the resident again refused medications. Subsequent DSNN entries of 10/17/2014 timed at 9:00 p.m. and 10/18/2014 timed at 7:30 p.m., and a Skilled Daily Nurse's Note's (SDNN) entry of 10/19/2014 timed at 5:55 p.m. for Resident #1 documented the resident continued to refuse to take her oral medications on occasion. More specifically, review of Resident #1's October 2014 MR revealed licensed nursing staff documented the resident refused the Risperidone 1 mg dose, ordered and scheduled to be administered at 8:00 a.m. daily, on eight (8) of thirty-one (31) days during the month of October, those dates being 10/04/2014, 10/05/2014, 10/17/2014, 10/19/2014, 10/23/2013, 10/24/2014, 10/28/2014 and 10/29/2014. Resident #1's October 2014 MR also documented that the resident refused the evening Risperidone 2 mg dose, ordered and scheduled to be administered at bedtime at 8:00 p.m., on five (5) of thirty-one (31) days of the month, those days being 10/03/2014, 10/17/2014, 10/18/2014, 10/19/2014, and 10/21/2014. However, even though Resident #1 continued to refused medications on multiple occasions during the month of October 2014, as documented in the resident's October MR and DSNN/SDNN entries referenced above, review of Resident #1's clinical record revealed no evidence to indicate that Resident #1's physician was notified of her continuing to refuse her ordered medication therapy, including the Risperidone medication therapy prescribed in response to her escalating behaviors, during the month of October 2014. The last documented evidence of Resident #1's attending physician being aware of the resident's refusal of medications was the 09/29/2014 Physician's Progress Notes entry referenced above in which the physician documented awareness of the resident's medication refusal. Even though Resident #1's DSNN/SDNN and October MR entries from 10/03/2014 through 10/21/2014 referenced above documented that Resident #1 refused medications on multiple occasions during October of 2014, daily DSNN/SDNN entries for Resident #1 dated 10/01/2014 at 2:30 a.m. and 8:00 p.m., 10/02/14 at 7:00 a.m., 10/03/2014 at 2:50 a.m. and 7:00 a.m., 10/04/14 at 3:00 a.m. and 8:00 p.m., 10/05/14 at 2:00 a.m. and 8:00 p.m., 10/06/2014 at 7:00 a.m. and 8:00 p.m., 10/07/2014 at 7:00 a.m. and 6:30 p.m., 10/08/2014 at 7:00 a.m. and 7:00 p.m., 10/09/2014 at 2:35 a.m. and 7:00 a.m., 10/10/2014 at 7:00 a.m. and 7:00 p.m., 10/11/2014 at 9:00 a.m. and 5:00 p.m., 10/12/2014 at 2:14 a.m. and 8:00 p.m., 10/13/2014 at 2:16 a.m. and 6:00 p.m., 10/14/14 at 2:05 a.m. and 7:00 a.m., 10/15/2014 at 7:00 a.m. and 9:00 p.m., 10/16/2014 at 2:40 a.m., 10/17/14 at 7:00 a.m., 10/18/14 at 8:00 a.m., 10/19/2014 at 2:30 a.m., 10/20/14 at 2:30 a.m. and 7:00 p.m., and 10/21/2014 at 7:00 a.m. documented that no behaviors had been noted/reported for Resident #1 during this period of time. A SDNN of 10/21/2014 at 5:30 p.m. documented that Resident #1 was calm, with no behaviors at that time, and that the resident had tolerated her medications without fussing. A final entry on Resident #1's Behavior Management Documentation Form dated 10/21/2014 then documented that Resident #1 was discontinued from the Behavior Management Program on that date. A subsequent SDNN entry of 10/24/2014 timed at 2:00 a.m. for Resident #1 documented the resident continued to refuse medications, but a later 10/24/2014, 7:00 a.m. SDNN documented that Resident #1 had no noted behaviors at that time. Continued review of facility records revealed a clinical record for Resident #2 (who, in addition to Resident #1, was reported by the facility to have been involved in the incident of 11/11/2014, as documented in facility ERII Number GA 575 referenced above). Review of Resident #2's clinical record revealed a SDNN of 10/24/2014 at 11:10 a.m. documenting this resident had arrived at the facility for admission on that date of 10/24/2014. This SDNN further documented that upon facility admission, Resident #2 was placed in resident room 260B (thereby making her the roommate of Resident #1 who resided in resident room 260A, as referenced above). Further record review for Resident #2 revealed an Admission MDS assessment having an Assessment Reference Date of 10/31/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #2 had a BIMS Summary Score of 4, indicating severe cognitive impairment, and Section G - Functional Status documented the resident required only limited assistance with walking. Continued review of the clinical record of Resident #1 revealed a SDNN of 10/25/2014 timed at 8:00 a.m. (the day after Resident #2's facility admission and placement in Resident #1's room as her roommate, as documented in Resident #2's 10/24/2014, 11:10 a.m. SDNN referenced above) which documented that Resident #1 was calm, cooperative, and taking her medication with no concerns at that time. This SDNN further indicated that staff would continue to monitor Resident #1 for any changes in status. A Physician's Progress Notes entry for Resident #1 dated 10/28/2014 (four days after Resident #2's placement as Resident #1's roommate, and one week after Resident #1's 10/21/2014 discharge from the Behavior Management Program, as documented on the Behavior Management Documentation Form referenced above) documented that Resident #1 was pleasantly confused at that time. This Physician's Progress Notes entry for Resident #1 further documented that Resident #1's mood was stable at present in relation to her Bipolar Disorder, and that her Schizophrenia and Dementia were stable at that time. However, further review of Resident #1's clinical record revealed a Nurse's Notes (NN) entry of 11/02/2014 at 11:00 a.m. (approximately one week after the 10/25/2014, 8:00 a.m. SDNN referenced above documented the resident to be calm and cooperative, and 5 days after the 10/28/2014 Physician's Progress Notes entry referenced above documented the resident's mood, Schizophrenia, and Dementia were stable) which documented that Resident #1 had made verbal threats against another resident (Resident #2) and that Resident #1 became aggressive. This SDNN documented the administration of a 0.5 ml intramuscular dose of Ativan to Resident #1. In the investigation summary (IS) completed by the facility as part of the facility's investigation into the 11/11/2014 altercation involving Resident #1 and Resident #2, as documented in ERII Number GA 575 referenced above, the facility documented that on 11/02/2014 (nine days prior to the 11/11/2014 altercation), Resident #1 was observed by staff carrying a picture of family members. This facility IS documented that Resident #1 alleged to a CNA that a family member had been murdered a number of years ago, an allegation which the facility had not determined to be valid. The facility IS documented that Resident #1's behavior of 11/02/2014 seemed to change suddenly, and she was observed holding the family picture up to the window of the Secured Unit and accusing a male resident, as he walked by, of being the one who "murdered" her family member. The IS documented that at 11:00 a.m. on 11/02/2014, Resident #1 put the family picture in the face of an unnamed female resident, who slapped the picture away from her face. Resident #1 then put the family picture in the face of Resident #2, who did not respond, and both Resident #1 and Resident #2 were redirected. This facility IS documented that as the CNA was redirecting Resident #1, Resident #1 stated "I am going to get you", and then told the staff, "If you don't get her, I am going to get her." This IS documented that later in the day of 11/02/2014, Resident #1 stated to the CNA, while referring to Resident #2, "I'm going to get that b---h." The IS documented that Resident #1 told the CNA that the room in which she resided was "her" room, but that Resident #2 was using the bathroom of the room they shared, and accused Resident #2 of wearing her clothes. The IS documented that at that point, the CNA informed Resident #1 that Resident #2 was wearing her own clothes and assisted Resident #1 to lie down. During an interview with the Administrator conducted on 11/18/2014 at 12:20 p.m., the Administrator identified CNA "CC" as the CNA referenced in the facility IS as hearing Resident #1 threaten Resident #2 on 11/02/2014. During an interview with CNA "CC" conducted on 11/18/2014 at 1:50 p.m., CNA "CC" acknowledged she was working on the Secured Unit on 11/02/2014, but stated she did not actually witness the incident during which Resident #1 placed a picture in the face of Resident #2. However, CNA "CC" further stated that later on 11/02/2014, after lunch, Resident #1 was sitting in the dining room, and CNA "CC" stated she heard Resident #1 say "I'm gonna get that b---h." CNA "CC" stated she asked Resident #1 to whom she was referring, and Resident #1 named Resident #2 (who CNA "CC" stated was not in the dining room at that time). CNA "CC" stated that she told Resident #1 she could not talk like that and that the facility would have to call the police, but stated that Resident #1 then said "Go ahead and call, I'm still gonna get her." CNA "CC" stated that CNA "EE" was also present at the time Resident #1 made the verbal threats toward Resident #2, and that Licensed Practical Nurse (LPN) "DD", who was also present and overheard Resident #1's threat toward Resident #2, stated she would call the supervisor. CNA "CC" further stated that, prior to these 11/02/2014 incidents during which Resident #1 was aggressive toward Resident #2 and other residents, she had not observed Resident #1 to make threats or be aggressive toward residents in the past, and that Resident #1 had only been aggressive toward staff at times. During an interview with CNA "EE" conducted on 11/18/2014 at 5:09 p.m., CNA "EE" stated that on 11/02/2014, while in the hallway of the Secured Unit, Resident #1 had held a family picture up to Resident #2's face (as indicated in the facility's IS referenced above), and then both residents were separated. CNA "EE" stated that Resident #2 then came back up the hall and Resident #1 again put the family picture in Resident #2's face. CNA "EE" stated that at that time, staff separated the two residents, with Resident #1 going to the dining room and Resident #2 going to the activity area. CNA "EE" stated that while Resident #1 was sitting at a table in the dining room, Resident #1 started saying things like "I'm a gonna get her." CNA "EE" further stated that the nurse overheard this, and instructed this CNA to watch Resident #1 to make sure Resident #1 did not go back to confront Resident #2, to allow the nurse to go make a telephone call. CNA "EE" stated that she had not observed Resident #1 to be aggressive toward other residents before this 11/02/2014 incident. In a written statement provided by LPN "DD" dated 11/14/2014, LPN "DD" documented that on 11/02/2014 at approximately 11:00 a.m., Resident #1 was walking in the hallway when she placed the family picture in the face of Resident #2, at which time the residents were redirected. LPN "DD" documented that as Resident #1 was being redirected, Resident #1 pointed at Resident #2 and stated "I am going to get you, I am going to get you." LPN "DD" documented that she and the CNA encouraged Resident #1 to not say that, but that Resident #1 then stated "If you don't get her, I am going to get her." LPN "DD" documented that Resident #1 then approached another resident but was redirected by staff, and after refusing to take a dose of Ativan by mouth, was escorted to her room and was administered an IM dose of Ativan. LPN "DD" further documented that she then reported the incident to the Director of Nursing (DON). During an interview with LPN "DD" and the DON conducted on 11/18/2014 at 12:45 p.m., LPN "DD" acknowledged awareness of the 11/02/2014 incident during which Resident #1 threatened Resident #2 and held a family picture in the face of Resident #2. LPN "DD" acknowledged that Resident #1 had been given an IM dose of Ativan after this incident, and stated that this behavior regarding Resident #1 threatening another resident and getting upset about the picture on 11/02/2014 was a new behavior for Resident #1. LPN "DD" stated she reported this behavior involving Resident #1 to the DON. The DON stated, during this interview, that she was not at work on 11/02/2014 (Sunday), but rather was at church when she received the telephone call from the nursing facility regarding Resident #1. The DON stated she returned the call later in the day of 11/02/2014, was told about the incident involving Resident #1 threatening Resident #2 and of the actions staff had taken to intervene, and was told that Resident #1 was calm at that time. During this interview, LPN "DD" asserted she was not aware that Resident #1 had threatened Resident #2 later in the day of 11/02/2014 (after the earlier 11:00 a.m. incident of 11/02/2014 of which LPN "DD" did acknowledge awareness, as she documented in her written statement referenced above, when Resident #1 pointed at Resident #2, stated "I am going to get you, I am going to get you", and stating "If you don't get her, I am going to get her."). LPN "DD" stated that if she had been made aware of the second threat, she would have called the DON again. The DON stated that if she had been made aware of Resident #1's second threat toward Resident #2, she would have had Resident #1 transferred to the hospital at that time. However, despite LPN "DD"'s acknowledgement, per her 11/14/2014 written statement referenced above, that she had witnessed and overheard Resident #1 making verbal threats toward Resident #2 on 11/02/2014, despite LPN "DD" stating during the 11/18/2014, 12:45 p.m. interview referenced above that Resident #1's behavior of threatening another resident on 11/02/2014 was a new behavior for the resident, and despite the DON's acknowledgement, during the 11/18/2014, 12:45 p.m. interview referenced above, that she was made aware on 11/02/2014 of Resident #1's verbal threat toward another resident on that date, further record review revealed no evidence to indicate that Resident #1's physician was notified of the resident's verbal threats against Resident #2, or of the resident's 11/02/2014 aggressive behavior toward residents. Additionally, record review for Resident #1 revealed no evidence to indicate that the facility developed and implemented additional interventions, monitoring, or supervision on or after 11/02/2014, after Resident #1's new behavior involving verbal threats and aggression against Resident #2, to address Resident #1's newly exhibited change in behavior, to both ensure the supervision and monitoring of Resident #1 related to this behavior and to ensure the safety of Resident #2. In addition, further review of the facility's Behavior Management Policy referenced above revealed the Policy to specify, in the Determining Placement of Patient/Residents On Behavior Management Program section, that any resident identified to have a new behavior or change in existing behavior, to include an event of even one (1) altercation involving resident-to-resident verbal threats, would be placed on a Behavior Management Program. This Behavior Management Policy further indicated that placement on the Behavior Management Program would be made due to events which resulted in injury, but also for behaviors, including verbal threats, having the potential for serious harm. However, review of Resident #1's clinical record revealed no evidence to indicate that Resident #1 was either placed on, or was considered for placement on, a Behavior Management Program (after having been discharged from the Program on 10/21/2014, as referenced above) after the incidents of 11/02/2014 during which Resident #1 exhibited the new behavior of voicing verbal threats against Resident #2. The facility's failure to place Resident #1 back on a Behavior Management Program (after her discharged from the Program on 10/21/2014, as documented on Behavior Management Documentation Form referenced above) was despite the fact that Resident #1's Behavior Management Documentation Form of 09/09/2014 (referenced above) documented only physically aggressive behaviors as the reason for her initial enrollment on a Behavior Management Program on 09/09/2014, and despite the fact that Resident #1 had subsequently exhibited a new aggressive behavior (verbally threatening Resident #2 on 11/02/2014). This was also despite the fact that the Behavior Management Program Policy referenced above specifically indicated that any resident identified to have a new behavior or change in existing behavior, to include an event of even one (1) altercation involving resident-to-resident verbal threats, would be placed on the Behavior Management Program. During an interview with the Administrator conducted on 11/19/2014 at 12:20 p.m., the Administrator was questioned regarding the failure of the facility to place Resident #1 on a Behavior Management Program after Resident #1's 11/02/2014 verbal threats toward Resident #2, which were a change in behavior for Resident #1. The Administrator stated that the 11/02/2014 incident involving Resident #1's verbal threat toward Resident #2 had been discussed in the morning meeting involving facility management staff on 11/03/2014. During a subsequent interview with the Administrator conducted on 11/19/2014 at 1:40 p.m., the Administrator stated that after discussion of the 11/02/2014 incident involving Resident #1's verbal threats toward Resident #2 in the morning meeting of 11/03/2014, a decision was made not to place Resident #1 on a Behavior Management Program because the altercation was without injury and was only one (1) altercation. When asked about the Behavior Management Program Policy (referenced above) which specified that altercations with injury were not the only criteria for placement on Behavior Management, and that the Policy specified verbal threats (even just one (1) threat) as criteria for placement on Behavior Management, the Administrator acknowledged that statement, but stated she did not interpret the Policy that way. When questioned regarding the failure of the facility to notify Resident #1's physician of Resident #1's change in behavior involving her multiple threats against Resident #2 on 11/02/2014, the failure to develop and implement any further interventions to prevent a recurrence, and the failure to place Resident #1 on a Behavior Managemen

Based on clinical record review, facility investigation summary review, and staff interview, the facility failed to provide monitoring, as specified by the Care Plan, related to verbal threats and aggression exhibited by one (1) resident (Resident #1), whose Care Plan specified monitoring for socially inappropriate/disruptive behavior, and who made multiple verbal threats of harm against another resident (Resident #2). The facility also failed to assess Resident #1 for the need for a psychiatric evaluation/obtain a psychiatric consultation as specified by the Care Plan, and failed to notify Resident #1's physician of medication regimen noncompliance, also as specified by the Care Plan. The total survey sample was eleven (11) residents. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Care Plan for Resident #1 identified the resident's use of [MEDICAL CONDITION] medication, and specified notification of the physician regarding non-compliance with the medication regimen. However, even though during October of 2014 Resident #1 refused her [MEDICATION NAME] 1 milligram (mg) dose on eight (8) days and her [MEDICATION NAME] 2 mg dose on five (5) days, there was no evidence to indicate that the physician was notified of the resident's medication regimen noncompliance, as specified by the Care Plan. Additionally, a Care Plan Problem/Need for Resident #1 identified that she displayed socially inappropriate/disruptive behavior, and a Care Plan Approach specified that staff monitor the resident in relation to her behavior. On 11/02/2014, Resident #1 exhibited a new behavior by making multiple verbal threats against Resident #2, including "If you don't get her, I am going to get her", and "I'm going to get that b---h." However, even though verbal threats against residents was a new behavior for Resident #1, the facility failed to implement, after this new behavior of verbal threats against another resident, any specific method to ensure close monitoring of Resident #1, as specified by the Care Plan. Also, despite Resident #1's Care Plan specifying she would be provided with a psychiatric consultation if needed, there was no evidence to indicate that, after this 11/02/2014 incident, Resident #1 was provided with, or was assessed for the need for, a psychiatric consultation. Subsequently, on 11/11/2014, Resident #2 (Resident #1's roommate) was found not breathing, having no pulse, and having an electric cord around her neck. Resident #1 stated to facility staff that she had "killed" Resident #2, and Resident #1 was arrested and charged with felony murder and aggravated assault. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Corporate Consultant were informed of the immediate jeopardy on November 19, 2014 at 3:36 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on November 11, 2014, the date Resident #1 was documented as stating she had "killed" her roommate, Resident #2, after Resident #2 was found to have no respirations, no pulse, and with an electric cord around her neck, and nine (9) days after November 2, 2014, when the facility failed to enact interventions in response to Resident #1's voiced threats against Resident #2. The immediate jeopardy continued through November 20, 2014, and was removed on November 21, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on November 20, 2014. During an interview conducted on 11/19/2014 at 1:40 p.m., the Administrator acknowledged the lack of evidence of physician notification regarding Resident #1's verbal threats against Resident #1. In an 11/19/2014, 2:30 p.m. interview, the Administrator acknowledged that no new interventions for monitoring had been put into place after Resident #1 verbally threatened Resident #2 on 11/02/2014. An allegation of jeopardy removal was received on November 20, 2014. Based on the corrective plans which had been developed and implemented by the facility via a credible allegation of jeopardy removal on November 20, 2014, the immediacy of the deficient practice was determined to have been removed on November 21, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of staffs' monitoring of resident behaviors, resident screening and placement in the Behavior Management Program as indicated, resident Care Plan updating and implementation regarding resident behaviors, and physician notification of resident behavioral changes, in accordance with facility policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility policies and procedures governing resident monitoring and the reporting of resident behavioral changes to supervisors and the physician, to therefore ensure resident safety. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the current status of residents, including the development and implementation of interventions to address aggressive behaviors. Findings include: Resident #1's 09/10/2014 Admission Minimum Data Set assessment documented an admission date of [DATE], and Section E - Behavior documented Resident #1 had shown physical behavioral symptoms one-to-three days during the look-back period. Section I - Active [DIAGNOSES REDACTED]. A 09/03/2014, 4:10 p.m. Daily Skilled Nurses Notes (DSNN) entry for Resident #1 documented additional [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan revealed a Problem/Need dated 09/18/2014 which indicated that Resident #1 displayed socially inappropriate/disruptive behavior related to her [DIAGNOSES REDACTED]. Approaches included on this Care Plan to address Resident #1's socially inappropriate/disruptive behaviors included monitoring the resident. Resident #1's Care Plan documented another Problem/Need dated 09/18/2014 which indicated the resident required [MEDICAL CONDITION] medication related to cognitive impairment, and Approaches to address this Problem/Need included obtaining a psychiatric consultation as needed. An additional Care Plan Problem/Need dated 09/18/2014 indicated that Resident #1 had the potential for side effects and/or adverse reactions related to [MEDICAL CONDITION] medication use, and Approaches included notifying the physician of signs/symptoms of adverse medication reactions and/or of non-compliance with the medication regimen. Resident #1's 09/03/2014 admission physician's orders [REDACTED]. A subsequent 09/18/2014, 7:00 a.m. DSNN entry documented the physician ordered that Resident #1 also receive [MEDICATION NAME] one (1) mg each morning for escalating behaviors. Review of Resident #1's September 2014 Medication Record (MR) and Nurse's Medication Notes revealed nursing staff documented the resident refused all medications (including the [MEDICATION NAME] 2 mg dose) at 8:00 p.m. on 09/20/2014, and refused all medications (including the [MEDICATION NAME] 1 mg dose) at 8:00 a.m. on 09/19/2014, 09/20/2014, and 09/23/2014. A 09/29/14 Physician's Progress Notes entry for Resident #1 documented the physician's awareness that Resident #1 was not taking medications. Resident #1's October 2014 MR documented Resident #1 refused the daily 8:00 a.m. [MEDICATION NAME] 1 mg dose on eight (8) of thirty-one (31) days, and refused the nightly 8:00 p.m. [MEDICATION NAME] 2 mg dose on five (5) of thirty-one (31) days. However, despite Resident #1's Care Plan specifying that the physician would be notified of non-compliance with the medication regimen, record review revealed no evidence to indicate that Resident #1's physician was notified of Resident #1 continuing to refuse medications, including [MEDICATION NAME], on these thirteen (13) occasions during October of 2014. Further review of Resident #1's record revealed a Nurse's Notes (NN) entry of 11/02/2014 at 11:00 a.m. which documented that Resident #1 made verbal threats against another resident (Resident #2, who resided in room [ROOM NUMBER]B as the roommate of Resident #1). This 11/02/2014 NN entry documented that an intramuscular dose of [MEDICATION NAME] was administered to Resident #1 and that staff were monitoring Resident #1. Review of Resident #1's record revealed no evidence of her having made threats toward other residents before the 11/02/2014, 11:00 a.m. NN entry referenced above. During an on 11/18/2014, 12:45 p.m. interview, Licensed Practical Nurse (LPN) "DD" stated that on 11/02/2014, Resident #1 had held a family picture in the face of Resident #2 and verbally threatened her, which LPN "DD" acknowledged was a new behavior for Resident #1. Further record review for Resident #1, however, revealed that even though Resident #1 had exhibited threatening behavior toward Resident #2 on 11/02/2014, and even though this was a new behavior for Resident #1 (per the 11/18/2014, 12:45 p.m. interview with LPN "DD" referenced above), there was no evidence to indicate that the facility put into place interventions, specific to a method and/or frequency, to ensure close staff monitoring of Resident #1 in relation to this newly-exhibited threatening behavior toward other residents. This was despite the Care Plan of Resident #1 specifying the Approach, as referenced above, that staff would provide monitoring of the resident in relation to her disruptive behaviors. Additional record review for Resident #1 revealed that, despite Resident #1's verbally threatening behavior toward Resident #2 on 11/02/2014, and despite Resident #1's current Care Plan noting the resident's need for [MEDICAL CONDITION] medications and specifying a psychiatric consultation as needed, there was no evidence to indicate that Resident #1 was assessed for the need for a psychiatric evaluation after this 11/02/2014 incident involving the new behavior of verbally threatening another resident. Then, an 11/11/2014, 7:00 a.m. NN entry for Resident #1 documented that the nurse heard staff yelling (from the resident's room) and responded to find Resident #2 (Resident #1's roommate) not breathing, with no pulse and with an electric bed cord around Resident #2's neck. In an investigation summary (IS) completed by the facility related to the 11/11/2014 incident involving Resident #2 (as documented in the 11/11/2014, 7:00 a.m. NN entry for Resident #1 referenced above), the facility documented that on 11/11/2014 at 7:00 a.m., the nurse noted Resident #2 having no respirations or pulse and on the floor of her room with the bed's electric cord unplugged and on or near her neck. This IS further documented that on 11/02/2014 (nine days prior to 11/11/2014 when Resident #2 was found not breathing and with no pulse), Resident #1 was observed to hold a family picture in the face of Resident #2, and as a certified nursing assistant (CNA) was redirecting Resident #1, Resident #1 stated "I am going to get you", then said to the staff member "If you don't get her, I am going to get her", and later stated to the CNA "I'm going to get that b---h" (referring to Resident #2). However, as indicated above, even though Resident #1 made multiple verbal threats against Resident #2 on 11/02/2014 (per Resident #1's 11/02/2014, 11:00 a.m. NN entry and the facility's IS, both referenced above), record review revealed no evidence to indicate that the facility initiated any additional method or process by which to ensure close monitoring of Resident #1 (as specified by Resident #1's Care Plan) on or after 11/02/2014, to ensure Resident #2's safety. During an 11/19/2014, 2:30 p.m. interview, the Administrator acknowledged that after Resident #1 made verbal threats against Resident #2 on 11/02/2014, no new interventions were developed related to Resident #1's verbal threats against Resident #2. Then, as documented in the 11/11/2014, 7:00 a.m. NN entry for Resident #1 referenced above, on 11/11/2014, Resident #2 was found not breathing and with no pulse. Further review of the facility IS report referenced above revealed that, based on verbal reports from sources "close to" the police department, an autopsy report for Resident #2 concluded that Resident #2's trachea was crushed. This IS further documented that Resident #1 told a nurse consultant she had "killed" Resident #2, and the IS documented Resident #1 was arrested and charged with felony murder and aggravated assault. Based on the above, Resident #1 had [DIAGNOSES REDACTED]. Resident #1's Care Plan identified that the resident had displayed socially inappropriate/disruptive behavior, with an Approach related to this behavior including the monitoring of the resident. Resident #1's Care Plan also identified the resident's receipt of [MEDICAL CONDITION] medication, with an Approach specifying a psychiatric consultation as needed, and also identified Resident #1's potential for side effects/adverse reactions related to [MEDICAL CONDITION] medication use, with an Approach specifying notification of the physician of non-compliance with the medication regimen. However, the facility failed to notify Resident #1's physician, as specified by the Care Plan, of the resident's refusal of drug therapy, including [MEDICATION NAME], on thirteen (13) occasions in October of 2014. Then, when Resident #1 exhibited a new behavior on 11/02/2014 by making verbal threats against Resident #2, the facility failed to develop interventions to ensure the close monitoring of Resident #1, as specified by the Care Plan, and failed to evaluate Resident #1 to determine the need for a psychiatric evaluation, also as specified by the Care Plan. Subsequently, on 11/11/2014, Resident #2 was found on the floor with an electric cord around her neck, not breathing and having no pulse. Resident #1 was documented as stating to facility staff that she had "killed" Resident #2, was arrested, and was charged with felony murder and aggravated assault. Cross refer to F323 for more information regarding Resident #1 and Resident #2, and F406 for more information regarding Resident #1. The facility presented a credible allegation of jeopardy removal (CAJR) on 11/20/2014, and it was determined that the immediate jeopardy was removed on 11/21/2014, at which time the facility had implemented the following interventions: 1. On 11/11/2014, upon the discovery of the incident of that date, Resident #1 was immediately placed on one-to-one staff observation until she was later transferred out of the facility. 2. On 11/13/2014, the facility's Interdisciplinary Team (consisting of the Administrator, DON, ADON, Admissions Personnel, LPN Supervisor, and Social Services Director) completed Behavioral Symptom Screening Forms on every facility resident. This process of resident behavior screening had been initiated on 11/12/2014. All residents screened during this process and identified as having had physical or verbal behaviors in the previous month were placed on the Behavior Monitoring Program, to ensure the monitoring of these residents and to ensure that no further behavioral interventions were necessary. All residents will have a behavior screen done upon facility admission, quarterly, upon significant change in status, and with any new behavior. 3. On 11/13/2014, the facility's Interdisciplinary Team completed a review, initially begun on 11/12/2014, of the Care Plans of all residents having any physical or verbal behaviors in the previous month. These Care Plans were revised as needed, based on these reviews. Resident Care Plans will be reviewed quarterly, annually, with a significant change in condition, and with any new behavior. 4. On 11/14/2014, the facility's Medical Director reviewed Resident #1's medical record, making no recommendations. 5. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team would screen and review all new resident admissions. This screening process would apply to all new resident admissions, and no resident would be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool, which documents: the date; the resident's name; the History and Physical; PASRR Level II; Nurse' Notes/MR notation; any Consultation Information; and a signature of the reviewer. 6. On 11/20/2014, the facility implemented a new procedure by which the Administrator would conduct a monthly audit of a minimum of 10 percent of the Resident Behavioral Symptom Screening forms and resident Care Plans for residents in behavioral management, to ensure the accuracy and completion of these documents. The Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Documentation Form for residents in behavioral management, to ensure the accuracy and completion of this Form. This Form (a previously existing form) allows for the weekly documentation of residents in the Behavior Management Program, the tracking of the effectiveness of existing behavioral interventions, and the documentation of any newly developed interventions. In addition, the Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Log Forms (a previously existing form) for all residents in a Behavior Management Program, to ensure accuracy and completion of this Form. This Form serves to document any observed behaviors, including agitated or combative behaviors, per day and per shift. These monthly form audits referenced above will be documented by the Administrator dating and signing the review of each of the referenced forms. 7. On 11/20/2014, the facility implemented a procedure by which a designated CNA was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. This Behavior Monitoring Form allows for the documentation of resident behaviors, interventions, the reporting of the behavior(s) to the Charge Nurse and the identity of the staff member reporting the behavior, and a signature of the nurse of verification. If, during these continuous rounds conducted on the Memory Support Unit, behaviors were observed, this staff member was to intervene as necessary to de-escalate the behavior, and also to report the resident behavior to the Charge Nurse. This monitoring was actually initiated on 11/11/2014, when the staff member was immediately assigned to the Memory Support Unit to begin the continuous rounds. 8. On 11/20/2014, the facility's Interdisciplinary Team continued the process of reviewing resident Preadmission Screening and Resident Review (PASRR) Level II Assessments. This review revealed three (3) residents having PASRR Level II assessments with a recommendation for a psychiatric consultation. One (1) of these residents was seen by a psychiatrist on a regular basis. Appointments were made on 11/20/2014 for the remaining two (2) residents, identified with recommendations for a psychiatric consultation, to have a consultation with a psychiatrist. On 11/20/2014, the facility implemented a procedure by which the Administrator or Social Service Director will make a copy of each resident's PASRR, and initial and date that copy, which will then be kept in the resident's medical record. 9. On 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training related to a number of areas. In-service training was provided to staff to educate them in ways to prevent abuse, including behaviors what to report, and to whom to report observations of resident abuse. This included both physical and verbal resident behaviors. This in-service training also addressed how to identify abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. Staff were informed that any resident suspected of any alleged abuse would be protected from any further abuse by the removal of the alleged perpetrator from the facility, as deemed appropriate. Staff were advised of reporting any alleged abuse immediately to their supervisor, leading up to the Administrator, who would then report the allegation of abuse to the appropriate State and corporate agencies. In-service training was also provided regarding employment screening, via criminal background checks, reference checks, and licensure/certification verification. As of 11/20/2014, eighty-nine (89) of one-hundred-and-two (102) staff had received this in-service training. This number included thirty-three (33) of thirty-seven (37) CNA staff; thirteen (13) of fourteen (14) LPN staff; nine (9) of eleven (11) housekeepers; four (4) of five (5) laundry workers; seventeen (17) of twenty (20) dietary workers; seven (7) of eight (8) Registered Nurses; seven (7) of seven (7) department heads (not including the DON, ADON, LPN Supervisor, Senior Care Partner, and MDS Nurse) that did not include nurses, including the Activities Director, Social Worker, Maintenance Director, Financial Counselor, Medical Records, Admissions Coordinator, and Housekeeping Supervisor. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. Additionally, going forward, all employees will receive training upon hire during the orientation process, and quarterly, related to resident abuse, resident neglect, and the procedures by which to deal with residents having verbal or physical behaviors. 10. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training, originally initiated on 11/14/2014, specifically intended for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 11. On 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors. As of 11/20/2014, eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses had received this training. The remaining three (3) LPN staff and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 12. On 11/20/2014, the facility implemented a new procedure by which the results of Administrator and/or Social Service Director audits of the Admission Audit Tool, Behavior Monitoring Form, Behavior Management Documentation Form, Behavior Symptom Screening Form, Management Log Form, and Care Plan and PASRR Assessment reviews would be presented to the QA Sub-Committee each week for four (4) weeks, then monthly by the Administrator or Director of Health Services. This process will allow the QA Sub-Committee to monitor staff compliance with the facility's policies and procedures regarding residents having verbal and/or physically aggressive behaviors which could have the potential to lead to resident abuse. Audit results will also be presented to the facility's QA Committee quarterly for the Committee's review and oversight of facility staff conformance with facility policies and procedures related to the management of resident behaviors, the screening of resident behaviors, physician notification, and resident monitoring. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 11/21/2014, a review of facility investigative documents, including the facility IS, confirmed that Resident #1 was immediately placed on one-to-one observation on 11/11/2014 immediately after the incident involving Resident #1 and Resident #2, as indicated in Step #1 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records completed on that date, but which had been ongoing throughout the abbreviated survey, revealed that the Interdisciplinary Team had conducted behavioral screenings on residents for the purpose of ensuring appropriate resident placement in the Behavioral Monitoring Program, as indicated in Step #2 of the CAJR referenced above. - On 11/21/2014, a sampled review of multiple resident records, but which had been ongoing throughout the abbreviated survey, was completed and verified that resident Care Plans had been reviewed and updated by the Interdisciplinary Team, as related to physically/verbally aggressive behaviors. This was in accordance with Step #3 of the CAJR referenced above. - On 11/21/2014, review of facility investigative documents confirmed that the Medical Director had reviewed Resident #1's medical record and submitted a written summary of this information to the facility on [DATE]. This was in accordance with Step #4 of the CAJR referenced above. (Of note, on 11/20/2014 at 11:12 a.m., a telephone call had been placed to Resident #1's physician, but the physician declined interview.) - On 11/21/2014, interview with the Administrator at 11:20 a.m. confirmed that the Interdisciplinary Team will screen and review all new resident admissions, with no resident being admitted until a review of the resident's medical condition and potential for aggressive behaviors can be assessed. This review will be documented using the Admission Audit Tool. This Team will include the Administrator, DON, ADON, Admissions Personnel, an LPN Supervisor, and the Social Services Director. This was in accordance with Step #5 of the CAJR referenced above. - On 11/21/2014, facility document review and interview with the Administrator confirmed that the Administrator will be conducting monthly audits of the Resident Behavioral Symptom Screening forms, the Behavior Management Documentation Forms, the Behavior Management Log Forms, and resident Care Plans for resident requiring behavioral management services. This was in accordance with Step #6 of the CAJR referenced above. - On 11/21/2014, a 9:55 a.m. observation on the Secured Unit confirmed the presence of an assigned staff member to conduct ongoing and continuous rounds for the purpose of observing for any resident aggressive behaviors. These rounds were documented on the Behavior Monitoring Form. In addition, it was confirmed by interview with the Administrator that this process of ongoing, continuous rounds will be a permanent intervention. This was in accordance with Step #7 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records, which had been ongoing throughout the abbreviated survey, was completed and verified that the Interdisciplinary Team had reviewed all resident PASRR Level II Assessments, with the appropriate follow-up for residents needing additional psychiatric services. This action was also confirmed during an 11/21/2014, 10:45 interview with a Corporate Nursing Consultant. This was in accordance with Step #8 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted staff in-service training for staff, including (but not limited to) licensed nursing staff, CNA staff, Social Services staff, MDS staff, Medical Records staff, the Maintenance Director, and the Admissions Coordinator, regarding resident abuse and the Behavior Management Policy. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #9 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff and CNA staff, regarding resident behavior management policies and the documentation of resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #10 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff, regarding the notification of the physician for changes in condition and new resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #11 of the CAJR referenced above. - On 11/21/2014, an 11:20 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing management level oversight of the assessment, planning of care, and provision of care to residents having behavioral problems, will be reviewed by the QA Committee to provide ongoing QA Committee oversight of this care. This was in accordance with Step #12 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice had been removed on 11/21/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team will screen and review all new resident admissions, and no resident will be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool. This was, however, a new procedure, having been implemented on 11/19/2014, only two (2) days prior to the 11/21/2014 exit date of this abbreviated survey; therefore, the Interdisciplinary Team's ongoing compliance with this newly-implemented procedure could not be fully evaluated at the time of survey exit, and will need further review on a future date. On 11/20/2014, the facility implemented a new procedure by which designated staff was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. The use of this Behavior Monitoring Form was, however, only implemented as of 11/20/2014, one (1) day prior to the 11/21/2014 date of survey exit, thereby preventing the evaluation of facility staffs' ongoing compliance with the use of this Form and concomitant monitoring of aggressive resident behaviors. Such compliance will require further review on a future date. In addition, on 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training which included abuse prevention and reporting, and the identi

Based on clinical record review, facility investigation summary review, and staff interview, the facility failed to immediately consult with the physician related to the sudden onset of verbal threats and aggression of one (1) resident (Resident #1), who made multiple verbal threats of harm against another resident (Resident #2, the roommate of Resident #1), on the total survey sample of eleven (11) residents. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Interventions were developed to address Resident #1's behaviors. Resident #1 was documented as having no behaviors observed/reported from 10/01/2014 through 10/21/2014, and a 10/28/2014 Physician's Progress Note documented that Resident #1's mood, [MEDICAL CONDITION] Disorder, and [MEDICAL CONDITION] were stable. However, on 11/02/2014, Resident #1 was reported by facility staff to have made multiple verbal threats against Resident #2, including "If you don't get her, I am going to get her", and "I'm going to get that b---h." Even though Resident #1's verbal threats against Resident #2 were a change in behavior and a new behavior, the facility failed to consult with the physician to inform the physician of Resident #1's aggressive behavior and verbal threats. Then, on 11/11/2014, facility staff discovered Resident #2 not breathing, having no pulse, and with an electric cord around her neck. Resident #1 stated to facility staff that she had "killed" Resident #2, and Resident #1 was arrested and charged with felony murder and aggravated assault. This resulted in a situation in which the facility's noncompliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury, impairment or death to residents. The facility's Administrator and Corporate Consultant were informed of the immediate jeopardy on November 19, 2014 at 3:36 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on November 11, 2014, the date Resident #1 was documented as stating she had "killed" her roommate, Resident #2, after Resident #2 was found to have no respirations, no pulse, and with an electric cord around her neck, and nine (9) days after November 2, 2014, when the facility failed to enact interventions in response to Resident #1's voiced threats against Resident #2. The immediate jeopardy continued through November 20, 2014, and was removed on November 21, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on November 20, 2014. During an interview with the Administrator conducted on November 19, 2014 at 1:40 p.m., the Administrator acknowledged the November 2, 2014 incident during which Resident #1 was reported to have verbally threatened Resident #2, but also acknowledged that Resident #1's physician was not consulted regarding this change in behavior. An allegation of jeopardy removal was received on November 20, 2014. Based on the corrective plans which had been developed and implemented by the facility via a credible allegation of jeopardy removal on November 20, 2014, the immediacy of the deficient practice was determined to have been removed on November 21, 2014. The facility remained out of compliance at a lower scope and severity of "D" while the facility continued management level staff oversight of staffs' monitoring of resident behaviors, resident screening and placement in the Behavior Management Program as indicated, resident Care Plan updating and implementation regarding resident behaviors, and physician notification of resident behavioral changes, in accordance with facility policies and procedures. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about facility policies and procedures governing resident monitoring and the reporting of resident behavioral changes to supervisors and the physician, to therefore ensure resident safety. Resident records were reviewed to ensure that resident assessments and Care Plans accurately reflected the current status of residents, including the development and implementation of interventions to address aggressive behaviors. Findings include: Resident #1's Admission Minimum Data Set assessment of 09/10/2014 documented diagnoses, in Section I - Active Diagnoses, which included, but were not limited to, Hypertension, [MEDICAL CONDITION] Reflux Disease, Diabetes Mellitus, and [MEDICAL CONDITION] Disorder ([MEDICAL CONDITION]). A 09/03/2014, 4:10 p.m. Daily Skilled Nurses Notes (DSNN) entry for Resident #1 documented additional [DIAGNOSES REDACTED]. Resident #1's admission physician's orders [REDACTED]. A 09/06/2014, 5:30 a.m. DSNN entry documented that Resident #1 hit a nurse across the side of the face and refused to take any medications. DSNN entries of 09/14/2014 documented Resident #1 continued to refuse medications, and a 09/16/2014, 11:30 a.m. DSNN entry documented Resident #1 swung at a nurse and grabbed at another staff. A 09/18/2014, 7:00 a.m. DSNN entry documented Resident #1 was refusing care and that when notified, the physician ordered [MEDICATION NAME] one (1) mg each morning for escalating behaviors. In a 09/29/2014 Physician's Progress Notes entry for Resident #1, the physician documented that Resident #1 was combative and not taking medications. However, DSNN/SDNN entries completed daily for Resident #1 from 10/01/2014 through 10/21/2014 documented that no behaviors had been noted/reported for Resident #1 during that period, and a 10/28/2014 Physician's Progress Notes entry documented Resident #1's mood, [MEDICAL CONDITION], and Dementia were stable. However, an 11/02/2014, 11:00 a.m. Nurses Notes (NN) entry documented that Resident #1 made verbal threats against another resident (Resident #2, the roommate of Resident #1), and documented administration of a 0.5 ml IM dose of [MEDICATION NAME]. This was only five (5) days after the 10/28/2014 Physician's Progress Note referenced above indicated Resident #1's mood, [MEDICAL CONDITION], and Dementia were stable; but, further record review revealed no evidence to indicate that the physician was consulted regarding Resident #1's change in behavior on 11/02/14 when she verbally threatened Resident #2. Then, an 11/11/2014, 7:00 a.m. NN entry for Resident #1 documented that Resident #2 had been found not breathing, having no pulse, and an electric cord around her neck. An 11/11/2014, 7:10 a.m. NN entry for Resident #1 documented that Emergency Medical Services and a police officer had responded. A facility investigation summary (IS) into the 11/11/2014 incident involving Resident #2 (as documented in the 11/11/2014, 7:00 a.m. NN referenced above) documented that prior to 11/11/2014, on 11/02/2014, staff observed Resident #1 holding a picture of family and alleging that a family member had been murdered. The facility IS documented that Resident #1's behavior seemed to change suddenly, and that Resident #1 put the family picture in the face of Resident #2, prompting staff to redirect both residents. This IS documented that at that time, Resident #1 stated to the certified nursing assistant (CNA) "I am going to get you", then stated to staff member, "If you don't get her, I am going to get her", and later on 11/02/2014, stated to the CNA "I'm going to get that b---h", referring to Resident #2. During an 11/18/2014, 12:45 p.m. interview with the DON and Licensed Practical Nurse (LPN) "DD", LPN "DD" stated she was the nurse who administered the dose of IM [MEDICATION NAME] to Resident #1 on 11/02/2014 (as documented in the 11/02/2014, 11:00 a.m. NN referenced above). LPN "DD" stated that the behavior involving Resident #1 getting upset about a picture and verbally threatening other residents on 11/02/2014 was a new behavior. However, even though LPN "DD" acknowledged during the 11/18/2014, 12:45 p.m. interview referenced above that Resident #1's 11/02/2014 behavior of verbally threatening Resident #2 was a new behavior, record review revealed no evidence of Resident #1's physician being consulted on or after 11/02/2014 regarding Resident #1's verbally threatening behavior toward another resident. During an 11/19/2014, 1:40 p.m. interview, the Administrator acknowledged that Resident #1's physician was not consulted regarding her change in behavior when she made multiple verbal threats against Resident #2 on 11/02/2014. In the facility's IS referenced above, the facility documented that on 11/11/2014, upon responding to the room of Resident #2, a nurse found Resident #2 on the floor with an electric cord unplugged and on or near the resident's neck, and having no respirations and no pulse. This facility IS report further documented that, based on sources "close to" the police department, Resident #2's autopsy report concluded that Resident #2's trachea was crushed. This IS documented Resident #1 told a nurse consultant she "killed" Resident #2, and documented that on 11/13/2014, Resident #1 was arrested and charged with felony murder and aggravated assault. Based on the above, Resident #1 was admitted on [DATE] having [DIAGNOSES REDACTED]. Resident #1 was documented to have exhibited behavioral problems including slapping staff and pulling staffs' hair, but was not initially documented to have a history of threatening other residents. Nursing notes entries for October of 2014 documented Resident #1's behaviors had lessened, and on 10/28/2014, the physician noted Resident #1's [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION], Dementia and mood were stable. However, despite Resident #1 then exhibiting a significant change in behavior by making multiple verbal threats against Resident #2 on 11/02/2014, the facility failed to consult with the physician regarding this significant change in behavior for Resident #1. Then, on 11/11/2014, Resident #2 was found in her room with an electric cord around her neck, not breathing and having no pulse. Resident #1 stated to facility staff she had "killed" Resident #2, and was arrested and was charged with felony murder and aggravated assault. Cross refer to F323 for more information regarding Resident #1 and Resident #2. The facility presented a credible allegation of jeopardy removal (CAJR) on 11/20/2014, and it was determined that the immediate jeopardy was removed on 11/21/2014, at which time the facility had implemented the following interventions: 1. On 11/11/2014, upon the discovery of the incident of that date, Resident #1 was immediately placed on one-to-one staff observation until she was later transferred out of the facility. 2. On 11/13/2014, the facility's Interdisciplinary Team (consisting of the Administrator, DON, ADON, Admissions Personnel, LPN Supervisor, and Social Services Director) completed Behavioral Symptom Screening Forms on every facility resident. This process of resident behavior screening had been initiated on 11/12/2014. All residents screened during this process and identified as having had physical or verbal behaviors in the previous month were placed on the Behavior Monitoring Program, to ensure the monitoring of these residents and to ensure that no further behavioral interventions were necessary. All residents will have a behavior screen done upon facility admission, quarterly, upon significant change in status, and with any new behavior. 3. On 11/13/2014, the facility's Interdisciplinary Team completed a review, initially begun on 11/12/2014, of the Care Plans of all residents having any physical or verbal behaviors in the previous month. These Care Plans were revised as needed, based on these reviews. Resident Care Plans will be reviewed quarterly, annually, with a significant change in condition, and with any new behavior. 4. On 11/14/2014, the facility's Medical Director reviewed Resident #1's medical record, making no recommendations. 5. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team would screen and review all new resident admissions. This screening process would apply to all new resident admissions, and no resident would be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool, which documents: the date; the resident's name; the History and Physical; PASRR Level II; Nurse' Notes/MR notation; any Consultation Information; and a signature of the reviewer. 6. On 11/20/2014, the facility implemented a new procedure by which the Administrator would conduct a monthly audit of a minimum of 10 percent of the Resident Behavioral Symptom Screening forms and resident Care Plans for residents in behavioral management, to ensure the accuracy and completion of these documents. The Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Documentation Form for residents in behavioral management, to ensure the accuracy and completion of this Form. This Form (a previously existing form) allows for the weekly documentation of residents in the Behavior Management Program, the tracking of the effectiveness of existing behavioral interventions, and the documentation of any newly developed interventions. In addition, the Administrator will conduct a monthly audit of a minimum of 10 percent of the Behavior Management Log Forms (a previously existing form) for all residents in a Behavior Management Program, to ensure accuracy and completion of this Form. This Form serves to document any observed behaviors, including agitated or combative behaviors, per day and per shift. These monthly form audits referenced above will be documented by the Administrator dating and signing the review of each of the referenced forms. 7. On 11/20/2014, the facility implemented a procedure by which a designated CNA was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. This Behavior Monitoring Form allows for the documentation of resident behaviors, interventions, the reporting of the behavior(s) to the Charge Nurse and the identity of the staff member reporting the behavior, and a signature of the nurse of verification. If, during these continuous rounds conducted on the Memory Support Unit, behaviors were observed, this staff member was to intervene as necessary to de-escalate the behavior, and also to report the resident behavior to the Charge Nurse. This monitoring was actually initiated on 11/11/2014, when the staff member was immediately assigned to the Memory Support Unit to begin the continuous rounds. 8. On 11/20/2014, the facility's Interdisciplinary Team continued the process of reviewing resident Preadmission Screening and Resident Review (PASRR) Level II Assessments. This review revealed three (3) residents having PASRR Level II assessments with a recommendation for a psychiatric consultation. One (1) of these residents was seen by a psychiatrist on a regular basis. Appointments were made on 11/20/2014 for the remaining two (2) residents, identified with recommendations for a psychiatric consultation, to have a consultation with a psychiatrist. On 11/20/2014, the facility implemented a procedure by which the Administrator or Social Service Director will make a copy of each resident's PASRR, and initial and date that copy, which will then be kept in the resident's medical record. 9. On 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training related to a number of areas. In-service training was provided to staff to educate them in ways to prevent abuse, including behaviors what to report, and to whom to report observations of resident abuse. This included both physical and verbal resident behaviors. This in-service training also addressed how to identify abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. Staff were informed that any resident suspected of any alleged abuse would be protected from any further abuse by the removal of the alleged perpetrator from the facility, as deemed appropriate. Staff were advised of reporting any alleged abuse immediately to their supervisor, leading up to the Administrator, who would then report the allegation of abuse to the appropriate State and corporate agencies. In-service training was also provided regarding employment screening, via criminal background checks, reference checks, and licensure/certification verification. As of 11/20/2014, eighty-nine (89) of one-hundred-and-two (102) staff had received this in-service training. This number included thirty-three (33) of thirty-seven (37) CNA staff; thirteen (13) of fourteen (14) LPN staff; nine (9) of eleven (11) housekeepers; four (4) of five (5) laundry workers; seventeen (17) of twenty (20) dietary workers; seven (7) of eight (8) Registered Nurses; seven (7) of seven (7) department heads (not including the DON, ADON, LPN Supervisor, Senior Care Partner, and MDS Nurse) that did not include nurses, including the Activities Director, Social Worker, Maintenance Director, Financial Counselor, Medical Records, Admissions Coordinator, and Housekeeping Supervisor. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. Additionally, going forward, all employees will receive training upon hire during the orientation process, and quarterly, related to resident abuse, resident neglect, and the procedures by which to deal with residents having verbal or physical behaviors. 10. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training, originally initiated on 11/14/2014, specifically intended for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 11. On 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors. As of 11/20/2014, eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses had received this training. The remaining three (3) LPN staff and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work, and will not be allowed to work until in-service is completed. 12. On 11/20/2014, the facility implemented a new procedure by which the results of Administrator and/or Social Service Director audits of the Admission Audit Tool, Behavior Monitoring Form, Behavior Management Documentation Form, Behavior Symptom Screening Form, Management Log Form, and Care Plan and PASRR Assessment reviews would be presented to the QA Sub-Committee each week for four (4) weeks, then monthly by the Administrator or Director of Health Services. This process will allow the QA Sub-Committee to monitor staff compliance with the facility's policies and procedures regarding residents having verbal and/or physically aggressive behaviors which could have the potential to lead to resident abuse. Audit results will also be presented to the facility's QA Committee quarterly for the Committee's review and oversight of facility staff conformance with facility policies and procedures related to the management of resident behaviors, the screening of resident behaviors, physician notification, and resident monitoring. During this abbreviated survey, the State Survey Agency reviewed the corrective actions implemented by the facility, as reflected in the CAJR referenced above, with findings as follow: - On 11/21/2014, a review of facility investigative documents, including the facility IS, confirmed that Resident #1 was immediately placed on one-to-one observation on 11/11/2014 immediately after the incident involving Resident #1 and Resident #2, as indicated in Step #1 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records completed on that date, but which had been ongoing throughout the abbreviated survey, revealed that the Interdisciplinary Team had conducted behavioral screenings on residents for the purpose of ensuring appropriate resident placement in the Behavioral Monitoring Program, as indicated in Step #2 of the CAJR referenced above. - On 11/21/2014, a sampled review of multiple resident records, but which had been ongoing throughout the abbreviated survey, was completed and verified that resident Care Plans had been reviewed and updated by the Interdisciplinary Team, as related to physically/verbally aggressive behaviors. This was in accordance with Step #3 of the CAJR referenced above. - On 11/21/2014, review of facility investigative documents confirmed that the Medical Director had reviewed Resident #1's medical record and submitted a written summary of this information to the facility on [DATE]. This was in accordance with Step #4 of the CAJR referenced above. (Of note, on 11/20/2014 at 11:12 a.m., a telephone call had been placed to Resident #1's physician, but the physician declined interview.) - On 11/21/2014, interview with the Administrator at 11:20 a.m. confirmed that the Interdisciplinary Team will screen and review all new resident admissions, with no resident being admitted until a review of the resident's medical condition and potential for aggressive behaviors can be assessed. This review will be documented using the Admission Audit Tool. This Team will include the Administrator, DON, ADON, Admissions Personnel, an LPN Supervisor, and the Social Services Director. This was in accordance with Step #5 of the CAJR referenced above. - On 11/21/2014, facility document review and interview with the Administrator confirmed that the Administrator will be conducting monthly audits of the Resident Behavioral Symptom Screening forms, the Behavior Management Documentation Forms, the Behavior Management Log Forms, and resident Care Plans for resident requiring behavioral management services. This was in accordance with Step #6 of the CAJR referenced above. - On 11/21/2014, a 9:55 a.m. observation on the Secured Unit confirmed the presence of an assigned staff member to conduct ongoing and continuous rounds for the purpose of observing for any resident aggressive behaviors. These rounds were documented on the Behavior Monitoring Form. In addition, it was confirmed by interview with the Administrator that this process of ongoing, continuous rounds will be a permanent intervention. This was in accordance with Step #7 of the CAJR referenced above. - On 11/21/2014, a sampled review of resident records, which had been ongoing throughout the abbreviated survey, was completed and verified that the Interdisciplinary Team had reviewed all resident PASRR Level II Assessments, with the appropriate follow-up for residents needing additional psychiatric services. This action was also confirmed during an 11/21/2014, 10:45 interview with a Corporate Nursing Consultant. This was in accordance with Step #8 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted staff in-service training for staff, including (but not limited to) licensed nursing staff, CNA staff, Social Services staff, MDS staff, Medical Records staff, the Maintenance Director, and the Admissions Coordinator, regarding resident abuse and the Behavior Management Policy. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #9 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff and CNA staff, regarding resident behavior management policies and the documentation of resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #10 of the CAJR referenced above. - On 11/21/2014, review of facility staff in-service documentation, to include facility Inservice Report Sign-In Sheet Form review, revealed that the facility had conducted additional staff in-service training, specific for licensed nursing staff, regarding the notification of the physician for changes in condition and new resident behaviors. All staff having not yet completed this in-service training will receive training upon their return to work. This was in accordance with Step #11 of the CAJR referenced above. - On 11/21/2014, an 11:20 a.m. interview with the Administrator confirmed that the results of all audits, as referenced in the CAJR intended to provide ongoing management level oversight of the assessment, planning of care, and provision of care to residents having behavioral problems, will be reviewed by the QA Committee to provide ongoing QA Committee oversight of this care. This was in accordance with Step #12 of the CAJR referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined in the CAJR referenced above, it was determined that the immediacy of the deficient practice had been removed on 11/21/2014; however, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On 11/19/2014, the facility implemented a procedure by which the Interdisciplinary Team will screen and review all new resident admissions, and no resident will be admitted until a detailed review of the resident's mental condition and the potential for aggressive or physical behaviors can be assessed. This resident screening and review will be documented on the Admission Audit Tool. This was, however, a new procedure, having been implemented on 11/19/2014, only two (2) days prior to the 11/21/2014 exit date of this abbreviated survey; therefore, the Interdisciplinary Team's ongoing compliance with this newly-implemented procedure could not be fully evaluated at the time of survey exit, and will need further review on a future date. On 11/20/2014, the facility implemented a new procedure by which designated staff was to document, using the Behavior Monitoring Form, continuous rounds in the Memory Support Unit on the hallways and resident areas to monitor for any aggressive resident behavior. The use of this Behavior Monitoring Form was, however, only implemented as of 11/20/2014, one (1) day prior to the 11/21/2014 date of survey exit, thereby preventing the evaluation of facility staffs' ongoing compliance with the use of this Form and concomitant monitoring of aggressive resident behaviors. Such compliance will require further review on a future date. In addition, on 11/20/2014, the facility's Interdisciplinary Team continued to provide staff in-service training which included abuse prevention and reporting, and the identification of abuse by observation of residents having suspicious bruising, showing signs of being afraid, or patterns of behaviors. As of 11/20/2014, thirty-three (33) of thirty-seven (37) CNA staff, thirteen (13) of fourteen (14) LPN staff, nine (9) of eleven (11) housekeepers, four (4) of five (5) laundry workers, seventeen (17) of twenty (20) dietary workers, and seven (7) of eight (8) Registered Nurses had received this in-service training. The remaining four (4) CNA staff, one (1) LPN staff, two (2) housekeepers, one (1) laundry worker, three (3) dietary workers, and one (1) Registered Nurse who had not been available due to being off duty or on leave will receive this in-service training upon their return to work. On 11/20/2014, the Interdisciplinary Team continued to conduct additional staff in-service training for licensed nursing staff and CNA staff regarding the resident behavior management policies and the documentation of resident behaviors. As of 11/20/2014, six (6) of eight (8) Registered Nurses, thirteen (13) of fourteen (14) LPN staff, and thirty-one (31) of thirty-seven (37) CNA staff had received this in-service training. The remaining two (2) Registered Nurses, one (1) LPN, and six (6) CNA staff will need to receive this in-service training upon their return to work. Also, on 11/20/2014, staff in-service training was conducted regarding the notification of the physician of a change in condition and of new resident behaviors for eleven (11) of fourteen (14) LPN staff and seven (7) of eight (8) Registered Nurses, but the remaining three (3) LPN staff and one (1) Registered Nurse will receive this in-service training upon their return to work. Therefore, due to multiple licensed and certified staff members yet remaining to receive in-service training at the time of survey exit, their completion of this required training could not be assessed at the time of survey exit, and will need to be evaluated at a future time. Therefore, due to the need for future evaluation and assessment of the facility's ongoing compliance with newly-implemented procedures regarding the assessment, supervision, and monitoring of residents having aggressive behaviors, to include pending staff in-service training regarding these issues, the noncompliance continues, with the scope and severity of the deficiency reduced to the "D" level.