Every finding on record at PruittHealth- North Augusta

Based on observation, interview, and facility policy review, the facility failed to store and label medications with an opened date on 2 (Medication Cart 1 and Medication Cart 2) of 3 medication carts reviewed. Findings included: Review of a facility policy titled, Medication Storage Policy, revised 11/10/2025, indicated, It is the policy of [facility name] to ensure all medications are stored, secured, and maintained in accordance with federal, state, and facility standards to promote patient safety and regulatory compliance. During a concurrent interview and observation of a Medication Cart 2 located at Nursing Station 2 on 05/27/26 at 11:17 AM, the surveyor noted there was one, round, blue-colored pill under a medication bubble-pack card inside the locked narcotic drawer. Registered Nurse (RN)1 identified the loose pill as clonazepam, a controlled medication used to treat seizures, panic attacks, and anxiety. Also noted was an undated, opened box that contained a foiled package that contained ipratropium bromide 0.5 milligrams (mg) and albuterol sulfate 3 mg. RN1 stated the box and foiled package did not include an opened date, but it should have. During a concurrent interview and observation of Medication Cart 1 located at Nursing Station 1 on 05/27/26 at 1:04 PM, the surveyor noted an undated plastic bag that contained a bottle of morphine sulfate. Licensed Practical Nurse (LPN)2 confirmed the bag did not have an opened date and stated that another nurse had recently opened the medication. During a telephone interview on 05/28/26 at 4:28 PM, the Pharmacy Consultant stated medications should be labeled with an opened date to ensure proper tracking and reflected best practice. During an interview on 05/29/26 at 3:33 PM, the Director of Nursing (DON) stated she expected staff to properly label medications with an opened date. The DON explained that without an opened date, staff could not determine a medication's expiration, which could result in the use of ineffective medications. The DON stated unsecured medications in a medication cart posed a safety risk and could result in medication errors if residents received incorrect or missed doses.

Based on interview, record review, and review of facility policy, the facility failed to protect Resident (R)5 from physical abuse/mistreatment by Certified Nursing Assistant (CNA)1, for 1 of 4 residents reviewed for abuse.Findings include:Review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property last revised on 10/27/20 revealed, It is the policy of [NAME] Health and its entities to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment, and misappropriation of patient property. The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. This policy applies to the entire organization, and all partners, volunteers, contractors, staff of other agencies serving patients, family members, legal guardians, friends, or other individuals who come into contact with patients, including other patients. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Abuse includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Abuse also includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitation or enabled through the use of technology. Mistreatment is defined as the inappropriate or treatment or exploitation of a patient. Providers are to identify, correct, and intervene in situations in which abuse, neglect, mistreatment, or exploitation may occur.Review of R5's Face Sheet revealed R5 was admitted to the facility on [DATE], with diagnoses including but not limited to acute and chronic respiratory failure with hypoxia, dementia without behaviors, dysphasia following cerebral infarction, and muscle weakness.Review of R5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/19/25, revealed that a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated that R5 was cognitively intact. Further review of the MDS revealed that R5 had no behaviors during this assessment period and is dependent on staff for most Activities of Daily Living (ADL).Review of the Facility reported Five-Day Follow-Up Report dated 10/16/25 revealed, Interventions by facility to prevent future injury/alleged abuse; residents were interviewed, staff were interviewed to see if additional witness existed. [R5] said that [CNA1] did 'pop' him with her hand. He would like for her to continue to provide care for him, [CNA1] was terminated from employment. Staff educated on abuse as well as creating a homelike environment while maintaining professional standards. Summary report of facility investigation includes; Medical Doctor (MD), police, and Ombudsman were notified. [CNA1] was suspended pending investigation, after review of resident interview and staff statements, no other witnessed the abuse. No other residents were similarly affected. Body audit showed no injury was sustained. [R5] and his Resident Representative (RR) would like [CNA1] to continue to provide care to resident and appreciate the rapport she has built with resident over time however, [CNA1] crossed professional boundary and was terminated from employment. Resident referred to mental health for psychosocial support, staff educated on abuse as well as creating a homelike environment while maintaining professional standards, residents to be educated on abuse in resident council meeting.Review of CNA1's Witness Statement revealed, I [CNA1] was in room (redacted) to change [R5]. [R5] and I was joking around something we always do on a daily when [R5] said a joke about my mom. I told [R5] okay stop playing and [R5] attempted to kick me. I once again stated to [R5] to stop playing so I can finish cleaning him up from his bowel movement, I asked him to turn on his side and tapped him on the side of his thigh to turn over. I was able to complete patient care and ask the resident if he needed anything else and he stated yes (the chicken out of the microwave). I told the resident I will be back to check on him before the end of my shift and continued my rounds.Review of CNA2's Witness Statement revealed, I was on the linen cart that was in-between rooms (redacted and redacted) when I witnessed [CNA1] hit [R5]. She [CNA1] told him to swing his leg into the bed and [R5] said 'no', she popped him and he popped her arm back. They started passing lick back and forth, I went and told the nurse what I saw.Review of Licensed Practical Nurse (LPN)1's Witness Statement revealed, I received report from [CNA2] that [R5] was hit by [CNA1]. I went down and checked on the resident and reported it to the Director of Nursing immediately. A body audit was completed, and resident had complaints of pain in his leg, as needed pain medication was administered.During an observation and interview on 02/12/26 at 3:16 PM, R5 revealed that he was unable to recall the incident with CNA1. R5 denied being abused while a resident at the facility and stated that he feels safe with staff.During a phone interview on 02/12/26 at 3:44 PM, CNA2 revealed that they witnessed CNA1 hit R5, they immediately reported this incident to the nurse on duty.During an attempted phone interview on 02/12/26 at 4:03 PM, with LPN1 was unsuccessful, a voicemail was left with callback information.During a phone interview on 02/12/26 at 4:12 PM, CNA1 revealed, I remember [R5], I took care of him when I worked for the facility. Some days he would be okay, and other days he would act out (say sexually inappropriate things to staff/refuse care, and become physical with staff). I was fired because of this incident from the facility because they told me I had abuse and neglect training and knew the policies. [R5] and I had a playful relationship, on that day [R5] was being resistant to care and saying inappropriate things, so I told him to roll over and lightly/playfully tapped him on his leg/thigh. Another staff member told me and said that I hit the resident in an abusive manner, but I don't understand how she saw/witnessed that because I had the door closed when I was providing care.During an interview on 02/12/26 at 5:04 PM, the Director of Nursing (DON) revealed I was informed by LPN1 that CNA2 witnessed CNA1 hit R5. I was not at the facility at this time but instructed LPN1 to protect R5 and send CNA1 [sic], we then informed [R5's] Resident Representative and other parties (state agency, Medical Doctor MD, law enforcement, etc). When we began our investigation, [CNA1] admitted to popping [R5] on his thigh in a playful manner and later reported this incident to the CNA licensing board as well. [CNA1] was terminated from the facility due to this incident.During an interview on 02/12/26 at 5:41 PM, the Administrator revealed that CNA1 was terminated due to this incident with R5 and the facility substantiated the allegation of abuse.

Based on review of facility policy, observations, and interviews, the facility failed to maintain resident safety from potential harm for 1 of 1 residents reviewed. Specifically, a staff member did not follow facility policy regarding a Hoyer lift transfer, resulting in Resident (R)9 falling to the floor.Findings Include:A review of the facility policy titled Clinical Procedure: Transfers with Mechanical Lift, with no revision date, revealed At least two staff members are needed to operate a mechanical lift. Raise the lift until it can safely go over the person. Position the lift over the person. Open the spreader bar so the legs are in the widest position. Lock the wheels on the legs. Lower the lift until it is just over the person. Attach the straps on the sling to the lift with the hook facing away from the person. Cross the person's arms. Raise the lift high enough that the person and sling are no longer touching the surface. One person moves the lift while the other person supports the individual's legs. Position the lift so the person's back is toward the back of the receiving chair or wheelchair. One person lowers the individual slowly into the chair while the other person guides the individual into the chair for proper body alignment. Unhook the sling from the lift. Raise the lift and remove it from the area. Remove the sling from under the person. After the procedure: Document the procedure and results per your organization's policy. Notify the provider of any abnormal findings. A review of R9's Face Sheet revealed that R9 was admitted to the facility on [DATE] at 02:40 PM with diagnoses to include, but not limited to, cerebrovascular disease, muscle weakness, restless legs syndrome, edema and other lack of coordination.A review of R9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/06/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating she was cognitively intact. Further review of R9's MDS showed that she is dependent for transfers, including chair/bed-to-chair and tub/shower transfers.A review of R9's Care Plan revealed Resident at risk for falls related to impaired mobility and side effect of medication - needs full body lift for transfer. 9/5/25- fall. Goal: R9 will not sustain an injury related to falling through the next review. Approach: Assist for transfers using full-body mechanical lift once sufficient staff is obtained. Start Date: 02/04/2024A review of R9's Progress note dated 09/06/2025 at 01:58 AM states: Resident resting at present, no distress or complaints related to post fall. Neurological status at resident's baseline. Denies pain or discomfort.A review of R9's Progress note dated 09/08/2025 08:25 AM states, 09/05/25, 1015 - During AM med pass, writer entered room. Observed resident on floor within Hoyer lift net sling, slings attached to Hoyer lift, and wheelchair adjacent to resident. Assigned nurse aide stated the brakes on the wheelchair failed to engage, and caused the lift to lose balance. Nurse assessed pt, no change in ROM observed, no change in orientation noted, resident able to track finger, verbally responsive to commands. Assigned nurse aide denied head involvement upon observation of fall. Resident reported mild pain to buttocks, administered PRN Acetaminophen. No new affected skin areas observed from fall. Neuro checks in progress, no change in baseline. Resident socializing with other residents in activity room. Writer attempted to reach RP sister, no answer. Provider made aware. Plan of care ongoing.A review of R9's post-fall observation report dated 09/06/2025 revealed, Witnessed fall, during transfer to chair. Resident location prior to fall- in bed. Potential factors could have contributed to the fall, not using a 2-person transfer. Measures to be taken to prevent further falls- Staff education. Due to positive COVID-19 status, observation and interview was unable to be conducted with R9 on 12/03/2025.Attempts were made to contact R9's Responsible Party (RP) via phone on 12/03/2025 at 1:00 and 1:19 PM- Unsuccessful both times, and a detailed message was left for a return call.An interview with Certified Nursing Aide (CNA)1 on 12/03/25 at 12:45 PM via phone revealed that on Friday, September 5th, she was doing rounds and making her way to Rooms 117 A & B. She stated she provided a brief change to R9's roommate first because she knew R9 would take longer. CNA1 stated that R9 requires a Hoyer lift for transfers, which requires two people to assist. She reported that although there were other CNAs working on the floor, none were available to help her transfer R9 from the bed to the chair. CNA1 stated she cleaned R9, got her dressed, and was on her way to grab the lift. When she was in the process of using the lift, she noticed that a wheel on the lift got stuck and that R9's arm was out of the sling. CNA1 stated that the Hoyer lift was approximately at her stomach/hip level from what she could recall. She stated that as soon as she noticed the issue, she stopped to reposition everything, and that is when R9 dropped to the ground, landing on her bottom. CNA1 stated that R9 did not hit her head and did not have any injuries that she could recall. She stated that other staff heard a loud noise and came into the room to assist her and R9. CNA1 reported that the nurse on duty entered the room, obtained R9's vital signs, assessed her, and assisted in getting her into her wheelchair. R9 then continued with her day. CNA1 stated that she spoke with the nurse, who informed her he would document the incident, and that they kept tabs on R9's vital signs for the remainder of the day. CNA1 stated that at the end of her shift, she checked on R9, who reported that her bottom was sore but denied pain. CNA1 also stated that she is no longer employed with the facility following this incident. CNA1 stated that prior to this incident, she had completed her annual competency, which included how to use a lift, and she had been successfully signed off on it.An interview with Licensed Practical Nurse (LPN)1 on 12/03/25 at 12:46 PM revealed that she recalls the incident involving R9 and CNA1. LPN1 stated, On 09/05/25, she was standing at the medication cart at the nurse's station with LPN2 as he was preparing medications to administer. They heard screams for help coming from R9's room. A few CNAs (CNA3 and CNA4) proceeded to the room along with LPN1 and LPN2. Upon arriving, LPN1 witnessed R9 on the floor on her buttocks and CNA1 at her side. LPN2 did not stay to assist, as he was headed to finish administering morning/afternoon medications to other residents. LPN1 stayed to assist and noticed that the wheelchair was stuck on the Hoyer lift, but the lift itself was in an upright position. LPN1 asked R9 if she had hit her head, and R9 replied no. LPN1 also asked if she was hurting anywhere, and R9 stated, my a**, I fell on my a**. LPN1 stated they were able to free the wheelchair from the Hoyer lift. She assisted CNAs 1, 2, and 4 with carefully maneuvering R9 from the floor to her wheelchair using the Hoyer lift. After securing R9 in her wheelchair, LPN1 obtained a set of vital signs, as LPN2 had requested. After obtaining her vitals, LPN1 stated that she watched R9 apply her lipstick and wheel herself down the hallway. LPN1 then provided the obtained vital signs to LPN2. LPN1 stated that when she first entered the room, CNA1 was the only aide operating the lift, which contributed to the fall. LPN1 stated that following this event, the facility conducted an in-service related to Hoyer lifts and transfers.An interview with CNA4 on 12/03/25 at 1:10 PM revealed that she is familiar with R9 and stated that on 09/05/25, she was on her way to get the Hoyer lift from R9's room. While on the way, CNA4 stated she heard loud booming noises. The nurses at the nurse's station also heard the noise, and all of them ran to R9's room. CNA4 stated that she saw R9 on the floor, still hooked up to the Hoyer pad on the lift, lying on her back. The Hoyer lift was on R9, with one of its legs resting on her chest/stomach, and the wheelchair was tilted on the Hoyer lift. LPN1 and LPN2 asked CNA4 to assist with removing the lift from the resident, while CNA1 stood and watched. LPN2 instructed them to place R9 back in her wheelchair instead of returning her to bed. CNA4 stated that there was no other aide in the room assisting CNA1, and she did not recall CNA1 asking her for help. From what she observed, R9 did not have any injuries.An interview with LPN2 on 12/03/25 at 1:39 PM revealed that he remembers the encounter on 09/05/2025 with R9. He stated that he was R9's nurse that day. LPN2 stated that he did not witness the incident; however, he heard a loud clash while in the middle of medication pass. He immediately locked the cart and rushed into R9's room, where he found her on the floor, still strapped to the Hoyer lift. Other staff arrived around the same time. LPN2 stated that CNA1 did not have anyone assisting her at the time of the incident. R9 was assessed and had no open areas, nor any signs or symptoms of injury or pain. LPN2 stated that he monitored the resident for the remainder of his shift. R9 complained of soreness but denied any pain. LPN2 stated that the occurrence occurred during the weekend, when the Administrator and the DON were not in the building. He reported that he called the DON to inform her of R9 having a fall but did not provide details about the Hoyer lift or that CNA1 admitted to using the lift alone. LPN2 stated that he takes full accountability for the oversight, attributing it to being distracted during medication pass. LPN2 stated that the following week, when the investigation was initiated, he was terminated due to this incident.A review of the Termination Record of Partner Corrective Action Form dated 09/10/2025 for Certified Nursing Assistant (CNA)1 states, Serious Rule Violation- During the course of investigation for a fall, partner was identified as the CNA completing a transfer with a resident. The investigation showed that the CNA was utilizing a hoyer lift alone. Partner admitted this to the nurse on duty. Partner confirmed with the DHS that she was alone with the hoyer lift. 5 CNAs and 3 nurses were currently on the unit. There is never a reason to violate policy and multiple staff were available to assist. Partner signed off on most recent skills fair including hoyer lifts and transfers on 08/29/2025. For the safety of all residents, partners are expected to comply with policy. The partner has been terminated from [NAME] Health North [NAME]. A review of the Termination Record of Partner Corrective Action Form dated 09/10/2025 for Licensed Practical Nurse (LPN)2 states, Serious Rule Violation-During the course of investigation for a fall, the partner was the nurse on duty. He was alerted to the fall when he heard the clatter in the room. CNA admitted to him that she was using the Hoyer lift alone. The partner failed to send the CNA home when the policy violation was realized. Partner monitored CNA to make sure she was following policy the rest of the shift. The partner has been terminated from [NAME] Health North [NAME].An interview with the Facility Administrator (FA) on 12/03/25 at 4:27 PM, in the presence of the Director of Health Services (DHS), revealed that the FA is responsible for the submission of reportables, and the DHS assists with investigating the clinical aspects. The FA stated that DHS and she received a phone call from LPN2 on 09/05/25, reporting that R9 had a witnessed fall, there were no injuries, and the resident did not complain of pain or discomfort. Over the weekend, new staff, as well as R9's roommate at the time, commented to the new nurse and CNAs on duty about the incident on 09/05/25. The FA stated that this resulted in numerous calls and texts reporting that the fall occurred because CNA1 did not follow facility protocol with the Hoyer lift. The FA stated that DHS reached out to LPN2 and CNA1 on Sunday to schedule a meeting for the following Monday. LPN2 attended the meeting, but CNA1 did not show up. During the meeting, DHS discussed documentation with LPN2, who was forthcoming about withholding information. He admitted that he had observed only one aide operating the lift, did not question the fall, and allowed CNA1 to continue working. Following this, LPN2 was terminated. Regarding CNA1, the FA stated that she submitted her resignation letter via email; she was scheduled to come to the facility that day. The FA stated that clinical staff are educated on resident transfers at the time of hire and at least annually. Equipment is maintained with a preventative maintenance schedule, including regular inspections by the company that provides the lifts, and were reassessed by facility maintenance following the event, with no issues noted. The FA also stated that CNA1 had completed her annual training the month prior, which included instruction on the use of mechanical lifts. Audits were conducted on transfer status for all residents, and all clinical staff were re-educated on transfer policy. This event was also discussed in QAPI meeting in September 2025. Some follow up actions included having all staff demonstrate how to use the lifts, and periodic review on lifts to ensure no deviation from policy. The CNA who executed the transfer in question was terminated for failure to follow facility policy. Lastly, the FA and DHS stated that their expectation of all clinical staff is to follow facility policy and to ensure that all resident transfers are conducted safely and in accordance with established procedures at all times.

Based on observations, interviews, and facility policy review, the facility failed to ensure that one of six medication carts (200 hall), a medication patch for (Resident (R) 64), and medical supplies for (R107) were properly secured out of a total resident census of 119. This had the potential to cause medication diversion, medication administration errors, and unsanitary medical supplies from being used for the resident. Findings include: Review of the facility's policy titled, Medication Administration: General Guidelines dated 04/10/2019 revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication .Medications are prepared, administered, and recorded only by licensed nursing, medical, or pharmacy personnel .During routine administration of medications, the medication cart is kept in the doorway of the patient/resident's room, with open drawers facing inward and all other sides closed and locked. No medications are kept on top of the cart, and all outward sides must be inaccessible to patients/residents or others passing by . 1. During an observation on 04/21/25 at 9:26 AM, an unlocked and unattended medication cart was observed on the 200-unit hallway near room [ROOM NUMBER]. Approximately a minute later, Licensed Practical Nurse (LPN) 2 exited the resident room. LPN2 confirmed she should not leave the medication unlocked and unattended. The Nursing Home Administrator was observed approaching the 200-unit at this time, and also confirmed the medication cart should have been locked when the nurse went into the resident room. 2. During an observation and interview on 04/21/25 at 10:25 AM, a pain relief pad 4% maxpad was observed lying across the overbed table in R64's room. It was dated 04/21. R64 stated it was a Lidocaine patch for the pain in her shoulder, and that the nurse was going to put it on her soon. Review of R64's Face Sheet, located in the Resident tab of the electronic medical record (EMR) revealed R64 was admitted to the facility on [DATE] with diagnoses that included encounter for palliative care, epilepsy, and chronic kidney disease. Review of R64's EMR titled quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/21/25, revealed a Brief Interview for Mental Status (BIMS) score of nine out of 15, which indicated the resident had moderate cognitive impairment. The assessment indicated the resident required substantial/maximum for bed mobility and was dependent on staff for transfers. Review of R64's EMR titled Physician Orders located under the Resident tab and dated 03/19/24, indicated [R64] pain relief pad 4% maxpad .apply to right shoulder for twelve hours, then remove for twelve hours . During an interview on 04/21/25 at 10:28 AM, LPN3 stated she was going to put the patch on R64 after she had finished her breakfast. She confirmed she had left the Lidocaine patch on the resident's table unsupervised and stated she normally did not leave medication unattended. LPN3 said she had gone to a different resident room for a minute and was letting R64 finish breakfast. 3. During an observation on 04/21/25 at 11:56 AM, an opened Enteral Feeding Tube Clog Remover, size 16 French and length 39.5cm (centimeters), was observed lying across the overbed table in R107's room. R107 was observed holding the items, swinging it around, and attempting to pull out the tubing from the packaging. Review of R107's Face Sheet, located in the Resident tab of the EMR revealed R107 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease and abnormal weight loss. Review of R107's EMR titled admission MDS with an ARD of 03/11/25, revealed a BIMS score of 00 out of 15, which indicated the resident had significant cognitive impairment. The assessment indicated the resident had no upper extremity impairment and was dependent on activities of daily living. Review of R107's EMR titled Physician Orders located under the Resident tab and dated 04/02/25, indicated [R107] Glucerna 1.5 full strength via G [gastrostomy] tube .every shift . During an interview on 04/21/25 at 12:00 PM, LPN3 said the medical supply left on R107's table was to be used for his gastrostomy tube. She took the tubing and put it in the resident's nightstand drawer and said it was not for R107 to handle. During an interview on 04/21/25 at 12:04 PM, LPN4 said she had been busy helping a staff member with a resident shower. She stated she should not have left the tubing for the resident to handle. During an interview on 04/23/25 at 10:55 AM, the Nursing Home Administrator stated that all staff knew to keep medication carts locked up when unattended, to keep medications stored safely and not unattended with residents, and to not leave medical supplies, such as tubing, by resident bedsides. She stated nursing staff were educated on this. During an interview on 04/23/25 at 11:45 AM, the Director of Nursing said that all nurses were supposed to keep medication carts unlocked, to keep medications secured. She confirmed medications and medical supplies, such as tubing, should not be left unattended.

Based on observation and interview, the facility failed to ensure Resident (R)2's call light was within reach and operational for 1 of 5 residents reviewed. Findings include: The facility did not provide a policy regarding Call Lights. Review of R2's Face Sheet revealed R2 was admitted to the facility on [DATE], with diagnoses including but not limited to: heart disease, dysphagia, vascular dementia, and diastolic heart failure. Review of R2's Significant Change of Status Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/25/24, revealed a Brief Interview of Mental Status (BIMS) score of 99 indicating R2 refused to answer questions. During an observation on 04/23/24 at 10:54 AM, R2 was lying in bed with a blanket covering him. R2's call light was not able to be located. During an observation on 04/23/24 at 12:10 PM, R2 was lying in bed covered with a blanket. R2's call light could not be located. During an observation and interview on 04/23/24 at approximately 12:10 PM, a Floor Technician (FT) observed the call light on the back wall behind the head of the bed. Further observation revealed it was a call light cord sticking out of the wall approximately 1 or 2 inches. The FT confirmed it was the call light cord and pulled it out of the wall and stated, This appears like it was cut. During an interview on 04/23/24 at 12:19 PM, Certified Nursing Assistant (CNA)1 confirmed R2 was able to use the call light if he needed to. During and observation and interview on 04/23/24 at 12:22 PM, Respiratory Therapist (RT)1 and RT2 entered R2's room and asked if there was a concern, as the call light was on in the room. They observed the call light and said, It looks like it has been cut. During an interview on 04/23/24 at 2:27 PM, the Maintenance Director (MD) stated, The call cords get stuck if they are wrapped around the bedrails or get caught in the bedframe. They snap off and break. During an interview on 04/23/24 at 12:50 PM, the Administrator stated, I'm not aware of any call cords that are broken. The company does not have a call light policy. I would expect all call lights to be within reach and working.

Based on interviews, record reviews, and facility policy review, the facility failed to ensure narcotic pain medication that was ordered for 3 (Residents (R)1, R2, and R3) of 4 sampled residents was not misappropriated by staff. Findings include: Review of the facility policy titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property Mission Statement, revised on 11/21/2016, revealed, It is the mission of [name of the facility] and its affiliated providers actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patients property. Review of the facility Five-Day Follow-Up Report, dated 12/15/2023, revealed during medication administration on 12/08/2023 at 5:00 AM, Licensed Practical Nurse (LPN)2 noticed an oxycodone pill (a narcotic pain medication) for R1 came out of the punch card package too easily. Upon examination, LPN2 could tell that the pill was not oxycodone and the medication packaging had been tampered with. The facility's investigation report revealed LPN2 inspected the pills in the punch card package labeled oxycodone and found two of three of the medications in was famotidine (medication used to treat acid reflux/heartburn). Upon completion of medication cart review, the facility found three medication cards had been tampered with and there was a total of 11 missing narcotic pain medications for three residents. The facility's investigation revealed four of eight oxycodone pills for R3 had also been replaced with famotidine and five of 22 hydrocodone pills for R2 had been replaced with sodium bicarbonate pills (a medication used to treat heartburn/acid reflux). 1. Review of R1's Resident Face Sheet revealed the facility admitted the resident on 09/23/14, with diagnoses including but not limited to: traumatic hemorrhage of cerebrum, urethral stricture, urinary tract infection, chronic pain syndrome, and traumatic brain injury with loss of consciousness of unspecified duration. Review of R1's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/13/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated the resident had moderate cognitive impairment. According to the MDS, the resident received a scheduled pain medication regimen. Review of R1's Care Plan last reviewed/revised on 12/17/23, revealed the resident was at risk for pain secondary to diagnoses of gastrointestinal reflux disease and a history of cerebral vascular accident/transient ischemic attack. Review of R1's Physician Order Report revealed an order dated 09/25/23, for oxycodone 5 milligram (mg) tablets, one tablet every eight hours. During an interview on 02/27/24 at 10:30 AM, R1 stated they were not in pain and had no concerns with the administration of pain medication. During an interview on 02/28/24 at 3:00 PM, Registered Nurse (RN)3 stated R1 received routine pain medication and did not complain of pain. 2. Review of R2's Resident Face Sheet revealed the facility admitted the resident on 01/19/22, with diagnoses including but not limited to: chronic pain syndrome, peripheral vascular disease, and spinal stenosis of the lumbar region with neurogenic claudication. Review of R2's quarterly MDS, with an ARD of 01/11/24, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. According to the MDS, the resident received a scheduled pain medication regimen. Review of R2's Care Plan last reviewed/revised on 01/17/24, revealed the resident was at risk for experiencing pain due to a diagnosis of cervical spine compression. Review of R2's Physician Order Report revealed an order dated 10/23/23, for hydrocodone-acetaminophen 7.5 milligram (mg)/325 mg tablet every twelve hours at 9:00 AM and 9:00 PM for spinal stenosis of the lumbar region with neurogenic claudication. During an interview on 02/27/24 at 10:45 AM, R2 stated they had no concerns with receiving their pain medication. During an interview on 02/28/24 at 3:00 PM, RN3 stated R2 received routine pain medication and did not complain of pain. 3. Review of R3's Resident Face Sheet revealed the facility admitted the resident on 06/30/23, with diagnoses including but not limited to: osteomyelitis, pressure ulcers, and chronic pain syndrome. Review of R3's quarterly MDS with an ARD of 12/29/23, revealed the resident had a BIMS score of 15 out 15, which indicated the resident was cognitively intact. According to the MDS, the resident received as needed pain medication. Review of R3's Care Plan last reviewed/revised on 02/22/24, revealed the resident had pain related to paraplegia. During an interview on 02/27/24 at 10:50 AM, R3 stated they had no concerns with the administration of their pain medication. During an interview on 02/28/24 at 10:47 AM, Licensed Practical Nurse (LPN)2 stated on 12/08/23 at approximately 4:00 AM or 5:00 AM, she noticed that R1's oxycodone medication came out of the package/card very easy. LPN2 stated she could see that the back of the oxycodone medication card was altered, and the medication was replaced with Pepcid (name brand for famotidine). LPN2 stated famotidine pills looked similar to oxycodone but had a different number on the pill. LPN2 stated she immediately called the previous Director of Health Services (DHS). LPN2 stated when she received the medication cart from RN3, she did not look at the back of the medication packages. During an interview on 02/27/24 at 5:14 PM, RN3, who worked the morning shift from 7:00 AM to 7:00 PM, stated she did not remember exactly when the incident happened. RN3 stated she did not notice any discrepancies with the pill packs. RN3 stated she examined the front and back of the narcotic pill packages and examined the medication to verify the count before assuming responsibility of the medication cart. Review of the facility witness statement for LPN1 dated 12/08/23, revealed the LPN did not notice or see any unusual discrepancies with narcotics for either medication cart. During an interview on 02/28/24 at 11:06 AM, the previous DHS stated LPN2 called her and reported the drug diversion incident. The previous DHS stated she could tell that the medication card/package was altered. According to the previous DHS, the Administrator began the investigation, and she did not remember details. During an interview on 02/28/24 at 4:50 PM, the Administrator stated she expected staff not to divert residents' medications. The surveyor's investigation or the facility's investigation could not determine who was responsible for the misappropriation of the narcotics.

Based on record review, policy review, and staff interviews, the facility failed to ensure 1 out of 2 residents were free from misappropriation of resident medication. This failure resulted in the misappropriation/divergence of Resident (R)1's ordered pain medication. Findings include: Review of the facility's policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property Mission Statement, with a revised date of 11/21/16 reveals, It is the mission of the facility and its affiliated providers actively to preserve each patient's right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of patient property. The purpose of our abuse prohibition procedures is to assure that our partners are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of patient abuse, neglect, exploitation, mistreatment, and misappropriation of property. Our policies and procedures establish standards of practice for screening and training partners, protecting patients, and the prevention, identification and responding/reporting of abuse, neglect, exploitation, mistreatment, and misappropriation of property. Review of R1's Face Sheet revealed R1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. R1 was admitted with diagnoses including, but not limited to; type 2 diabetes mellitus, blindness in one eye, dysphagia, chronic pain syndrome, epilepsy, and diffuse traumatic brain injury. Review of R1's Quarterly Minimum Data Set (MDS) with an Assessment Referenced Date (ARD) of 09/13/23 revealed R1 had a Brief Interview for Mental Status (BIMS) score of 12 of 15, indicating R1 was moderately cognitively impaired. Review of R1's Physician orders with a start date of 09/25/23 revealed that R1 is to be administered 5 MG Oxycodone tablet orally, every eight hours at 6:00 AM, 2:00 PM, and 10:00 PM. Review of R1's Progress Note on 10/19/23 revealed that a 2 PM dose of Oxycodone not given as drug is unavailable in the cart. Nurse called pharmacy to ask for authorization to access the E-kit (Emergency Kit) but to no avail. NP (Nurse Practitioner) notification order obtained. During an interview on 11/02/23 at 6:24 PM, the Administrator revealed that the narcotic medication card and record sheet was missing for R1. During the facility investigation they counted back from when the medication was administered, and it would have been the 8th of October that it was missing. The Administrator and the Physician went through all the cards on the cart to make sure none of the cards were tampered with. The nurse didn't have signatures on the reconciliation sheet, but they do know that two cards were received. The Administrator stated if the nurse had reviewed the administration and inventory sheet, it would have been caught. They were able to narrow it down to two nurses (Licensed Practical Nurse (LPN)1 and LPN2), and every nurse was drug tested . The Administrator further stated ten pills were unaccounted for. The Administrator added her expectation is to follow Med Pass, how to do it appropriately, there is no reason for medication to go missing from a cart, especially a narcotic. All nursing staff should follow protocol, include inventory sheet, and count medications during shift change. During an interview on 11/03/23 at 2:59 PM, LPN1 revealed that she wasn't aware of anything missing until the director called her, she was on vacation prior to the incident taking place. LPN1 further stated they had to come in and do a screening because the facility couldn't find a narcotic sheet, and there were about 10-12 missing pills, I started the new sheet and asked where the old sheet was. LPN1 revealed she is responsible for logging medication in and on the 8th of October she was out on vacation. LPN1 states the policy always involves two nurses, the nurse coming on and the nurse going off should count together. LPN1 revealed nurses leave the keys inside the clipboard, so the policy is not always followed how it's supposed to be. When the pharmacy brings medication in the nurse receive it, they must sign for it, count it and then log it in their book. The second nurse should cosign to say that it was received and counted. LPN1 further states that there may not always be a second nurse to approve that. If that happens another unit nurse would inform that the previous nurse left the keys in the clipboard. There are multiple times that she has received keys that are left in the clipboard. It happens so much that they just get on board and continue with their assignments for the day. On Monday nights we should complete an inventory if they are running low on narcotic scripts and inform the following day nurse to make a request for that medication. During an interview on 11/03/23 at 3:12 PM, LPN2 revealed she doesn't know anything about it, the day she returned she got a report from another nurse that the sheet was missing along with the whole card of medication. LPN2 includes she didn't receive inventory and didn't count it. LPN2 further states she is familiar with the medication and the resident that receives it, she thinks he still got it, he had enough for that day, LPN2 was not sure if he went without the medication after that. LPN2 states she doesn't usually work Mondays but the night nurse reported it to her.

Based on job description and interviews the facility failed to have qualified staff (Dietary Manager (DM)) with the appropriate competencies and skills sets to carry out food and nutrition services. This had the potential to affect all 96 census residents of the facility. Findings include: Review of the facility's job description titled, Position Description, revised on 01/16, indicated the job purpose of the DM plans, organizes, develops, and directs the overall operation of the Dietary Department in accordance with current federal, state, and local regulations governing the center and as directed by the Administrator. Participates in center/agency surveys (Licensure/JCAHO/Health Department) and any other required surveys. During an interview on 07/25/23 at 09:31 AM, Dietary Aide (DA)2 stated, The DM quit at least a month ago. During an interview on 07/25/23 at 9:45 AM, DA3, stated, The former DM quit over three weeks ago. During an interview on 07/25/23 at 9:51 AM, Cook stated, The DM quit over three weeks ago. During an interview on 07/26/23 at 02:50 PM, DA1 stated, The DM quit almost a month ago. During an interview on 07/26/23 at 02:58 PM, the DM from another facility stated, The DM quit three weeks ago, and I fill in at the facility when I can. During an interview on 07/26/23 at 03:35 PM, the Registered Dietician (RD), stated The facility has been without a DM for three weeks. She also stated, I come to the facility on e day a month to review the monthly weight loss chart. During an interview on 07/27/23 at 04:33 PM, the Administrator revealed that she has been without a DM for three weeks. She also stated, The DM from our sister facility assists when she can.

Based on observations, interviews, and review of facility laundry records, the facility failed to ensure staff adhered to wearing the appropriate personal protective equipment (PPE) for residents in contact and droplet isolation for two (Resident (R)147 and R76) of two residents. The facility also failed to ensure that daily hot water temperatures were maintained in the laundry. This failure has the potential to spread blood borne pathogens. Findings include: 1. Observation on 07/25/23 at 7:45 AM revealed Resident (R)147 had an isolation cart outside his room. The signage on the cart indicated the resident was on contact and droplet precautions. The signage gave directions for the staff to perform hand hygiene, don mask, gown, and gloves before entering the resident's room. A staff member was observed entering the resident's room to answer his call light. A staff member did not perform hand hygiene, nor did she don mask, gown, and gloves. Observation on 07/25/23 at 8:40 AM a staff member performed hand hygiene and donned PPE to take R147 breakfast tray in room; the breakfast tray was not an isolation tray. Observation on 07/25/23 at 9:09 AM certified nursing assistant (CNA)1 entered R147's room without donning PPE and removed the resident's breakfast tray and placed it on the cart. Interview on 07/25/23 at 8:10 AM with Licensed Practical Nurse (LPN)4 revealed he thought the resident was not on isolation precautions, but he would check. LPN4 returned a few minutes later and confirmed the resident was on isolation precautions and the staff should don mask, gown, and gloves before entering the room. During an interview on 07/25/23 at 9:30 AM, CNA1 acknowledged that she entered R147's without donning PPE. CNA1 stated that she simply forgot to follow the directions for isolation. 2. Observation on 07/27/23 at 11:49 AM of R76's room revealed a sign that indicated R76 was on contact and droplet precautions due to positive for COVID. Registered Nurse (RN)1 and LPN 6 were observed at the nurses' station. RN1 wearing her face mask down around her chin area. LPN6 was observed without a face mask. Interview on 07/27/23 at 10:30 AM with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed residents that were in isolation should have received their meals in Styrofoam dishes and the trays should have been left outside the resident's room. The DON also stated that nursing staff on the unit where R76's resides should have been wearing face masks. The DON stated when staff entered the resident's room it was an expectation that staff would don full PPE. Interview on 07/27/23 at 11:49 AM with RN1 revealed R76 recently tested positive for COVID. RN1 stated the staff on the unit should wear a face mask and full PPE when in the resident's room. RN1 acknowledged that she was not wearing her face mask correctly. Interview on 07/27/23 at 11:56 AM with LPN6 revealed he was not aware of any resident on the unit tested positive for COVID on this unit. LPN6 stated he was unaware that he should wear a face mask on this unit. 3. On 07/26/23 at 3:00 PM tour of the laundry facility and review of the laundry maintenance logs revealed the facility's document titled Water Temperature Daily Log revealed missing documentation of the water temperatures for the months of July, June, May, April, March, and February 2023. Interview on 07/26/23 at 4:15 PM, the Laundry Supervisor revealed the water temperatures for the washing machine were to be taken daily. The temperature range should not go below 160 degrees. The Laundry Supervisor reviewed the logs and acknowledged the temperatures were not done daily. During an interview with DON and ADON on 07/27/23 at 10:30 AM the findings in the laundry department regarding the water temperatures was discussed. The DON stated it was important that water temperatures are monitored on a daily basis to prevent the spread of blood borne pathogens. It was even more important since the facility has a resident that tested positive for COVID.

Based on interview, record review, document review and the facility failed to ensure one (Resident (R)19) of the twenty-four residents in the sample was allowed to make choices regarding the care of her hair. Failure to allow the resident to make choices did not allow the resident the right to make choices regarding her care at the facility. Findings include: Interview on 07/25/23 at 930 AM, R19 expressed concerns as to why she couldn't get her hair blow dried anymore after her showers, since she could not do it herself due to her physical disabilities. She did not like to towel dry her hair because her hair was still wet, and she felt like it would cause her to catch a cold. She reported that she did ask staff why she could no longer get her hair blow dried and they said it was a safety issue. She stated that they used to use a blow dryer to perform that task for her. The staff told her that she will have to be taken to the salon and sit under a hair dryer after her showers. The resident revealed that this did not occur, and it was more time-consuming for the staff to do that. She was not getting her hair shampooed as often since she can't get it blow dried, and the staff did not always have time. Review of the resident's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/26/23 revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was cognitively intact. Review of the Certified Nursing Assistance (CNA) bathing logs dated 07/11/23, 07/20/23 and 07/25/23 did not reveal that R19 had her hair blow dried on her shower days. Record review of the resident's care plan dated 07/21/23, in the electronic medical record (EMR) under the Care Plan tab revealed that the resident was alert and oriented and chose not to wash her hair and she would not air dry it or towel dry it and desired to have it blow dried. Review of the Resident's Rights and choices booklet, that was provided to the residents upon admission revealed in the section of Planning and Implementing Care, item b; that the resident has the right to participate in the development and implementation of a person-centered plan of care including, but not limited to: the right to receive the services and or items included in the plan of care. Also, in the section of Self-Determination, item b: the resident has the right to make choices about aspects of their life in the facility that are significant to them. Interview on 07/26/23 at 3:00 PM with CNA7 revealed she was aware that the resident desired to get her hair blow dried with showers and did not like it to be toweled dried. She stated they used to do it for her but was told by management that they could no longer use her blow dryer and that the resident had to be taken to the salon to sit under a hair dryer, which may sometimes not be done. Interview on 07/26/23 at 3:10 PM the Nurse Navigator (NN) revealed that an alternative to blow drying this resident's hair was to take her to sit under a dryer in the salon because they did not want the resident to use the blow dryer on her own. NN agreed that due to the resident's physical condition that the resident was not capable of using the blow dryer herself. The NN stated the CNA could do it for her, but not too sure why this was no longer being done. NN did not recall that the resident tried to use the blow dryer herself. Interview on 07/26/23 at 5:00 PM with the Social Services Director (SSD), revealed that there was no safety hazard with the resident's dryer, and that the resident should not have had to go to the salon to dry her hair. The SSD agreed that a better alternative would be to have the CNA's blow dry her hair on R19's shower days.

Based on interview, record review, and review of facility policy the facility failed to investigate grievance concerns filed by two Residents (R)44 and R32 regarding nursing care from a sampled 24 residents. Finding include: Review of the facility's policy titled Grievances: Healthcare Centers with a revision date 11/21/22, reads in part A grievance includes, but is not limited to, complaints with respect to care and treatment that has been furnished to a patient, as well as that which has not been furnished, the behavior of staff and of other patients, and other concerns regarding the patient's facility stay. 1 During an interview on 07/26/23 at 1:46 PM, R44 stated that he had problems with one certified nursing assistant (CNA) in particular. The resident identified CNA2. R44 stated that a couple of weeks ago he asked CNA2 to change his linen since he spilled his urinal in his bed. The resident made repeated requests for the CNA2's assistance in cleaning him up. The resident stated CNA2 left the facility after her shift without cleaning him up. R44 further stated the same situation occurred a few days later when he requested assistance in being repositioned in the bed. This time CNA2 came in the room to assist another CNA (unidentified) in repositioning. R44 stated that CNA2 jerked him roughly into an upright position while the other CNA assisted in pulling him up in bed. The resident further stated that CNA2 then shoved him back onto the bed. The resident stated he felt CNA2 did this intentionally. R44 asked the other CNA if she observed what CNA2 did, and the CNA replied yes. The resident stated he was told an investigation was completed and that the CNA who witnessed the incident denied seeing CNA2 shoving him into the mattress. The resident further stated that he also had problems with CNA1 providing his care. The resident stated he did not want CNA1 or CNA2 to provide his care. The resident stated that he felt both employees were abusive towards him and that he felt uncomfortable with them caring for him. - The resident stated that he filed a complaint the next day to Social Services. R44 stated he reported this incident to the Administrator. R44 stated that he was not satisfied with the outcome of the facility's investigation. Review of R44's Face Sheet located in the resident's electronic medical records (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included quadriplegia, neurogenic bowel and bladder, fluid overload, and bilateral hand contractures. Review of the R44's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/23 located in the resident's EMR section titled Resident Assessment Instrument (RAI) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R44 had intact cognition. R44 was dependent on staff for all activities of daily living. Review of the facility's document titled Grievance /Complaint Log form: Healthcare Centers for the month June revealed R44 filed a grievance on 06/23/23. The log indicated the grievance was referred all staff on 06/28/23. The log sheet indicated action completed 06/23/23 through 07/08/23. The log further indicated the grievance was resolved. It was documented on the log the CNA would not go back in the resident's room. -The grievance log did not specify what the grievance was about. Review of the facility's grievance investigation form revealed the date of 06/23/23 was taken by Social Services Director (SSD). It was documented on the form that the grievance referred to all staff. The specifics of grievance read as follows Resident expressed concern over amount of time in which it took for staff to address his concerns, resident reported concern over staff responding to his call light, however when notified of the resident's concern he alleges that staff will walk out. Resident not happy with staff telling him that they will address his concern only for them to never follow back up with the concern. In the section of the form that indicated steps taken to investigate, the SSD documented spoke with resident and initiated in-service education regarding professional interactions ADL care. The SSD documented in-service education in which both CNA1 and CNA2 attended 06/27/23. -However, the grievance did not address the rough handling by CNA2. Also, the grievance investigation did not contain statements from other residents receiving care from CNA2, or staff members involved. An interview with the SSD on 07/26/23 at 5:30 PM revealed he stated the grievance findings were reviewed with the Administrator and she signed off on the correction action. An interview was conducted on 07/26/23 at 6:30 PM with the Administrator. The Administrator reviewed the grievance investigation report dated 06/23/23 and stated that what the grievance revealed was not what the resident reported to her. The resident reported to her that the CNA2 was rough with R44. The NHA confirmed that no investigation was completed regarding the reported incident of rough behavior by the staff. 2. During an interview on 07/24/23 at 11:30 AM R32 voiced concerns about an incident CNA1 's behavior towards the resident. R32 stated the CNA1 made crude remarks to her when providing care. R32 stated she was told that CNA1 would no longer be assigned to her. R32 stated now that even though the CNA was no longer taking care of her, CNA1 would stop at her room and glare at her. Or CNA1 would make comments to the other staff members to watch out that R32 would make trouble for them like she did her. R32 stated she did not want this CNA1 providing care for her again. R32 stated that she felt like CNA1 was making slanderous remarks against her and did not feel comfortable with CNA1. - The resident stated she reported the incident to the Administrator in June but was unable to remember the exact date. The resident stated since the staff members continued, there was still a problem. Review of R32's Face Sheet located in the resident's EMR revealed the resident was admitted to facility on 03/15/23 with diagnoses that included dementia, behavior disturbances, and depression. Review of the R32's Admission MDS with an ARD 3/12/23 revealed the resident had a BIMS score of 15 out of 15 indicating R32's cognition was intact. R32's required extensive to total assistance with two staff persons assistance for ADLs. Review of the facility's document titled Grievance /Complaint Log form: Healthcare Centers for the month June revealed R32 filed a grievance on 06/26/23. The log indicated the grievance was referred CNA/Nurses on 06/26 to 06/28/23. The log sheet indicated action completed 06/28/23. The log further indicated the grievance was resolved and the resident was satisfied with the resolution. -The grievance log did not specify what the grievance was about. A review of the grievance investigation completed by Social Services on June 26, 2023, of R32's allegation of CNA1 being rude, revealed the investigation indicated that the resident had expressed a concern of CNA1 being rude specifically not knocking on the door prior to entering the resident's room. The investigation did not include statements from the resident, from CNA1 or statements from other residents. The investigation was signed off by the Administrator and Social Services. A summary of the of the SSD's finding documented as follows in-service education initiated regarding professional highlighting conduct and communication, specifically providing daily care to meet each resident's personal and medical needs. Education also emphasized the importance of knocking prior to entering a resident's room. The SSD notified the resident of the findings of his investigation. The SSD documented the resident was satisfied with the findings. An interview with Social Services on 07/26/23 at 4:30 PM revealed R32 verbalized no further concerns about CNA1. An interview was conducted on 07/26/23 at 6:30 PM with the Administrator. The Administrator stated that she was aware of the incident of CNA making crude remarks made by CNA1 and discussed the incident with R32. The NHA stated that CNA1 would no longer be assigned to provide her care. The Administrator stated she was not aware of the resident's concern of CNA1 continued behavior of making comments to other staff that the resident would cause trouble for them.

Based on interview, record review, and review of facility policy, the facility failed to identify and investigate possible abuse allegations resulting from grievances filed by two Residents (R)44 and R32 from a sampled 24 residents. Findings include: Review of the facility's policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property with a revision date of 10/27/20 reads in part Providers are to identify, correct, and intervene in situations in which abuse, neglect, mistreatment, or exploitation may occur. This should include an analysis of the following .organizational processes including but not limited to staff competencies, grievance processes . 1 During an interview on 07/26/23 at 1:46 PM, R44 stated that he had problems with one certified nursing assistant (CNA)2 in particular. The resident identified CNA2. R44 stated that a couple of weeks ago he asked CNA2 to change his linen since he spilled his urinal in his bed. The resident made repeated requests for the CNA2's assistance in cleaning him up. The resident stated CNA2 left the facility after her shift without cleaning him up. The resident stated that he filed a complaint the next day to Social Services. R44 further stated the same situation occurred a few days later when he requested assistance in being repositioned in the bed. This time CNA2 came in the room to assist another CNA (unidentified) in repositioning. R44 stated that CNA2 jerked him roughly into an upright position while the other CNA assisted in pulling him up in bed. The resident further stated that CNA2 then shoved him back onto the bed. The resident stated he felt CNA2 did this intentionally. R44 asked the other CNA if she observed what CNA2 did, and the CNA replied yes. R44 stated he reported this incident to the Administrator. The resident stated he was told an investigation was completed and that the CNA who witnessed the incident denied seeing CNA2 shoving him into the mattress. The resident further stated that he also had problems with CNA1 providing his care. The resident stated he did not want CNA1 or CNA2 to provide his care. -The resident stated that he felt both employees were abusive towards him and that he felt uncomfortable with them caring for him. R44 stated that he was not satisfied with the outcome of the facility's investigation. The resident stated he felt that he was abused. Review of R44's Face Sheet located in the resident's electronic medical records (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included quadriplegia, neurogenic bowel, and bladder, and bilateral hand contractures. Review of the R44's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/09/23 located in the resident's EMR section titled Resident Assessment Instrument (RAI) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R44 had intact cognition. R44 was dependent on staff for all activities of daily living. Review of the facility's grievance investigation form revealed the date of 06/23/23 and was taken by Social Services Director (SSD). It was documented on the form that the grievance referred to all staff. The specifics of the grievance read as follows Resident expressed concern over amount of time in which it took for staff to address his concerns, resident reported concern over staff responding to his call light however when notified of the resident's concern he alleges that staff will walk out. Resident not happy with staff telling him that they will address his concern only for them to never follow back up with the concern. -In the section of the form that indicated steps taken to investigate, the SSD documented spoke with resident and initiated in-service education regarding professional interactions ADL care. The SSD documented in-service education in which both CNA1 and CNA2 attended 06/27/23. -However, the grievance did not address the rough handling by CNA2. Also, the grievance investigation did not contain statements from other residents receiving care from CNA2, or the staff members involved. An interview with the SSD on 07/26/23 at 5:30 PM revealed he did feel CNA2's behavior was abusive towards R44. SSD felt the staff members required additional training in customer service, providing ADL cares and professionalism. The SSD stated the grievance findings were reviewed with the Administrator and she signed off on the correction action. An interview was conducted on 07/26/23 at 6:30 PM with the Administrator. The Administrator reviewed the grievance investigation report dated 06/23/23 and stated that what the grievance revealed was not what the resident reported to her. The resident reported to her that the CNA2 was rough with R44. The Administrator stated the resident did identify CNA2 as the employee he was having trouble with, including the incident about the rough handling by CNA2. The Administrator stated R44 had asked that CNA2 not be assigned to him. -The Administrator was unable to provide documentation for investigating this incident. The Administrator confirmed that no investigation was completed regarding the reported incident of rough behavior by CNA2. However, the Administrator stated that she did not view this incident as abuse. 2. During an interview on 07/24/23 at 11:30 AM R32 voiced concerns about CNA1's behavior towards the resident. R32 stated CNA1made crude remarks to her when providing care. The resident stated she did report the incident to the Administrator in June and that it was decided that CNA1 would no longer be assigned to the resident. But now the resident reports that even though CNA1 was no longer taking care of her, CNA1 would stop at her room and glare at her. R32 also stated that she has heard the CNA telling other employees to watch for that R32 would make trouble for them like she did her. R32 stated that she felt like CNA1 was making slanderous remarks against her and did not feel comfortable with CNA1. Review of R32's Face Sheet located in the resident's EMR revealed the resident was admitted to facility on 03/15/23 with diagnoses that included, dementia, without behavior disturbances, and depression. Review of the R32's Admission MDS with an ARD 3/12/23 revealed the resident had a BIMS score of 15 out of 15 indicating R32's cognition was intact. R32's required extensive to total assistance with two staff persons assistance for ADLs. A review of the grievance investigation completed by Social Services on June 26, 2023, of R32's allegation of CNA1 being rude, revealed the investigation indicated that the resident had expressed a concern of CNA1 being rude, specifically not knocking on the door prior to entering the resident's room. The investigation was signed off by the Administrator and Social Services. A summary of the of the SSD's finding documented as follows an in-service education initiated regarding professional highlighting conduct and communication, specifically providing daily care to meet each resident's personal and medical needs. Education also emphasized the importance of knocking prior to entering a resident's room. The SSD notified the resident of the findings of his investigation. The SSD documented the resident was satisfied with the findings. -The investigation did not include statements from the resident, from CNA1 or statements from other residents. An interview was conducted on 07/26/23 at 5:30 PM with SSD regarding grievance investigations for R32 and R44. The SSD stated that he felt both CNAs needed to be retrained in customer service/courtesy and professionalism. SSD stated that he did not identify any elements of abuse to either resident. The SSD stated he conducted an in-service on resident care and professional behaviors for both staff members. An interview was conducted on 07/26/23 at 6:30 PM with the Administrator. The Administrator stated that she was aware of the incident of CNA making crude remarks made by CNA1 and discussed the incident with R32. The NHA stated that CNA1 would no longer be assigned to provide her care. The Administrator stated she was not aware of the resident's concern of CNA1 continued behavior of making comments to other staff that the resident would cause trouble for them. However, the Administrator stated that she did not feel abuse had occurred.

Based on observation, interview, record review, and review of facility policy, the facility failed to revise the care plan interventions for one of one Resident (R)87 from a sample 24 residents. R87 sustained numerous bed bug bites and his care plan was not revised to reflect the incident or treatment. Findings include: Review of facility's policy titled Care Plans with an effective date of 12/31/1996 reads in part .Care Plan Review and Update. Updates to the care plans should be made with any changes in condition at time the change in change occurred. Care plans will be updated by nurses, case mix directors, interdisciplinary team members so that the care plan will reflect the resident's needs at any given moment. Observation on 07/25/23 at 08:30 AM revealed R87 resting in bed and the resident had several areas on his face and arms that were scabbed over or open with dried blood. The resident's bed linen had several spots of dried blood. Observation on 07/25/23 at 12:45 PM revealed R87 sitting on the side of his bed scratching the open areas on his right arm. The resident also had multiple open and scabbed areas on his lower extremities in addition to the areas on his face and upper extremities. Review of R87's Face Sheet located in the resident's electronic medical record (EMR) revealed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder. Review of R87's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/27/23 located in the resident EMR tab titled Resident Assessment Instrument (RAI) revealed the resident had a Brief Interview for Mental Status score of eight out of 15 indicating the resident had moderately impaired cognition. The resident required extensive assistance with activities of daily living (ADLs) with one-person physical assistance. Review of the resident's Nurses Notes dated 07/05/23 located in the resident's EMR section titled Progress Notes revealed the resident was assessed to have numerous insect bites over his body. The staff obtained physicians orders for treatment. The resident received a shower and room change while environmental services treated his room. The administrative and the resident's responsible party were notified of the incident. Review of R87's Care Plan with review date of 07/05/23 located in the resident's EMR section titled RA) Care Planning revealed the care plan was not revised to reflect the incident with the bed bugs and treatment. Interview on 07/25/23 at 2:00 PM with Licensed Practical Nurse (LPN)2 and LPN4 revealed the resident's family brought a chair from home that was infected with bed bugs. As soon as the staff discovered the bug bites the appropriate people were notified and the resident was treated. Both staff members stated the resident had a problem with pruritis before the insect bites, however, the insect bites made the pruritis worse. Interview on 07/26/23 at 1:30 PM, LPN4 revealed the resident's care plan should have been revised to reflect the incident. LPN4 stated the interdisciplinary team was responsible for updating and revising the resident's care plans. Interview on 07/27/23 at 01:10 PM, the Assistant Director of Nursing (ADON) revealed any nurse can revise/update a resident's care plan as a change in condition occurs. The ADON stated she was aware of the incident with the bug bites; and agreed the care plan should have been revised to reflect the incident and treatment.

Based on observation, interviews, record review, and review of facility policy, the facility failed to properly secure an indwelling catheter drainage tubing for one of one Resident (R)148 from a sample of 24 residents. This failure has the potential to cause the resident to have reoccurring urinary tract infections. Findings include: Review of the facility's undated policy titled Procedure: Indwelling Urinary Catheter reads in part Secure with catheter securement device if available. Tape the catheter, use an adhesive catheter holder, or apply a Velcro leg strap to secure the catheter. Do not leave the room until the catheter is secured. The mechanical irritation caused by the catheter movement can cause complications. The catheter in the female is secure to the upper thigh and in the male resident the catheter is secured in place to the abdomen. Review of the R148 Face Sheet located in the resident's electronic medical records (EMR) section revealed the resident was admitted to the facility with diagnoses that included chronic kidney disease. Review of R148's Baseline Care Plans dated 7/19/23 located in the resident's EMR section titled Care Planning revealed the resident had a Foley catheter to drainage and to provide catheter care according to facility policy. Review of the R148's Physician Orders dated 07/19/23 located in the resident's EMR section titled Orders revealed the resident was to have catheter care per facility policy. Observation on 07/25/23 at 8:10 AM revealed R148 in bed and a Foley catheter connected to a drainage bag. The resident was able to show that she was not wearing a catheter strap. Observation on 07/26/23 at 10:42 AM revealed R148 in bed and a Foley catheter drainage bag clipped to side of bed. The catheter was not secured to the resident upper thigh. Observation and interview on 07/27/23 at 2:45 PM with Certified Nursing Assistant (CNA)5 confirmed that resident's Foley catheter was unsecured to the resident's thigh. During the observation, the CNA5 stated the resident should have had the catheter strap secured to her upper thigh to prevent the catheter from pulling and becoming dislodged. Interview on 07/27/23 at 3:15 PM, Licensed Practical Nurse (LPN)5 revealed it was an expectation for residents with indwelling or suprapubic catheters to have the catheter secured in place with a securement device to prevent pulling and dislodgement of the catheter. LPN5 was unaware the resident did not have a catheter securement device in place during the three days of the survey.

Based on observation, interview, record review, and the facility failed to maintain proper sanitary storage of the suction tubing for one Resident (R)48 of six sampled residents that required tracheostomy suctioning to prevent the risk of infections to vulnerable tracheostomy residents. This deficient practice increases the risk of infection for residents requiring tracheostomy suctioning. Findings include: Review of R48's Electronic Medical Record (EMR) Face Sheet located under the Profile tab, indicated R48 was admitted to the facility initially on 07/13/21 with diagnoses including chronic respiratory failure with hypoxia, metabolic encephalopathy, quadriplegia, chronic respiratory failure, tracheostomy, and traumatic brain injury. Review of R48's Physician Orders located in R48's EMR under the Orders tab, revealed. orders dated 05/17/23 to provide suctioning to tracheostomy as needed. During an observation of the R48 on 07/25/23 at 10:00 AM, the Respiratory Therapist (RT) was observed performing tracheostomy suctioning to the resident. The RT placed the end of the suction tubing to the outside of the plastic bag. The suction tip was exposed to the open air and was not covered. During an observation on 07/26/23 at 10:00 AM R48's suction tip remained hanging off the plastic bag from the canister, exposed without a covering. The RT revealed it has never been an issue before. Interview on 07/26/23 at 11:30 AM with the Respiratory Manager (RM), revealed that she was not aware that this practice of the suction tip storage was an issue She stated she would consult with corporate to determine if this practice was appropriate and that there was no specific policy on this issue to refer to. The RT and the RM revealed that this practice needed to be addressed immediately. RM revealed that effective immediately the suction tip would no longer be exposed hanging from the plastic bag and all suction tubing tips would be placed in a closed plastic bag to minimize exposer. RM and RT agreed this practice may have the potential to spread infection to vulnerable tracheostomy residents.

Based on observation, record review, and interview, the facility failed to ensure one of one Resident (R)145 of 24 sampled residents had a functioning call light system. This had the potential to affect the resident's ability to call for assistance. Findings include: Review of R145's Face Sheet located in the resident's electronic medical records (EMR) under the section titled Face sheet revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (with dialysis); major depressive disorder; and anxiety disorder. Review of the R145's Admission Nursing Notes dated 07/24/23 located in the resident's EMR section titled Progress Notes revealed the resident was admitted to the facility alert and oriented. The resident required staff assistance with activities of daily living; incontinent of bladder and bowel and was non ambulatory. Observation on 07/25/23 at 7:30 AM revealed R145 in bed calling for assistance. The resident call light was on the floor under the resident's bed. The call light was retrieved from under the bed and the button was pushed. Upon closer inspection it was noted the call light was not plugged into the wall unit. The wall unit was also lying on the floor under the resident's bed. Observation on 07/25/23 at 7:35 AM Licensed Practical Nurse (LPN)4 was notified about the resident's malfunctioning call light. LPN4 went to the resident's room to connect the call light system. The wall unit did not completely connect to the wall and the call light did not come on when the button was pushed. LPN4 notified the Maintenance Director of the situation. Interview on 07/25/23 at 7:30 AM, R145 revealed he was unable to use his call light since he was admitted to the facility last evening (07/24/23). The resident stated the staff came to his room one time during the night to administer pain medication and he informed the staff then that his call light was not working. The resident stated the staff did not return to fix his call light until this morning. Interview on 07/25/23 at 3:30 PM with LPN4 revealed the resident's call light did malfunction since it was pulled out of the wall. The LPN stated the Maintenance Director had to replace the call light unit. LPN4 also stated that the night shift should have addressed the issue of the resident's call light not working and another way for the resident to call for assistance.

Based on record review and interviews, the facility failed to prevent neglect to a Resident (R)9, diagnosed with Vascular Dementia and history of wandering. R9 had a successful elopement from the facility on 08/28/22 around 1:55 PM. R9 was noticed wandering outside of the building unsupervised by an employee. Once noticed, the employee attempted to get R9's attention, but he ran into a wooded area adjacent to the facility after being called. R9 was found by the police after receiving a call from a neighbor stating R9 was in their back yard, approximately 0.2 miles away from facility. R9 was dressed in pajamas and the weather was undocumented. On 04/10/23 at 4:08 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator, notifying them that an IJ existed at F600 with an effective date of 08/28/22. On 04/10/23 at 6:25 PM, the facility provided an acceptable IJ Removal Plan indicating they identified their own deficient practice and implemented a plan prior to the start of the survey. Verification of the removal plan confirmed the facility put forth good faith attempts and implemented a plan to remove the immediacy to include training, drills, and in-services, effective 09/16/22. Implementation of the removal plan for F600 includes daily checks for functionality of wander guard bracelets will be conducted by assigned nurses and/or designee and findings documented in the resident's electronic medical record. Functionality will be checked using the tag/device checker for activation and/or taking resident to door and listening for alarm sound and door locking. The Director of Health Services (DHS) and Administrator initiated education on 08/29/22 and Clinical Care Coordinator completed education on 08/29/22. All newly hired nursing staff will receive education in orientation. A mock elopement drill was performed to ensure compliance on 09/16/22 with in-service provided at that time. The facility will continue to complete elopement risk assessments upon admission, quarterly, annually and with significant change to identify high risk wanderers per policy, with appropriate interventions added as needed. The facility's door alarm device daily testing will be reviewed by Administrator and/or DHS for 2 weeks, then weekly for 4 weeks, then monthly for 3 months with results presented during monthly Quality Assurance Performance Improvement (QAPI) committee meeting with appropriate corrective actions as indicated. Per policy, door alarms will continue to be checked daily by Maintenance Director/ Designee (Manager on Duty) and wander guards will be checked for placement and functionality by assigned nurse(s), recorded in resident (s) electronic health record. Ongoing audits will be determined on findings and corrective actions needed. Audit tools will be reviewed by the Administrator and/or DHS weekly and results will be presented during the monthly QAPI committee meeting monthly for 3 months and/or until substantial compliance. Findings Include: A review of the facility's face sheet revealed R9 was admitted to the facility on [DATE] with diagnoses including,but not limited to: anxiety, vascular dementia, depressive disorder, wandering disease, chronic obstructive pulmonary disease, and heart failure. Review of a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/22 indicated R9 had a Brief Interview of Mental Status (BIMS) score of 1, indicating severe cognitive impairment. An Elopement Risk assessment dated [DATE] revealed R9 scored a 10, which indicates that he was moderate risk for elopement. Interventions included 3-day monitoring, 4 weeks behavior management program to determine appropriate interventions after 3-day evaluation, and/or quarterly assessments. If significant wandering persists, follow recommendations for High Risk, which is 3-day monitoring, weekly behavioral management and applying a wander guard. Review of R9's Care Plan dated 07/12/22 and updated on 08/22/22 revealed R9 is at risk for elopement related to poor memory, wandering and looking for exits. Interventions were: Use of Wander guard to alert patient and staff of attempts to exit facility unattended. Additional review of the care plan dated 08/22/22 and titled Behavior Symptoms indicated R9 was care planned for taking other residents and staff belongings and cutting off wander guard. Interventions put into place were to: Assess resident for placement in a specially designed therapeutic unit and obtain a psych consult/psychosocial therapy. Review of a Social Services Director (SSD) progress note dated 08/22/22 at 1:32 PM revealed, SSD was informed that R9 did not have his wander guard on. SSD went to R9's room and found a pair of scissors. SSD attempted to notify R9 Responsible Party but was unable to reach. Veterans Administration was notified via e-mail about behaviors Review of a nurse's progress note dated 08/28/22 at 4:00 PM revealed,R9 observed walking across parking lot towards wooded area, staff unable to stop him and he proceeded further into the woods and unable to be reached. Alert North [NAME] Police Station and active search began. Resident was found safe by police in neighboring yard. Physical exam by Director of Health Services and Resident to be sent to Veterans Administration Medical Center (VAMC). Review of nurse's progress note dated 08/28/22 at 4:11 PM revealed, R9 transported by ambulance to (VAMC) for evaluation and treatment as ordered. During an interview with the Administrator on 03/14/23 at 2:45 PM revealed, On 08/28/22 around 1:55 PM, CNA1 who was working as the receptionist this day, followed resident R9 out the front door into the parking lot as he was walking out of the door stating that he was leaving. Licensed Practical Nurse (LPN)1 noticed R9 walking across the parking lot and tried to assist CNA1 in re-directing. R9 began walking towards the woods and became combative and aggressive towards them, and staff are unable to hold residents. CNA1 called the Administrator while LPN1 called 911. The Administrator further stated, LPN1 stated the police instructed her not to follow R9 in the woods because if they had to use their dogs to track R9's scent, that would cause interference, therefore, R9 proceeded into the woods alone. Police arrived at 2:04 PM and began a search for R9 in the wooded area. At 3:00 PM, dispatch received a call-in reference to a male suspect in a nearby neighborhood. Officers responded to that location and R9 was escorted back to the facility. R9 was assessed for injuries was sent to the Veteran Affairs (VA) hospital. An interview with LPN1 on 04/10/23 at 12:38 PM revealed, On 08/28/22, as she was taking a smoke break, she noticed R9 walking from the side of the building. LPN1 stated that she called his name, and he started running towards the woods. LPN1 stated that she called for the receptionist for help. LPN1 stated she called the Administrator and she and other staff from facility came to assist, but R9 ran into the woods. LPN1 further stated, She cannot recall the time, but she remembers that R9 was wearing plaid pajamas and he had his backpack. She also added the weather was not too hot because she was sitting in her car. During an interview with CNA1 on 04/10/23 at 12:47 PM, she revealed she was working as the receptionist this day and LPN1 was taking her smoke break. LPN1 ran into the facility and stated that a resident had gone into the woods. CNA1 stated that she called the Administrator and 911. Police told them not to go into the woods because they did not want the dogs to pick up everyone's scent. About 3:00 PM, a neighbor called police saying an unidentified male was in their back yard. R9 returned to facility at 3:15 PM. Review of the police report revealed R9 was alert and verbally responsive with mild anxiety noted. A moderate amount of perspiration was noted to the face and arms. Clothes moist. Small open area to top of right earlobe. Small scratch to right forearm. R9 discharged from the facility to Veterans Administration Medical Center via ambulance. Family notified.

Based on record review, interviews, and the review of the facility's policy, the facility failed to provide adequate supervision to a Resident (R)9, diagnosed with Vascular Dementia and history of wandering. R9 had a successful elopement from the facility on 08/28/22 around 1:55 PM. R9 was noticed wandering outside of the building unsupervised by an employee. Once noticed, the employee attempted to get R9's attention, but he ran into a wooded area adjacent to the facility after being called. R9 was found by the police after receiving a call from a neighbor stating R9 was in their back yard, approximately 0.2 miles away from facility. R9 was dressed in pajamas and the weather was undocumented. On 04/10/23 at 4:08 PM, an Immediate Jeopardy (IJ) template was provided to the facility's Administrator, notifying them that an IJ existed at F689 with an effective date of 08/28/22. On 04/10/23 at 6:25 PM, the facility provided an acceptable IJ Removal Plan indicating they identified their own deficient practice and implemented a plan prior to the start of the survey. Verification of the removal plan confirmed the facility put forth good faith attempts and implemented a plan to remove the immediacy to include training, drills, and in-services, effective 09/16/22. Implementation of the removal plan for F689 includes daily checks for functionality of wander guard bracelets will be conducted by assigned nurses and/or designee and findings documented in the resident's electronic medical record. Functionality will be checked using the tag/device checker for activation and/or taking resident to door and listening for alarm sound and door locking. The Director of Health Services (DHS) and Administrator initiated education on 08/29/22 and Clinical Care Coordinator completed education on 08/29/22. All newly hired nursing staff will receive education in orientation. A mock elopement drill was performed to ensure compliance on 09/16/22 with in-service provided at that time. The facility will continue to complete elopement risk assessments upon admission, quarterly, annually and with significant change to identify high risk wanderers per policy, with appropriate interventions added as needed. The facility's door alarm device daily testing will be reviewed by Administrator and/or DHS for 2 weeks, then weekly for 4 weeks, then monthly for 3 months with results presented during monthly Quality Assurance Performance Improvement (QAPI) committee meeting with appropriate corrective actions as indicated. Per policy, door alarms will continue to be checked daily by Maintenance Director/ Designee (Manager on Duty) and wander guards will be checked for placement and functionality by assigned nurse(s), recorded in resident (s) electronic health record. Ongoing audits will be determined on findings and corrective actions needed. Audit tools will be reviewed by the Administrator and/or DHS weekly and results will be presented during the monthly QAPI committee meeting monthly for 3 months and/or until substantial compliance. Findings Include: Review of the facility's undated policy titled, Relias Training: Section 1-Safe Supports for Someone at Risk for Elopement, revealed an elopement occurs when a person supported leaves the premises of a residential care setting without authorization or the necessary supervision to do so. A review of the facility's face sheet revealed R9 was admitted to the facility on [DATE] with diagnoses including,but not limited to: anxiety, vascular dementia, depressive disorder, wandering disease, chronic obstructive pulmonary disease, and heart failure. Review of a Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/07/22 indicated R9 had a Brief Interview of Mental Status (BIMS) score of 1, indicating severe cognitive impairment. An Elopement Risk assessment dated [DATE] revealed R9 scored a 10, which indicates that he was moderate risk for elopement. Interventions included 3-day monitoring, 4 weeks behavior management program to determine appropriate interventions after 3-day evaluation, and/or quarterly assessments. If significant wandering persists, follow recommendations for High Risk, which is 3-day monitoring, weekly behavioral management and applying a wander guard. Review of R9's Care Plan dated 07/12/22 and updated on 08/22/22 revealed R9 is at risk for elopement related to poor memory, wandering and looking for exits. Interventions were: Use of Wander guard to alert patient and staff of attempts to exit facility unattended. Additional review of the care plan dated 08/22/22 and titled Behavior Symptoms indicated R9 was care planned for taking other residents and staff belongings and cutting off wander guard. Interventions put into place were to: Assess resident for placement in a specially designed therapeutic unit and obtain a psych consult/psychosocial therapy. Review of a Social Services Director (SSD) progress note dated 08/22/22 at 1:32 PM revealed, SSD was informed that R9 did not have his wander guard on. SSD went to R9's room and found a pair of scissors. SSD attempted to notify R9 Responsible Party but was unable to reach. Veterans Administration was notified via e-mail about behaviors Review of a nurse's progress note dated 08/28/22 at 4:00 PM revealed,R9 observed walking across parking lot towards wooded area, staff unable to stop him and he proceeded further into the woods and unable to be reached. Alert North [NAME] Police Station and active search began. Resident was found safe by police in neighboring yard. Physical exam by Director of Health Services and Resident to be sent to Veterans Administration Medical Center (VAMC). Review of nurse's progress note dated 08/28/22 at 4:11 PM revealed, R9 transported by ambulance to (VAMC) for evaluation and treatment as ordered. During an interview with the Administrator on 03/14/23 at 2:45 PM revealed, On 08/28/22 around 1:55 PM, CNA1 who was working as the receptionist this day, followed resident R9 out the front door into the parking lot as he was walking out of the door stating that he was leaving. Licensed Practical Nurse (LPN)1 noticed R9 walking across the parking lot and tried to assist CNA1 in re-directing. R9 began walking towards the woods and became combative and aggressive towards them, and staff are unable to hold residents. CNA1 called the Administrator while LPN1 called 911. The Administrator further stated, LPN1 stated the police instructed her not to follow R9 in the woods because if they had to use their dogs to track R9's scent, that would cause interference, therefore, R9 proceeded into the woods alone. Police arrived at 2:04 PM and began a search for R9 in the wooded area. At 3:00 PM, dispatch received a call-in reference to a male suspect in a nearby neighborhood. Officers responded to that location and R9 was escorted back to the facility. R9 was assessed for injuries was sent to the Veteran Affairs (VA) hospital. An interview with LPN1 on 04/10/23 at 12:38 PM revealed, On 08/28/22, as she was taking a smoke break, she noticed R9 walking from the side of the building. LPN1 stated that she called his name, and he started running towards the woods. LPN1 stated that she called for the receptionist for help. LPN1 stated she called the Administrator and she and other staff from facility came to assist, but R9 ran into the woods. LPN1 further stated, She cannot recall the time, but she remembers that R9 was wearing plaid pajamas and he had his backpack. She also added the weather was not too hot because she was sitting in her car. During an interview with CNA1 on 04/10/23 at 12:47 PM, she revealed she was working as the receptionist this day and LPN1 was taking her smoke break. LPN1 ran into the facility and stated that a resident had gone into the woods. CNA1 stated that she called the Administrator and 911. Police told them not to go into the woods because they did not want the dogs to pick up everyone's scent. About 3:00 PM, a neighbor called police saying an unidentified male was in their back yard. R9 returned to facility at 3:15 PM. Review of the police report revealed R9 was alert and verbally responsive with mild anxiety noted. A moderate amount of perspiration was noted to the face and arms. Clothes moist. Small open area to top of right earlobe. Small scratch to right forearm. R9 discharged from the facility to Veterans Administration Medical Center via ambulance. Family notified.

Based on observation, interview and record review, the facility failed to provide a referral to ensure proper treatment to maintain vision for one (1) of 21 residents sampled, Resident #70. Findings included: The facility presented a document signed by the Administrator, dated 11/12/21 at 2:50 p.m. which stated, To Whom it May Concern, (Facility) does not have a policy that outlines action taken concerning referrals from outside physicians' appointment. (sic) We will be developing procedures that will address this concern. Resident #70 admitted to the facility 1/31/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly Minimum Data Set (MDS) dated [DATE] recorded the resident with a Brief Interview for Mental Status (BIMS) staff assessment indicating his/her decision-making skills were modified independent. The MDS recorded Resident #70's vision was adequate. Review of the Vision Care Plan dated 6/21/21 and updated 10/8/21 recorded the problem of blurred vision in right eye. The interventions directed: Keep call light in reach at all times. Provide an environment free of clutter. Nurse Practitioner to see resident regarding blurred vision in right eye. Assess effect of vision loss on resident's functional status. Review of the Nursing Progress Notes dated 6/21/21 at 5:47 p.m. documented the resident returned from [CONDITION(S)], and upon arrival continues to complain of blurred vision to the right eye. Review of the Progress Note dated 6/21/21 at 5:59 p.m. revealed a doctor's order to schedule an eye appointment due to blurred vision in right eye. On 11/11/21 at 5:15 p.m., the Social Services Director (SSD) and the Nurse Navigator (NN) stated the resident had been seen by an Ophthalmologist on 9/7/21, but the visit note was faxed today day and had not been previously uploaded into the resident's Electronic Medical Record (EMR). The facility presented a second consultation for a vision exam in-house on 10/4/21 which had been uploaded into the EMR. The SSD and NN stated the first appointment was with the Ophthalmologist who referred the resident to [NAME] University Hospital, but nobody notified the facility that the appointment was made. And the facility did not know if the resident had this paperwork when s/he returned to the facility from that appointment. The SSD and NN stated since they did not have the Ophthalmologist's visit note, the resident did not go to the appointment. The NN stated, I think [the appointment follow-up] was overlooked. Review of the Ophthalmology Note revealed an appointment on 9/7/21, with a Chief Complaint of blurry vision, feels like right eye has gotten worse since June. Discussion - Detachment: RD OD [retinal detachment, right eye] (Recent)-Going to send referral to AU Health Retina for consult and treatment. Discussed with Patient - Detachment: RD Patient educated on condition. Discussed immediate referral to retina {sic} for consult and treatment. All questions were answered to the patient's satisfaction. Patient Instructions-Detachment: Retinal Detachment. Appointment with Retina specialist. Do not eat or drink anything prior until (sic) after you see the retinal doctor. Orders-Diagnostic Test-Fundus Photo OU [both eyes] Same Day. Review of the second referral from the EMR from 360 Care dated 10/4/21 recorded, The [AGE] year old [gender] presents for evaluation of decreased vision in the right eye and left eye. It occurs with no pattern. The onset was gradual .The symptom is intermittent. The condition is moderate. The Impression/Plan recorded, Retinal [CONDITION(S)]. Referral to Retinal Specialist for treatment. Please schedule with Retinal Specialist of facility choice with the next 2-3 (two to three) weeks. During observation and interview on 11/09/21 at 12:24 p.m., Resident #70 complained of vision that reminded him of a kaleidoscope in his/her right eye. S/he stated it has been blurry since Father's Day. S/he further stated the facility sent him/her to an Optician last month who said s/he needed to go to the hospital to another eye doctor, but s/he did not have an appointment for that. The resident appeared clean and well groomed, in bed. During interview on 11/11/21 at 10:15 a.m. Resident #70 stated his/her eyes still had the wavy vison, and now it won't go away. It's there when s/he closed his/her eyes s/he stated but was able to fall asleep. During interview on 11/12/21 at 9:05 a.m., Certified Nursing Assistant (CNA) #11 stated the resident never complained to him/her about his/her vision or any blurry eyes that s/he can recall. If the resident did, s/he would have told the nurse. During interview on 11/12/21 at 10:17 a.m., Licensed Practical Nurse (LPN) #13 stated the resident complained of blurry vision and s/he notified the Nurse Practitioner (NP). LPN #13 stated the resident was sent out to [NAME] Ophthalmologists and his/her paperwork came back with him/her and they noted they were sending a referral. LPN #13 stated the system was they wait until the referral is sent - usually they set up the appointment - we call back, the Business Office sometimes receives the referrals and then they send to the correct person. The NN reads back over the notes and then s/he lets us know what to do, where the resident is going and when. If they (referral provider) don't send it to us, and at times this has happened, then LPN #13 keeps track of it and makes a Nurse's Note and follows up. If s/he is off work, s/he reads back over all the Nurse's Notes when s/he returns to work to remind him/herself what to follow up on. During follow up interview on 11/12/21 at 11:34 a.m., the NN stated the process was if a resident goes out, the nurse on the unit gets the paperwork, otherwise s/he should request documents from the appointment and respond to it. The nurse does not sign or initial the referral that it was read and responded to. Then the document goes to medical records for uploading. Nurses should document orders or no new orders in the Progress Notes. The NN stated at times, if a nurse is too busy and requests help, then the NN takes the initiative and makes the appointment for that resident, but it is the nurse's job to follow up on the referrals. The resident needs attention from a specialist with a retinal problem. We have discussed ways to fix this system. During follow up interview on 11/12/21 at 2:01 p.m., the NN stated at times the provider notes from outside appointments are emailed, mailed to the Administrator, to the NN, or arrive with the resident and acknowledged there were no notes or documentation for Resident #70 in his/her record. During interview on 11/12/21 at 2:01 p.m., the Administrator stated, We missed following up on the referral when [the resident] came back with the notes. We obtained those notes yesterday. The nurse should have followed up to call for the notes. The Administrator further stated that anyone who received a referral should read it and execute the order. S/he stated, We will analyze the process and see how to modify it.

Based on observation, interviews, and record reviews, the facility failed to follow a physician's order to monitor an appetite and give a bolus feeding to a resident if the intake was less than 50%. This failed practice affected one (1) resident (Resident #60) out of 24 sampled residents. Findings: Review of the facility policy revised 6/2018, Weight Monitoring Program, documented, It is the Policy of (the facility) for each patient/resident to be weighed once a month unless ordered by the physician or contraindicated by patient/residents' medical condition. The Weight Team will review patient/resident weights on a monthly basis to determine risk of weight loss or weight gain. Resident #60 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted NPO (nothing by mouth). Review of the most recent quarterly Minimum Dated Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) which scored the resident as a 9 indicating moderate cognitive impairment. The MDS also documented the resident didn't have a swallowing problem, had an unplanned weight loss, and received 50% nutrition through a gastrostomy tube. The MDS also documented the resident could feed him/herself with tray set up. Review of the Physicians orders revealed the following: 5/25/21 Glucerna 1.5 full strength 85 milliliters (ml) per hour. Prosource No Carb (amino acids-protein hydrolysis), 6/10/21 Speech Therapy to be provided five (5) times per week, 6/14/21 Glucerna 1.5 85 ml per hour from 6:00 p.m.-8:00 a.m., 6/14/21 Glucerna 1.5 66 ml per hour 5:00 p.m.- 9:00 a.m., 7/2/21 pureed regular diet orally and patient to receive feeding assistance, 7/5/21 Patient to receive feeding assistance for small bites, and small sips 7/13/21 times daily. oral supplement, 7/13/21 Glucerna 1.5 at 66 ml per hour from 5 p.m.- 12 midnight 7/30/21 Glucerna 1.5 50 ml per hour from 5pm-12 midnight. 8/2/21 Standard 2.0 at 90 ml tid (three times daily), oral supplement, [MEDICATION(S)] and [MEDICATION(S)] ordered 8/4/21 Glucerna 1.5 40 ml per hour 5:00 p.m. -10:00 p.m. 8/20/21 Glucerna 1.5 ml 40 ml per hour from 9:00 p.m. to 4:00 a.m. 10/4/21 Discontinue enteral feedings. 10/8/21 Adaptive equipment: Divided plate 11/2/21 Glucerna 1.5 at 50 cc per hour from 6:00 p.m. to 6:00 a.m. for a 12-hour feeding. Special instructions were documented to stop feeding at 6:00 am. If patient accepts less than 50% of meal give one (1) can bolus of Glucerna or equivalent via g-tube, as needed. 11/12/21 If patient accepts less than 50% of meal give one (1) can bolus of Glucerna via G tube. Special Instructions: If patient accepts less than 50% of meal give one (1) can bolus via g tube - document meal percentage and if bolus was given after every meal. Review of the care plan, dated 5/25/21 and updated 11/2/21, documented the resident required a feeding tube due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal listed was that Resident #60 will not exhibit signs of complications from the feeding tube or enteral feeding solution and will eat and drink to satisfaction. Approaches listed were the following: Nutrition and hydration via gastrostomy tube and, oral diet per MD orders, and staff to assist resident with all meals for maximum intake. If resident consumes less than 50% notify the nurse promptly. Additionally, adaptive equipment: divided plate, built up handle utensils, supplements per MD orders, weights per protocol and keep NP (Nurse Practioner), RP (Responsible Party) and RD (Registered Dietitian) informed of any changes. Monitor for dehydration (dizziness on sitting/standing, change in mental status, decreased urine output, concentrated urine, poor skin turgor, dry, cracked lips, dry [MEDICATION(S)] membranes, sunken eyes, constipation, fever, infection, electrolyte imbalance), Speech therapy consult. Follow recommendations and monitor for signs of malnutrition (pale skin, dull eyes, swollen lips, swollen gums, swollen and/or dry tongue with [NAME] or magenta hue, poor skin turgor, cachexia, bilateral [CONDITION(S)], muscle wasting). A review of the Physicians Progress notes, dated 5/25/21, revealed the hospital records were reviewed and the resident had failure to thrive while still at home with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note also documented some intermittent high residuals and some emesis which was thought to be related to [CONDITION(S)] from uncontrolled diabetes. Further review of the Physicians Progress notes, dated 5/28/21 through 10/8/21, revealed Resident #60's weight loss and enteral feedings were addressed monthly with interventions. A review of the interdisciplinary progress notes, dated 6/2/21, revealed the resident was a new admission and placed into the Patient at Risk (PAR) meeting for weight management program. Further review of the progress notes dated 6/2/21 through 11/3/21, revealed the resident remained as part of the PAR program and was weighted weekly since admission to monitor weights and tolerance to the tube feeding. The progress notes revealed that the resident had a 23% weight loss in six (6) months which was significant for the time frame. A review of the Dietitian's progress notes, dated 6/14/21 through 11/3/2021, revealed Resident #60's weight loss was addressed monthly with numerous interventions. A progress note, dated 10/4/21, the Dietitian documented, Resident #60's IBW (Ideal Body Weight Range) was 108-138 pounds and that some weight loss was beneficial to the resident because their BMI (Body Mass Index) being 25.4 which indicated the resident was overweight. The Dietitian documented the weight loss was due to vomiting. A review of the Speech Therapy Notes, dated 6/10/21, with recertification through 11/15/21, revealed the Speech Therapist worked with Resident #60 for [CONDITION(S)] and dysphagia five (5) times per week. The Speech Therapist recommended a pureed diet, divided plate, and built-up utensils, and provided instructions to the staff for feeding, to better help the resident eat. Observations of Resident #60 on 11/10/21 at 1:00 p.m., revealed the resident received their lunch tray, which contained a pureed diet with built-up utensils. A CNA was going into her room to help her. On 11/11/21 at 1:00 p.m., Resident #60 was observed with lunch tray. S/he received the correct diet and built- up utensils. Resident #60 nodded yes when asked if s/he liked the food she received. On 11/12/21 at 9:45 a.m., in an interview about the bolus feedings, Licensed Practical Nurse (LPN) #18, who was taking care of Resident #60, stated the resident hasn't been documented as being given any bolus feedings. LPN #18 pulled up the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked about meal intake eaten, s/he couldn't find the documentation in the record that the meal intakes were recorded. On 11/12/21at 9:50 a.m., in an interview with Scheduler #19 about the bolus feedings, s/he stated s/he was not able to find any documentation of the amount of meal intakes for Resident #60. S/he stated the Certified Nursing Assistants (CNA) probably just told the nurse how much they ate. On 11/12/21 at 10:08 a.m., in an interview with LPN #20, s/he stated, I think if they signed off on the meal intake of less than 50%, they would give her the bolus. On 11/12/21 at 10:15 a.m., in an interview with Restorative Aide (RA) #14 s/he stated s/he feeds her/him, and s/he usually eats 25%, which is the average and usually vomits a little when done. She stated s/he thought the resident was getting the bolus. On 11/12/21 at 10:30 a.m., in an interview with Director of Nursing (DON), s/he stated s/he was made aware of the lack of documentation for the bolus feeding and oral eating percentages (intake or evidence of bolus). S/he stated she couldn't locate the information in the record. S/he stated the resident kept vomiting and losing weight and they tried to stabilize her. The DON stated the resident did gain two (2) pounds this week. S/he stated the resident was vomiting in the hospital as well and they did a complete workup on her/him before s/he got to the nursing home and could not find the reason for her vomiting. The DON stated the Weight Management Team even tried taking her/him off the feeding tube to see if that would increase her/his intake. S/he stated the team made adjustments to get her/him to eat and even the Speech Therapist was working with her/him. On 11/12/21 at 10:50 a.m., in an interview with the NP, s/he stated that s/he started working with the resident about two (2) months ago, and they may need to go to continuous enteral feeding again, s/he didn't know why the vomiting continued. S/he stated it didn't look like s/he was taking enough calories in to maintain her/his weight. S/he stated s/he didn't realize the documentation was lacking. On 11/12/21 at 12:25 p.m., in an interview with the Administrator s/he stated the expectation was for the doctor's orders to be followed. S/he stated the protocol to is to put the nurses in charge of the meal intake and not the Certified Nursing Assistants (CNAs). S/he stated the order was to be changed to bolus every day following meals, not as needed (prn). On 11/12/21 at 1:50 PM, in an interview with the RD, s/he stated the weight team was following the resident, and thought the vomiting was causing the weight loss and maybe the Vital 5 (another formula) should be tried.

Based on review of facility files and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Resident #2 made an allegation of abuse against CNA (Certified Nurse Aide) #2. The facility failed to thoroughly investigate and report the allegation of abuse and there was no action taken to protect Resident #2 after the allegation was made. The findings included: Cross refer to F607, F609 and F610. In an interview with the surveyor on 11/2/18 at approximately 4:25 PM, the Director of Nursing (DON) stated .RN (Registered Nurse) #1 talked to everyone, but did not get statements. The DON asked the Administer about reporting and s/he said since there was a witness in the room the whole time they did not have to investigate. (Noted per interview with CNA #2, s/he was not in the room the whole time. Cross refer to F610 for CNA interview). Review of the facility's policy titled Abuse Prevention & Reporting revealed, The Administrator will immediately begin an investigation and implement measures necessary to assure the safety and protection of the residents from the actual or alleged perpetrator . Review of the facility's policy titled Investigation of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revealed, The Administrator of the provider is responsible for assuring that an accurate and timely investigation is completed . Review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revealed, 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. The state survey agency in the state agency for adult protective services should be notified in accordance with state law through establish procedures of any allegations of abuse, neglect, exploitation or mistreatment, including injuries of an unknown source and misappropriation of patient property, within two hours after the allegation is made if the events upon which the allegation is based involved abuse or result in serious bodily injury, and not later than 24 hours if the events upon which the allegation is based do not involve abuse and do not result in serious bodily injury. The Ombudsman should also be notified as required by state law. The Administrator or designee should direct and investigation into the allegations or incident. On (MONTH) 7, (YEAR) at 1:23 PM the Administrator was notified that Immediate Jeopardy and/or Substandard Quality of Care was identified at F835 at a scope and severity of J. The Immediate Jeopardy and/or Substandard Quality of Care existed in the facility on (MONTH) 14, (YEAR).

Based on record review and interview, the facility failed to provide interventions to prevent the development of pressure ulcers for 1 of three residents reviewed for pressure ulcers. Resident #2 developed facility identified unstageable pressure sores to both legs. The findings included: Resident #2 was admitted with a Stage III pressure sore to his/her sacrum. During the resident's stay unstageable ulcers developed on the resident's legs. Throughout the resident's stay there were no Physician's Orders for treatment or preventive interventions. There were no Physician's Progress Notes to give description or progression of wounds. The facility admitted resident #2 on 12/1/17 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary dated 12/1/17 revealed the resident had a Stage III sacral decubitus. Encourage turning, wound care. The resident was admitted back to a hospital on [DATE] and discharged back to the facility on [DATE]. The Hospital Discharge Summary of 12/5/17 stated, Stage III decubitus ulcer and a history of [MEDICAL CONDITION]. Review of the Physician's Orders from 12/1/17 through 12/31/17 revealed no orders for treatment of [REDACTED]. There were no telephone orders for treatment of [REDACTED]. Review of the Physician's Progress Notes from 12/1/17 through 12/31/17 revealed the resident had a sacral pressure sore. There was no evidence the wound was seen or assessed by the physician. Review of the resident's care plan dated 12/14/17 revealed the resident was care planned for: Potential for further skin breakdown secondary to impaired mobility, bowel incontinence, and multiple chronic conditions. Resident has [DIAGNOSES REDACTED]. Resident currently has one unstageable sacral pressure sore. Interventions included: Incontinent care, monitor for infection and notify MD (physician). Offer supplemental nutrition to patient as ordered. Dietician to evaluate nutritional status. Turn and reposition patient during rounds and prn (as needed). Place pressure-redistribution product on bed/chair. The care plan was not updated for the developed pressure sores. There was no intervention for treatment of [REDACTED]. Review of the Wound Observation and Assessment Form revealed on 12/1/17: Bilateral pedal [MEDICAL CONDITION] 3+, observed with hyperkerotosis to Bil (bilateral) plantar aspects of feet. Full thickness PI (Pressure Injury) observed to sacrum measuring 5 x 1.5 x 0.1 centimeters (cms) with indistinct attached edges at uneven margins. Wound bed presents with 50 % red granulation tissue at 50% tightly adhered yellow slough. Light amount of serous drainage observed. Periwound firm and intact, free from maceration, induration, et [DIAGNOSES REDACTED]. Area cleansed with wound cleaner (wc)-[MEDICATION NAME] applied. Nurse Practitioner and Responsible Party notified. 12/6/17 readmitted with Full thickness PI observed to sacrum, measuring 4 x 2.5 x 0.1 with distinct attached edges at uneven margins. Wound bed presents with 50 % red granulation tissue at 50% tightly adhered yellow slough. Light amount of serous drainage observed. Area cleansed with wound cleaner and [MEDICATION NAME] dressing applied. Nurse Practitioner (NP) and Responsible Party (RP) notified. 12/12/17 Sacral area measured 5.5 x 4 x 0.1 with 70% tightly adhered yellow slough, 30% red granulation tissue. Light amount of serous drainage observed. Pressure relief cushion ordered for wheel chair/geri-chair. 12/19/17 PI to sacrum measuring 4.5 x 4 x 0.1. Area cleansed with wc, covered with [MEDICATION NAME] dressing. 12/26/17 PI to sacrum measuring 3.5 x 3.2 x 0.1, cleaned with wc covered with [MEDICATION NAME] dressing. Full thickness PI observed to lateral RLE (right lower extremity) with distinct attached edges with uneven margins. Area measured 8.4 x 2.7 x 0.1 with 50% dry eschar at 50% granulation tissue, light amount of serosanguinos drainage observed. Peri wound firm and intact, free from maceration, induration area cleaned with wound cleaner, hydrogel applied, followed by [MED] fiber and foam dressing. NP and RP notified. 12/29/17 Full thickness PI observed to Lateral Left Lower Extremity with uneven margins, distinct attached edges. Area measures 8 x 4.6 x 0.1 with 50% tightly adhered yellow slough at 50% red granulation tissue. Light amount of serosanguinous drainage observed. Cleaned with wc, hydrogel applied, followed by [MED] Fiber and foam dressing. Review of the Treatment Sheets revealed treatment for [REDACTED]. 12/26/17: Cleanse RLE lateral PI with wc, apply hydrogel and AG Fiber and foam dressing- change Tuesday and Fridays and prn. 12/29/17 Cleanse LLE lateral PI with wc, apply hydrogel and AG Fiber follow with foam dressing, change every Tuesday and Friday. The wounds were listed as unstageable. On 4/24/18 the Administrator was interviewed by the surveyor. The Administrator stated they were unable to locate an order for [REDACTED].

Based on record review and interview, the facility failed to provide Physician Services for treatment of [REDACTED]. Resident #2 developed pressure sores and had a decreased hemoglobin with no physician intervention. The findings included: Cross refer to F6[AGE] regarding development of pressure sores. The facility admitted resident #2 on 12/1/17 with [DIAGNOSES REDACTED]. Review of the Hospital Discharge Summary dated 12/1/17 revealed the resident had a Stage III sacral decubitus. Encourage turning, wound care. The resident was admitted back to a hospital on [DATE] and discharged back to the facility on [DATE]. The Hospital Discharge Summary of 12/5/17 stated, Stage III decubitus ulcer and a history of [MEDICAL CONDITION]. Review of the Physician's Orders from 12/1/17 through 12/31/17 revealed no orders for treatment of [REDACTED]. The resident's admission orders [REDACTED]. Review of the physician progress notes [REDACTED]. Monitor for signs and symptoms of bleeding. Physician had progress notes for 12/14/17, 12/29/17 and 12/31/17. There was no documentation of the resident's decreasing hemoglobin or pressure sores. Review of the Treatment Sheets revealed treatment for [REDACTED]. 12/26/17: Cleanse RLE lateral PI with wc, apply hydrogel and AG Fiber and foam dressing- change Tuesday and Fridays and prn. 12/29/17 Cleanse LLE lateral PI with wc, apply hydrogel and AG Fiber follow with foam dressing, change every Tuesday and Friday. The wounds were listed as unstageable. There were no physician's orders for the treatments implemented. Review of a lab report dated 12/9/17 for a Complete Blood Count (CBC) revealed the resident had a hemoglobin (hgb) of 8.30 (normal 13.[AGE]-17.30). A handwritten note dated 12/10/17 stated, ____ (Physician services) aware no new orders. A lab report dated 12/15/17 for a CBC had a hgb of 7.6. A hand written note on the lab report stated the same person was aware- new orders for Rocephn for Pneumonia. There was no mention of the resident's low hgb. A Discharge Recapitulation of Stay Form was completed for discharge of 12/21/17. Final Diagnoses: [REDACTED]. On 4/24/18 the Administrator was interviewed by the surveyor. The Administrator stated they were unable to locate an order for [REDACTED].

Based on review of facility Reportable Incidents and review of the facility's policy Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to implement its policies to ensure 1 of 1 resident reviewed for abuse was free from Misappropriation of Property. (Resident #141) The findings included: The facility admitted Resident #141 with [DIAGNOSES REDACTED]. Review of the facility's Reportable Incidents revealed an Initial 24-Hour Report dated 10/3/16 related to Resident #141. The 24-Hour Report indicated that on 10/03/16 the resident and a family member reported unauthorized transactions occurred on the resident's credit and/or debit card. Review of the Five-Day Follow-Up Report dated 10/07/16 indicated the facility notified local law enforcement and filed a report. The investigative report indicated that law enforcement investigated the allegation, and a warrant was issued for Alleged Perpetrator Certified Nurse Aide (CNA) #1. Review of the law enforcement Incident Report revealed that CNA #1 .admitted to all of the charges on both credit cards . Review of the facility's policy entitled, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revealed the policy stated, It is the policy of PruittHealth and its affiliated entities .to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, exploitation, mistreatment and misappropriation of patient property .The Organization and its partners should assure that best efforts are made to prevent any occurrences of any form of abuse, neglect, and exploitation. Further review of the policy revealed, 'Misappropriation of Patient Property' means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patient's belongings or money without the patient's consent.

On the days of the Complaint and Extended Survey, based on record review, interviews and review of the facility investigation, the facility failed to respond to the monitor alarm for 1 of 3 residents sampled requiring respiratory monitoring. There was no response to the monitor alarm for Resident #2 for 40 minutes based on the facility investigation; when the staff responded Resident #2's [MEDICAL CONDITION] (trach) tube was out and s/he was without signs of life. The findings included: The sensor off alarm for Resident #2 was documented as "off" at 3:32 AM on 1/31/13. The staff did not check on the resident until 3:45 AM. The nursing supervisor and another nurse were aware that the sensor off alarm sounded and they did not check on the resident. Another nurse checked on the resident after completing a code situation on another unit. Approximately 13 minutes passed from the documented time the alarm sounded (3:32 AM) until the staff responded (3:45 AM) to Resident #2's alarm; s/he was found with her/[MEDICAL CONDITION] and no signs of life. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of nurse's notes dated 1/31/13 revealed a nurse's note at 3:45 AM that stated, "Walked into pt's (patient's) room and [MEDICAL CONDITION] to patient's head. Called RT (Respiratory Therapy) to reply ASAP (as soon as possible). Re-inserted trach. Pt unresponsive. Felt for pulse and could not feel. RT bagged pt and pt still not responsive. Called 911". Review of the Respiratory Therapy Evaluation/Progress Notes revealed a note dated 1/31/13 at 0350 AM that stated, "I and fell ow RT come from just bagging pt (patient) and sending out from another code to a call immediately upon arrival to vent hall. Pt was unresponsive upon entering room pt had no pulse pt DNR (do not resuscitate). Checked monitor log and info was written which said we were aware of sensor off. However we were not because we were doing another code on station three." Review of the Resident #2's care plan dated 7/13/12 identified a risk for complications of respiratory distress... and accidental decannulation (pulling out [MEDICAL CONDITION]), r/t (related to) tracheotomy history of decannulation and pulling at tubes..." Approaches included "...O2 (oxygen) and pulse ox (oximeter) as ordered..." Review of the Physician's monthly Cumulative Orders for 1/1/13 through 1/31/13 revealed respiratory care orders that included "...Continuous Pulse Ox & ...CO2 monitoring..." On 3/25/13 at 2:30 PM the surveyor interviewed the Administrator regarding Resident #2's decannulation. The Administrator stated the facility completed an investigation of the incident. Review of the facility investigation file revealed that Registered Nurse (RN) #1 was at the monitor when the code was called. At 3:00 PM Licensed Practical Nurse (LPN) #3 was prepared to sit and watch the monitor however RN #1 was at the monitor. The facility investigation stated, "...There is no written logging of any alarms from 3:00-3:32 AM, when interviewed no staff heard any radio pages for alarms. The first entry written by RN #1 at 3:32 16-B {Resident #2} sensor Off (no notification given)..." The investigation further stated, "...We determined that we had a failure to effectively monitor the Oxinet system (16B {Resident #2} shows sensor off for 40 minutes)..." On 3/26 and 3/27/13 the Administrator was asked for any monitor read out tapes for the date and time of the incident. On 3/27/13 at 2:45 PM, the surveyor was told by the Administrator and Corporate Nurse that only current events could be printed out, passed events could not be printed. No print outs of the time of the incident were provided. On 3/27/13 the surveyor asked how the facility determined the alarm was not responded to for 40 minutes, the Administrator stated it was a typographical error. Review of the Oxinet (respiratory telemetry monitoring system) Trouble Log used by the ventilator unit monitoring staff to record ventilator alarms and sensor alarms of the residents with tracheotomies indicated a place to document the Date & Time; the Alarm Triggered; Response Time; Duration of Alarm. The 1/31/13 log entry from 12:11 AM until 2:51 AM indicated the alarm sounded approximately 7 times per hour. There were no entries after 2:51 AM until 3:32 AM, 40 minutes, when Resident #2, room [ROOM NUMBER]-B triggered a Sensor off alarm, Registered Nurse (RN) #1 documented that Respiratory Therapy (RT) was aware. The duration of the alarm was blank, indicating no resolution for the sensor off alarm. In an interview with the surveyor on 3/26/13 at 9:11 AM Respiratory Therapist (RT) #1 stated the therapists were on another hall performing a code and that s/he bagged the coded resident out of the building. When the coded resident was in the ambulance s/he came back to the nurse's station to find LPN #2 working with Resident #2 who had decannulated; LPN #2 had pushed [MEDICAL CONDITION] in. RT #1 stated that Resident #2's sensor was off and that the nurses were at the station when the sensor alarm went off. "They were aware." The RT stated that anyone could put a sensor back on and that the nurses were waiting on them and they were already in a code. "His/her sensor was off quite a while." The surveyor asked the RT, who was responsible for answering the alarms? The RT stated, "RT and nurses are able to answer the ventilator alarms. There are many times the nurses will not answer the lights/monitor. All staff is responsible for reapplying the sensor. Anyone can apply the sensor." On 3/26/13 at 10:30 AM RT #2 was interviewed by the surveyor. The RT confirmed s/he had been at a code on another unit and that between 3:45 and 4:00 AM when s/he returned to the vent s/he was called to Resident #2's room. S/he stated they were told the nurse put [MEDICAL CONDITION] in and that they put him/her on 100% oxygen but s/he was unresponsive. The RT stated that the monitor Tech ' s sees everything, pulse rate, saturation and if the sensor is off. S/he stated that the monitor says sensor off. S/he confirmed that Resident #2 had a history of [REDACTED]. "We carry our radios at all times. Did not hear anything called before we were back on unit." The surveyor interviewed the Registered Nurse (RN) #1 Supervisor on 3/26/13 at approximately 8:20 AM regarding the incident on 1/31/13. The RN stated that s/he came in to work that night at 1:00 AM to work on the Beauty Shop hall and cover the monitor. S/he stated that s/he gathered her/his charts to do the charting and realized the girl at the monitor left at 3:00 AM as scheduled. The RN stated that s/he noticed something pop up for Resident #2 but that s/he thought the resident was on the vent; if the vent became disconnected it would have been a big alarm. "That takes precedence over a sensor being off." S/he stated that s/he didn't realize Resident #2 was on [MEDICAL CONDITION]. S/he further stated that s/he paged over the Walkie Talkies that a sensor was off for Resident #2 and that no one responded back to her/him over the radio. The RN Supervisor was unable to say exactly what time s/he began watching the monitor. Review of the Oxinet Monitoring Log documented the alarm went off at 3:32 AM. The Supervisor stated that shortly after the alarm went off s/he asked Licensed Practical Nurse (LPN) #2 to check on the patient; LPN #2 found Resident #2 without a pulse and not breathing. When the surveyor asked about other staff the Supervisor stated that s/he was not sure what LPN #3 was doing or where the CNAs were. S/he stated that s/he didn't have visual eyesight on anybody. The surveyor asked the Supervisor if there was anyone else who could have watched the monitor? S/he replied that there was no one there I could ask to sit and visually monitor. "Someone has to sit at monitor at all times. That is why I didn't go check on patient." In an interview with the surveyor on 3/26/13 at approximately 1:35 PM LPN #3 stated that LPN #2 and the respiratory therapists were at a code on another unit. S/he stated that s/he was in the charting room and the RN Supervisor was monitoring the monitor; after a while s/he went to make rounds on her/his residents. S/he stated that later LPN #2 came down the hall and the next thing s/he heard was LPN#2 calling a code for Resident #2. When asked by the surveyor if s/he heard the call for the sensor monitor off? S/he stated, "I heard them call a couple of times. There wasn't calls saying that it was still off. Sometimes the machine will correct itself..." In an interview with the surveyor on 3/26/13 at 11:00 AM Licensed Practical Nurse (LPN) #2 stated s/he had just sat down from working a code on another unit. The Registered Nurse (RN) #1 told her to go check the sensor on Resident #2. The LPN stated s/he went to check the resident and found, "bed was at a 40 degree angle (head of bed), her/his hands were up (demonstrated palms up) and her/[MEDICAL CONDITION] out on the bed on the right. The tie was undone on the left side but the right side tie was intact. I called respiratory stat, put the head of the bed down and reinserted trach. Found Ambu bag and RT came right in. They took over the ambu bag and proceeded with respiration part. I was trying to feel for a pulse, no pulse, started chest compressions." LPN #2 referred to her facility obtained statement for the time s/he responded to resident. S/he confirmed the time of response as 3:45 AM. The LPN was unable to remember if s/he carried a Walkie Talkie (radio) the night of the incident. In an interview with the surveyor on 3/26/13 at 12:17 PM CNA #2 stated, "Everybody is suppose to carry a Walkie on the vent unit. That night I wasn't carrying a Walkie because it wasn't charged. All shifts use the Walkies, sometimes the Walkies are broke or not charged and have to wait for them to be charged. You were unable to hear if someone called across Walkies that night." The surveyor interviewed Certified Nursing Assistant (CNA) #1 on 3/27/13 at approximately 9:45 AM s/he stated, "There were two nurses at the monitor. The resident decannulated her/himself. S/he had a history of [REDACTED]. The nurses did not do anything until LPN #2 came back from a code and checked on the resident. I didn't have a Walkie. I did not hear call about sensor being off... I didn't know anything until I heard LPN #2 yell s/he needed help immediately. I went to assist her/him." CNA #1 stated that s/he had been told that if the Walkies were not charged, the nurses and RT's were to have the working Walkies. Walkie Talkie's were used by the facility staff to communicate with each other resident concerns, such as alarms sounding. On the night of the incident all of the staff did not have working Walkie Talkies; the staff stated the batteries were not charged. Review of the Monitor Tech Responsibilities Policy stated, "...Ensure that all staff on the vent unit have a working radio. Nurses and Therapist first, then CNAs. ...Perform a radio check twice per shift to ensure communication is open between all who have a radio. Write "radio check performed" on alarm log with time, date, and radio number involved. ...It is important to call all alarms on radio even if therapists are at the desk. This is done so that all staff with a radio are aware." Review of facility purchase order UHS 8... dated 2/25/13 and backordered 3/8/13 indicated 8 radios were ordered. The radios arrived at the facility 3/26/13. In an interview with the surveyor on 3/27/13 the Administrator confirmed the facility had ordered new Walkie Talkies as a result of the incident with Resident #2. In an interview with the surveyor on 3/27/13 at 9:05 AM the Director of Health Services stated that when a sensor monitor (measures oxygen saturation) comes off immediate response by the staff is expected. When the surveyor asked how may CNAs were cross trained for the monitor? S/he replied, "All vent CNAs." Allegation of Compliance For the resident affected by the alleged deficient practice: * Resident #2 passed away 1/31/2013 * Administrator and DHS conducted an internal investigation related to this event. Investigation was started on 1/31/13 and completed on 2/8/12. This incident was reported to DHEC (Department of Health and Environmental Control) as neglect 3/27/2013. * All staff assigned to the Vent hall on 1/31/2013 was interviewed during the time frame of investigation. * We discovered during the course of the investigation that the RN (registered nurse) Supervisor paged sensor issue for resident #2. RT (respiratory therapy) did not hear their response. The RN Supervisor failed to respond to the resident's needs. * We re-educated the Vent Hall Staff on the Monitor system as well as the radio check procedures on 02/03/2013. Facility implemented two new Monitoring logs (Oxinet monitoring Log,[MEDICAL CONDITION] sheet [MEDICAL CONDITION]) the Logs indicate response time as far as RT response. * DHS on 02/10/2013 reassigned the Vent Manager to 3rd shift to assist in education and training of RN Supervisor (including assessing critical situations) ending on 02/27/2013. * LPN (licensed practical nurse) who failed to respond to the code was terminated on 02/27/2013 due to an unrelated incident. * Portable Radios were examined for functionality to ensure they work effectively. Additional portable radios were ordered on [DATE] and until the additional radios were received an exchange system was utilized to ensure charged radios were available for use by all staff. A rotation system was utilized to ensure charged radios were available at the beginning of each shift. Additional radios were available on 03/27/13. Residents Potentially Affected: * Utilized the 72 hour behavior log and behavior symptom screening form to identify residents with the potential for de-cannulation. That is, all vent patients and patients that have tracheotomies was implemented on 02/01/2013 and is ongoing. * In-services were begun immediately for Respiratory Staff and Nursing staff all departments on 2/1/2013 completed 2/5/2013, conducted by the CCC (Clinical Competency Coordinator on: * In-serviced all licensed staff (RN, LPN and RT (respiratory therapy) on the revised code procedure. * In-serviced all staff (RN, LPN, RT, CNA) that work on the vent unit on the Oxinet Monitoring System and completion of the flow records (new Log indicate response time from RT). * In-serviced all nursing staff (RN, LPN) on when to notify the DHS, the MD and the Administrator. * In-serviced all nursing (RN, LPN, and CNA) and respiratory staff assigned to the vent unit on trachs and vents. * In-serviced nursing staff (RN, LPN, CNA) on behavioral management. * In-serviced nursing staff (RN, LPN, CNA, RT) on occurrences esp (especially) r/t (related to) de-cannulations completed on 02/25/2013 by the CCC. * All staff educated on Abuse and Neglect 2/11/2013 was conducted by the corporate educator. * All Respiratory Therapy staff were educated on Vent Check (verification equipment functioning properly, and parameters are correct) 2/5/2013 by the RT Manager. * All residents [MEDICAL CONDITION] (Collar) trials will be checked every hour by the respiratory therapist and or nurse. This will be documented on a log and checked by the RT manager and the vent manager. This procedure was started on 02/04/2013 and is ongoing. * Clinical Competency Coordinator (CCC) RT Manager educated all Vent Staff Nurses and RT's regarding our policy on assessment Q (every) 4 hours of every Vent resident (Completed 2/5/2013). * CCC educated all licensed staff (RN, LPN and RT's) on assessment and documentation (Completed 3/26/2013). * The Administrator, DHS, Unit Managers, SCP (Senior Care Partners), RT Manager, Social Worker and CCC were retrained on Neglect and reporting on 3/27/2013 by the Area Vice President. Plan completed 03/27/2013 Observation of the Walkie Talkies during the survey revealed no concerns. The monitor tech's were observed on all shift at the monitor. Interviews with LPN #2, RN #1 and RT's #1 and #2 revealed they attended inservice related to vent/trach care, decannulation and emergency care; Abuse/neglect training and policy changes related to the incident of 1/31/13. Inservice sign-in logs and inservice content was reviewed for attendance and quality of the content. Tools designed to monitor radio use/order and a new monitor log were in use during the survey. The AOC submitted by the facility on 03/27/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility staff had been educated and was knowledgeable of the care and monitoring of the resident with a [MEDICAL CONDITION]. The Administrator was informed of this on 03/27/2013 at 3:15 PM. The Substandard Quality of Care and/or Immediate Jeopardy was removed at F-328 but the citation remained at a lower scope and severity "D".

On the day of the Complaint and Extended Survey, based on record review and interviews, the facility failed to follow Resident #2's care plan related to her/him having a history of pulling out his/her [MEDICAL CONDITION] (trach) tube. The facility staff failed to respond based on their investigation for 40 minutes to the monitor alarm for Resident #2; when the staff responded Resident #2'[MEDICAL CONDITION] was out and s/he was without signs of life. The findings included: The "sensor off" alarm for Resident #2 (a resident with a [MEDICAL CONDITION]) was documented as "off" at 3:32 AM on 1/31/13. The nursing supervisor who was monitoring the alarm and another nurse were aware that the sensor off alarm sounded and they did not check on the resident. At 3:45 AM another nurse checked on the resident and found her/[MEDICAL CONDITION] and no signs of life. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of nurse's notes dated 1/31/13 revealed a nurse's note at 3:45 AM that stated, "Walked into pt's (patient's) room and [MEDICAL CONDITION] to patient's head. Called RT (Respiratory Therapy) to reply ASAP (as soon as possible). Re-inserted trach. Pt unresponsive. Felt for pulse and could not feel. RT bagged pt and pt still not responsive. Called 911". Review of the Resident #2's care plan dated 7/13/12 and updated 1/10/13 identified a risk for complications of respiratory distress... and accidental decannulation (pulling out [MEDICAL CONDITION]), r/t (related to) tracheotomy history of decannulation and pulling at tubes..." Approaches included "...O2 (oxygen) and pulse ox (oximeter) as ordered... The surveyor interviewed the Registered Nurse (RN) Supervisor on 3/26/13 at approximately 8:20 AM regarding the incident on 1/31/13. The RN confirmed s/he did not immediately respond to the alarm or followup on the Walkie Talkie alert to Respiratory Therapy and other staff in the facility. When the surveyor asked about other staff the Supervisor stated that s/he was not sure what LPN #3 was doing or where the CNAs were. S/he stated that s/he didn't have visual eyesight on anybody. The surveyor asked the Supervisor if there was anyone else who could have watched the monitor? S/he replied that there was no one there I could ask to sit and visually monitor. "Someone has to sit at monitor at all times. That is why I didn't go check on patient." Allegation of Compliance For the resident affected by the alleged deficient practice: * Resident #2 passed away 1/31/2013 * Administrator and DHS conducted an internal investigation related to this event. Investigation was started on 1/31/13 and completed on 2/8/12. This incident was reported to DHEC (Department of Health and Environmental Control) as neglect 3/27/2013. * All staff assigned to the Vent hall on 1/31/2013 was interviewed during the time frame of investigation. * We discovered during the course of the investigation that the RN (registered nurse) Supervisor paged sensor issue for resident #2. RT (respiratory therapy) did not hear their response. The RN Supervisor failed to respond to the resident's needs. * We re-educated the Vent Hall Staff on the Monitor system as well as the radio check procedures on 02/03/2013. Facility implemented two new Monitoring logs (Oxinet monitoring Log,[MEDICAL CONDITION] sheet [MEDICAL CONDITION]) the Logs indicate response time as far as RT response. * DHS on 02/10/2013 reassigned the Vent Manager to 3rd shift to assist in education and training of RN Supervisor (including assessing critical situations) ending on 02/27/2013. * LPN (licensed practical nurse) who failed to respond to the code was terminated on 02/27/2013 due to an unrelated incident. * Portable Radios were examined for functionality to ensure they work effectively. Additional portable radios were ordered on [DATE] and until the additional radios were received an exchange system was utilized to ensure charged radios were available for use by all staff. A rotation system was utilized to ensure charged radios were available at the beginning of each shift. Additional radios were available on 03/27/13. Residents Potentially Affected: * Utilized the 72 hour behavior log and behavior symptom screening form to identify residents with the potential for de-cannulation. That is, all vent patients and patients that have tracheotomies was implemented on 02/01/2013 and is ongoing. * In-services were begun immediately for Respiratory Staff and Nursing staff all departments on 2/1/2013 completed 2/5/2013, conducted by the CCC (Clinical Competency Coordinator on: * In-serviced all licensed staff (RN, LPN and RT (respiratory therapy) on the revised code procedure. * In-serviced all staff (RN, LPN, RT, CNA) that work on the vent unit on the Oxinet Monitoring System and completion of the flow records (new Log indicate response time from RT). * In-serviced all nursing staff (RN, LPN) on when to notify the DHS, the MD and the Administrator. * In-serviced all nursing (RN, LPN, and CNA) and respiratory staff assigned to the vent unit on trachs and vents. * In-serviced nursing staff (RN, LPN, CNA) on behavioral management. * In-serviced nursing staff (RN, LPN, CNA, RT) on occurrences esp (especially) r/t (related to) de-cannulations completed on 02/25/2013 by the CCC. * All staff educated on Abuse and Neglect 2/11/2013 was conducted by the corporate educator. * All Respiratory Therapy staff were educated on Vent Check (verification equipment functioning properly, and parameters are correct) 2/5/2013 by the RT Manager. * All residents [MEDICAL CONDITION] (Collar) trials will be checked every hour by the respiratory therapist and or nurse. This will be documented on a log and checked by the RT manager and the vent manager. This procedure was started on 02/04/2013 and is ongoing. * Clinical Competency Coordinator (CCC) RT Manager educated all Vent Staff Nurses and RT's regarding our policy on assessment Q (every) 4 hours of every Vent resident (Completed 2/5/2013). * CCC educated all licensed staff (RN, LPN and RT's) on assessment and documentation (Completed 3/26/2013). * The Administrator, DHS, Unit Managers, SCP (Senior Care Partners), RT Manager, Social Worker and CCC were retrained on Neglect and reporting on 3/27/2013 by the Area Vice President. Plan completed 03/27/2013 Observation of the Walkie Talkies during the survey revealed no concerns. The monitor tech's were observed on all shift at the monitor. Interviews with LPN #2, RN #1 and RT's #1 and #2 revealed they attended inservice related to vent/trach care, decannulation and emergency care; Abuse/neglect training and policy changes related to the incident of 1/31/13. Inservice sign-in logs and inservice content was reviewed for attendance and quality of the content. Tools designed to monitor radio use/order and a new monitor log were in use during the survey. The AOC submitted by the facility on 03/27/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility staff had been educated and was knowledgeable of the care and monitoring of the resident with a [MEDICAL CONDITION]. The Administrator was informed of this on 03/27/2013 at 3:15 PM. The Substandard Quality of Care and/or Immediate Jeopardy was removed at F-282 but the citation remained at a lower scope and severity "D".

On the days of the Complaint and Extended Survey the facility Administration failed to implement it's resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The Administration failed to ensure the policies and procedures of the facility were carried out to prevent harm to residents with know respiratory concerns; failed to ensure professional standards were maintained to ensure quality care was provided to a resident with a [MEDICAL CONDITION]. The findings included: Review of the facility investigation provided to the surveyor on 3/25/13 indicated the facility identified Resident #2 as not receiving appropriate monitoring or assessment by the facility staff. The facility investigation of the incident revealed the facility failed to respond to monitor alarms in a timely manner; the Walkie Talkie radio communication system failed to work; the Registered Nurse Supervisor failed to assess a critical situation and the facility failed to report potential neglect to the State Agency. Interview with the Director of Health Services and the Administrator on 3/25/13 revealed the staff failed to respond to Resident #2's monitor alarms; there were concerns with the radios related to the incident with Resident #2; the incident with Resident #2 was not identified as neglect and not report to the State Agency. Allegation of Compliance For the resident affected by the alleged deficient practice: * Resident #2 passed away 1/31/2013 * Administrator and DHS conducted an internal investigation related to this event. Investigation was started on 1/31/13 and completed on 2/8/12. This incident was reported to DHEC (Department of Health and Environmental Control) as neglect 3/27/2013. * All staff assigned to the Vent hall on 1/31/2013 was interviewed during the time frame of investigation. * We discovered during the course of the investigation that the RN (registered nurse) Supervisor paged sensor issue for resident #2. RT (respiratory therapy) did not hear their response. The RN Supervisor failed to respond to the resident's needs. * We re-educated the Vent Hall Staff on the Monitor system as well as the radio check procedures on 02/03/2013. Facility implemented two new Monitoring logs (Oxinet monitoring Log,[MEDICAL CONDITION] sheet [MEDICAL CONDITION]) the Logs indicate response time as far as RT response. * DHS on 02/10/2013 reassigned the Vent Manager to 3rd shift to assist in education and training of RN Supervisor (including assessing critical situations) ending on 02/27/2013. * LPN (licensed practical nurse) who failed to respond to the code was terminated on 02/27/2013 due to an unrelated incident. * Portable Radios were examined for functionality to ensure they work effectively. Additional portable radios were ordered on [DATE] and until the additional radios were received an exchange system was utilized to ensure charged radios were available for use by all staff. A rotation system was utilized to ensure charged radios were available at the beginning of each shift. Additional radios were available on 03/27/13. Residents Potentially Affected: * Utilized the 72 hour behavior log and behavior symptom screening form to identify residents with the potential for de-cannulation. That is, all vent patients and patients that have tracheotomies was implemented on 02/01/2013 and is ongoing. * In-services were begun immediately for Respiratory Staff and Nursing staff all departments on 2/1/2013 completed 2/5/2013, conducted by the CCC (Clinical Competency Coordinator on: * In-serviced all licensed staff (RN, LPN and RT (respiratory therapy) on the revised code procedure. * In-serviced all staff (RN, LPN, RT, CNA) that work on the vent unit on the Oxinet Monitoring System and completion of the flow records (new Log indicate response time from RT). * In-serviced all nursing staff (RN, LPN) on when to notify the DHS, the MD and the Administrator. * In-serviced all nursing (RN, LPN, and CNA) and respiratory staff assigned to the vent unit on trachs and vents. * In-serviced nursing staff (RN, LPN, CNA) on behavioral management. * In-serviced nursing staff (RN, LPN, CNA, RT) on occurrences esp (especially) r/t (related to) de-cannulations completed on 02/25/2013 by the CCC. * All staff educated on Abuse and Neglect 2/11/2013 was conducted by the corporate educator. * All Respiratory Therapy staff were educated on Vent Check (verification equipment functioning properly, and parameters are correct) 2/5/2013 by the RT Manager. * All residents [MEDICAL CONDITION] (Collar) trials will be checked every hour by the respiratory therapist and or nurse. This will be documented on a log and checked by the RT manager and the vent manager. This procedure was started on 02/04/2013 and is ongoing. * Clinical Competency Coordinator (CCC) RT Manager educated all Vent Staff Nurses and RT's regarding our policy on assessment Q (every) 4 hours of every Vent resident (Completed 2/5/2013). * CCC educated all licensed staff (RN, LPN and RT's) on assessment and documentation (Completed 3/26/2013). * The Administrator, DHS, Unit Managers, SCP (Senior Care Partners), RT Manager, Social Worker and CCC were retrained on Neglect and reporting on 3/27/2013 by the Area Vice President. Plan completed 03/27/2013 Observation of the Walkie Talkies during the survey revealed no concerns. The monitor tech's were observed on all shift at the monitor. Interviews with LPN #2, RN #1 and RT's #1 and #2 revealed they attended inservice related to vent/trach care, decannulation and emergency care; Abuse/neglect training and policy changes related to the incident of 1/31/13. Inservice sign-in logs and inservice content was reviewed for attendance and quality of the content. Tools designed to monitor radio use/order and a new monitor log were in use during the survey. The AOC submitted by the facility on 03/27/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility staff had been educated and was knowledgeable of the care and monitoring of the resident with a [MEDICAL CONDITION]. The Administrator was informed of this on 03/27/2013 at 3:15 PM. The Substandard Quality of Care and/or Immediate Jeopardy was removed at F-490 but the citation remained at a lower scope and severity "D".

On the day of the Complaint and Extended Survey, based on record review, interviews, review of the facility policy Pulse Oximeter/ETCO2 Monitoring/Oxi-Net System and review of the South Carolina Code of Ethics for Nurses the facility failed to provide services that meet professional standards of quality. The facility staff failed to respond based on their investigation for 40 minutes to the monitor alarm for Resident #2; when the staff responded Resident #2's [MEDICAL CONDITION] (trach) tube was out and s/he was without signs of life. The findings included: The "sensor off" alarm for Resident #2 (a resident with a [MEDICAL CONDITION]) was documented as "off" at 3:32 AM on 1/31/13. The nursing supervisor who was monitoring the alarm and another nurse were aware that the sensor off alarm sounded and they did not check on the resident. At 3:45 AM another nurse checked on the resident and found her/his [MEDICAL CONDITION] (trach) tube out and no signs of life. The facility admitted Resident #2 with [DIAGNOSES REDACTED]. Review of nurse's notes dated 1/31/13 revealed a nurse's note at 3:45 AM that stated, "Walked into pt's (patient's) room and [MEDICAL CONDITION] to patient's head. Called RT (Respiratory Therapy) to reply ASAP (as soon as possible). Re-inserted trach. Pt unresponsive. Felt for pulse and could not feel. RT bagged pt and pt still not responsive. Called 911". Review of the Oxinet (respiratory telemetry monitoring system) Trouble Log used by the ventilator unit monitoring staff to record ventilator alarms and sensor alarms of the residents with tracheotomies indicated a place to document the Date & Time; the Alarm Triggered; Response Time; Duration of Alarm. The 1/31/13 log entry from 12:11 AM until 2:51 AM indicated the alarm sounded approximately 7 times per hour. There were no entries after 2:51 AM until 3:32 AM, 40 minutes, when Resident #2, room [ROOM NUMBER]-B triggered a Sensor off alarm, Registered Nurse (RN) #1 documented that Respiratory Therapy (RT) was aware. The duration of the alarm was blank, indicating no resolution for the sensor off alarm. The surveyor interviewed the Registered Nurse (RN) Supervisor on 3/26/13 at approximately 8:20 AM regarding the incident on 1/31/13. The RN stated that s/he came in to work that night at 1:00 AM to work the Beauty Shop hall and to cover the monitor. S/he stated that s/he gathered her/his charts to do the charting and realized the girl at the monitor left at 3:00 AM as scheduled. The RN stated that s/he noticed something pop up for Resident #2 but that s/he thought the resident was on the vent; if the vent became disconnected it would have been a big alarm. "That takes precedence over a sensor being off." S/he stated that s/he didn't realize Resident #2 was on [MEDICAL CONDITION]. S/he further stated that s/he paged over the Walkie Talkies that a sensor was off for Resident #2 and that no one responded back to her/him over the radio. The RN Supervisor was unable to say exactly what time s/he begin watching the monitor. Review of the Oxinet Monitoring Log documented the alarm went off at 3:32 AM. The Supervisor stated that shortly after the alarm went off s/he asked Licensed Practical Nurse (LPN) #2 to check on the patient; LPN #2 found Resident #2 without a pulse and not breathing. When the surveyor asked about other staff the Supervisor stated that s/he was not sure what LPN #3 was doing or where the CNAs were. S/he stated that s/he didn't have visual eyesight on anybody. The surveyor asked the Supervisor if there was anyone else who could have watched the monitor? S/he replied that there was no one there I could ask to sit and visually monitor. "Someone has to sit at monitor at all times. That is why I didn't go check on patient." In an interview with the surveyor on 3/26/13 at approximately 1:35 PM LPN #3 stated, "There was a code called for the other unit... The other nurse went to the code. I was in the charting room. ...RN Supervisor was monitoring the monitor. I went down checking my residents, doing tubes, making rounds. The other nurse came down the hallway; the next thing I heard was LPN#2 calling a code. When asked if the nurse heard the call for the sensor monitor off, s/he stated, "I heard them call a couple of times. There wasn't calls' saying that it was still off. Sometimes the machine will correct itself..." Review of the facility Pulse Oximeter/ETCO2 Monitoring/Oxi-Net System policy stated, "Pulse oximetry is a non-invasive method of monitoring the percentage of hemoglobin which is saturated oxygen... Monitoring Procedure ...It is the responsibility of the ventilator unit personnel to respond to all monitor alarms..." Review of the South Carolina Code of Ethics for Nurses revealed Provision 1, "The nurse, in all professional relationships, practices with [MEDICATION NAME] and respect for the inherent dignity and self worth and uniqueness of every individual unrestricted..." Provision 2 "The nurse's primary commitment is to the patient..." Provision 3, "the nurse promotes, advocates for and strives to protect the health safety and rights of each patient." Provision 4, "the nurse is responsible and accountable for individual nursing practice." Allegation of Compliance For the resident affected by the alleged deficient practice: * Resident #2 passed away 1/31/2013 * Administrator and DHS conducted an internal investigation related to this event. Investigation was started on 1/31/13 and completed on 2/8/12. This incident was reported to DHEC (Department of Health and Environmental Control) as neglect 3/27/2013. * All staff assigned to the Vent hall on 1/31/2013 was interviewed during the time frame of investigation. * We discovered during the course of the investigation that the RN (registered nurse) Supervisor paged sensor issue for resident #2. RT (respiratory therapy) did not hear their response. The RN Supervisor failed to respond to the resident's needs. * We re-educated the Vent Hall Staff on the Monitor system as well as the radio check procedures on 02/03/2013. Facility implemented two new Monitoring logs (Oxinet monitoring Log,[MEDICAL CONDITION] sheet [MEDICAL CONDITION]) the Logs indicate response time as far as RT response. * DHS on 02/10/2013 reassigned the Vent Manager to 3rd shift to assist in education and training of RN Supervisor (including assessing critical situations) ending on 02/27/2013. * LPN (licensed practical nurse) who failed to respond to the code was terminated on 02/27/2013 due to an unrelated incident. * Portable Radios were examined for functionality to ensure they work effectively. Additional portable radios were ordered on [DATE] and until the additional radios were received an exchange system was utilized to ensure charged radios were available for use by all staff. A rotation system was utilized to ensure charged radios were available at the beginning of each shift. Additional radios were available on 03/27/13. Residents Potentially Affected: * Utilized the 72 hour behavior log and behavior symptom screening form to identify residents with the potential for de-cannulation. That is, all vent patients and patients that have tracheotomies was implemented on 02/01/2013 and is ongoing. * In-services were begun immediately for Respiratory Staff and Nursing staff all departments on 2/1/2013 completed 2/5/2013, conducted by the CCC (Clinical Competency Coordinator on: * In-serviced all licensed staff (RN, LPN and RT (respiratory therapy) on the revised code procedure. * In-serviced all staff (RN, LPN, RT, CNA) that work on the vent unit on the Oxinet Monitoring System and completion of the flow records (new Log indicate response time from RT). * In-serviced all nursing staff (RN, LPN) on when to notify the DHS, the MD and the Administrator. * In-serviced all nursing (RN, LPN, and CNA) and respiratory staff assigned to the vent unit on trachs and vents. * In-serviced nursing staff (RN, LPN, CNA) on behavioral management. * In-serviced nursing staff (RN, LPN, CNA, RT) on occurrences esp (especially) r/t (related to) de-cannulations completed on 02/25/2013 by the CCC. * All staff educated on Abuse and Neglect 2/11/2013 was conducted by the corporate educator. * All Respiratory Therapy staff were educated on Vent Check (verification equipment functioning properly, and parameters are correct) 2/5/2013 by the RT Manager. * All residents [MEDICAL CONDITION] (Collar) trials will be checked every hour by the respiratory therapist and or nurse. This will be documented on a log and checked by the RT manager and the vent manager. This procedure was started on 02/04/2013 and is ongoing. * Clinical Competency Coordinator (CCC) RT Manager educated all Vent Staff Nurses and RT's regarding our policy on assessment Q (every) 4 hours of every Vent resident (Completed 2/5/2013). * CCC educated all licensed staff (RN, LPN and RT's) on assessment and documentation (Completed 3/26/2013). * The Administrator, DHS, Unit Managers, SCP (Senior Care Partners), RT Manager, Social Worker and CCC were retrained on Neglect and reporting on 3/27/2013 by the Area Vice President. Plan completed 03/27/2013 Observation of the Walkie Talkies during the survey revealed no concerns. The monitor tech's were observed on all shift at the monitor. Interviews with LPN #2, RN #1 and RT's #1 and #2 revealed they attended inservice related to vent/trach care, decannulation and emergency care; Abuse/neglect training and policy changes related to the incident of 1/31/13. Inservice sign-in logs and inservice content was reviewed for attendance and quality of the content. Tools designed to monitor radio use/order and a new monitor log were in use during the survey. The AOC submitted by the facility on 03/27/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility staff had been educated and was knowledgeable of the care and monitoring of the resident with a [MEDICAL CONDITION]. The Administrator was informed of this on 03/27/2013 at 3:15 PM. The Substandard Quality of Care and/or Immediate Jeopardy was removed at F-281 but the citation remained at a lower scope and severity "D".

On the days of the Complaint and Extended Survey, based on record review, interviews, review of the facility investigation, and review of the facility Policies on Abuse the facility failed to follow their policy related to identification and reporting of neglect. Resident #2 found with her/his [MEDICAL CONDITION] (trach) tube out and no signs of life. The findings included: Resident #2 with a known history of pulling out her/his trach. The sensor off alarm for Resident #2 alarmed on 1/31/13 at approximately 3:32 AM. The facility staff failed to respond to the alarm until approximately 3:45 AM. The facility investigation stated the alarm was not responded to for 40 minutes. The resident was found at approximately 3:45 AM with no signs of life, [MEDICAL CONDITION] out and lying on the bed. Review of the facility investigation of the incident that occurred on 1/31/13 with Resident #2, stated, "...It was the decision of the team not to report this to either Certification or licensure as it does not meet the criteria on the SC (South Carolina) grid. We determined that we had a Failure to effectively monitor the Oxinet system (16-B {Resident #2} shows sensor off for 40 minutes)..." Following a review of the facility investigation and in interviews with the staff it was determined that the facility failed to understand the definition of neglect or the need to report the staff involved in the incident to the State Agencies. Review of the facility Policy/Procedure (P/P) for Abuse Reporting: Healthcare Centers, Home Health Agencies, Hospice Agencies, Source Program & United Medical issued December 2001 last revised 7/09 indicated, "... 1. Once an occurrence is identified involving alleged mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of patient/resident property, the occurrence will be immediately reported to the Administrator. 'Immediate reporting' should not exceed 24 hours after the occurrence. 2. The Administrator or designee will immediately notify the appropriate state agencies and the legal representative and/or interested family member of the incident and the pending investigation. The Ombudsman and Police Department will also be notified as indicated. The Administrator or designee will direct the investigation..." The Abuse Identification Policy issued December, 2001 listed Abuse and Neglect Indicators, on page 1 of 3, one of the twenty-two neglect indicators included, "Inability to access medical or nursing personnel when necessary". The facility Policy/Procedure for abuse included a grid available for nursing home facilities as a reporting tool at www.scdhec.gov/health/cert/reporting_timeframe.htm. Under the section "Types of Accidents/Injuries to Report", Neglect was listed. Under the section on what agencies and time frames to report, the grid stated, "Ombudsman", "Neglect to be reported within 24 hours". Under "Certification", the grid stated, "Neglect", "Immediately (in accordance with Omnibus Adult Protection Act), but not to exceed 24 hours after discovery of the incident". In an interview with the surveyor on 3/26/13 the Administrator confirmed s/he did not believe the incident needed to be reported. Allegation of Compliance For the resident affected by the alleged deficient practice: * Resident #2 passed away 1/31/2013 * Administrator and DHS conducted an internal investigation related to this event. Investigation was started on 1/31/13 and completed on 2/8/12. This incident was reported to DHEC (Department of Health and Environmental Control) as neglect 3/27/2013. * All staff assigned to the Vent hall on 1/31/2013 was interviewed during the time frame of investigation. * We discovered during the course of the investigation that the RN (registered nurse) Supervisor paged sensor issue for resident #2. RT (respiratory therapy) did not hear their response. The RN Supervisor failed to respond to the resident's needs. * We re-educated the Vent Hall Staff on the Monitor system as well as the radio check procedures on 02/03/2013. Facility implemented two new Monitoring logs (Oxinet monitoring Log,[MEDICAL CONDITION] sheet [MEDICAL CONDITION]) the Logs indicate response time as far as RT response. * DHS on 02/10/2013 reassigned the Vent Manager to 3rd shift to assist in education and training of RN Supervisor (including assessing critical situations) ending on 02/27/2013. * LPN (licensed practical nurse) who failed to respond to the code was terminated on 02/27/2013 due to an unrelated incident. * Portable Radios were examined for functionality to ensure they work effectively. Additional portable radios were ordered on [DATE] and until the additional radios were received an exchange system was utilized to ensure charged radios were available for use by all staff. A rotation system was utilized to ensure charged radios were available at the beginning of each shift. Additional radios were available on 03/27/13. Residents Potentially Affected: * Utilized the 72 hour behavior log and behavior symptom screening form to identify residents with the potential for de-cannulation. That is, all vent patients and patients that have tracheotomies was implemented on 02/01/2013 and is ongoing. * In-services were begun immediately for Respiratory Staff and Nursing staff all departments on 2/1/2013 completed 2/5/2013, conducted by the CCC (Clinical Competency Coordinator on: * In-serviced all licensed staff (RN, LPN and RT (respiratory therapy) on the revised code procedure. * In-serviced all staff (RN, LPN, RT, CNA) that work on the vent unit on the Oxinet Monitoring System and completion of the flow records (new Log indicate response time from RT). * In-serviced all nursing staff (RN, LPN) on when to notify the DHS, the MD and the Administrator. * In-serviced all nursing (RN, LPN, and CNA) and respiratory staff assigned to the vent unit on trachs and vents. * In-serviced nursing staff (RN, LPN, CNA) on behavioral management. * In-serviced nursing staff (RN, LPN, CNA, RT) on occurrences esp (especially) r/t (related to) de-cannulations completed on 02/25/2013 by the CCC. * All staff educated on Abuse and Neglect 2/11/2013 was conducted by the corporate educator. * All Respiratory Therapy staff were educated on Vent Check (verification equipment functioning properly, and parameters are correct) 2/5/2013 by the RT Manager. * All residents [MEDICAL CONDITION] (Collar) trials will be checked every hour by the respiratory therapist and or nurse. This will be documented on a log and checked by the RT manager and the vent manager. This procedure was started on 02/04/2013 and is ongoing. * Clinical Competency Coordinator (CCC) RT Manager educated all Vent Staff Nurses and RT's regarding our policy on assessment Q (every) 4 hours of every Vent resident (Completed 2/5/2013). * CCC educated all licensed staff (RN, LPN and RT's) on assessment and documentation (Completed 3/26/2013). * The Administrator, DHS, Unit Managers, SCP (Senior Care Partners), RT Manager, Social Worker and CCC were retrained on Neglect and reporting on 3/27/2013 by the Area Vice President. Plan completed 03/27/2013 Observation of the Walkie Talkies during the survey revealed no concerns. The monitor tech's were observed on all shift at the monitor. Interviews with LPN #2, RN #1 and RT's #1 and #2 revealed they attended inservice related to vent/trach care, decannulation and emergency care; Abuse/neglect training and policy changes related to the incident of 1/31/13. Inservice sign-in logs and inservice content was reviewed for attendance and quality of the content. Tools designed to monitor radio use/order and a new monitor log were in use during the survey. The AOC submitted by the facility on 03/27/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility staff had been educated and was knowledgeable of the care and monitoring of the resident with a [MEDICAL CONDITION]. The Administrator was informed of this on 03/27/2013 at 3:15 PM. The Substandard Quality of Care and/or Immediate Jeopardy was removed at F-226 but the citation remained at a lower scope and severity "D".

On the days of the Complaint and Extended Survey, based on record review, interviews and review of the facility investigation, the facility failed to identify and report neglect to the State Agency. The Oxinet (respiratory telemetry monitoring system) alarm for Resident #2 was not responded to by the facility for 40 minutes based on the facility investigation; s/he was found with her/his [MEDICAL CONDITION] (trach) tube out and no signs of life. The facility investigation of the incident revealed the facility failed to respond to monitor alarms in a timely manner; the Walkie Talkie radio communication system failed to work and the Registered Nurse Supervisor failed to assess a critical situation. The findings included: Review of the facility investigation of the incident stated, "...It was the decision of the team not to report this to either Certification or licensure as it does not meet the criteria on the SC (South Carolina) grid. We determined that we had a Failure to effectively monitor the Oxinet system (16-B {Resident #2} shows sensor off for 40 minutes) as well as failure to transcribe and carry out an order..." Review of the facility Policy/Procedure (P/P) for Abuse Reporting: Healthcare Centers, Home Health Agencies, Hospice Agencies, Source Program & United Medical issued December 2001 last revised 7/09 indicated, "... 1. Once an occurrence is identified involving alleged mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of patient/resident property, the occurrence will be immediately reported to the Administrator. 'Immediate reporting' should not exceed 24 hours after the occurrence. The facility Policy/Procedure for abuse also included a grid available for nursing home facilities as a reporting tool at www.scdhec.gov/health/cert/reporting_timeframe.htm. Under the section "Types of Accidents/Injuries to Report", Neglect was listed. Under the section on what agencies and time frames to report, the grid stated, "Ombudsman", "Neglect to be reported within 24 hours". Under "Certification", the grid stated, "Neglect", "Immediately (in accordance with Omnibus Adult Protection Act), but not to exceed 24 hours after discovery of the incident". In an interview with the surveyor on 3/26/13 the Administrator confirmed s/he did not believe the incident needed to be reported. Allegation of Compliance For the resident affected by the alleged deficient practice: * Resident #2 passed away 1/31/2013 * Administrator and DHS conducted an internal investigation related to this event. Investigation was started on 1/31/13 and completed on 2/8/12. This incident was reported to DHEC (Department of Health and Environmental Control) as neglect 3/27/2013. * All staff assigned to the Vent hall on 1/31/2013 was interviewed during the time frame of investigation. * We discovered during the course of the investigation that the RN (registered nurse) Supervisor paged sensor issue for resident #2. RT (respiratory therapy) did not hear their response. The RN Supervisor failed to respond to the resident's needs. * We re-educated the Vent Hall Staff on the Monitor system as well as the radio check procedures on 02/03/2013. Facility implemented two new Monitoring logs (Oxinet monitoring Log,[MEDICAL CONDITION] sheet [MEDICAL CONDITION]) the Logs indicate response time as far as RT response. * DHS on 02/10/2013 reassigned the Vent Manager to 3rd shift to assist in education and training of RN Supervisor (including assessing critical situations) ending on 02/27/2013. * LPN (licensed practical nurse) who failed to respond to the code was terminated on 02/27/2013 due to an unrelated incident. * Portable Radios were examined for functionality to ensure they work effectively. Additional portable radios were ordered on [DATE] and until the additional radios were received an exchange system was utilized to ensure charged radios were available for use by all staff. A rotation system was utilized to ensure charged radios were available at the beginning of each shift. Additional radios were available on 03/27/13. Residents Potentially Affected: * Utilized the 72 hour behavior log and behavior symptom screening form to identify residents with the potential for de-cannulation. That is, all vent patients and patients that have tracheotomies was implemented on 02/01/2013 and is ongoing. * In-services were begun immediately for Respiratory Staff and Nursing staff all departments on 2/1/2013 completed 2/5/2013, conducted by the CCC (Clinical Competency Coordinator on: * In-serviced all licensed staff (RN, LPN and RT (respiratory therapy) on the revised code procedure. * In-serviced all staff (RN, LPN, RT, CNA) that work on the vent unit on the Oxinet Monitoring System and completion of the flow records (new Log indicate response time from RT). * In-serviced all nursing staff (RN, LPN) on when to notify the DHS, the MD and the Administrator. * In-serviced all nursing (RN, LPN, and CNA) and respiratory staff assigned to the vent unit on trachs and vents. * In-serviced nursing staff (RN, LPN, CNA) on behavioral management. * In-serviced nursing staff (RN, LPN, CNA, RT) on occurrences esp (especially) r/t (related to) de-cannulations completed on 02/25/2013 by the CCC. * All staff educated on Abuse and Neglect 2/11/2013 was conducted by the corporate educator. * All Respiratory Therapy staff were educated on Vent Check (verification equipment functioning properly, and parameters are correct) 2/5/2013 by the RT Manager. * All residents [MEDICAL CONDITION] (Collar) trials will be checked every hour by the respiratory therapist and or nurse. This will be documented on a log and checked by the RT manager and the vent manager. This procedure was started on 02/04/2013 and is ongoing. * Clinical Competency Coordinator (CCC) RT Manager educated all Vent Staff Nurses and RT's regarding our policy on assessment Q (every) 4 hours of every Vent resident (Completed 2/5/2013). * CCC educated all licensed staff (RN, LPN and RT's) on assessment and documentation (Completed 3/26/2013). * The Administrator, DHS, Unit Managers, SCP (Senior Care Partners), RT Manager, Social Worker and CCC were retrained on Neglect and reporting on 3/27/2013 by the Area Vice President. Plan completed 03/27/2013 Observation of the Walkie Talkies during the survey revealed no concerns. The monitor tech's were observed on all shift at the monitor. Interviews with LPN #2, RN #1 and RT's #1 and #2 revealed they attended inservice related to vent/trach care, decannulation and emergency care; Abuse/neglect training and policy changes related to the incident of 1/31/13. Inservice sign-in logs and inservice content was reviewed for attendance and quality of the content. Tools designed to monitor radio use/order and a new monitor log were in use during the survey. The AOC submitted by the facility on 03/27/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility staff had been educated and was knowledgeable of the care and monitoring of the resident with a [MEDICAL CONDITION]. The Administrator was informed of this on 03/27/2013 at 3:15 PM. The Substandard Quality of Care and/or Immediate Jeopardy was removed at F-225 but the citation remained at a lower scope and severity "D".

On the days of the Complaint and Extended Survey, based on record review, interviews and review of the facility investigation the facility failed to provide services to avoid physical harm to Resident #2 who was found with her/his [MEDICAL CONDITION] (trach) tube removed. The facility investigation of the incident revealed the facility failed to respond to monitor alarms in a timely manner; the Walkie Talkie radio communication system failed to work and the Registered Nurse Supervisor failed to assess a critical situation. The findings included: Resident #2 with a known history of pulling out her/his trach. The sensor off alarm for Resident #2 alarmed on 1/31/13 at approximately 3:32 AM. The facility staff failed to respond to the alarm until approximately 3:45 AM. The facility investigation stated the alarm was not responded to for 40 minutes. The resident was found at approximately 3:45 AM with no signs of life, [MEDICAL CONDITION] out and lying on the bed. The facility staff neglected to respond to monitor alarms in a timely manner. Review of the facility investigation file related to the incident with Resident #2, revealed an investigation summary that stated, "...We determined that we had a failure to effectively monitor the Oxinet (respiratory telemetry monitoring) system (16-B {Resident #2} shows sensor off for 40 minutes)..." Review of the Oxinet (respiratory telemetry monitoring system) Trouble Log used by the ventilator unit monitoring staff to record ventilator alarms and sensor alarms of the residents with tracheotomies indicated a place to document the Date & Time; the Alarm Triggered; Response Time; Duration of Alarm. The 1/31/13 log entry from 12:11 AM until 2:51 AM showed approximately 7 entries per hour. There were no entries after 2:51 AM until 3:32 AM, 40 minutes. At 3:32 AM Resident #2, room [ROOM NUMBER]-B triggered a Sensor off alarm and it was documented that Respiratory Therapy (RT) was aware. The duration of the alarm was blank, indicating no resolution for the sensor off alarm. The surveyor interviewed the Registered Nurse (RN) #1 Supervisor on 3/26/13 at approximately 8:20 AM regarding the incident on 1/31/13. The RN stated that s/he came in to work that night at 1:00 AM to work on the Beauty Shop hall and to cover the monitor. S/he stated that s/he gathered her/his charts to do the charting and realized the girl at the monitor left at 3:00 AM as scheduled. The RN stated that s/he noticed something pop up for Resident #2 but that s/he thought the resident was on the vent; if the vent became disconnected it would have been a big alarm. "That takes precedence over a sensor being off." S/he stated that s/he didn't realize Resident #2 was on [MEDICAL CONDITION]. S/he further stated that s/he paged over the Walkie Talkies that a sensor was off for Resident #2 and that no one responded back to her/him over the radio. The RN Supervisor was unable to say exactly what time s/he begin watching the monitor. Review of the Oxinet Monitoring Log documented the alarm went off at 3:32 AM. The Supervisor stated that shortly after the alarm went off s/he asked Licensed Practical Nurse (LPN) #2 to check on the patient; LPN #2 found Resident #2 without a pulse and not breathing. When the surveyor asked about other staff the Supervisor stated that s/he was not sure what LPN #3 was doing or where the CNAs were. S/he stated that s/he didn't have visual eyesight on anybody. The surveyor asked the Supervisor if there was anyone else who could have watched the monitor? S/he replied that there was no one there I could ask to sit and visually monitor. "Someone has to sit at monitor at all times. That is why I didn't go check on patient." Allegation of Compliance For the resident affected by the alleged deficient practice: * Resident #2 passed away 1/31/2013 * Administrator and DHS conducted an internal investigation related to this event. Investigation was started on 1/31/13 and completed on 2/8/12. This incident was reported to DHEC (Department of Health and Environmental Control) as neglect 3/27/2013. * All staff assigned to the Vent hall on 1/31/2013 was interviewed during the time frame of investigation. * We discovered during the course of the investigation that the RN (registered nurse) Supervisor paged sensor issue for resident #2. RT (respiratory therapy) did not hear their response. The RN Supervisor failed to respond to the resident's needs. * We re-educated the Vent Hall Staff on the Monitor system as well as the radio check procedures on 02/03/2013. Facility implemented two new Monitoring logs (Oxinet monitoring Log,[MEDICAL CONDITION] sheet [MEDICAL CONDITION]) the Logs indicate response time as far as RT response. * DHS on 02/10/2013 reassigned the Vent Manager to 3rd shift to assist in education and training of RN Supervisor (including assessing critical situations) ending on 02/27/2013. * LPN (licensed practical nurse) who failed to respond to the code was terminated on 02/27/2013 due to an unrelated incident. * Portable Radios were examined for functionality to ensure they work effectively. Additional portable radios were ordered on [DATE] and until the additional radios were received an exchange system was utilized to ensure charged radios were available for use by all staff. A rotation system was utilized to ensure charged radios were available at the beginning of each shift. Additional radios were available on 03/27/13. Residents Potentially Affected: * Utilized the 72 hour behavior log and behavior symptom screening form to identify residents with the potential for de-cannulation. That is, all vent patients and patients that have tracheotomies was implemented on 02/01/2013 and is ongoing. * In-services were begun immediately for Respiratory Staff and Nursing staff all departments on 2/1/2013 completed 2/5/2013, conducted by the CCC (Clinical Competency Coordinator on: * In-serviced all licensed staff (RN, LPN and RT (respiratory therapy) on the revised code procedure. * In-serviced all staff (RN, LPN, RT, CNA) that work on the vent unit on the Oxinet Monitoring System and completion of the flow records (new Log indicate response time from RT). * In-serviced all nursing staff (RN, LPN) on when to notify the DHS, the MD and the Administrator. * In-serviced all nursing (RN, LPN, and CNA) and respiratory staff assigned to the vent unit on trachs and vents. * In-serviced nursing staff (RN, LPN, CNA) on behavioral management. * In-serviced nursing staff (RN, LPN, CNA, RT) on occurrences esp (especially) r/t (related to) de-cannulations completed on 02/25/2013 by the CCC. * All staff educated on Abuse and Neglect 2/11/2013 was conducted by the corporate educator. * All Respiratory Therapy staff were educated on Vent Check (verification equipment functioning properly, and parameters are correct) 2/5/2013 by the RT Manager. * All residents [MEDICAL CONDITION] (Collar) trials will be checked every hour by the respiratory therapist and or nurse. This will be documented on a log and checked by the RT manager and the vent manager. This procedure was started on 02/04/2013 and is ongoing. * Clinical Competency Coordinator (CCC) RT Manager educated all Vent Staff Nurses and RT's regarding our policy on assessment Q (every) 4 hours of every Vent resident (Completed 2/5/2013). * CCC educated all licensed staff (RN, LPN and RT's) on assessment and documentation (Completed 3/26/2013). * The Administrator, DHS, Unit Managers, SCP (Senior Care Partners), RT Manager, Social Worker and CCC were retrained on Neglect and reporting on 3/27/2013 by the Area Vice President. Plan completed 03/27/2013 Observation of the Walkie Talkies during the survey revealed no concerns. The monitor tech's were observed on all shift at the monitor. Interviews with LPN #2, RN #1 and RT's #1 and #2 revealed they attended inservice related to vent/trach care, decannulation and emergency care; Abuse/neglect training and policy changes related to the incident of 1/31/13. Inservice sign-in logs and inservice content was reviewed for attendance and quality of the content. Tools designed to monitor radio use/order and a new monitor log were in use during the survey. The AOC submitted by the facility on 03/27/2013 had been implemented by the facility and was in practice removing the immediacy of the deficient practice. Facility staff had been educated and was knowledgeable of the care and monitoring of the resident with a [MEDICAL CONDITION]. The Administrator was informed of this on 03/27/2013 at 3:15 PM. The Substandard Quality of Care and/or Immediate Jeopardy was removed at F-224 but the citation remained at a lower scope and severity "D".

On the day of the complaint inspection, based on record review, interviews, and review of the facility's investigative file into a fall with fracture, the facility failed to ensure that residents received ongoing thorough and accurate assessments, updated care planning, appropriate interventions and assistive devices for 1 of 1 resident who was assisted with a transfer by one person, fell , and fractured a hip (#1). The findings included: Cross refers to F-280 as it related to the failure of the facility to review and revise Resident #1's care plan. Cross refers to F-407 as it relates to the failure of the facility to provide Physical and/or Occupational Therapy services to maximize Resident #1 potential outcomes. Resident #1 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instrument with an assessment reference date of 2/10/12 revealed the resident was cognitively intact. He required total assist of two people for transfer from bed to chair. The resident's balance was coded as "8" (activity did not occur) for moving from seated to standing position; and "2" (not steady, only able to stabilize with human assistance) for surface to surface transfer. The resident had lower extremity limitations on one side. Review of the resident's care plan showed a problem of Self Care Deficit Activities of Daily Living with a problem onset date of 2/6/12. One of the approaches to assist the resident with his activities of daily living stated: "Total lift for all transfers after obtaining sufficient assistance." Review of the ADL (activities of daily living) Care Plan Record used by Certified Nursing Assistants (CNAs) showed "transfer total lift." No date was included to show when this intervention was initiated. Review of the Monthly Nursing Summary dated 3/17/12 showed the resident was "lifted mechanically." Review of the Nurse's Notes revealed an entry on 3/26/12, at 8 PM, saying the resident fell during transfer after losing his strength. He landed on his left leg. The resident complained of pain to the left thigh and the leg appeared to be externally rotated. Evaluation at the hospital revealed a fractured femur. The resident had surgery to repair the fracture and returned to the facility on [DATE]. The CNA assisting the resident at the time of his fall provided a written statement saying that she went to help the resident to bed that evening. She asked him if he could stand and he said yes. The resident stood up from the wheelchair but then began to lean to the left and fell . The CNA wrote that she had transferred the resident by stand and pivot in the past and there had been no problems. When interviewed by the facility, the CNA stated she had started transferring the resident without a lift after the white therapist showed her how to stand and pivot him. The CNA confirmed this information during an interview on 6/21/12 at 3:10 PM. Review of the facility's investigation revealed the CNA received a verbal disciplinary action to "read ADL care plan prior to providing care. If information conflicts with what has been told use safest measure and get order clarified." An interview with the Administrator, Clinical Competency Coordinator (CCC), and Consultant Nurse at 2 PM on 6/21/12 revealed the resident was re-evaluated by the unit nurse after he was discharged from therapy. The CCC nurse stated she found a lift assessment dated [DATE] in the former CCC's office. It showed the resident did not require a mechanical lift for transfers. The CCC nurse worked on the unit the evening of the resident's fall. She stated that initially, she thought of the incident as neglect because the care plans said he required mechanical lift and the CNA used stand/pivot. She sent the CNA home. During the investigation, it was discovered that some of the CNAs were informed by therapy staff that stand/pivot was all right to use with the resident, and that an "informal" inservice was done. The staff present during the interview said therapy should have updated the care plan and ADL care plan.

NOT CORRECTED On the day of the First Follow Up Visit based on record review, interview and review of the facility's Compliance Documents, the deficient practice was not corrected. The facility failed to ensure that residents received ongoing thorough and accurate assessments, updated care planning and appropriate interventions for 2 of 4 residents reviewed for falls. Resident #5 and #6 with a history of falls were not accurately assessed or care planned for transfer and/or falls. The findings included: The facility admitted resident #5 with [DIAGNOSES REDACTED]. Review of the audit of residents with a change in their transfer assistance revealed resident #5 as the only resident with a change. Review of the medical record revealed a Lift Evaluation Form completed in June 2012. The Lift Evaluation stated, Lift Required: "sit to stand lift". A second Lift Evaluation Form dated 7/21/12, stated, Lift Required: "none". The Evaluation form was completed by the Director of Health Services (DHS). An Inservice Education Program Summary form dated for 8/3/12, completed by the Physical Therapist, stated, Pt (patient) currently requires anywhere from CGA to Max A (maximum assistance) with transfers. Secondary to B (both) knees buckling. Rec (recommend) hoyer (total) lift transfers or sit to std (stand) lift transfers in order to ensure safe transfers." Review of the Resident's care plan dated 8/8/12 included as an approach to use a mechanical lift. Review of the CNA Care Record, under the section transfer, had assist-one checked and then marked through with a D/C (discontinue). Mechanical lift with two was also checked and then marked though with a D/C. Under "Other" mechanical lift or sit to stand lift had been written in and marked through. On the bottom of the page under the section Special Needs, mechanical lift had been written in and then a line line drawn through it and a D/C 7/20. Review of the Significant Change MDS of 8/6/12 under transfers, the resident was coded to require extensive assistance of two plus persons. The resident's Scored Fall Risk assessment dated [DATE] had scored the resident a 20. The facility identified anything above 10 to be high risk for falls. Four CNAs were interviewed on 8/20/12. When asked by the Surveyor how they would transfer the resident, they looked at the CNA Care Record and stated that it was confusing and they would have to ask the nurse. The CNAs were not able to tell from the Record how the resident was transferred. The facility did not update the CNA Care Record so the CNAs responsible for the transfer of the resident would know how the resident was transferred. The Care Record, Physical Therapy Teaching and Lift Assessment were not the same. The Physical Therapy Teaching did not depict the lift the resident was to use. The Teaching spoke of the resident's knees buckling. The Therapist left the decision of which lift to use up to the discretion of the CNA. The facility admitted resident #6 with [DIAGNOSES REDACTED]. Review of the medical record revealed an admission Nurses Note of 8/13/12 at 3:52 PM, "Pt (patient) has a hx (history of falls, bed is in low position..." 8/14/12 at 3:00 AM: "Res (resident) up in wheelchair sitting in front of nurses station D/T (due to) trying to get out of bed on numerous occasions unassisted. Gait is very poor and resident is very weak." 8/14/12 at 2:30 PM: "Res. noted on bathroom floor. Res went to BR (bathroom) without assist.... Intervention assist resident to bathroom more often." 8/15/12 at 10:50 AM: "Bed alarm in place." 8/15/12 at 4:30 PM: "On floor in doorway with chair alarm sounding.....skin tear noted to right upper leg...." 8/15/12 at 10:28 PM: "Resident continues to attempt to ambulate without assistance. Resident agitated and combative with staff, yelling and refusing assistance. Staff trying to calm resident..." 8/15/12 @ 10:30 PM: "...PA, (Physician's Assistant) called and made aware of behaviors. Ativan 0.5 mg (milligrams) IM (Intramuscular) q (every) 6 H (hours) PRN (as needed) x 72 hrs ordered...Wife repeated asked this nurse to restrain... Informed her that we could not follow request due to Policies and protocols. 8/15/12 at 10:40 PM: "Ativan 0.5 mg IM administered in right deltoid..." 8/15/12 at 10:45 PM: "Resident stood up and lowered self to floor and proceeded to lie down..." 8/16/12 at 2:40 AM: "Resident allowed staff to assist him to geri chair..." 8/16/12 at 1:50 PM: "Resident noted on floor bedside (sic) his bed on his buttock. Asses (sic) Resident head to toe. Has multi-discoloration to bilateral arms..." The resident had 4 falls within 3 days of admission. There was no evidence the facility had evaluated the falls or performed a post fall assessment to determine the cause of the falls. During an interview the Director of Health Services (DHS) confirmed the facility did not perform post fall assessments. She stated they had weekly meetings and discussed the occurrences. She stated they were suppose to have had a meeting on Friday (8/17/12) but were unable to have the meeting. There was no evidence of followed up regarding the resident's falls. The Resident was observed on 8/20/12 at 7:05 PM seated in a geri chair, sitting at the nurse's station, eyes closed, legs were elevated, with an alarm on his geri chair. Observation of his room revealed the bed in a low position and fall mats on the floor. There was no assessment for the use of the geri chair. The geri chair with the legs elevated or reclined would prevent the resident from getting up Review of the Interim Care Plan revealed a problem checked for resident to be at risk for falls related to behavior. On 8/14/12, "Fall without injury" was added, 8/15/12 "Fall with skin tear" with approaches added that included bed alarm for safety, assist to bathroom more often; 8/14/12 scheduled toileting program was added. The nurse's notes frequently spoke to the resident's combative behaviors and resistance to care. Review of the behavior meeting notes dated 8/20/12 stated the resident was on behavior management. The behavior addressed the resident's risk for elopement. There was no mention of the resident's actual documented behaviors. Review of the CNA (Certified Nursing Assistant) Care Record revealed the record was not updated to show the approaches for the resident to prevent falls. Geri chair/wheelchair was not checked, there was no mention of the fall mats, chair alarm and no scheduled toileting. Four CNAs were interviewed. They all stated they would check the (activities of daily living) ADL Book for the CNA Care Record to know what to do for their residents. The CNA Care Record included transfers, behaviors, toileting programs and other approaches needed to provide resident care. The DHS was interviewed at 6:30 PM. She stated, "I did the lift evaluation. The education was done. I just forgot to change the lift evaluation to mechanical lift."

On the day of the complaint inspection, based on record reviews and interviews, the facility failed to provide Physical and/or Occupational Therapy services to maximize Resident #1 potential outcomes. The findings included: Cross refers to F-280 as it relates to the failure of the facility to review and revise Resident #1's care plan. Cross refers to F-323 as it relates to the failure of the facility to ensure that Resident #1 received thorough and accurate assessments and appropriate interventions to prevent injury. Resident #1 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instrument with an assessment reference date of 2/10/12 revealed the resident was cognitively intact. He required total assist of two people for transfer from bed to chair. The resident's balance was coded as "8" (activity did not occur) for moving from seated to standing position; and "2" (not steady, only able to stabilize with human assistance) for surface to surface transfer. The resident had lower extremity limitations on one side. Review of the resident's care plan showed a problem of Self Care Deficit Activities of Daily Living with a problem onset date of 2/6/12. One of the approaches to assist the resident with his activities of daily living stated: "Total lift for all transfers after obtaining sufficient assistance." Review of the ADL (activities of daily living) Care Plan Record used by Certified Nursing Assistants (CNAs) showed "transfer total lift." No date was included to show when this intervention was initiated. Review of the Monthly Nursing Summary dated 3/17/12 showed the resident was "lifted mechanically." Review of the Nurse's Notes revealed an entry on 3/26/12, at 8 PM, saying the resident fell during transfer after losing his strength. He landed on his left leg. The resident complained of pain to the left thigh and the leg appeared to be externally rotated. Evaluation at the hospital revealed a fractured femur. The resident had surgery to repair the fracture and returned to the facility on [DATE]. The CNA assisting the resident at the time of his fall provided a written statement saying that she went to help the resident to bed that evening. She asked him if he could stand and he said yes. The resident stood up from the wheelchair but then began to lean to the left and fell . The CNA wrote that she had transferred the resident by stand and pivot in the past and there had been no problems. When interviewed by the facility, the CNA stated she had started transferring the resident without a lift after the white therapist showed her how to stand and pivot him. The CNA confirmed this information during an interview on 6/21/12 at 3:10 PM. Review of the facility's investigation revealed the CNA received a verbal disciplinary action to "read ADL care plan prior to providing care. If information conflicts with what has been told use safest measure and get order clarified." An interview with the Therapy Outcomes Coordinator, an Occupational Therapist (OT), on 6/21/12 at 2:20 PM revealed the therapy department had been working with the resident, and by January 2012, the resident was able to stand and pivot with assist for transfers. He did tell some of the CNAs it was all right to use this method with the resident. The OT stated he also brought this information to the weekly meeting where nursing managers, Director of Health Services, Minimum Data Set Coordinators, Social Services, and financial staff were present. The resident was discharged from OT on 1/12/12. Review of the OT - Therapist Progress Report and Discharge Summary showed under the heading Patient / Caregiver Training: "IDt team (interdisciplinary team) provided with progress update during case mix meeting. ..." An interview with the Administrator, Clinical Competency Coordinator (CCC), and Consultant Nurse at 2 PM on 6/21/12 revealed that during the investigation, it was discovered that some of the CNAs were informed by therapy staff that stand/pivot was all right to use with the resident, and that an "informal" inservice was done. The staff present during the interview said therapy should have updated the care plan and ADL care plan. Review of the facility's investigative materials concerning the resident's fall included the results of other CNA interviews. Seven CNAs were questioned regarding how they transferred the resident. Two stated that sometimes, if he could not bear weight, they used the sit to stand lift. The remaining five CNAs said they always use the sit to stand lift with the resident.

On the day of the complaint inspection, based on record review, interviews, and review of the facility's investigative file into a fall with fracture, the facility failed to ensure that Resident #1's care plan was periodically reviewed and revised related to the appropriated interventions and assistive devices. Resident #1 was assisted with a transfer by one person, fell , and fractured a hip. The findings included: Cross refers to F-323 as it relates to the failure of the facility to ensure that Resident #1 received thorough and accurate assessments and appropriate interventions to prevent injury. Cross refers to F-407 as it relates to the failure of the facility to provide Physical and/or Occupational Therapy services to maximize Resident #1 potential outcomes. Resident #1 with [DIAGNOSES REDACTED]. Review of the annual Resident Assessment Instrument with an assessment reference date of 2/10/12 revealed the resident was cognitively intact. He required total assist of two people for transfer from bed to chair. The resident's balance was coded as "8" (activity did not occur) for moving from seated to standing position; and "2" (not steady, only able to stabilize with human assistance) for surface to surface transfer. The resident had lower extremity limitations on one side. Review of the resident's care plan showed a problem of Self Care Deficit Activities of Daily Living with a problem onset date of 2/6/12. One of the approaches to assist the resident with his activities of daily living stated: "Total lift for all transfers after obtaining sufficient assistance." Review of the ADL (activities of daily living) Care Plan Record used by Certified Nursing Assistants (CNAs) showed "transfer total lift." No date was included to show when this intervention was initiated. Review of the Monthly Nursing Summary dated 3/17/12 showed the resident was "lifted mechanically." Review of the Nurse's Notes revealed an entry on 3/26/12, at 8 PM, saying the resident fell during transfer after losing his strength. He landed on his left leg. The resident complained of pain to the left thigh and the leg appeared to be externally rotated. Evaluation at the hospital revealed a fractured femur. The resident had surgery to repair the fracture and returned to the facility on [DATE]. The CNA assisting the resident at the time of his fall provided a written statement saying that she went to help the resident to bed that evening. She asked him if he could stand and he said yes. The resident stood up from the wheelchair but then began to lean to the left and fell . The CNA wrote that she had transferred the resident by stand and pivot in the past and there had been no problems. When interviewed by the facility, the CNA stated she had started transferring the resident without a lift after the white therapist showed her how to stand and pivot him. The CNA confirmed this information during an interview on 6/21/12 at 3:10 PM. Review of the facility's investigation revealed the CNA received a verbal disciplinary action to "read ADL care plan prior to providing care. If information conflicts with what has been told use safest measure and get order clarified." An interview with the Administrator, Clinical Competency Coordinator (CCC), and Consultant Nurse at 2 PM on 6/21/12 revealed the resident was re-evaluated by the unit nurse after he was discharged from therapy. The CCC nurse stated she found a lift assessment dated [DATE] in the former CCC's office. It showed the resident did not require a mechanical lift for transfers. The CCC nurse worked on the unit the evening of the resident's fall. She stated that initially, she thought of the incident as neglect because the care plans said he required mechanical lift and the CNA used stand/pivot. She sent the CNA home. During the investigation, it was discovered that some of the CNAs were informed by therapy staff that stand/pivot was all right to use with the resident, and that an "informal" inservice was done. The staff present during the interview said therapy should have updated the care plan and ADL care plan. An interview with the Therapy Outcomes Coordinator, an Occupational Therapist (OT), on 6/21/12 at 2:20 PM revealed the therapy department had been working with the resident, and by January 2012, the resident was able to stand and pivot with assist for transfers. He did tell some of the CNAs it was all right to use this method with the resident. The OT stated he also brought this information to the weekly meeting where nursing managers, Director of Health Services, Minimum Data Set Coordinators, Social Services, and financial staff were present. The resident was discharged from OT on 1/12/12. Review of the OT - Therapist Progress Report and Discharge Summary showed under the heading Patient / Caregiver Training: "IDt team (interdisciplinary team) provided with progress update during case mix meeting. ..." Review of the facility's investigative materials concerning the resident's fall included the results of other CNA interviews. Seven CNAs were questioned regarding how they transferred the resident. Two stated that sometimes, if he could not bear weight, they used the sit to stand lift. The remaining five CNAs said they always use the sit to stand lift with the resident. Review of the resident's care plan and ADL care plan did not show instructions for use of a sit to stand lift with the resident.

On the day of the complaint and extended inspection based on record review and interview, the facility's Medical Director failed to assure resident care policies were implemented appropriately and failed to assure each resident's medical care was coordinated. The findings included: Resident #1 had bilateral hand mittens that she was able to remove and decannulated herself 7 times. She died on [DATE] after she removed the cannula. Resident #2 disconnected himself from the vent 5 times while wearing mittens. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. Adequate interventions were not initiated to address the resident's self injurious behaviors. During an interview on [DATE] at 5:15 PM, the facility Medical Director confirmed that he was the medical director for the entire facility. He stated that the Pulmonologist (Attending Physician) was the "medical director" for the vent unit. The Medical Director confirmed again that he was over the entire facility and was responsible for residents and staff. The Medical Director stated that he was not aware of the Resident #1's death nor was he aware of the events surrounding her death. The Medical Director confirmed that if a restraint was not effective then other interventions should be initiated. He stated that 1:1's could be an intervention. The Medical Director stated that if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]." The Attending Physician was asked if the interventions were effective and he stated, "Yes." The Attending Physician was asked how many time the resident had decannulated herself and he stated that he didn't "know for sure but would have said three." The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one (prior to the resident's death). He was asked again if the interventions were effective and he replied no. Cross Refers 483.25 (h) Quality of Care F-323 was identified at a scope and severity level of "K." It was determined that Substandard Quality of Care and Immediate Jeopardy existed at the facility as of [DATE]. Three of three residents were not assessed adequately for the necessary supervision required preventing decannulation and/or disconnecting from the ventilator. Resident #1 removed her mittens and self decannulated 7 times. Resident #1 expired on [DATE] as a result of her self decannulation; Resident #2 disconnected from the ventilator 5 times; Resident #3 decannulated 4 times and pulled out a PICC line resulting in a [MEDICAL CONDITION]. There were no adequate assessments or interventions put on place to protect Residents #1, #2, or #3. 483.12 (d)-(4) Restraints F-221 was identified at a scope and severity level of "K." Two residents were not assessed for the efficacy of the ordered restraints. Resident #1 frequently removed her mittens and decannulated herself. On [DATE], Resident #1 expired as a result of removing her restraint and decannulating self. Resident #2 disconnected from the ventilator 5 times. There was not an assessment that addressed the ineffectiveness of the restraints. Resident #3 decannulated 4 times and pulled out a PICC line that resulted in a [MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. 483.20 Resident Assessment F-280 was identified at a scope and severity level of "K." The Facility staff failed to care plan [MEDICAL CONDITION] patients with behaviors and/or restraints. 483.20 Resident Assessment F-281 was identified at a scope and severity level of "K." Staff failed to answer ventilator associated alarms timely and failed to implement effective interventions to provide adequate supervision and a safe environment. 483.25 (f) (1) Behavior Management F-319 was identified at a scope and severity level of "K." The facility failed to address, monitor and implement effective interventions for residents that displayed self injurious behaviors. 483.75 Administration F-490 was identified at a scope and severity level of "K." The facility Administration failed to monitor/supervise the care provided residents with tracheostomies, behaviors and/or restraints. 483.75 Quality Assurance F-520 was identified at a scope and severity of "K". The facility failed to identify deficient practice related to residents with tracheostomies, behaviors and/or restraints. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the day of the complaint and extended inspection based on observations, record review, review of facility policy "Physical Restraint", and interview, the facility failed to adequately assess 2 of 3 residents with restraints for the effectiveness of those restraints and 1 of 3 residents was not assessed for a restraint. Resident #1 had bilateral hand mittens that she was able to remove and decannulated herself 7 times. She died on [DATE] after she removed the cannula. Resident #2 had bilateral hand mittens as an intervention to prevent him from disconnecting himself from the ventilator. In spite of the interventions he was able to disconnect himself from the ventilator 5 times. Resident #3 decannulated himself 4 times and pulled out his central intravenous catheter. Resident #3 did not have adequate interventions put in place and was not assessed for the need of a restraint. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]." Review of the Nurse's Notes revealed Resident #1 self decannulated 7 times between ,[DATE] and [DATE], she was noted to pull off her mittens frequently. On [DATE] Resident #1 expired after she removed her cannula. . Record review revealed no restraint assessment or reassessments were completed to determine the ineffectiveness of the mittens. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #2 disconnected himself from the ventilator 5 times and had multiple self inflicted injuries from biting and scratching himself. In addition, Resident #2 had fallen out of bed twice. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #2 was "deserving of 1:1's." The Attending Physician also agreed that there were more interventions that could be initiated. Record review revealed Resident #2 did not have a restraint assessment or reassessment completed that addressed the effectiveness of the restraint used. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC (Peripherally Inserted Central Catheter) line resulting in a [MEDICAL CONDITIONS]. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. During an interview on [DATE] at 5:15 PM, the Medical Director confirmed that if a restraint was not effective then other interventions should be initiated. The Medical Director stated that if a resident displayed self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. Review of the facility policy "Physical Restraint" on [DATE] revealed the following information under "Policy": "....Physical restraints may be temporarily required as an intervention for emergent and/or therapeutic care when needed to treat a patient/resident's specific medical condition." In addition: "Physical restraints may only be utilized when the following criteria have been met and there is supportive documentation present in the patient/resident's clinical record." The areas listed included; "A completed Physical Assessment.......When the patient/resident's physical restraint has been determined to be used as an intervention for emergent and/or therapeutic care and treatment, the physical restraint will only be used for certain time periods and under specific conditions." Listed under "Physical Device Initial/Annual Assessment" the following requirement for assessment was included under "Admission..." "When the patient/resident's condition is suspect for potential use of a physical restraint", and under "Quarterly (in conjunction with the MDS (Minimum Data Set) cycle)-Physical Restraint Elimination Assessment. (#1) When the patient/resident currently has a physical restraint. (#2) When the patient/resident's condition is now suspect for potential use of a physical restraint." Cross Refer to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to follow policy through ongoing assessment of the most appropriate and effective interventions to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the day of the complaint and extended inspection based on record review, review of facility policy "Ventilation, Mechanical", review of facility policy "Admission Behavior Logs", and interview, the facility failed to assure 3 of 3 residents reviewed had their care plans reviewed and revised to reflect the current status of each resident. Resident #1's care plan did not reflect the 7 decannulations and was not updated with interventions to prevent the decannulations. Resident #2 disconnected himself from the vent 5 times. The care plan was not updated to reflect those incidents and was not updated to reflect interventions to prevent his behaviors. Resident #3's care plan was not updated to reflect his behaviors of self injury, decannulation or pulling out his PICC (peripherally inserted central catheter) line. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #1 pulled off her mittens and decannulated herself 7 times. She died on [DATE] after she removed her cannula Review of the Care Plan revealed a Problem Area identified [DATE] of restlessness and "Patient has pulled [MEDICAL CONDITION] episodes of agitation and often picks and pulls at trach. Approaches included "Refer to psych as needed, help resident determine source of anxiety and precipitating events and alert staff to help to decrease them, ensure any needed/ordered safety devices are on and operating properly, evaluate resident's effectiveness of medication therapy, continue to reiterate to patient [MEDICAL CONDITION] necessary and possible consequences of pulling it." Another problem area identified on [DATE] "limb restraints used to prevent pt from removing trach." Approaches included "apply limb restraint as ordered, review the continued need for limb restraint." The care plan was not updated to include the seven incidents of decannulation. The care plan also did not include revised interventions to prevent decannulation. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #2 disconnected himself from the ventilator 5 times and fell out of bed twice. Review of the Care Plan dated [DATE] and updated [DATE] revealed a Problem area of Combative Behavior. Approaches included "monitor and document patient behavior. Report negative behavior increase to physician. Administer behavior medications as ordered, review patient drug regime, apply mittens when needed for protection of patient and others." Further review revealed a problem area of Restraints. The care plan was last updated on [DATE]. Approaches included "bed bolsters to define parameters of bed [DATE] and mittens to bilateral hands. Identify factors that increase patient potential for injury and or agitation, close observation to maintain resident's safety." Resident #2's care plan was not updated with his behavior of disconnecting from the vent. No new interventions were added to address the behaviors. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC line resulting in a [MEDICAL CONDITION]. Review of the Care Plan revealed a Problem Area of Respiratory Distress. There was no care plan for the resident's behavior of decannulating self or pulling at the PICC line. The care plan was not updated to reflect the resident's 4 decannulations nor any interventions to prevent the behavior. On [DATE] review of the facility policy "Ventilation, Mechanical" revealed the following information: Listed under the title "Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for [MEDICAL CONDITION] replacement." Under the title of "Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient. #3 The Interdisciplinary Team will develop a plan of care based on individual resident/patient needs. Review of the facility's policy on Behavior Logs revealed: An individualized Behavior Management Program will be initiated when the following events occur: One altercation resulting in injury. This would also include behaviors with potential for serious harm...Once identified as being at risk for occurrence/behaviors the resident will be placed on the Occurrence Prevention/Behavior Management Program...A summary of the reasons why the resident is placed on the program will be written in the nurses notes. Information should include but not limited to history of occurrence, medications, gait, diagnoses, occurrence trends and behavior symptoms...The Occurrence Prevention Team and DON will establish the "initial interventions"...Care Plans should accurately reflect occurrence prevention or behavior management...The resident will be assessed weekly for effectiveness of current interventions. If interventions are not effective, new approaches must be added to the care plan." During an interview on [DATE] at 2:30 PM, Resident #1, #2 and #3's findings were reviewed with the Administrator and the Director of Nurses. Cross Refers to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the day of the complaint and extended inspection based on observations, record reviews, interviews, review of the facility policy "Ventilation, Mechanical", and review of the South Carolina Code of Ethics for Nurses, the facility failed to assure staff members provided services that met professional standards of quality for 3 of 3 residents reviewed. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. Staff members also failed to appropriately respond to alarms. The findings included: During initial tour of the facility on [DATE] at 9:45 AM, an alarm monitor was observed at the desk, several alarms were sounding. Licensed Practical Nurse #1 was observed to stand at the nurse's station and chart for 10 minutes. During those 10 minutes 4 vent alarms sounded and heart rate, oxygen saturation and respiratory rate alarms sounded. The nurse was observed to periodically glance at the monitor and then continue to chart. After 10 minutes, Certified Respiratory Therapist (CRT) #1 walked to the nurse's station, LPN (Licensed Practical Nurse) #1 informed the CRT #1 that the alarms were sounding. The CRT then went to check on those residents. During an interview on [DATE] at 11:00 AM, CRT #1 stated that all staff members responded to alarms. She stated that the Respiratory Therapists were to respond first then the nurses. CRT #1 stated that there were two types of alarms, the vent alarms sound very loudly and are linked to the call bell system. The other alarms were the heart rate, SPO2 % and respiratory rate. Those alarms were linked to the monitor at the desk. CRT #1 stated that the non-vent alarms sounded loudly at the desk and the nurses would respond immediately to those alarms. On [DATE] review of the facility policy "Ventilation, Mechanical" revealed the following information: Listed under the title "Equipment" was "#4 Alarms: Resident/patient disconnect (low pressure) and high pressure alarms are to be used at all times. If disconnection from the ventilator is likely to cause serious effects, a remote alarm will be used." Under "Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for [MEDICAL CONDITION] replacement." Under the title of "Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient......" The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #1 self decannulated 7 times between ,[DATE] and [DATE]. On [DATE] Resident #1 expired following her decannulation. Resident #1 was also noted to pull off her mittens frequently. Review of the Physician's Orders revealed a telephone order dated [DATE] for bilateral hand mittens. On [DATE] at 4:30 PM, [MEDICATION NAME] as needed was discontinued. On [DATE] an order was written for [MEDICATION NAME] 15 mg every night. On [DATE] at 10:55 PM, [MEDICATION NAME] 0.5 mg x 1 dose now was ordered. On [DATE] [MEDICATION NAME] was discontinued. On [DATE] [MEDICATION NAME] 1 mg as needed at night was ordered. Further review revealed upon Resident #1's readmission on [DATE] she was receiving [MEDICATION NAME] 50 mg every night. No other as needed medications were available for Resident #1's anxiety at that time. On [DATE], the ventilator was discontinued and Resident #1 was [MEDICAL CONDITION] only. On [DATE] at 5 PM, [MEDICATION NAME] was increased to 100 mg every night. On [DATE] at 3 PM, an order was written for [MEDICATION NAME] 25 mg as needed three times daily. On [DATE], [MEDICATION NAME] 15 mg as needed as ordered. On [DATE] at 11:30 AM, [MEDICATION NAME] and [MEDICATION NAME] were discontinued [MEDICATION NAME] mg at bedtime was ordered. Review of the MAR (Medication Administration Record) dated [DATE] revealed Resident #1 received as needed [MEDICATION NAME] on [DATE] for pulling at trach. (No corresponding notes were located). And on ,[DATE] received [MEDICATION NAME] at 11 PM after decannulating. Resident #1 received as needed [MEDICATION NAME] four times for increased anxiety. Review of the MAR indicated [REDACTED]. On [DATE] [MEDICATION NAME] was discontinued. No as needed [MEDICATION NAME] was administered. Review of the MAR indicated [REDACTED]. Resident #1 received as needed [MEDICATION NAME] on ,[DATE] at 3 PM and ,[DATE] at 12:45 AM. [MEDICATION NAME] as needed was not administered. [MEDICATION NAME] mg was administered on [DATE]. Resident #1 did not receive any as needed medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of the Physician's Progress Notes revealed on [DATE] the Attending Physician documented "No problems are reported by the staff, other than her occasionally being anxious and pulling at things, so she sometimes needs to wear protective mittens. On [DATE] the Attending Physician documented "she was hospitalized earlier this week with mental status changes and diminished level of consciousness. She was agitated at night, but sleeping during the day. She remained off the ventilator, [MEDICAL CONDITION]. We seem to have straightened things out by putting her on [MEDICATION NAME] 50 mg every night, which helped her sleep through the night, without being agitated, so that she is more awake and alert during the day." During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]." The Attending Physician was asked if the interventions were effective and he stated "Yes." The Attending Physician was asked how many times the resident had decannulated herself and he stated that he didn't "know for sure but would have said three." The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one that led to her death). He was asked again if the interventions were effective and he replied no. The Attending Physician was asked what other interventions could have been put in place and he stated that he "honestly didn't know what else" could have been done. He was asked about 1:1's or psychoactive medications; he stated that he could have tried other medications and that 1:1's would have been better for the patient. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed Resident #2 disconnected himself from the ventilator 5 times and had multiple self inflicted injuries from biting and scratching himself. Review of the Physician ' s Orders revealed no PRN (as needed) medication was ordered for agitation. During an interview on [DATE] at 11:40 AM, the Attending Physician agreed that there were more interventions that could be initiated. He agreed that Resident #2's behaviors were similar to Resident #1's; however there were no negative outcomes as of yet for Resident #2. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC line resulting in a [MEDICAL CONDITION]. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. Review of the Physician's Orders revealed there was not a psychiatric referral made when Resident #3 began displaying behaviors. No medications were ordered to address the behaviors. There were no other interventions ordered or put in place to protect the resident's airway and intravenous access. During an interview on [DATE] at 5:15 PM, the Medical Director stated if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. Resident #1, #2 and #3 did not have new and effective interventions put in place to prevent the resident from displaying self injurious behaviors. During an interview on [DATE] at 2:30 PM, Resident #1, #2 and #3's findings were reviewed with the Administrator and the Director of Nurses. Review of the South Carolina Code of Ethics for Nurses revealed Provision 1, "The nurse, in all professional relationships, practices with [MEDICATION NAME] and respect for the inherent dignity and self worth and uniqueness of every individual unrestricted..." Provision 2 "The nurse's primary commitment is to the patient..." Provision 3, "the nurse promotes, advocates for and strives to protect the health safety and rights of each patient." Provision 4, "the nurse is responsible and accountable for individual nursing practice." Cross Refers to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the day of the complaint and extended inspection based on record review, interviews and review of the facility's policy on "Behavior Logs", the facility failed to ensure 3 of 3 residents displaying psychosocial difficulties received the necessary treatment and services. Resident #1 had a history of [REDACTED]. On [DATE] after decannulating herself she expired. Resident #2, care planned for the use of restraints, was able to disconnect from the ventilator 5 times. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. No appropriate interventions were put in place to address each resident's behaviors. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #1 self decannulated 7 times between ,[DATE] and [DATE]. On [DATE] Resident #1 expired after her decannulation. Resident #1 was also noted to pull off her mittens (restraints) frequently. Review of the physician's orders [REDACTED]. On [DATE] at 4:30 PM, [MEDICATION NAME] as needed was discontinued. On [DATE] an order was written for [MEDICATION NAME] 15 mg every night. On [DATE] at 10:55 PM, [MEDICATION NAME] 0.5 mg x 1 dose now was ordered. On [DATE] [MEDICATION NAME] was discontinued. On [DATE] [MEDICATION NAME] 1 mg as needed at night was ordered. Further review revealed upon Resident #1's readmission on [DATE] she was receiving [MEDICATION NAME] 50 mg every night. No other as needed medications were available for Resident #1's anxiety at that time. On [DATE], the ventilator was discontinued and Resident #1 was [MEDICAL CONDITION] only. On [DATE] at 5 PM, [MEDICATION NAME] was increased to 100 mg every night. On [DATE] at 3 PM, an order was written for [MEDICATION NAME] 25 mg as needed three times daily. On [DATE], [MEDICATION NAME] 15 mg as needed as ordered. On [DATE] at 11:30 AM, [MEDICATION NAME] and [MEDICATION NAME] were discontinued [MEDICATION NAME] mg at bedtime was ordered. Review of the MAR (Medication Administration Record) dated [DATE] revealed Resident #1 received as needed [MEDICATION NAME] on [DATE] for pulling at trach. (No corresponding notes were located). And on ,[DATE] received [MEDICATION NAME] at 11 PM after decannulating. Resident #1 received as needed [MEDICATION NAME] four times for increased anxiety. Review of the MAR indicated [REDACTED]. On [DATE] [MEDICATION NAME] was discontinued. No as needed [MEDICATION NAME] was administered. Review of the MAR indicated [REDACTED]. Resident #1 received as needed [MEDICATION NAME] on ,[DATE] at 3 PM and ,[DATE] at 12:45 AM. [MEDICATION NAME] as needed was not administered. [MEDICATION NAME] mg was administered on [DATE]. Resident #1 did not receive any as needed medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of the physician's orders [REDACTED]. Resident #1 did not receive any PRN (give as needed) medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of documentation on the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the Behavior Monthly Flow Record dated [DATE] revealed Resident #1 had 18 episodes of pulling at her trach. No other documentation was noted on the flow sheets. No other flow sheets were located at the time of the survey. Review of the Care Plan revealed a Problem Area identified [DATE] of restlessness and "Patient has pulled [MEDICAL CONDITION] episodes of agitation and often picks and pulls at trach. Approaches included "Refer to psych as needed, help resident determine source of anxiety and precipitating events and alert staff to help to decrease them, ensure any needed/ordered safety devices are on and operating properly, evaluate resident's effectiveness of medication therapy, continue to reiterate to patient [MEDICAL CONDITION] necessary and possible consequences of pulling it." The care plan was not updated to include the seven incidents of decannulation. The care plan also did not include adequate interventions to prevent decannulation. Review of the Physician's Progress Notes revealed on [DATE] the Attending Physician documented "No problems are reported by the staff, other than her occasionally being anxious and pulling at things, so she sometimes needs to wear protective mittens. On [DATE] the Attending Physician documented "she was hospitalized earlier this week with mental status changes and diminished level of consciousness. She was agitated at night, but sleeping during the day. She remained off the ventilator, [MEDICAL CONDITION]. We seem to have straightened things out by putting her on [MEDICATION NAME] 50 mg every night, which helped her sleep through the night, without being agitated, so that she is more awake and alert during the day." During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]." The Attending Physician was asked if the interventions were effective and he stated "Yes." The Attending Physician was asked how many times the resident had decannulated herself and he stated that he didn't "know for sure but would have said three." The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one that led to her death). He was asked again if the interventions were effective and he replied no. The Attending Physician was asked what other interventions could have been put in place and he stated that he "honestly didn't know what else" could have been done. He was asked about 1:1's or psychoactive medications; he stated that he could have tried other medications and that 1:1's would have been better for the patient. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurses Notes revealed Resident #2 had disconnected himself from the ventilator 5 times and had multiple self inflicted injuries from biting and scratching himself. Review of the Care Plan dated [DATE] revealed a Problem area of Combative Behavior. The care plan was updated on [DATE]. Approaches included "monitor and document patient behavior. Report negative behavior increase to physician. Administer behavior medications as ordered, review patient drug regime, apply mittens when needed for protection or patient and others." No care plan was noted to address Resident #2's falls. No new interventions were put in place after either fall on ,[DATE] or ,[DATE]. Further review revealed a problem area of Restraints. The care plan was last updated on [DATE]. Approaches included "bed bolsters to define parameters of bed [DATE] and mittens to bilateral hands. Identify factors that increase patient potential for injury and or agitation, close observation to maintain resident's safety." No behavior monitoring flow sheets were located. Review of the physician's orders [REDACTED]. No as needed medication was ordered for agitation. Review of the Physician's Progress Notes revealed Resident #2 was seen last by a Psychiatrist on [DATE]. At that time the [MEDICATION NAME] was increased. Review of the Attending Physician's Progress Notes revealed on [DATE], Resident #2 "remains on the ventilator and is wearing protective mittens so that he doesn't hurt himself. No changes in his therapy." On [DATE] the Attending Physician documented "he's comfortable on the ventilator, but he continues to need to wear mittens to protect him from hurting himself as he is frequently agitated, swinging his arms and grabbing at things." During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #2 was "deserving of 1:1's." The Attending Physician also agreed that there were more interventions that could be initiated. He agreed that Resident #2's behaviors were similar to Resident #1's; however there were no negative outcomes as of yet for Resident #2. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #3 decannulated himself 4 times and pulled out his PICC line resulting in a [MEDICAL CONDITION]. Review of the Care Plan revealed no problem area related to the resident's behavior of decannulating self or pulling at the PICC line. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. Review of the Psychiatrist Note dated [DATE] revealed Resident #3 had previously been on [MEDICAL CONDITION] medications, however all medications were discontinued prior to his admission on [DATE]. Review of the physician's orders [REDACTED]. No medications were ordered to address the behaviors. There were no other interventions ordered or put in place to protect the resident's airway and intravenous access. During an interview on [DATE] at 5:15 PM, the Medical Director stated if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. During an interview on [DATE] at 2:30 PM, Resident #1, #2 and #3's findings were reviewed with the Administrator and the Director of Nurses. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. Review of the facility's policy on Behavior Logs revealed: An individualized Behavior Management Program will be initiated when the following events occur: One altercation resulting in injury. This would also include behaviors with potential for serious harm...Once identified as being at risk for occurrence/behaviors the resident will be placed on the Occurrence Prevention/Behavior Management Program...A summary of the reasons why the resident is placed on the program will be written in the nurses notes. Information should include but not limited to history of occurrence, medications, gait, diagnoses, occurrence trends and behavior symptoms...The Occurrence Prevention Team and DON will establish the "initial interventions"...The Charge Nurse will be responsible for observation, communication with other staff and documentation. Care Plans should accurately reflect occurrence prevention or behavior management...The resident will be assessed weekly for effectiveness of current interventions. If interventions are not effective, new approaches must be added to the care plan." Cross Refers to F-323 as it relates to the facility's failure to provide adequate supervision to each resident to prevent accidents and the facility's failure to provide a safe environment. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the day of the complaint and extended inspection based on observation, record review, review of facility policy "Ventilation, Mechanical" and interview, the facility failed to assure 3 of 3 residents were provided the adequate supervision to prevent accidents and failed to provide an environment as free of hazards as is possible. Resident #1's restraints were ineffective and she self decannulated 7 times. No new interventions were put in place to protect the resident. Resident #1 expired as a result of the self decannulation on [DATE]. Resident #2 wears bilateral mittens but still disconnects from the vent. Resident #2 fell twice with no interventions put in place after the second fall. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a DVT (deep vein thrombosis). No interventions were put in place to protect the resident. The findings included: During initial tour of the facility on [DATE] at 9:45 AM, an alarm monitor was observed at the desk, several alarms were sounding. Licensed Practical Nurse #1 was observed to stand at the nurses station and chart for 10 minutes. During those 10 minutes 4 vent alarms sounded and multiple heart rate, oxygen saturation and respiratory rate alarms sounded. The nurse was observed to periodically glance at the monitor and then continue to chart. After 10 minutes, Certified Respiratory Therapist (CRT) #1 walked to the nurses station, LPN #1 informed the CRT #1 that the alarms were sounding. The CRT then went to check on those residents. During an interview on [DATE] at 11:00 AM, CRT #1 stated that all staff members responded to alarms. She stated that the Respiratory Therapists were to respond first then the nurses. CRT #1 stated that there were two types of alarms, the vent alarms sound very loudly and are linked to the call bell system. The other alarms were the heart rate, SPO2 % and respiratory rate. Those alarms were linked to the monitor at the desk. CRT #1 stated that the non-vent alarms sounded loudly at the desk and the nurses would respond immediately to those alarms. On [DATE] review of the facility policy "Ventilation, Mechanical" revealed the following information: Listed under the title "Equipment" was "#4 Alarms: Resident/patient disconnect (low pressure) and high pressure alarms are to be used at all times. If disconnection from the ventilator is likely to cause serious effects, a remote alarm will be used." Under "Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for tracheostomy tube replacement." Under the title of "Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient......" The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] at 12 AM, "Rs (Resident) pulling at vent tubes. Redirected resident." [DATE] at 12 AM, "Resident continues to pull ventilatory (sic) tubing off." [DATE] at 10:40 AM, "Resident pulled trachea out. No bleeding noted, respiratory therapist reinserted trachea. Resident was medicated for agitation. Trachea was reinserted without complications." At 11:55 PM, "Resident pulled trachea out again. Family member was notified. (Family) requested that doctor be called for an order for [REDACTED]. On [DATE] at 12:10 AM, Attending Physician "notified of resident pulling out trachea times two without complications." Attending Physician "gave orders for hand mittens to both hands." On [DATE] at 6 PM, Resident #1 was medicated for anxiety with 0.5 mg (milligrams) of Xanax. At 6:28 PM, Resident #1 "slipped right hand out of mittens and pulled trach out. Resp (respiratory) therapist replace trach without any problem. On [DATE] at 6 AM, "Resident pulled hand free from mitten and disconnected the vent from the trach." On [DATE] at 12 AM, Resident "asking staff to remove mittens so she can remove trach." On [DATE] at 4 AM, Resident #1 "has hand mittens in place, but she managed to disconnect vent tubing several times during the night." On [DATE] at 2:45 AM, "resident managed to remove one glove." On [DATE] at 6 PM, Resident #1 had mittens off and decannulated herself. Family at bedside. Respiratory Therapist reinserted without any problems. On [DATE] at 9:15 PM and 10:15 PM, "attempting to remove mittens." On [DATE] at 12 AM, the nurse documented that Resident #1 did not "appear to comprehend function and purpose of trach." At 7:50 AM, "writer entered resident's room and found resident with trach out. Non responsive to verbal stimuli. RT (Respiratory Therapist) notified and trach placed back in. Resident remained non responsive..." Resident #1 was sent to the emergency room via ambulance at 8:32 AM. The resident was admitted to the hospital. On [DATE] Resident #1 was readmitted to the facility. On [DATE] at 12 AM, "Resident managed to remove R (right) mitten." On [DATE] at 12 AM, "Resident attempting to pull trach. Mittens reapplied." On [DATE] at 2:40 AM, Resident #1's mittens were removed per staff member, resident grabbed trach and removed halfway. At 7:30 AM, Resident #1 pulled the mittens off and was pulling at her trach. On [DATE], Resident continues to try to pull mittens off. On [DATE] Resident #1 was moved off of the vent hall. Resident #1 remained on continuous SPO2 monitoring as well as heart rate monitoring. "Family member requested medications for anxiety. Vistaril 25 mg three times daily as needed was ordered." Resident #1 was noted to be on a trach collar. On [DATE] at 1 AM, "family requested something for anxiety." On [DATE] at 6 PM, "pt's (patient) family request that pts MD be called due to concerns of pt not resting at night. New order received for Restoril 15 mg at night as needed." On [DATE] at 10:45 AM, "Daughter requested for patient to have something routinely at bedtime for rest...new orders received." (Vistaril and Restoril were discontinued and Ambien 5 mg was ordered.) On [DATE] at 2:45 AM, Resident #1 was observed to have her trach to trach collar at 4 L oxygen and mittens to bilateral hands in place. At 3:20 AM, "Trach decannulation. RT called to room. Pt assessed, unresponsive to verbal stimuli, sternal rub. Vital signs checked, no pulse, no respirations. CPR started. EMS called. AED applied. Instructions to resume CPR. CPR continued until paramedics arrived." At 3:45 AM, Resident #1 was transferred to the hospital. At 4:08 AM, Resident #1 was pronounced expired. Review of the Physician's Orders revealed a telephone order dated [DATE] for bilateral hand mittens. On [DATE] at 4:30 PM, Haldol as needed was discontinued. On [DATE] an order was written for Remeron 15 mg every night. On [DATE] at 10:55 PM, Risperdal 0.5 mg x 1 dose now was ordered. On [DATE] Lexapro was discontinued. On [DATE] Risperdal 1 mg as needed at night was ordered. Further review revealed upon Resident #1's readmission on [DATE] she was receiving Seroquel 50 mg every night. No other as needed medications were available for Resident #1's anxiety at that time. On [DATE], the ventilator was discontinued and Resident #1 was on trach collar only. On [DATE] at 5 PM, Seroquel was increased to 100 mg every night. On [DATE] at 3 PM, an order was written for Vistaril 25 mg as needed three times daily. On [DATE], Restoril 15 mg as needed as ordered. On [DATE] at 11:30 AM, Vistaril and Restoril were discontinued and Ambien 5 mg at bedtime was ordered. Review of the MAR (Medication Administration Record) dated [DATE] revealed Resident #1 received as needed Haldol 3 milligrams on [DATE] for pulling at trach. (No corresponding notes were located but the MAR had documentation the medication was effective). And on ,[DATE] received Haldol at 11 PM after decannulating. Resident #1 received as needed Xanax four times for increased anxiety. Review of the MAR dated [DATE] revealed Resident #1 received Xanax six times between [DATE] and [DATE]. On [DATE] Xanax was discontinued. No as needed Risperdal was administered. Review of the MAR dated [DATE] revealed on [DATE] Resident #1 received 2 mg Haldol one time dose. Resident #1 received as needed Vistaril on ,[DATE] at 3 PM and ,[DATE] at 12:45 AM. Risperdal as needed was not administered. Ambien 5 mg was administered on [DATE]. Resident #1 did not receive any as needed medications for anxiety prior to any of the seven actual decannulations. Resident #1 did not receive as needed medications for anxiety for many of the multiple episodes of removing her mittens or disconnecting the tubing from the vent. Review of the Behavior Monthly Flow Record dated [DATE] revealed Resident #1 had 18 episodes of pulling at her trach. No other documentation was noted on the flowsheets. No other flowsheets were located at the time of the survey. Review of the Care Plan revealed a Problem Area identified [DATE] of restlessness and "Patient has pulled out trach during episodes of agitation and often picks and pulls at trach. Approaches included "Refer to psych as needed, help resident determine source of anxiety and precipitating events and alert staff to help to decrease them, ensure any needed/ordered safety devices are on and operating properly, evaluate resident's effectiveness of medication therapy, continue to reiterate to patient why trach is necessary and possible consequences of pulling it." Another problem area was identified on [DATE] of "limb restraints used to prevent pt from removing trach." Approaches included "apply limb restraint as ordered, review the continued need for limb restraint." The care plan was not updated to include the seven incidents of decannulation. The care plan also did not include new interventions to prevent decannulation. Review of the Physician's Progress Notes revealed on [DATE] the Attending Physician documented "No problems are reported by the staff, other than her occasionally being anxious and pulling at things, so she sometimes needs to wear protective mittens. On [DATE] the Attending Physician documented "she was hospitalized earlier this week with mental status changes and diminished level of consciousness. She was agitated at night, but sleeping during the day. She remained off the ventilator, tolerating trach collar. We seem to have straightened things out by putting her on Seroquel 50 mg every night, which helped her sleep through the night, without being agitated, so that she is more awake and alert during the day." During an interview on [DATE] at 11 AM, CRT #1 stated that all staff members responded to alarms. She stated that the Respiratory Therapists were to respond first then the nurses. CRT #1 stated that there were two types of alarms, the vent alarms sound very loudly and are linked to the call bell system. The other alarms were the heart rate, SPO2 % and respiratory rate. Those alarms were linked to the monitor at the desk. CRT #1 stated that the non-vent alarms sounded loudly at the desk and the nurses would respond immediately to those alarms. CRT #1 stated that she routinely cared for Resident #1 and stated that she had a history of [REDACTED]. During an interview on [DATE] at 12:40 PM, CNA (Certified Nursing Assistant) #1 stated that she cared for Resident #1. She stated that she was aware that Resident #1 had a history of [REDACTED]. One nurse notified LPN #2 that the alarm was sounding for Resident #1. LPN #2 then went to check on the resident. CNA #1 was walking down the hallway when LPN #1 called out for help and informed CNA #1 that Resident #1's trach was out. CNA #1 stated that she then went and got the Respiratory Therapist. During an interview on [DATE] at 12:55 PM, LPN #1 stated that she cared for Resident #1. LPN #1 stated that she did not hear an alarm sounding, however the vent nurse informed her of the alarm. LPN #1 stated that she went and checked on the resident and noted that she had decannulated herself and was non responsive. She stated that she called for help. The RT came to the room and reinserted the trach and CPR was initiated. LPN #1 stated that she knew the resident had a history of [REDACTED]. During an interview on [DATE] at 1 PM, RT (Respiratory Therapist) #1 stated that on the morning of [DATE] at around 3 AM, she was at the desk charting. She stated that CNA #1 came to the desk and informed her that Resident #1's trach was out. RT #1 then went to the resident's room, reinserted the trach and started CPR. RT #1 stated that she knew Resident #1 had a history of [REDACTED]. During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #1 had a history of [REDACTED]." The Attending Physician was asked if the interventions were effective and he stated "Yes." The Attending Physician was asked how many times the resident had decannulated herself and he stated that he didn't "know for sure but would have said three." The Attending Physician was informed of the 7 decannulations (one requiring hospitalization and the one that led to her death). He was asked again if the interventions were effective and he replied no. The facility admitted Resident #2 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed Resident #2 had bed bolsters and bilateral mittens in place for safety prior to February 2011. On [DATE] at 4 AM, Resident #2 "disconnected self from vent." On [DATE] at 12 AM, Resident "very agitated at times and pulls self off vent." On [DATE] at 5 PM, "upon entering room, I noted the resident in C bed lying on the floor, between the bed and the wall. Vent was unhooked. Resident was placed back on vent." (On ,[DATE] a bed alarm was ordered). On [DATE] at 3:40 AM, "found on floor between beds by RT who alerted nurse immediately. Vent alarm sounding, bed alarm working. Assisted back to bed, vent reconnected." On [DATE] at 8 PM, Resident #2 was "able to disconnect vent and turn self in bed with feet hanging out of bed." Further review of the nurses notes revealed Resident #2 had noted self injurious behaviors, including biting and scratching himself. Resident #2 also had a history of [REDACTED]. Review of the Respiratory Therapy Notes revealed no entries related to the resident disconnecting himself from the vent. Review of the Care Plan dated [DATE] revealed a Problem area of Combative Behavior. The care plan was updated on [DATE]. Approaches included "monitor and document patient behavior. Report negative behavior increase to physician. Administer behavior medications as ordered, review patient drug regime, apply mittens when needed for protection of patient and others." No care plan was noted to address Resident #2's falls. No new interventions were put in place after either fall on ,[DATE] or ,[DATE]. Further review revealed a problem area of Restraints. The care plan was last updated on [DATE]. Approaches included "bed bolsters to define parameters of bed [DATE] and mittens to bilateral hands. Identify factors that increase patient potential for injury and or agitation, close observation to maintain resident's safety." Review of the Physician's Orders revealed Resident #2 was receiving Seroquel three times daily and Depakene at bedtime. No as needed medication was ordered for agitation. Review of the Physician's Progress Notes revealed Resident #2 was seen last by a Psychiatrist on [DATE]. At that time the Seroquel was increased. Review of the Attending Physician's Progress Notes revealed on [DATE], Resident #2 "remains on the ventilator and is wearing protective mittens so that he doesn't hurt himself. No changes in his therapy." On [DATE] the Attending Physician documented "he's comfortable on the ventilator, but he continues to need to wear mittens to protect him from hurting himself as he is frequently agitated, swinging his arms and grabbing at things." During an interview on [DATE] at 11:40 AM, the Attending Physician stated that Resident #2 was "deserving of 1:1's." The Attending Physician also agreed that there were more interventions that could be initiated. He agreed that Resident #2's behaviors were similar to Resident #1's. The facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Nurse's Notes revealed on [DATE] at 4 PM, "Resident pulls at all devices. Pulled trach out..." On [DATE] "Res pulled out his PICC (Peripherally Inserted Central Catheter) to the R arm. Arm swollen three times the size. Called 911 to transfer to hospital. Called (Medical Director) about pt pulling out PICC line. (Resident #3 was diagnosed with [REDACTED]. On [DATE] at 5 PM, Resident #3 "pulled out trach, resp called Trach #3 put back in." On [DATE] at 6:40 PM, Pulmonologist consult for possible trach decannulation." On [DATE] at 10:30 PM, "pulled his trach out, respiratory but it back in." On [DATE] at 7 PM, "CNA called this nurse to res room. Res had trach lying on his throat, nursing attempted to replace and resp came into room with in two minutes, also attempted to replace trach...MD aware and order to send to (ER) for trach replacement." The ER was unable to reinsert the trach and the resident was stable. The resident was sent back to the facility decannulated per the physician. Review of the Care Plan revealed a Problem Area of Respiratory Distress. There was no care plan for the resident's behavior of decannulating self or pulling at the PICC line. Resident #3's behaviors were not addressed and no safety measures were put in place to protect the resident's airway or intravenous access. Review of the Psychiatrist Note dated [DATE] revealed Resident #3 had previously been on psychotropic medications, however all medications were discontinued prior to his admission on [DATE]. Review of the Physician's Orders revealed there was not a psychiatric referral made when Resident #3 began displaying behaviors. No medications were ordered to address the behaviors. There were no other interventions ordered or put in place to protect the resident's airway and intravenous access. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. During an interview on [DATE] at 5:15 PM, the Medical Director stated that he was not aware of the Resident #1's death nor was he aware of the events surrounding her death. The Medical Director confirmed that if a restraint was not effective then other interventions should be initiated. He stated that 1:1's could be an intervention. The facility Medical Director stated that if a resident was displaying self injurious behaviors then communication and redirection should be attempted first. Medications and psych referrals would also be initiated. The facility Medical Director stated that after all other interventions were evaluated then he would expect the staff to evaluate the resident for restraints. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the day of the complaint and extended inspection, based on record review, observations, interviews, and review of facility policies "Physical Restraints" "Ventilation, Mechanical" "Admission Behavior Logs", the Administration failed to administer effectively and efficiently to attain or maintain the highest practicable physical well being for 3 of 3 residents with tracheostomies, behaviors and/or restraints. The facility Administration failed to ensure staff monitored, evaluated, or adequately care planned the behaviors of the identified residents resulting in decannulation and disconnections from the ventilator. (Resident's #1, #2, and #3) The findings included: Resident #1 removed her mittens and decannulated herself 7 times. Resident #1 expired on [DATE] after she removed her cannula. Resident #2 disconnected himself from the vent 5 times while wearing mittens. No assessments were completed related to the efficacy of the interventions and restraints. No new and effective interventions were put in place for either resident to prevent the decannulations/disconnections. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. Adequate interventions were not initiated to address the resident's self injurious behaviors. The facility administration failed to monitor the care provided to residents with tracheostomies, behaviors and/or restraints. Review of the facility policy "Physical Restraint" on [DATE] revealed the following information under "Policy": "....Physical restraints may be temporarily required as an intervention for emergent and/or therapeutic care when needed to treat a patient/resident's specific medical condition." In addition: "Physical restraints may only be utilized when the following criteria have been met and there is supportive documentation present in the patient/resident's clinical record." The areas listed included; "A completed Physical Assessment.......When the patient/resident's physical restraint has been determined to be used as an intervention for emergent and/or therapeutic care and treatment, the physical restraint will only be used for certain time periods and under specific conditions." Listed under "Physical Device Initial/Annual Assessment" the following requirement for assessment was included under "Admission..." "When the patient/resident's condition is suspect for potential use of a physical restraint", and under "Quarterly (in conjunction with the MDS cycle)-Physical Restraint Elimination Assessment. (#1) When the patient/resident currently has a physical restraint. (#2) When the patient/resident's condition is now suspect for potential use of a physical restraint." "A Restraint Committee will meet at least monthly. A Restraint Committee Coordinator will be appointed by the Administrator." On [DATE] review of the facility policy "Ventilation, Mechanical" revealed the following information: Listed under the title "Equipment" was "#4 Alarms: Resident/patient disconnect (low pressure) and high pressure alarms are to be used at all times. If disconnection from the ventilator is likely to cause serious effects, a remote alarm will be used." Under "Staff training & Considerations: #3 Appropriate response to emergencies involving the ventilator resident/patient. #4 Appropriate response to ventilator problems, power failures, decannulation, or need for [MEDICAL CONDITION] replacement." Under the title of "Monitoring: #1 The frequency of monitoring will be based on each individual resident/patient......" Review of the facility's policy on Behavior Logs revealed: An individualized Behavior Management Program will be initiated when the following events occur: One altercation resulting in injury. This would also include behaviors with potential for serious harm...Once identified as being at risk for occurrence/behaviors the resident will be placed on the Occurrence Prevention/Behavior Management Program...A summary of the reasons why the resident is placed on the program will be written in the nurses notes. Information should include but not limited to history of occurrence, medications, gait, diagnoses, occurrence trends and behavior symptoms...The Occurrence Prevention Team and DON will establish the "initial interventions"...The Charge Nurse will be responsible for observation, communication with other staff and documentation. Care Plans should accurately reflect occurrence prevention or behavior management...The resident will be assessed weekly for effectiveness of current interventions. If interventions are not effective, new approaches must be added to the care plan." Cross Refer to the following citations; 483.25 (h) Quality of Care F-323 was identified at a scope and severity level of "K." It was determined that Substandard Quality of Care and Immediate Jeopardy existed at the facility as of [DATE]. Three of three residents were not assessed adequately for the necessary supervision required preventing decannulation and/or disconnecting from the ventilator. Resident #1 removed her mittens and self decannulated 7 times. Resident #1 expired on [DATE] as a result of her self decannulation; Resident #2 disconnected from the ventilator 5 times; Resident #3 decannulated 4 times and pulled out a PICC line resulting in a [MEDICAL CONDITION]. There were no adequate assessments or interventions put on place to protect Residents #1, #2, or #3. 483.12 (d)-(4) Restraints F-221 was identified at a scope and severity level of "K." Two residents were not assessed for the efficacy of the ordered restraints. Resident #1 frequently removed her mittens and decannulated herself. On [DATE], Resident #1 expired as a result of removing her restraint and decannulating self. Resident #2 disconnected from the ventilator 5 times. There was not an assessment that addressed the ineffectiveness of the restraints. Resident #3 decannulated 4 times and pulled out a PICC line that resulted in a [MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. 483.20 Resident Assessment F-280 was identified at a scope and severity level of "K." The Facility staff failed to care plan [MEDICAL CONDITION] patients with behaviors and/or restraints. 483.20 Resident Assessment F-281 was identified at a scope and severity level of "K." Staff failed to answer ventilator associated alarms timely and failed to implement effective interventions to provide adequate supervision and a safe environment. 483.25 (f) (1) Behavior Management F-319 was identified at a scope and severity level of "K." The facility failed to address, monitor and implement effective interventions for residents that displayed self injurious behaviors. 483.75 Administration F-501 was identified at a scope and severity level of "K." The facility Medical Director, failed to ensure facility policies were developed and followed to meet the needs of the residents ensuring they were receiving services appropriate to their needs. 483.75 Quality Assurance F-520 was identified at a scope and severity of "K". The facility failed to identify deficient practice related to residents with tracheostomies, behaviors and/or restraints. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the day of the complaint and extended inspection based on observations, record reviews and interviews the facility failed to identify and implement plans of action for concerns identified related to residents with tracheostomies, behaviors and/or restraints. The findings included: Resident #1 had bilateral hand mittens that she was able to remove and she decannulated herself 7 times. She died on [DATE] after she removed the cannula. Resident #2 disconnected himself from the vent 5 times while wearing mittens. Resident #3 decannulated himself 4 times and pulled out his PICC (peripherally inserted central catheter) line resulting in a [MEDICAL CONDITION] ([MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the adequate interventions to prevent decannulation of their tracheostomies or disconnection from the ventilator. During an interview on [DATE] at 5 PM and 6 PM, the Administrator stated that there was not a plan of action in place related to the identified concerns of tracheostomies, behaviors and restraints. She stated that the facility was aware of the incident on [DATE] with Resident #1, however she stated that the facility did not identify any concerns with Resident #1. She also confirmed that the facility did not identify any concerns related to Resident #2 or #3. 483.25 (h) Quality of Care F-323 was identified at a scope and severity level of "K." It was determined that Substandard Quality of Care and Immediate Jeopardy existed at the facility as of [DATE]. Three of three residents were not assessed adequately for the necessary supervision required preventing decannulation and/or disconnecting from the ventilator. Resident #1 removed her mittens and self decannulated 7 times. Resident #1 expired on [DATE] as a result of her self decannulation; Resident #2 disconnected from the ventilator 5 times; Resident #3 decannulated 4 times and pulled out a PICC line resulting in a [MEDICAL CONDITION]. There were no adequate assessments or interventions put on place to protect Residents #1, #2, or #3. 483.12 (d)-(4) Restraints F-221 was identified at a scope and severity level of "K." Two residents were not assessed for the efficacy of the ordered restraints. Resident #1 frequently removed her mittens and decannulated herself. On [DATE], Resident #1 expired as a result of removing her restraint and decannulating self. Resident #2 disconnected from the ventilator 5 times. There was not an assessment that addressed the ineffectiveness of the restraints. Resident #3 decannulated 4 times and pulled out a PICC line that resulted in a [MEDICAL CONDITION]. Resident #1, #2 and #3 were not provided with the necessary care and services to prevent decannulation of their tracheostomies or disconnection from the ventilator. 483.20 Resident Assessment F-280 was identified at a scope and severity level of "K." The Facility staff failed to care plan [MEDICAL CONDITION] patients with behaviors and/or restraints. 483.20 Resident Assessment F-281 was identified at a scope and severity level of "K." Staff failed to answer ventilator associated alarms timely and failed to implement effective interventions to provide adequate supervision and a safe environment. 483.25 (f) (1) Behavior Management F-319 was identified at a scope and severity level of "K." The facility failed to address, monitor and implement effective interventions for residents that displayed self injurious behaviors. 483.75 Administration F-490 was identified at a scope and severity level of "K." The facility Administration failed to monitor/supervise the care provided residents with tracheostomies, behaviors and/or restraints. 483.75 Administration F-501 was identified at a scope and severity level of "K." The facility Medical Director, failed to ensure facility policies were developed and followed to meet the needs of the residents ensuring they were receiving services appropriate to their needs. The facility Administrator and Director of Nursing were present on [DATE] at 2:30PM when advised by the surveyor that Immediate Jeopardy and Substandard Quality of Care had been identified during the complaint inspection after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.75 F-505 which was identified at a scope and severity of "K" which began on 9/12/10. The facility failed to assure laboratory test results were returned to the facility in a timely manner and promptly provided to the physician to use for assessment, diagnoses, treatment and initiation of appropriate infection control practice. The systematic failure to provide lab services and notify the physician promptly placed residents at risk for serious harm. The immediate jeopardy was not removed upon exit from the facility. Residents #'s 1,4,5,6,14,15,21 and 29 who were 8 of 22 sampled residents reviewed for Physician notification of lab services were identified with concerns related to physician notification resulting in a delay of treatment. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for "Sputum Culture today" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16-10 and reported it on 9-20-10. The RN reviewed the Lab Book and confirmed that the lab was entered to be done on 9-13-10 and there was no follow-up to ensure that the results were received and called to the physician in a timely manner. She also reviewed the medical record and could locate no evidence that the physician was ever notified of the results which showed "pseudomonas aeruginosa 2+" and the gram stain with "many" positive rods and "many" white blood cells. Further review revealed that a weekly PT ([MEDICATION NAME])/INR (International Normalization Ratio) was done and the report available to the facility on [DATE] via computer. The lab report noted that the resident was currently "on 2 mg [MEDICATION NAME]" and was faxed to the physician on 11-3-10 (2 days later). The PT was 12.9 seconds with a reference range of 10.0 to 13.0. The INR ratio was 1.0 L(ow) with a reference range of 2.0-3.0. The physician wrote an order on the lab report on 11-4-10 to "Please ^ (increase) to 3 mg". This order was transcribed onto a Physician's Interim Order form on 11-5-10. During an interview on 12-15-10 at 8:50 AM, Licensed Practical Nurse #4 reviewed the medical record and confirmed that the [MEDICATION NAME] was not increased until 11-5-10 based on the 11-1-10 PT/INR results. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record on 12/13/10 revealed the resident had a Urine Culture and Sensitivity obtained on 9/16/10. The resident was started empirically on Bactrim on 9/17/10. Per the lab result, a report of the lab was available on 9/18/10 which indicated the resident had an E-Coli infection which was not sensitive to the Bactrim as ordered. Nurses notes documented on 9/20/10 that the resident expressed to the nursing staff that she thought the Bactrim was "not strong enough to cure UTI" (urinary tract infection). On 9/21/10 the resident complained of burning all over and asked to go to the emergency room . The resident returned from the emergency room with a new order for Keflex for 10 days and a [DIAGNOSES REDACTED]. The lab report filed in the medical record indicated the result was possibly faxed to the facility on [DATE] and clearly faxed on 9/22/10 and faxed to the physician on 9/22/10. There was no documentation that the facility tried to access the lab result after 48 hours, or attempted to access the result once the resident complained of not feeling better. On 12/14/10 during an interview with the ADON (Assistant Director of Nursing) who was also the Unit Manager she stated that just because the lab result was available in the computer did not mean the facility could access the information. She then called the lab and learn that if the report indicated the result was available it would indeed be available in the computer for the facility staff to access. There was no explanation provided by the Assistant Director of Nursing as to why there was a delay in the receipt of the lab result or fax to the physician. The resident was not included on the audit log on the nursing unit for monitoring for the return of the result or physician notification. Resident # 15 was admitted on [DATE]. A PT/INR ([MEDICATION NAME] time/International Normalization Ratio) was obtained on 11/29/10. The lab report indicated that the result was available on 11/29/10. The report was faxed to the facility on [DATE] and the physician notified on 12/1/10 who then ordered for the [MEDICATION NAME] to be held one day on 12/1/10. The result of the [MEDICATION NAME] was 27.0 (high) and INR 3.4 (high) Resident # 15 had a urine culture obtained on 11/19/10. The lab report indicated the result was available on on 11/21/10. A physician order [REDACTED]. Further interview with the Director of Nursing (DON) revealed that there had been intermittent problems with accessing lab results on the facility computers. A back up plan was for the lab results to be faxed to the facility. However, the fax was located in the business office which closed at 5:30PM and was not open on weekends. Additionally, the DON stated she had trained new hires on how to access labs but now was aware that the weekend supervisor (who worked a 16 hour shift) and potentially other staff hired prior to her arrival did not know to access the labs. Therefore, any lab result received on the weekend was not currently accessible to the nursing staff. Resident #6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During record review of laboratory reports it was found that a sputum culture was done on 6/10/10 with a report date of 6/12/10. The results were not faxed to the Physician until 6/15/10 at which time the resident was [MEDICATION NAME] mg PO BID for 5 days for a Pseudomonas infection. A Pro-Time of 10/18/10 with a report date of 10/18/10 was not sent to the Physician until 10/21/10 . The result of the lab test was a [MEDICATION NAME] time 18.6 (high) and 1.8 (low). A Pro-time was drawn on 11/1/10 with a report date of 11/1/10 . The result of the test was 21.3 (high) and 2.3. The physician was faxed the results on 11/3/10. There was no documentation found that nursing identified the delay in treatment. The facility admitted Resident #4 on 7/26/10 with [DIAGNOSES REDACTED]. Record review on 12/13/10 revealed the resident to be on [MEDICATION NAME] Therapy requiring PT/INR's ([MEDICATION NAME] Time/ International Nationalizing Ratio) to be drawn routinely. Further record review revealed the labs to be drawn timely; however, copies of the lab results did not appear to return timely to the facility or to be acted upon timely. Resident #4 had labs drawn: 8/24/10 not called to Doctor until 8/26/10 with an order for [REDACTED]. During an interview with RN #1 (Registered Nurse), the nurse showed an audit form that was being used to track labs. However, check marks were only placed if report faxed, placed in folder, or phone call made to Physician. Some sheets only had dates report received and date report placed in the chart. No follow-up was done by the nurses if a report had been delayed to find out why report delayed or to ask what results were. The lab test for 10/25/10 PT/INR for Resident #4 had not been listed on the audit sheet. This was confirmed by RN #1. Therefore, no one questioned why the result was not faxed until 10/29 and not faxed to doctor until 11/2. The Physician ordered an increase of 1 mg (milligram) to the current [MEDICATION NAME] order on 11/2/10. The facility admitted Resident #5 on 8/26/09 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Record review on 12/13/20 revealed a lab report for a Complete Blood Count (CBC) and a Basic Metabolic Profile (BMP) drawn on 2/08/10. The report was reviewed on 2/14/10 and iron studies ordered. A lab report done on 8/30/10 and sent to facility on 8/30/10 for CBC and BMP had irregularities noted. Note on bottom of report faxed to doctor- fax unsuccessful. There was no documentation of any follow up to refax or call to the doctor. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 11/29/2010 indicated Resident #21 "complained of congestion, called (the Attending Physician) new order for sputum C&S (culture and sensitivity). At 3:40 PM, the "sputum culture was obtained from resp(iratory) therapist." On 12/4/2010 at 4 AM, Resident #21 complained of nausea and vomiting and a headache. His temperature was 100.4 degrees, pulse of 112 and blood pressure of 145/95 (significantly higher than the 100's systolic as his baseline). On 12/5/2010, Resident #21 refused care. On 12/6/2010 Resident #21 continued to complain of nausea and vomiting, headache and neck ache. On 12/7/2010 at 12:00 AM, Resident #21's temperature was 102.7 and he stated that he did not feel well. His temperature was rechecked at 3:20 AM, and it was recorded as 103 degrees. The physician was notified and an order was obtained to send him to the emergency room . Resident #21 returned from the emergency roiagnom on [DATE] at 9:15 AM, with orders for intravenous antibiotics (IV) for "[MEDICAL CONDITION]." On 12/8/2010, Resident #21's antibiotics were changed from IV [MEDICATION NAME] to Cipro, [MEDICATION NAME] and intramuscular (IM) [MEDICATION NAME]. On 12/9/2010 at 9:40 AM, "new order airborne precautions move to room [ROOM NUMBER]....MRSA sputum." Review of the Physician's Telephone Orders revealed the following: 11/29/2010, "Sputum C&S"; 12/7/2010 "Send to ER (emergency room ) for increased temperature"; 12/7/2010 " [MEDICATION NAME] 1 gram IV every day for 10 days". 12/8/2010 "DC(discontinue) [MEDICATION NAME] and [MEDICATION NAME] mg (milligrams) BID(twice a day), [MEDICATION NAME] 120 mg IM for 7 days"; 12/9/2010 " airborne precautions, move to room [ROOM NUMBER]". Review of the Respiratory Therapy notes revealed on 11/27/2010, Resident #21's sputum was thin and yellow. Additional notes revealed the sputum was noted to be increasing in quantity and was noted to be thick and yellow. No respiratory distress was documented. Review of the Laboratory data revealed a sputum culture was sent to the lab on 11/30/2010. The lab reported the final results to the facility on [DATE]. The facility notified the the Attending Physician on 12/8/2010, two days after receipt of the report. On 12/8/2010 the antibiotic treatment was altered for Resident #21 because [MEDICAL CONDITION] was not sensitive to the current treatment. There was no documentation noted that the nursing staff followed up to assure the timely receipt of the culture, which resulted in the resident not being place on appropriate transmission based precautions in a timely manner. The resident resided in a room with three other residents at high risk for infection related to cormorbidities. The facility admitted Resident #29 on 1/2/2010 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. The results of the culture were made available to the facility on [DATE]. The physician was not notified of the positive culture until 11/15/2010. Further review revealed a PT/INR dated 10/11/2010 was available the same day and the physician was not notified until 10/13/2010. An additional PT/INR was available to the facility on [DATE], with physician notification occurring on the 28th . A PT/INR was dated 11/1/2010 and the results were available to the facility on [DATE] but the physician was not notified until 11/3/2010. During an interview the Nurse Manager from Station II, confirmed the delay in obtaining the culture results from 11/30/2010 for Resident #21 and confirmed the delay in notification for the culture and PT/INR results for Resident #29. She stated that normally cultures take 2-3 days to report. She stated that it was the nurses' responsibility to call and check on the results if they were delayed. The nurse stated that the lab normally faxed over the results when they were available. Lab results were also available through the computer. The Nurse Manager stated that the fax machine was located in the business office or the Admissions office, both of which were locked after 5 PM and on weekends. She/he stated that if a lab was faxed on the weekend, the nurses would not receive the results until the following Monday. If the lab was faxed after 5 PM, the nurses would receive the results the next day. The Nurse Manager confirmed that there had been a two day delay in notifying the physician of [MEDICAL CONDITION] positive culture. She stated that the nurses should have faxed the results to the physician immediately upon receipt of the lab. The Nurse Manager also confirmed that Resident #21 was not placed on isolation precautions for [MEDICAL CONDITION] pneumonia until 12/9/2010, 3 days after the report was made available to the facility. During an interview,a representative from the contract Lab stated that sputum cultures take 1-2 days to report. She/he stated that all cultures were sent to --- Hospital. She stated that if there was a delay in obtaining the results that a lab tech would call the hospital to check on the results. She stated that no documentation of the phone calls were kept. The Lab tech stated that the facility had access to the lab results on the computer and the results were available to the facility on the date reported. She also stated that a fax was automatically generated and sent to the facility upon report of the lab. She stated that there was no confirmation receipt kept for specific lab reports. During an interview, the Director of Nursing confirmed the delay in obtaining the culture report and confirmed the delays in reporting the result to the physician for both Resident #21 and #29. She/he also stated that Resident #21 should have been placed on isolation precautions immediately upon receipt of the lab results on 12/6/2010 and should not have waited 3 days. The facility's policy on Changes in Condition was reviewed. The policy documented that the nurses were to "verbally report resident's status to the physician and provide detailed description of the observed signs and symptoms and any laboratory and or radiology test results. Communication...must occur in a timely manner..." The facility Administrator and two Corporate Nurse Consultants were present on 12/14/10 at 10:30AM when advised by the Team Leader that Immediate Jeopardy and Substandard Quality of Care had been identified by the survey team after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing. First Follow-Up Visit During an unannounced onsite visit on 12/30/2010 at 10:30 AM, it was determined based on interviews, observations, review of records, and review of facility policies, that the Allegation of Compliance submitted by the facility on 12/22/2010 had been implemented by the facility and was in practice as of 12/22/2010, removing the immediacy of the deficient practice. The citation at F-505 remained at a lowered scope and severity of " E". The facility will be in compliance at F-505 when an acceptable Plan of Correction is submitted and a follow up visit is conducted to determine that the facility has implemented their Plan of Correction as stated.

On the days of the Recertification and Complaint survey, based on observations, interviews, record reviews, and review of facility policies for Change of Condition and Laboratory Services, it was determined on 12/14/10 at 10:30AM that Immediate Jeopardy and Substandard Quality of Care existed for CFR 483.20 F-281 at a scope and severity of "K", starting 9/12/10. The facility Nursing staff repeatedly failed to identify a delay in the receipt of laboratory tests and subsequently failed to contact the attending physicians in a timely manner to obtain further medical direction for the assessment, monitoring and treatment of [REDACTED]. Residents # 1, 4, 5, 6, 7, 14, 15, 21,and 29 were 9 of 22 sampled residents reviewed for professional standards related to physician notification of laboratory results who were found to be affected by the deficient practice. The findings included: The facility admitted Resident #1 on 6-2-10 with [DIAGNOSES REDACTED]. Record review on 12-14-10 at approximately 5 PM revealed that on 9-12-10, Respiratory Therapy noted moderate yellow sputum and a Physician's Interim Order for "Sputum Culture today" was obtained. Further review revealed no laboratory results in the medical record. Review of the Respiratory Therapy notes revealed that the sputum specimen was obtained on 9-15-10. During an interview on 12-14-10 at 6 PM, Registered Nurse (RN) #3 reviewed the medical record and Lab Book and could find no record of the sputum culture having been completed. During an interview on 12-15-10 at 9:20 AM, RN #3 stated that the physician's orders [REDACTED]. She reviewed the Respiratory Therapy Notes with the surveyor and confirmed that the sputum specimen had been obtained on 9-15-10. The lab report was obtained from the computer and RN #3 verified that the lab had received the specimen on 9-16-10 and reported it on 9-20-10. The RN reviewed the Lab Book and confirmed that the lab was entered to be done on 9-13-10 and there was no follow-up to ensure that the results were received and called to the physician in a timely manner. She also reviewed the medical record and could locate no evidence that the physician was ever notified of the results which showed "pseudomonas aeruginosa 2+" and the gram stain with "many" positive rods and "many" white blood cells. Further review revealed that a weekly PT ([MEDICATION NAME])/INR (International Normalization Ratio) was done and the report available to the facility on [DATE] via computer. The lab report noted that the resident was currently "on 2 mg [MEDICATION NAME]" and was faxed to the physician on 11-3-10 (2 days later). The PT was 12.9 seconds with a reference range of 10.0 to 13.0. The INR ratio was 1.0 L(ow) with a reference range of 2.0-3.0. The physician wrote an order on the lab report on 11-4-10 to "Please ^ (increase) to 3 mg". This order was transcribed onto a Physician's Interim Order form on 11-5-10. During an interview on 12-15-10 at 8:50 AM, Licensed Practical Nurse #4 reviewed the medical record and confirmed that the [MEDICATION NAME] was not increased until 11-5-10 based on the 11-1-10 PT/INR results. There was no documentation that the nursing staff identified the delay in contacting the physician and initiated corrective action. Resident # 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the medical record on 12/13/10 revealed the resident had a Urine Culture and Sensitivity obtained on 9/16/10. The resident was started empirically on Bactrim on 9/17/10. Per the lab result, a report of the lab was available on 9/18/10 which indicated the resident had an E-Coli infection which was not sensitive to the Bactrim as ordered. Review of the nurses notes revealed on 9/20/10 the resident expressed to the nursing staff that she thought the Bactrim was "not strong enough to cure UTI" (urinary tract infection). On 9/21/10 the resident complained of burning all over and asked to go to the emergency room . The resident returned from the emergency with a new order for Keflex for 10 days and a [DIAGNOSES REDACTED]. There was no documentation that the facility tried to access the lab result after 48 hours, or attempted to access the result once the resident complained of not feeling better. On 12/14/10 during an interview with the ADON (Assistant Director of Nursing) who was also the Unit Manager she stated that just because the lab result was available in the computer did not mean the facility could access the information. She then called the lab to learn that if the report indicated the result was available it would indeed be available in the computer for the facility staff to access. There was no explanation provided by the Assistant Director of Nursing as to why there was a delay in the receipt of the lab result or fax to the physician. The resident was not included on the audit log on the nursing unit for monitoring for the return of the result or physician notification. Resident # 15 was admitted on [DATE]. A PT/INR ([MEDICATION NAME] time/International normalized ratio) was obtained on 11/29/10. The lab report indicated that the result was available on 11/29/10. The report was faxed to the facility on [DATE] and the physician notified on 12/1/10 who ordered for the [MEDICATION NAME] to be held one day on 12/1/10. The result of the [MEDICATION NAME] was 27.0 (high) and INR 3.4 (high) Resident # 15 had a urine culture obtained on 11/19/10. The lab report indicated the result was available on on 11/21/10. A physician order [REDACTED]. There was no indication that the nursing staff followed the facility protocol for lab services or questioned the delay in treatment for [REDACTED]. Resident #6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. During record review of laboratory reports it was found that a sputum culture was done on 6/10/10 with a report date of 6/12/10. The results were not faxed to the Physician until 6/15/10 at which time the resident was [MEDICATION NAME] mg PO BID for 5 days for a Pseudomonas infection. A Pro-Time of 10/18/10 with a report date of 10/18/10 was not sent to the Physician until 10/21/10 . The result of the lab test was a [MEDICATION NAME] time 18.6 (high) and 1.8 (low). A Pro-time was drawn on 11/1/10 with a report date of 11/1/10 . The result of the test was 21.3 (high) and 2.3. The physician was faxed the results on 11/3/10. There was no documentation found that nursing identified the delay in treatment. The facility admitted Resident # 7 on 11-23-10 with [DIAGNOSES REDACTED]. On 12-13-10 at approximately 11:30 AM, review of the Medical Record revealed that the resident was on an anticoagulant therapy. Review of the physicians orders revealed the following order dated 12-6-10: "^ (increase) [MEDICATION NAME] to 7 mg (milligrams) Q (every) day. INR on Friday 12/10/10". Further review revealed that no labs had been drawn for Resident # 7 on Friday 12-10-10. Licensed Practical Nurse (LPN # 2) confirmed that the lab had not been written in the log book, nor drawn on 12-10-10. A new lab order was written on 12/13/10 after it was brought to the attention of the staff by the surveyor. The results revealed a low INR of 1.1 ratio. The results were faxed to the physician at 8:10 PM on 12-13-10, and new orders were put in place to begin on 12-14-10. The delay of treatment was 4 days. The facility admitted Resident #4 on 7/26/10. The resident was being maintained on bedrest with [DIAGNOSES REDACTED]. Record review on 12/13/10 revealed the resident to be on [MEDICATION NAME] Therapy requiring PT/INR's ([MEDICATION NAME] Time/ International Normalization Ratio) to be drawn routinely. Further record review revealed the labs were drawn timely; however, copies of the lab results did not return timely to the facility nor were they found to have been acted upon timely. Resident #4 had anticoagulant monitoring labs drawn on 8/24/10 which were not called to the Doctor until 8/26/10 when an order was received to increase the [MEDICATION NAME] dose. A PT/INR done and reported on 9/2710 was not received by the facility until 10/21. There was no order change required for this lab. On 10/11 a PT/INR was drawn and reported. and faxed to the physician on 10/13. On 10/25/10 a PT/INR was drawn and results available on 10/25/10. There were three fax dates noted on the report. (10/29/10, 11/1/10, and 11/2/10). On 11/210 the physician faxed an order to the facility to increase the [MEDICATION NAME] dose to 4 milligrams. This was not transcribed to a telephone order nor started until 11/5/10. During an interview with RN #1 (Registered Nurse), the nurse showed this surveyor an audit form that was being used to track labs. However, check marks were only placed if report was faxed, placed in folder, or phone call made to Physician. Some sheets only had the dates reports were received and dates reports were placed in the chart. No follow-up was done by the nurses if a report had been delayed to ascertain the result or the reason why the lab was delayed. The lab test for the 10/25/10 PT/INR for Resident #4 was not been listed on the audit sheet as confirmed by RN #1. The facility admitted Resident #5 on 8/26/09 and readmitted the resident on 11/17/10 with [DIAGNOSES REDACTED]. Record review on 12/13/10 revealed a lab report for a Complete Blood Count (CBC) and a Basic Metabolic Profile (BMP) drawn on 2/08/10. Iron studies were not ordered until 2/14/10 based on the result of the lab of 2/8/10. CBC and BMP were done and reported to the facility on [DATE] with multiple abnormal values noted. The lab report documented an unsuccessful attempt to fax the report to the physician. There was no evidence of subsequent follow up. On 12/14/10, Registered Nurse # 1 was unable to provide an explanation. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE]. [DIAGNOSES REDACTED]. Review of the Nurses' Progress Notes dated 11/29/2010 indicated Resident #21 "complained of congestion, called (the Attending Physician) new order for sputum C&S (culture and sensitivity). At 3:40 PM, the "sputum culture was obtained from resp(iratory) therapist." On 12/4/2010 at 4 AM, Resident #21 complained of nausea and vomiting and a headache. His temperature was 100.4 degrees, pulse of 112 and blood pressure of 145/95 (significantly higher than the 100's systolic as his baseline). On 12/5/2010, Resident #21 refused care. On 12/6/2010 Resident #21 continued to complain of nausea and vomiting, headache and neck ache. On 12/7/2010 at 12:00 AM, Resident #21's temperature was 102.7 and he stated that he did not feel well. His temperature was rechecked at 3:20 AM, and it was recorded as 103 degrees. The physician was notified and an order was obtained to send him to the emergency room . Resident #21 returned from the emergency roiagnom on [DATE] at 9:15 AM, with orders for intravenous antibiotics (IV) for "[MEDICAL CONDITION]." On 12/8/2010, Resident #21's antibiotics were changed from IV [MEDICATION NAME] to Cipro, [MEDICATION NAME] and intramuscular (IM) [MEDICATION NAME]. On 12/9/2010 at 9:40 AM, "new order airborne precautions move to room [ROOM NUMBER]....MRSA sputum." Review of the Physician's Telephone Orders revealed the following: 11/29/2010, "Sputum C&S"; 12/7/2010 "Send to ER (emergency room ) for increased temperature"; 12/7/2010 " [MEDICATION NAME] 1 gram IV every day for 10 days". 12/8/2010 "DC(discontinue) [MEDICATION NAME] and [MEDICATION NAME] mg (milligrams) BID(twice a day), [MEDICATION NAME] 120 mg IM for 7 days"; 12/9/2010 " airborne precautions, move to room [ROOM NUMBER]". Review of the Respiratory Therapy notes revealed on 11/27/2010, Resident #21's sputum was thin and yellow. Additional notes revealed the sputum was noted to be increasing in quantity and was noted to be thick and yellow. No respiratory distress was documented. Review of the Laboratory data revealed a sputum culture was sent to the lab on 11/30/2010. The lab reported the final results to the facility on [DATE]. The facility notified the the Attending Physician on 12/8/2010, two days after receipt of the report. On 12/8/2010 the antibiotic treatment was altered for Resident #21 because [MEDICAL CONDITION] was not sensitive to the current treatment. There was no documentation noted that the nursing staff followed up to assure the timely receipt of the culture, which resulted in the resident not being place on appropriate transmission based precautions in a timely manner. The resident resided in a room with three other residents at high risk for infection related to cormorbidities. The facility admitted Resident #29 on 1/2/2010 with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. The results of the culture were made available to the facility on [DATE]. The physician was not notified of the positive culture until 11/15/2010. Further review revealed a PT/INR dated 10/11/2010 was available the same day and the physician was not notified until 10/13/2010. An additional PT/INR was available to the facility on [DATE], with physician notification occurring on the 28th . A PT/INR was dated 11/1/2010 and the results were available to the facility on [DATE] but the physician was not notified until 11/3/2010. During an interview the Nurse Manager from Station II, confirmed the delay in obtaining the culture results from 11/30/2010 for Resident #21 and confirmed the delay in notification for the culture and PT/INR results for Resident #29. She stated that normally cultures take 2-3 days to report. She stated that it was the nurses' responsibility to call and check on the results if they were delayed. The nurse stated that the lab normally faxed over the results when they were available. Lab results were also available through the computer. The Nurse Manager stated that the fax machine was located in the business office or the Admissions office, both of which were locked after 5 PM and on weekends. She/he stated that if a lab was faxed on the weekend, the nurses would not receive the results until the following Monday. If the lab was faxed after 5 PM, the nurses would receive the results the next day. The Nurse Manager confirmed that there had been a two day delay in notifying the physician of [MEDICAL CONDITION] positive culture. She stated that the nurses should have faxed the results to the physician immediately upon receipt of the lab. The Nurse Manager also confirmed that Resident #21 was not placed on isolation precautions for [MEDICAL CONDITION] pneumonia until 12/9/2010, 3 days after the report was made available to the facility. During an interview,a representative from the contract Lab stated that sputum cultures take 1-2 days to report. She/he stated that all cultures were sent to --- Hospital. She stated that if there was a delay in obtaining the results that a lab tech would call the hospital to check on the results. She stated that no documentation of the phone calls were kept. The Lab tech stated that the facility had access to the lab results on the computer and the results were available to the facility on the date reported. She also stated that a fax was automatically generated and sent to the facility upon report of the lab. She stated that there was no confirmation receipt kept for specific lab reports. During an interview, the Director of Nursing confirmed the delay in obtaining the culture report and confirmed the delays in reporting the result to the physician for both Resident #21 and #29. She/he also stated that Resident #21 should have been placed on isolation precautions immediately upon receipt of the lab results on 12/6/2010 and should not have waited 3 days. The facility provided policy entitled Change of Condition Care Guard Program stated on page 2 of 3...: "With the patient/resident's medical record in front of you and the documented assessment on the Change of Condition Nurses Notes form verbally report patient/resident's status to the physician and provide detailed description of the observed signs and symptoms, and any laboratory and or radiology test results that have been obtained." The facility provided policy entitled Laboratory Services: Procedure for processing page 2 of 2 (1/99) stated..."The nurse will screen the reports for abnormal results and document the follow up as needed." The facility Administrator and two Corporate Nurse Consultants were present on 12/14/10 at 10:30AM when advised by the Team Leader that Immediate Jeopardy and Substandard Quality of Care had been identified by the survey team as existing in the facility on 9/12/10 after conferring with the State Agency. The Immediate Jeopardy was not removed upon exit from the facility and remains ongoing.

On the days of the Recertification, Complaint survey,and Extended Survey, based on record reviews, review of facility documents, and interviews, the facility failed to ensure that the resident's legal representative was provided with the opportunity to purchase copies of the medical record for 2 of 7 resident representative requests reviewed (Residents #23 and #39) and failed to provide copies of requested records in two working days for 3 of 7 resident representative requests approved to received them (Residents C, D, E). The findings included: During the Entrance Conference, the facility was asked to provide a list of requests made since [DATE] for copies of resident medical records. A list of nineteen names was provided. The facility was then asked to provide dated request forms and evidence the copies were provided as requested. Documents for eighteen residents were provided which included Authorization For Use & Disclosure Of Information, PHI (protected health information) Request Cover Sheet, written requests, Power of Attorney documentation, Certificates of Appointment, Fiduciary Letters, letters of denial, e-mail correspondence with the facility medical records person, "Goin Postal" receipts for certified letters, Medical Record Billing Invoices, and Certified Mail receipts. None of the resident information packets contained copies of all the above listed forms, usually two or three forms were provided for each resident. All of the resident representatives who requested copies of the medical record were identified by the facility as the resident's Responsible Party and were the individuals notified concerning changes in the resident's condition or treatment (protected health information). The denials all stated in part: "... As you may be aware, the Health Insurance Portability and accountability Act and the privacy regulations promulgated thereunder (collectively, "HIPAA") has imposed strict requirements on health care providers regarding the release of protected health information ("PHI") Under HIPAA, a provider may release PHI of an individual to a personal representative authorized under state law to act on behalf of the individual. See 45 CFR 164.502(g). Further, HIPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. 164.514(h)(1)(i). Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living or the permanent administrator or executor of the estate if the individual is deceased . The center will not be able to release these records until it receives verification of the applicable representation. ..." Resident #23 arrived at the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident assessments of [DATE] and [DATE] showed no memory, decision making, or communication problems. On admission, the resident's brother was listed as the Responsible Party but this was changed to his son on an unknown date. The resident's son did start receiving the resident's Statement of Account by [DATE]. Resident #23's son began requesting copies of the medical record on [DATE]. The resident was transferred to the hospital on [DATE] and expired later that day. His son continued to make multiple requests for copies of the medical record and enlisted the aide of The Regional Ombudsman. His requests were repeatedly denied by the corporation legal staff. The Power of Attorney document provided by the son was deemed unacceptable. The probate court's certification of the son as the resident's personal representative was also deemed insufficient. Resident #23's son was directed to produce a fiduciary letter. During an interview with the Administrator on [DATE] at 8:35 AM, a representative from the corporate legal department was called and confirmed that copies of the resident's medical record had not been provided because the son failed to produce fiduciary letters. Resident #39 entered the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's daughter was listed as her Responsible Party. Review of the resident assessment of [DATE] revealed the facility was unable to assess the resident's memory and decision making ability due to her medical status. Communication was impaired. Resident #39 was found unresponsive on [DATE]. Cardiopulmonary resuscitation was initiated and the resident was sent to the hospital where she expired. The daughter was notified of all the events leading to discharge. On [DATE], the resident's daughter requested copies of her mother's medical record and was denied that same day. The corporate representative stated during the interview on [DATE] that it was because she did not have the resident's Healthcare Power of Attorney. Information provided by the facility revealed the following information concerning lack of timeliness in addressing requests for copies of the medical record made by resident representatives: The resident representative for Resident C requested copies of the medical record on [DATE] and was initially denied on [DATE] but documents provided by the facility showed this decision was reversed at a later date. The second request, made on [DATE], showed corporate approval on [DATE] and a posting bill dated [DATE]. Resident D's representative made a request for copies on [DATE] and did not receive approval for the copies until [DATE]. Resident E's representative requested copies of the record on [DATE] but did not receive approval for the copies until [DATE].

On the days of the Recertification, Complaint survey,and Extended Survey, based on record reviews, review of facility documents, and interviews, the facility failed to ensure that the resident's legal representative was provided with the opportunity to purchase copies of the medical record for 2 of 7 resident representative requests reviewed (Residents #23 and #39) and failed to provide copies of requested records in two working days for 3 of 7 resident representative requests approved to received them (Residents C, D, E). The findings included: During the Entrance Conference, the facility was asked to provide a list of requests made since [DATE] for copies of resident medical records. A list of nineteen names was provided. The facility was then asked to provide dated request forms and evidence the copies were provided as requested. Documents for eighteen residents were provided which included Authorization For Use & Disclosure Of Information, PHI (protected health information) Request Cover Sheet, written requests, Power of Attorney documentation, Certificates of Appointment, Fiduciary Letters, letters of denial, e-mail correspondence with the facility medical records person, "Goin Postal" receipts for certified letters, Medical Record Billing Invoices, and Certified Mail receipts. None of the resident information packets contained copies of all the above listed forms, usually two or three forms were provided for each resident. All of the resident representatives who requested copies of the medical record were identified by the facility as the resident's Responsible Party and were the individuals notified concerning changes in the resident's condition or treatment (protected health information). The denials all stated in part: "... As you may be aware, the Health Insurance Portability and accountability Act and the privacy regulations promulgated thereunder (collectively, "HIPAA") has imposed strict requirements on health care providers regarding the release of protected health information ("PHI") Under HIPAA, a provider may release PHI of an individual to a personal representative authorized under state law to act on behalf of the individual. See 45 CFR 164.502(g). Further, HIPAA requires that the provider verify the identity of the personal representative and that person's authority to access PHI as a personal representative. 164.514(h)(1)(i). Such a personal representative may be a durable power of attorney for health care or guardian of the person if the individual is living or the permanent administrator or executor of the estate if the individual is deceased . The center will not be able to release these records until it receives verification of the applicable representation. ..." Resident #23 arrived at the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of the resident assessments of [DATE] and [DATE] showed no memory, decision making, or communication problems. On admission, the resident's brother was listed as the Responsible Party but this was changed to his son on an unknown date. The resident's son did start receiving the resident's Statement of Account by [DATE]. Resident #23's son began requesting copies of the medical record on [DATE]. The resident was transferred to the hospital on [DATE] and expired later that day. His son continued to make multiple requests for copies of the medical record and enlisted the aide of The Regional Ombudsman. His requests were repeatedly denied by the corporation legal staff. The Power of Attorney document provided by the son was deemed unacceptable. The probate court's certification of the son as the resident's personal representative was also deemed insufficient. Resident #23's son was directed to produce a fiduciary letter. During an interview with the Administrator on [DATE] at 8:35 AM, a representative from the corporate legal department was called and confirmed that copies of the resident's medical record had not been provided because the son failed to produce fiduciary letters. Resident #39 entered the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident's daughter was listed as her Responsible Party. Review of the resident assessment of [DATE] revealed the facility was unable to assess the resident's memory and decision making ability due to her medical status. Communication was impaired. Resident #39 was found unresponsive on [DATE]. Cardiopulmonary resuscitation was initiated and the resident was sent to the hospital where she expired. The daughter was notified of all the events leading to discharge. On [DATE], the resident's daughter requested copies of her mother's medical record and was denied that same day. The corporate representative stated during the interview on [DATE] that it was because she did not have the resident's Healthcare Power of Attorney. Information provided by the facility revealed the following information concerning lack of timeliness in addressing requests for copies of the medical record made by resident representatives: The resident representative for Resident C requested copies of the medical record on [DATE] and was initially denied on [DATE] but documents provided by the facility showed this decision was reversed at a later date. The second request, made on [DATE], showed corporate approval on [DATE] and a posting bill dated [DATE]. Resident D's representative made a request for copies on [DATE] and did not receive approval for the copies until [DATE]. Resident E's representative requested copies of the record on [DATE] but did not receive approval for the copies until [DATE].