Every finding on record at River Brook Healthcare Center

Based on record review, staff interviews, the facility failed to ensure that two of three sampled residents (R) (R2 and R7) received a 30 day discharge notice and failed to notify the ombudsman of a facility initiated transfer or discharge.1.Review of the admission Record revealed Resident 2 (R2) was admitted to the facility on [DATE] with diagnoses including, but not limited to, hypertension, depression, diffuse traumatic brain injury with loss of consciousness, and traumatic ischemia of muscle.Review of the Progress Notes dated 01/10/2026 through 01/20/2026 revealed an entry dated 01/19/2026 indicating that R2 was accepted to an out of county (named) facility. The note stated that R2 and a family member were informed of the discharge, and the nurse and CNA were also notified of the transfer. Staff were informed that transport would arrive at 8:30 AM. On 01/20/2026 at 8:30 AM, R2 was transferred via EMS on a stretcher. All of the resident's belongings were packed and sent with him.Review of the Order Summary Report revealed no evidence of a physician order for discharge.There was no evidence of a 30 day discharge notice or a request for transfer to another Skilled Nursing Facility (SNF). There were no behaviors documented, and the ombudsman had not been notified of the discharge.Review of the Discharge Recapitulation dated 01/20/2026 revealed an incomplete form. The form contained only the resident's demographic information and name, with all other sections left blank.Interview on 03/30/2026 at 2:34 PM with Ombudsman CC revealed that R2 was discharged from the facility without notification to the ombudsman or the family. The ombudsman stated the resident did not want to move because his mother lived in the local area.Interview on 03/30/2026 at 3:27 PM with R2 revealed staff came to his room and told him to be ready the next morning because they needed to work on his room. He was told the move was temporary. Upon arrival at the receiving facility, he was informed he would not be returning.Interview on 03/31/2026 at 10:15 AM with the Maintenance Director revealed he did not perform any renovation to R2's room.Interview on 04/02/2026 at 11:05 AM with the Social Services Director revealed the resident frequently complained about being in the facility and expressed a desire to go to New York, and later to an Assisted Living Facility (ALF). She stated that some residents on A Hall had to be moved due to environmental issues, and because R2 was unhappy, she told him he would be leaving the next morning to go to a (named) facility. R2 left less than 24 hours after being informed he was moving for room renovation. She acknowledged she did not contact the ombudsman regarding his discharge.2. Review of the admission Record revealed Resident 7 (R7) was admitted to the facility on [DATE] with diagnoses including, but not limited to, end stage renal disease on dialysis, paraplegia, hypertensive heart and chronic kidney disease, type 2 diabetes, hypertension, and seizures.Review of the progress notes dated 11/01/2025 through 03/31/2026 revealed an entry dated 03/16/2026 documenting that an R7 family member accused the roommate of slapping R7. The roommate denied the allegation. Law enforcement was contacted due to family members attempting to fight and verbally threaten the roommate. The roommate was moved to a different room.Review of the Order Summary Report revealed no evidence of a physician order related to the discharge.There was no evidence that the resident received a 30 day discharge notice, and the discharge recapitulation summary was not completed.Interview on 03/31/2026 at 1:08 PM with Ombudsman BB revealed the resident wanted to return to the facility. She stated the resident was not given a 30 day notice, and the facility did not notify the ombudsman prior to the discharge. She stated the resident could have appealed with her assistance.Interview on 04/02/2026 at 11:05 AM with the Social Services Director revealed she sent a referral package to a (named) facility after speaking with corporate and the previous administrator. She stated the resident's family member had to be escorted out by law enforcement. She also stated the resident kept her television on all night and talked loudly on her phone using speaker mode. The resident was not given a 30 day discharge notice because she had found another facility, and the ombudsman was not notified. The resident was transferred out of the facility within 24 hours.

Based on record review, staff interviews, and review of the facility policy titled, RAI/Care Planning Management, the facility failed to ensure that two of three sampled residents(R) (R2 and R7), whose care plans indicated they wished to remain in the facility, had their expressed desires honored.Findings includeReview of the policy titled, RAI/Care Planning Management revised August 2017. A discharge plan will be included in the care plan at admission. Goals will be resident specific, measurable and realistic.1.Review of the admission Record revealed R2 was admitted to the facility with diagnoses including, but not limited to, hypertension, depression, diffuse traumatic brain injury with loss of consciousness, and traumatic ischemia of muscle.Review of the care plan revealed R2's plan was to remain a long term care resident. Interventions included encouraging and assisting the resident to participate in activities of choice, and for the Social Services Director to visit as needed.2. Review of the admission Record revealed R7 was admitted to the facility on [DATE] with diagnoses including, but not limited to, end stage renal disease on dialysis, paraplegia, hypertensive heart and chronic kidney disease, type 2 diabetes, hypertension, and seizures.Review of the care plan revealed the resident had voiced no desire to be discharged from long term care and required 24 hour care. The family was unable to provide care at that time. The care plan also directed staff to refer to Social Services if the resident voiced or demonstrated interest in seeking outside resources to live elsewhere.Interview on 04/02/2026 at 11:02 AM with the Licensed Practical Nurse (LPN) MDS Coordinator revealed that the Social Services Director (SSD) initiates the transfer/discharge process. The LPN stated she did not know why the required process was not followed for these residents.

Based on staff interview, record review, and review of the facility policy titled The Care Plan, the facility failed to implement the care plan interventions related to falls for one of five residents (R) (R12). This failure resulted in actual harm on 9/19/2025, when R12 had a fall from her bed, resulting in two fractured ribs, a hematoma to the right side of her head, and a laceration to her upper lip.Findings included:Review of the facility policy titled, The Care Plan, dated January 2025, under Standard: Care plans are to be accessible for clinical staff in order to facilitate care plan interventions or to update as indicated due to resident condition change.Record review for R12 revealed the resident was admitted to the facility with the diagnoses of, but not limited to, seizures, anxiety disorder, major depressive disorder, and generalized muscle weakness.Review of the residents' care plan indicated a focus of R12 was at risk for falls related to (r/t) history of falls, poor safety awareness, chairfast, totally dependent upon staff, restlessness and agitation, contracture of multiple muscle sites, muscle weakness, seizures, sacrococcygeal disorders, and spastic mobility. Goal: R12 will be free from fall-related injuries through nursing/therapy interventions by the next review. Target Date: 10/13/2025. She will have pain r/t fracture (fx) secondary to a fall, managed through the next review date. Interventions included: Bilateral Fall mat at bedside, Certified Nursing Assistant (CNA) to assure proper positioning in bed, utilizing appropriate wedges, and keep bed in lowest position.Review of the Post Fall Evaluation documentation located in the Electronic Health Record (EHR) under progress notes dated 9/19/2025 in the contributing factors section revealed Recent change in environment: Yes. Was fluid spilled on the floor: No. Clutter present on the floor: No. Floor mat was on the floor: Yes. Poor lighting in the area: No. The bed was at an improper height: Yes.An interview on 9/28/2025 at 8:15 am with the Director of Nursing (DON) revealed R12 had a fall on 9/19/2025 from the bed after the CNA moved the resident to a different room and did not ensure the resident's bed was in the lowest position, causing the resident to sustain a cut lip, hematoma, and fractured ribs. Continued interview also revealed that the nursing staff is expected to ensure that the residents' plan of care is followed at all times.

Based on staff interview and record review, the facility failed to ensure one of five residents (R) (R12) was free from falls with major injury. This failure resulted in actual harm on 9/19/2025 when R12 had a fall from her bed, resulting in two fractured ribs, a hematoma to the right side of her head, and a laceration to her upper lip. Findings included:Record review for R12 revealed the resident was admitted to the facility with the diagnoses of, but not limited to, seizures, anxiety disorder, major depressive disorder, and generalized muscle weakness. Review of the Quarterly Minimum Data Set, dated [DATE], Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score not assessed due to the resident rarely/never understood. Section GG (Functional Abilities) indicated the resident was dependent on staff for dressing, bathing, transfers, and toileting.A review of the residents' care plan indicated that R12 was at risk for falls r/t a history of falls, poor safety awareness. It was noted that R12 would be free from fall-related injuries through the nursing/therapy interventions by the next review. Interventions included, but were not limited to, keeping the bed in the lowest position.A review of the Post Fall Evaluation documentation located in the Electronic Health Record (EHR) under progress notes dated 9/19/2025 in the contributing factors section revealed: The bed was at an improper height: Yes.A review of the documentation of the fall incident that occurred on 9/19/2025 in the EHR under Progress Notes revealed 9/19/2025 15:43 Incident Note: This nurse was notified @ 1515 by a CNA walking by the room that the resident was on the floor. The resident was lying on the left side of her bed on the floor. The resident had a small laceration to her upper lip, a hematoma to the right side of her forehead, and redness to her right side of her abdomen. Resident unable to voice pain/description of fall. Upon head-to-toe assessment resident was placed back into bed with the bed positioned in the lowest position. Neuros were initiated @ time of fall. MD notified and ordered to send to ER for eval. 911 called @ 1519. {sic} 9/19/2025 21:54 Health Status Note: Note Text: returned to Facility via EMS. Right temple abrasion noted. 4th and 5th rib fx noted. Abrasion to the right side of lip noted. The hospital reports no bleeding in the brain. Respirations are even and non-labored. {sic}Review of R12's hospital records dated 9/19/2025 revealed under Emergency Department (ED) Course statement: Patient has a contusion to her right temporal region and right rib fractures X 2. CT brain and CT c spine show no acute process. X-ray of the right ribs shows minimally displaced fractures involving the right fourth and fifth ribs. {sic}An interview on 9/28/2025 at 8:15 am with the Director of Nursing (DON) revealed R12 had a fall on 9/19/2025 from the bed after the Certified Nurse Aide (CNA) moved the resident to a different room and did not ensure the resident's bed was in the lowest position, causing the resident to sustain a cut lip, hematoma, and fractured ribs. Continued interview also revealed that the nursing staff is expected to ensure that residents who are at risk for falls have all interventions in place and utilized at all times.

Based on observations, staff interviews, and review of the facility policy titled Medication Administration, the facility failed to ensure the disposal of expired and discharged medications in one of one drug storage rooms. Findings included:A review of the facility's policy titled Medication Administration, dated January 2025, documented that medication destruction is per pharmacy policy. The Consultant Pharmacist and the Director of Nursing (DON) follow the policy for destruction of medications. See Pharmacy Policy Manual.A review of the Pharmacy Policy Manual, with a revision date of 7/1/2024, revealed that the facility should destroy discontinued or outdated medications by one of three (3) methods:11.1 Prior to destruction, an authorized facility staff member should remove medications, including pills, capsules, liquids, creams, etc., from their dispensing containers and pour the medications into a container or plastic bag. An authorized facility staff member may add a substance that renders the medications unusable to the plastic container or bag.11.2 An authorized Facility staff member should place medication containers in a container or box. The facility staff member should then seal the box with strong tape and label the box as MEDICATION FOR DESTRUCTION. The container or box should be secured in a locked cabinet or room until it is disposed of or picked up by a licensed waste disposal company. If the facility chooses to dispose of the box by using a licensed waste disposal company. The facility should call the waste disposal company to pick up the waste and accept responsibility for the proper destruction by incineration.11.3 Facility-approved commercially available drug disposal kits.During an observation of the medication room on 9/27/2025 at 9:05 am, a large box was observed filled to the top with medication packs and vials. There was no lid on the box of medications, there was no description of what the medications were, and there was no quantity of medications in the box. During an interview on 9/27/2025 at 9:12 am, Registered Nurse (RN) AA stated that the box of medications in the medication room was discharged , and the expired medications were removed. She stated that she empties the box of medications in the medication room monthly by putting the medications into smaller boxes, and she then gives the smaller boxes to the DON. RN AA stated that she does not log or label what is in the small boxes. She stated that the DON gives the boxes of discharged and expired medications to the pharmacist when they come into the facility. RN AA stated that the pharmacist comes in monthly and takes the boxes and destroys the medicines, but she is not part of that process.During an interview on 9/27/2025 at 9:35 am, the DON stated that the pharmacist comes in and scans the medications and does a return slip. She stated that the pharmacist comes in and scans the discharged and expired medications, but she does not take them with her. She stated that someone else would come in within one to two weeks or sooner and pick the meds up. The DON stated that the medications in the box in the med room are not narcotics. She stated that she does not log the discharge or expired medications that are in the box. She stated that there is no account for what is in the box until the pharmacist comes in and scans the medications. She stated that the facility does not log discharged or expired medications anywhere. She stated that it sits in the box in the medication room until the pharmacist comes in monthly.During an interview on 9/28/2025 at 7:59 am, Licensed Practical Nurse (LPN) BB stated that when she has an expired or discontinued medication, she removes it from the medication cart and puts it in a box in the medication room. She stated that she does not log the medications anywhere; she just puts them in the box. LPN BB stated that the DON scans the medications, but she does not know when it is scanned.

Based on observations, staff interview, and review of facility documentation, the facility failed to ensure a safe/clean and comfortable environment by not initiating roof repairs required after known damage following most recent hurricane activity in 2024. The facility also failed to ensure air condition units in residents' rooms (2B and 3B)on one of three halls (200 Hall) were maintained to include cleaning and repair. Findings included:1. Review of the roof replacement proposal revealed estimate was prepared on 6/2/2025 for the facility to include the following: The labor, material, and equipment required to finish this job will be for the total of: 1)System Plus/2 year workmanship- $99,455.00, Silver Pledge/10 year workmanship -$102, 125.00, and Golden Pledge/25 year workmanship - $104,795.00.Observation on 9/26/2025 at 8:00 am revealed that the eaves and gutters can be seen hanging down from the roof in room [ROOM NUMBER] and room [ROOM NUMBER] on the A Hall through the resident's window.Observation on 9/27/2025 at 8:15 am in the courtyard outside of the 100 Hall revealed that the eaves and gutters were detached from the roof and hanging down over the window of room [ROOM NUMBER] in the 100 Hall. There were also gutters and eaves scattered around on the ground under the window into the shrubbery. There were gaps in the roof that allowed access to vermin. Interview on 9/27/2025 at 8:30 am with Licensed Practical Nurse (LPN) CC revealed that there is one room on the 100 Hall that leaks after it has been a hard rain, room [ROOM NUMBER] by the window. During the interview, it was disclosed that the area had been leaking for approximately two months, and maintenance had placed a piece of wood over the area; however, the area still leaks when it rains. Continued interview also revealed that the resident who was in that room by the window was moved to another room; however, there is still a resident in the room in bed A.An interview on 9/27/2025 at 9:00 am with the Maintenance Director revealed that his responsibilities included doing minor repairs within the facility, ensuring that there is no trash on the grounds around the facility, and that the dumpster area is clean. The grass is cut by a company that he could not recall the name of, and the gutters were to be cleaned by this company as well. Continued interview also revealed that the area on the roof by the 100 Hall was damaged in June 2025 or July 2025 after it had been raining for several days in a row. During the interview, the Maintenance Director indicated that corporate was aware of the damage and had been to the facility to assess, and an estimate had been sent for repairs. There was no indication that the staff member had knowledge of who or when the estimated damage had occurred. The staff member did state that there is one room that leaks when it rains, room [ROOM NUMBER] on the 100 hall, and a piece of plywood was put over the area inside the room to prevent the water from leaking into the room; however, it still leaks.An interview on 9/27/2025 at 10:12 am with the Administrator revealed that the damage to the roof happened after the last hurricane came through in November of 2024. The corporate office is aware of the damage, but since the air conditioning in the dining area had gone out, portable air conditioning had to be brought in. The company opted to fix the air conditioning first, and a check was issued for that, which should be replaced within the next couple of days. Continued interview also revealed that there was a quote obtained from two local companies on 6/2/2025, and there was no indication of when the roof would be repaired. The administrator stated he would contact the corporate office to see when the estimated time of repair will be completed.Follow-up Interview on 9/27/2025 at 3:00 pm with the Administrator revealed that the anticipated repair for the damage to the roof will be at the end of the current year 2025.2. A tour on 9/26/2025, at 8:00 am, revealed that two rooms in B Hall have air conditioning filters that were clogged with dust and had not been replaced (room [ROOM NUMBER]B and room [ROOM NUMBER]B).A record review revealed that the facility lacks a policy for environmental management. An interview on 9/27/2025, at 9:00 am, with the Maintenance Director revealed that his responsibilities included performing minor repairs within the facility. He confirmed that the air conditioning filters should be checked weekly by maintenance housekeeping. He stated that he will ensure regular monitoring of the filters, changing them when needed to ensure that staff check and change them as needed. An interview on 9/27/2025, at 9:05 am with the Director of Nursing (DON) revealed that maintenance is responsible for ensuring the air conditioning unit filters are monitored by both housekeeping and maintenance. DON confirmed that the filters will be changed immediately.

Based on observations, staff interviews, record review, and review of the facility policy titled Medication Administration, the facility failed to assess one of four sampled residents (R) (R50) for the ability to self-administer medications before leaving medications at the bedside. Findings included:A review of the facility's policy titled Medication Administration dated January 2025 revealed that there may be occasions where a resident has been assessed to safely self-administer medications. In this case, the licensed nurse will assist the resident in maintaining the medications in a secure area and will be available for resources if the resident has questions regarding medication dosage, side effects, or effectiveness. Self- administration of medications by a resident is assessed at each care plan review to ensure function is still appropriate. A review of the electronic medical record (EMR) revealed that R50 was admitted to the facility on [DATE] with diagnoses including, but not limited to, atherosclerotic heart disease of native artery without angina pectoris, chronic kidney disease, stage 3A, and generalized anxiety disorder.A review of R50's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed R50 was cognitively impaired with a Brief Interview for Mental Status (BIMS) score of five.A review of R50's Medication Administration Record (MAR) for September 2025 indicated the following order: Apply zinc barrier cream to bilateral buttocks once per shift - every shift for MASD prevention. There was no order for Equate nasal spray 1FL oz, and there was no order for Remedy Antifungal powder 3 ounce (oz). During an observation on 9/26/2025 at 8:00 am, R50 was observed in bed. On the left side of the resident's bedside table was a small white plastic basket. The following medications were observed in the basket: 1.) Equate nasal spray 1 FL oz, in which R50 stated that she uses the spray herself, and she sprays her nose sometimes every day, and sometimes now and then.2.) A bottle of Remedy Antifungal powder, 3 oz. R50 stated she put the powder under her stomach, and sometimes the aides put the powder under her stomach.3.) A 4-oz tube of Silicone Cream with zinc oxide. R50 stated that the aides put the cream on her when they changed her. An interview on 9/27/2025 at 10:57 am, Licensed Practical Nurse (LPN) BB confirmed the medications inside the white plastic basket on R50's bedside table. LPN BB stated that R50's family must have brought the nasal spray in because it was store-brand nasal spray, and it should not have been at the bedside. LPN BB stated that the zinc cream was signed off on the treatment cart, but she was not sure if the treatment nurse or the Certified Nursing Assistants (CNAs) put it on her. She stated that she was going to find out. LPN BB stated that the antifungal powder should be in a zip-lock bag, and it should be kept in the resident's drawer. LPN BB stated that the Director of Nursing (DON) told her to put the zinc cream on the treatment cart. A review of R50's medical record revealed there was no self-administration assessment completed, a Physician's Order, or care plan that would indicate the resident was able to self-administer the medications observed in her possession. During an interview on 9/28/2025 at 8:23 am, the treatment nurse revealed that she administers the zinc oxide cream for R50. She stated that after she applies the cream, she puts the cream in the treatment cart. The surveyor informed the treatment nurse that the zinc oxide cream was observed in R50 room inside a white plastic basket on her bedside table within her reach on 9/26/2025 and on 9/27/2025. The treatment nurse stated that she may have forgotten it and left it in her room.An interview on 9/28/2025 at 8:58 am, the DON stated that she was not aware that there were medications at R50's bedside. She stated that R50 has not been assessed for self-administration of medications. She stated that if a resident self-administers medications, there has to be an order, and the resident has to be assessed. She stated that no medication should be left at the bedside unless there is an order and the resident is assessed. DON stated that she expects that no medications should be left at the bedside unless there is an order and the resident has been assessed.

Based on resident and staff interviews and record review, the facility failed to exercise confidentiality related to the medical care for one of 42 sampled residents (R) (R64). Findings included:A record review of Residents' Rights revealed that the facility staff will treat all residents' information with confidentiality. Residents shall be treated with dignity and respect at all times.During an interview on 9/26/2025 at 8:00 am, R64 revealed that she made a complaint about Licensed Practical Nurse (LPN) DD exposing her medical care to her sister without her permission. Her nurse told her about her medical care against her wishes. When she found out about the situation, she called for the social worker to bring the Administrator and the Director of Nursing (DON) to her because she had a complaint about a nurse, LPN DD.During an interview on 9/27/2025 at 12:00 pm, the Social Worker revealed that R64 requested that she contact the Administrator and DON so that she could make a complaint about LPN DD. She did not reveal the issue to her.During an interview on 9/27/2025 at 12:15 pm, the DON revealed that she started working at the facility in July 2025, and she was instructed not to put LPN DD on the 200 hall with R64, but was not told why.During an interview on 9/27/2025 at 3:24 pm, the Administrator confirmed that he spoke with R64 after the Social Worker told him that the resident needed to speak with him and the DON. He stated that when he went to R64's room, she explained to him that she had not permitted LPN DD to disclose her medical care to her family, and the nurse spoke with the resident's family about her care when she left the facility to pick up some of the resident's supplies from her sister's house. The Administrator confirmed that the resident does not have a power of attorney or a representative. He stated she has a BIMS score of 14, and her information should not have been exposed to anyone without R64's consent. The Administrator noted that LPN DD was educated on the rights of residents and that LPN DD was no longer working in the 200 hall where the resident resides.

Based on observations, interviews, and review of the facility policy titled Restraint Policy, the facility failed to assess the use of a Geri chair as a potential restraint device for one of three sampled residents (R) (R49) reviewed for potential restraint use.Findings included:A review of the facility policy titled Restraint Policy, dated January 2025, revealed that the goal of this facility is to ensure that each resident attains and maintains his/her highest practical level of function and well-being in an environment that limits restraint use to circumstances in which the medical symptoms of the resident warrant the use of the least restrictive restraint. Physical Restraint options include but are not limited to: Wheelchair lap belts or buddies, Chairs that prevent rising, wedge cushions, and side rails. Physical restraints that may not be used in the facility include: Placing a resident so close to a wall that the resident is restricted from movement or rising for restraint purposes.A review of the electronic medical record (EMR) revealed that R49 was admitted to the facility with the diagnoses of, but not limited to, Alzheimer's disease, schizoaffective disorder, and dementia with behavioral disturbance.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R49 presented with no Brief Interview for Mental Status (BIMS) score, which indicated the resident was rarely/never understood, and the interview was not conducted; that R49 had no impairment in Range of Motion (ROM); and that R49 was independent in moving from side to side, transfers, and walking 150 feet once standing in the room, corridor, and similar places. A review of Section P (Restraints and Alarms) indicated that the resident did not utilize a chair that prevented rising.A review of the care plan for R49 indicated a focus of resident was at risk for falls related to (r/t) confusion, gait/balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, vision/hearing problems. The goal was documented that R49 will not sustain serious injury through the review date, with a target date of 12/11/2025. Interventions included, but were not limited to, ensuring that the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair (w/c). There was no indication of the resident using a Geri-chair for mobility.During an observation on 9/26/2025 at 8:30 am, R49 was in the day room on the 100 Hall, sitting in a reclined Geri-chair. The resident was attempting to get out of the chair and was unable to ambulate due to the chair being reclined and locked.During an observation on 9/26/2025 at 11:30 am, R49 was in the day room on the 100 Hall, sitting in a reclined Geri-chair. The resident was attempting to get out of the chair and was unable to ambulate due to the chair being reclined and locked.During an observation on 9/27/2025 from 8:00 am to 11:00 am, R49 was noted sitting at the dining room table against the wall in the day room of the 100 hall. The resident was in a Geri-chair that was positioned in the sitting position, and the dining table was pushed directly in front of the resident. The resident was observed attempting to rise from the chair and was unable to due to the positioning of the chair between the table and the wall.During an observation on 9/27/2025 at 3:15 pm, R49 was sitting up in the Geri-chair with the dining room table in front of her, and the wall was noted to the other side of the resident. The position of the Geri-chair prevented the resident from ambulating freely.During an interview on 9/27/2025 at 3:30 pm, Licensed Practical Nurse (LPN) CC revealed that R49 is currently using the Geri-chair due to the resident having an unsteady gait and having had several falls. Continued interview also revealed that R49 was recently admitted to hospice services, who ordered the Geri-chair for the resident.During an interview on 9/28/2025 at 8:20 am, the Director of Nursing (DON) revealed that residents in Geri-chairs should not be reclined back so that their movement is restricted. Continued interview revealed that the expectation is for staff to ensure residents are in the least restrictive and safest environment.

Based on observations and staff interviews, the facility failed to ensure that privacy curtains provided full visual privacy in four of 20 sampled resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]).Findings included:During an observation on Hall 200 on 9/26/2025 at 9:02 am and 9/27/2025 at 9:22 am, the following was observed: room [ROOM NUMBER]: Bed B was missing privacy curtains, and Bed A's privacy curtain was jammed.room [ROOM NUMBER]: Bed B was missing privacy curtains, and Bed A's privacy curtain was jammed.room [ROOM NUMBER]: Bed B was missing privacy curtains. room [ROOM NUMBER]: Bed B was missing privacy curtains. The environmental tour began on 9/27/2025 at 9:32 am with the Housekeeping Director and the Regional Nurse. This observation revealed resident privacy curtains with a width space/gap which did not ensure full visual privacy coverage during patient care, including Rooms 3, room [ROOM NUMBER], and room [ROOM NUMBER]. During an interview on 9/27/2025 at 9:23 am, the Housekeeper Supervisor reported that he has been employed with the facility since 9/15/2025. He confirmed the missing curtains and the curtains that were jammed. He confirmed that prior to the survey, the privacy curtains were not addressed by him. During an interview on 9/27/2025 at 11:02 am, the Director of Nursing (DON) reported that her expectation is for all staff to check privacy curtains and ensure curtains are in place. She reported that this could be a dignity issue. DON reported being unaware of the missing privacy curtains and curtains being jammed due to poorly damaged hooks.Policy requested but not provided during the survey.

Based on record review and staff interview, the facility failed to ensure that the person in the role of the Infection Preventionist (IP) completed specialized training in Infection Prevention and Control. This failure placed all residents at risk for the potential transmission of infections and communicable diseases. The facility had a census of 68 residents. Findings include: Review of the job description for the Infection Control Preventionist dated 2020, noted a requirement of certification in Infection Control Preventionist training. During an interview with Unit Manager AA on 7/11/2024 at 11:35 am, she stated she started working at the facility about a week ago as the Unit Manager and was filling in as the IP until the position was filled. During an interview with the Administrator on 7/11/2024 at 1:25 pm, he stated RN AA and the Director of Nursing currently do not have IP certification, but they were enrolled in the IP certification course to be done online.

Based on observation, record review and staff interview, the facility failed to ensure enhanced barrier precautions (EBP) were implemented for three residents (R) (R2, R3, and R4) who had pressure ulcers from a total sample of seven residents. Findings include: Review of an undated document titled Implementation of Personal Protective Equipment (PPE) Use In Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) revealed EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of PPE and the availability of PPE and hand hygiene supplies at the point of care. EBP expands the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. Examples of high-contact resident care activities requiring gown and glove use for EBPs include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care- any skin opening requiring a dressing. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) . Make PPE, including gowns and gloves, available immediately outside of the resident room .Ensure access to alcohol-based hand rub in every resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room .Provide education to residents and visitors. During observations of pressure ulcer treatment for R2, R3 and R4 on 7/10/2024 at 11:10 am, 7/11/2024 at 11:10 am and on 7/11/2024 at 10:55 am the wound care nurse was not wearing a gown. There was also no signage on these resident's doors to indicate EBPs were to be implemented for these residents. During an interview with the Wound Nurse on 7/11/2024 at 11:10 am, she stated she had not been instructed to use EBPs. She stated they do that when a resident has something such as ESBL (extended-spectrum beta lactamases). During an interview with Registered Nurse (RN) AA on 7/11/2024 at 11:35 am, she stated they received an email about a week ago regarding EBPs and they were working on implementing that now and educating the staff.

Based on staff interview, record review, and review of the Arbitration Agreement, the facility failed to ensure that the Arbitration Agreement presented to Residents (Rs) and Resident Representatives (RRs) during admission included a clause that a mutually convenient venue for the Arbitration would be selected. This failure affected all 73 residents of the facility who had signed the Arbitration Agreement and any future residents who might sign the agreement. Findings include: Review of the facility's Arbitration Agreement, undated, provided by the facility, revealed the agreement did not provide for the selection of a venue that is convenient to both parties. During an interview on 2/29/2024 at 1:15 PM, the Administrator confirmed he had reviewed the Arbitration Agreement, and it did not include the clause that a mutually convenient venue for the arbitration would be selected for both parties. The Administrator stated a sister facility was cited for this deficiency last week, so the agreement was updated and emailed to him today. During an interview on 2/29/2024 at 3:30 PM, the Business Director confirmed all 73 Rs and/or RRs had signed an arbitration agreement with the facility.

Based on staff interview, record review and review of the facility policy titled, Behavior Management Standard, the facility failed to ensure the resident, his or her family, and/or the resident representative (RR) was provided information related to the risks and benefits for psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for four of five residents reviewed for unnecessary medications (Resident (R) 10, R53, R59, and R19). Findings include: Review of the facility's policy titled Behavior Management Standard, dated October 2023, provided by the facility, revealed .Guidelines The Interdisciplinary Team [IDT], the resident and the resident's responsible party will be involved in the assessment and decision to include psychoactive medications into the resident plan of core. The IDT will also be responsible to ensure a comprehensive assessment and review of the resident has occurred before psychoactive medications are introduced. Residents in specialty units will have behavior intervention plans to improve life skills and quality of life. The IDT will ensure the resident or the resident's responsible party will be apprised of the risks and benefits of the medication being considered 1.Review of R10's Admission Record, undated, located in the Electronic Medical Record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and anxiety disorder. Review of R10's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/29/2024, located in the EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident was moderately impaired in cognition. The MDS also indicated that R10 received an antidepressant medication during the seven days of the look back period. Review of R10's Physician's Orders located in the EMR under the Orders tab, revealed an order for escitalopram oxalate (an antidepressant) oral tablet 20 milligrams (MG) give one tablet by mouth one time a day (dated 1/06/2024), Remeron (an antidepressant) oral tablet 15 MG give one tablet by mouth at bedtime (dated 1/13/2024), sertraline (an antidepressant) tablet 50 MG give one tablet by mouth one time a day (dated 2/29/2024) and lorazepam (an antianxiety medication) oral tablet 0.5 MG give 0.5 tablet by mount two times a day (dated 2/28/2024). Review of the R10's EMR revealed there was no documented evidence that the risks and benefits for the above ordered medications were provided to R10 or his RR. 2. Review of R53's Admission Record, undated, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with multiple diagnoses of depression, anxiety disorder, and bipolar disorder. Review of R53's quarterly MDS with an ARD of 7/05/2023, located in the EMR under the MDS tab, revealed a BIMS of 12 out of 15 which indicated he was moderately cognitively impaired. The MDS revealed R53 exhibited verbal behaviors directed toward others and other behavioral symptoms not directed toward others one to three days during the look back period. R53 also rejected evaluation or care one to three days during the look back period. R53 received antidepressants during the seven days of the look back period. Review of R53's Physician's Orders, dated 2/16/2024, located in the EMR under the Orders tab, revealed an order for sertraline tablet 25 MG give one tablet by mouth one time a day. Review of the R53's EMR revealed there was no documented evidence that the risks and benefits for the antidepressant medication was provided to R53 or his RR. 3. Review of R59's Admission Record, undated, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included major depressive disorder and generalized anxiety disorder. Review of R59's quarterly MDS, with an ARD of 2/29/2024, located in the EMR under the MDS tab, revealed the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated that R59 received an antidepressant during the seven days of the look back period. Review of R59's Physician's Orders, dated 11/18/2023, located in the EMR under the Orders tab, revealed an order for escitalopram oxalate oral tablet 20 MG give one tablet by mouth one time a day. Review of the R59's EMR revealed there was no documented evidence that the risks and benefits for the antidepressant medication was provided to R59 or her RR. During an interview on 2/29/2024 at 9:02 AM, the Unit Manager (UM) acknowledged the admission nurse would explain the risks and benefits of the antipsychotic medications to the resident and RR and would have them sign the psychoactive medication informed consent form for the ordered antipsychotic medications but not for the antianxiety or the antidepressant medications. During an interview on 2/29/2024 at 9:06 AM, the Director of Nursing (DON) stated the nurses should get consents for all psychoactive medications, which included antidepressants, antipsychotics, and antianxiety medications, so the family and resident know the risks and benefits of taking the medications. 20243 4. Review of R19's Face Sheet found in R19's EMR under the Admission tab revealed R19 was admitted to the facility on [DATE] with diagnoses of major depressive disorder and generalized anxiety disorder. Review of R19's Quarterly MDS with an ARD of 1/05/2024, found in R19's EMR under the MDS tab revealed the resident had a BIMS score of 15 out of 15 which indicated the resident was cognitively intact. The MDS also indicated that R19 received an antidepressant and antianxiety medication for seven days of the look back period. Review of R19's Physician's Order found in R19's EMR under the Orders tab, dated 11/06/2023 revealed an order for buspirone HCL (an antianxiety) 7.5 milligrams (mg) oral three times a day. An order dated 10/19/2023 for mirtazapine (an antidepressant) 7.5 mg oral at bedtime and, an order dated 2/28/2024 revealed an order for sertraline HCL (an antidepressant) 75 mg oral at bedtime. There was no documented evidence that the facility had provided R19 information regarding the relative benefits and risks of the antidepressant, or the antianxiety medication ordered.

Based on staff interviews, and record review, the facility failed to ensure that three Resident (R) 27, R16 and R19) of 24 sampled residents and/or their representatives were informed and provided written information to formulate an advanced directive. Findings include: 1. Review of R27's Face Sheet found in R27's Electronic Medical Record (EMR) under the Admission tab revealed R27 was admitted to the facility on [DATE]. Further review of the Face Sheet revealed the resident was listed as a Full Code. There was no evidence in the EMR that the resident had been provided information regarding advance directives or had the opportunity to formulate any. 2.Review of R16's Face Sheet found in R16's EMR under the Admission tab revealed R16 was admitted to the facility on [DATE]. Further review of the Face Sheet revealed the resident was listed a Do not Resuscitate (DNR). There was no evidence in the EMR that the resident had been provided information regarding advance directives or had the opportunity to formulate any. 3.Review of R19's Face Sheet: found in R19's EMR under the Admission tab revealed R19 was admitted to the facility on [DATE]. Further review of the Face Sheet revealed the resident was a Full Code. During an interview on 2/29/2024 at 9:20 AM the Admissions employee stated that the facility did not have documentation to support that the facility had informed or given R27, R16 and R19 an opportunity to formulate an advance directive. During an interview on 2/29/2024 at 11:15 AM the Administrator stated that his expectations going forward would be to develop a new policy for advanced directives utilizing corporate assistance and the state of Georgia guidelines. The Administrator stated that there needed to be form for the resident to acknowledge receipt of the information and indicate that they have an advanced directive, or they want an advanced directive, or they need assistance to formulate an advanced directive including a place for the resident's signature.

Based on observation, resident interview, staff interview, record review, and review of the facility policy titled, Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of two residents reviewed for abuse (Resident (R) 41). Findings include: Review of the facility's policy titled Freedom of Abuse, Neglect and Exploitation; Abuse Prevention: Fast Alerts, revised January 2019, revealed . It is the policy of this facility to take all steps reasonable and necessary to protect the residents from harm at all times, including protection from any type of abuse listed from other residents. Procedures: 1. If a resident-to-resident altercation occurs, staff should intervene immediately. Separate the residents and take them to areas away from each other until the situation has diffused. 1:1 [one to one] supervision may be needed if resident behaviors are harmful . 3. If the resident(s) has been injured, provide immediate first aid. If necessary, pursue physician's orders and send the resident to the hospital. 4. If the resident(s) is cognitively alert, counsel the resident on proper behavior. 5. Notify the Director of Nursing and the Administrator immediately. Notify the physician and family/guardian. Notify the Regional Nurse Consultant for guidance Review of R41's Admission Record, undated, located in the electronic medical record (EMR) under the Profile tab, revealed the resident was admitted to the facility on [DATE] with diagnoses that included unspecified mood (affective) disorder, Alzheimer's disease, and cognitive communication deficit. Review of R41's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 7/22/2023, located in the EMR under the MDS tab, revealed R41 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated the resident was moderately cognitively impaired. The MDS revealed R41 did not exhibit any behaviors during the look back period. R41 was administered antipsychotics during the last seven days. R41 still resided in the facility. Review of R41's Care Plan, dated 8/02/2023, located in the EMR under the Care Plan tab revealed R41 received physical aggression and was involved in a resident-to-resident altercation and appeared to be the victim on 8/02/2023. The Care Plan also revealed the interventions as 15-minute checks until aggressor leaves the facility (discontinued 8/02/2023), notify the Medical Director and family as needed, observe resident for injury, refer to mental health provider as needed, report to appropriate agencies, residents separated, social services director to visit as needed, pain and skin assessment completed, and safety/comfort maintained. Review of R53's Admission Record, undated, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] with multiple diagnoses of depression, anxiety disorder, and bipolar disorder. Review of R53's quarterly MDS with an ARD of 7/05/2023, located in the EMR under the MDS tab, revealed a BIMS of 12 out of 15 which indicated he was moderately cognitively impaired. The MDS revealed R53 exhibited verbal behaviors directed toward others and other behavioral symptoms not directed toward others one to three days during the look back period. R53 also rejected evaluation or care one to three days during the look back period. R53 received seven antipsychotics, and antidepressants during the look back period. Review of R53's Nursing Progress Note, dated 8/02/2023 at 4:03 PM, located in the EMR under the Prog Note tab, revealed This writer notified by nurse on hall r/t [related to] altercation between residents. This writer interviewed resident r/t incident. Resident reports he was moving items that were not his, that belonged to roommate to [sic] the second drawer. When he was approached by roommate who was standing to [sic] close to him, and hovering. Resident then states he punched him in the mouth knocking him to the floor. He then kicked him while he was on the floor. He said that when the other resident attempted to get up, he tried to knock him down again, and he was grabbed in the arms. This writer assisted nurse on hall to complete skin assessment on resident. Resident noted to have open area/scratches to right shin, right thumb, left inner wrist, and left inner elbow. Wound care nurse notified to complete tx [treatment]. All appropriate parties were notified. Residents are separated and on 15 min [minute] checks until seen by [behavioral health provider] tomorrow. New order form [behavioral health provider] to obtain UA [urinalysis] and send referral to [behavioral health unit]. Review of R53's Nursing Progress Note, dated 8/02/2023 at 7:02 PM, revealed [Behavioral health unit] contacted for bed availability. Referral sent to [behavioral health unit] for acceptance . 911 called for EMS transport at 7:10 PM . Family and MD [physician] aware . Resident left facility at 7:30 PM via stretcher without incident. Review of R53's Census located in the EMR under the Census tab, revealed R53 resided on the 100 hall (secure unit) in room A 11-C on 8/02/2023 then returned to the 100 hall in room A 2-B on 8/09/2023. Review of R53's Physician's Orders, dated 8/09/2023, revealed an order for Quetiapine Fumarate [an antipsychotic] Oral Tablet 200 MG [milligrams] give 200 mg by mouth at bedtime related to bipolar disorder. Review of R53's Care Plan, dated 8/02/2023, indicated R53 has physically aggressive behaviors related to depression and poor impulse control with interventions of 8/02/2023 residents separated, notify physician and family as needed, one on one observation until sent out, refer to [behavioral health unit] as indicated, and sent out on 8/02/2023. Review of a Facility Reported Incident (FRI), dated 8/02/2023, provided by the facility, revealed that, . CNAs were alerted to commotion within these residents room upon a investigation discovered that [R53] and [R41] were face to face with [R53's] hand drawn back in a fist. Residents were immediately separated and placed on one-to-one observation period [15-minute checks] nursing staff and supervision staff were immediately notified. Upon further investigation it was revealed that [R53] had punched [R41] in the nose because [R41] was hovering over him while he was in his dresser drawer, once [R41] fell to the floor [R41] continued to attempt to kick [R41] in the abdomen before [R41] got up. Skin assessments were conducted for both residents and revealed that both residents had minor scratches however no other injuries occurred. No witnesses to the incident, however when both residents were asked what occurred their stories were cohesive. When asked why, [R53] stated that he just punched [R41] due to him hovering over him. [R41] stated he just walked over to [R53] while he was in his dresser and was punched in the nose and then fell to the floor. MD & [and] [behavioral health provider] immediately notified regarding incident [sic]. [behavioral health provider] completed follow-up with [R41] post incident, [R53] was already discharged to behavioral at this time. Abuse and De-escalation of resident behaviors educations provided to all staff. Police notified. Conclusion of investigation: The allegation of resident-to-resident abuse is substantiated as evident that [R53] did assault [R41]. [R53] remains in the senior behavioral unit at this time for stabilization with no estimated discharge date back to facility, as [R53] is still getting medications adjusted. SSD [Social Services Director] & [behavior health provider] to continue to follow up with [R41] for ongoing Wellness. Action Plan To Address: RP [Responsible Party], MD, [behavioral health provider], Police notifications, [behavioral health unit] admission for aggressor, 1:1 until aggressor discharged to [behavioral health unit], [behavioral health provider] followup, SSD follow-up, Abuse and De-escalation of resident behaviors education, Care Plans/Kardex Updated. During an interview on 2/26/2024 at 3:59 PM, R53 stated he hit a resident in the face last year but was not sure why and did not know the resident's name. Observation on 2/27/2024 at 12:29 PM revealed R41 had a white mesh STOP sign across the doorway held by Velcro and the resident was sitting on the side of his bed. During an interview with R41 at this time, R41 stated a male resident hit him on his head last year and he did not know why. R41 indicated the male resident had not bothered him since then and he was not sure if he had sustained any injuries. During an interview on 2/27/2024 at 12:38 PM, the Unit Manager (UM) confirmed that a nursing assistant reported to her that R53 hit R41 in their shared room on 8/02/2023. The UM stated R41 had moved things out of R53's dresser and R53 was putting them back in the drawer while R41 was hovering over him. R53 told him that he felt threatened, so he hit him in the face, and he fell to the floor. R41 had a scrape on his knee and cut on the left side of his lip. R53 was provided 15-minute checks by staff on 8/02/2023 from 3:15 PM until 7:15 PM then he was sent out to the hospital on 8/02/2023 at 7:20 PM. The UM indicated that R53 had not been in further altercations with R41 or any other residents since readmission to the facility on [DATE].

Based on staff interview and record review, the facility failed to develop a comprehensive care plan directing measurable goals and interventions for two of 24 residents (Resident (R) 9 and R42) reviewed for care planning. This failure placed residents at risk for unmet care needs and the inability to meet their maximum practicable level of functioning. Findings include: 1. Review of R42's undated Admission Record located in the Profile tab of the electronic medical record (EMR), revealed R42 was admitted to the facility on [DATE]. R42's diagnoses included seizures, chronic obstructive pulmonary disease (COPD), chronic kidney disease, acute and chronic respiratory failure, and anxiety disorder. Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/12/2024, located in R42's EMR under the MDS tab, indicated R42 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated R42 was moderately cognitive impaired. Review of the Smoking and Safety form dated 1/10/2024 and located in R 42's EMR under the Assessments tab, indicated R42 dipped tobacco. R42 was not deemed to have any concerns related to safety such as poor vision, balance problems while sitting/standing, or falling asleep easily during tasks. Review of R42's Comprehensive Care Plan, located in the EMR under the Care Plan tab, last revised 2/08/2024, revealed no focused area, measurable goals, or interventions addressing tobacco use. During an interview on 2/28/2024 at 1:24 PM, Licensed Practical Nurse (LPN) 4 stated they treat those residents who used chewing tobacco as smokers, so those residents also attended smoke breaks with typical smokers. The facility maintained the tobacco for the residents. During an interview on 2/27/2024 at 12:20 PM, the Director of Nursing (DON) reviewed R42's Smoking and Safety evaluation, dated 01/10/24, and confirmed R42 was noted as a tobacco user. The DON reviewed R42's Care Plan, last revised 2/08/2024, and confirmed it did not address tobacco use. The DON stated R42 should have care-planned interventions for tobacco use in the formal care plan. During an interview on 2/28/2024 at 1:12 PM, the Administrator stated R42's tobacco use should be addressed in the formal Care Plan. 36246 2. Review of an Admission Record, found in R9's EMR under the Profile tab indicated R9 was admitted to the facility on [DATE]. The Admission Record indicated that as of 10/01/2015, R9's diagnoses included other psychotic disorder not due to a substance or known physiological condition. Review of the quarterly MDS with an ARD of 1/03/2024, in R9's EMR, under Behaviors, indicated R9 exhibited no hallucinations, delusions, or behaviors during the 7-day assessment period. The MDS, under Cognitive Patterns, indicated R9 had short- and long-term memory deficits and was severely impaired for decision making. The MDS under Active Diagnosis indicated R9 had a diagnosis of psychotic disorder and under Medications, indicated R9 received no antipsychotic medications. Review of the Clinical Physician Orders, in R9's EMR, dated February 2024 indicated that R9 was receiving services from a Psychiatric provider. Review of Physician Orders, dated 3/30/2021, indicated the following behaviors were being monitored: depression, itching, picking at skin, restlessness, agitation, hitting, biting, kicking, spitting, cursing, racial slurs, hallucinations, psychosis, aggression, and refusing care. Review of R9's Care Plan located in the Care Plan tab of the EMR, did not indicate that a Care Plan was developed to address the new diagnosis, behavioral symptoms, or any necessary interventions. During an interview with the DON on 2/29/2024 at 9:30 AM, the DON reviewed R9's Care Plan and agreed it did not address the new diagnosis of psychotic disorder.

Based on resident interviews, staff interviews, record review, and review of the facility policy titled, Trauma Informed Care the facility failed to ensure that one resident (Resident (R) 19) of one reviewed for trauma received trauma-informed care. The facility failed to ensure a behavioral health consult occurred after the resident triggered 10 of 10 indicators on a trauma screen conducted by the facility. Findings include: Review of the facility policy titled Trauma Informed Care dated October 2023 revealed, When a resident verbalizes trauma or during an interview, or documented history trauma is identified, the Trauma Screening Tool should be conducted with the resident. lf determined that trauma has occurred and the resident is in need of additional support and services, psychiatric services is notified for a consultation and treatment plan if indicated. Review of R19's Face Sheet found in R19's Electronic Medical Record (EMR) under the Admission tab revealed R19 was admitted to the facility on [DATE] with diagnoses of major depressive disorder, bipolar disorder, and generalized anxiety disorder. Review of R19's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/05/2024, found in R19's EMR under the MDS tab revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicted the resident was cognitively intact. Review of an undated Trauma Screening Questionnaire located in R19's EMR revealed the following 10 questions: Have you recently experienced any of the following, 1. Resident was experiencing : upsetting thoughts or memories, 2. Upsetting dreams about the event, 3. Acting or feeling as though the event were happening again, 4. Feeling upset by reminders of the event, 5. Bodily reactions, 6. Difficulty falling or staying asleep, 7. Irritability or outbursts of anger, 8. Difficulty concentrating, 9. Heightened awareness of potential dangers to yourself and others, 10. Feeling jumpy or being startled by something unexpected. R19 indicated yes to all 10 questions. There was a handwritten note on form that revealed, Behavioral Health seeing R19 today. During an interview on 2/26/2024 at 11:50 AM R19 stated that she had been sexually assaulted in her younger life and currently is experiencing nightmares and difficulty sleeping. R19 stated that she had spoken to the Social Service Director (SSD) in the past, but nothing had happened since that conversation. R19 stated she takes antidepressants, antianxiety medication, and medication to help her sleep; however, the medications do not stop the nightmares. R19 stated that she would like to speak to someone who could help her. During an interview on 2/27/2024 at 3:05 PM with the Administrator and the SSD, the SSD stated that she had spoken to R19 and made a referral to the facility's behavioral health psychiatric group. The SSD stated a notation had been made on the trauma screening form. The Administrator stated that there had been a change in the assigned behavioral/psychiatric representative to the facility and wondered if that was where the ball was dropped. In a follow up interview on 2/29/2024 at 10:00 AM the SSD stated that the undated trauma screening for R19 occurred on 10/10/2023 and was uploaded into the EMR on that date. The SSD stated that a call was made to the behavioral health group on 10/10/2023, but a progress note was not written. The SSD could not provide any documentation to show R19 had ever been seen by the behavior health group. In an interview on 2/29/2024 at 10:45 AM the Administrator stated that his expectations going forward would be that trauma screening results will be reported to the Director of Nursing (DON), Medical Director and himself.

Based on staff interview, and record review, the facility failed to maintain an accurate medical record for one of 29 residents (Resident (R)38). Specifically, R38's code status was not accurately documented throughout the electronic medical record (EMR). The failure to document a resident's code status accurately in the EMR had the potential to result in a resident not receiving cardiopulmonary resuscitation (CPR) or receiving CPR when they should not, according to their documented wishes. Findings include: Review of the Admission Record in R38's EMR indicated R38 was admitted to the facility on [DATE] with re-admission on [DATE]. R38's diagnoses included adult failure to thrive and malignant neoplasm (cancer) of the prostate. Review of the Admission Record, under other information indicated R38's code status was listed as Full Code (R38 would receive CPR in the event of a cardiac arrest). At the bottom of the Admission Record, under Advance Directive for R38, documentation indicated DNR (Do Not Resuscitate), allow natural death. Review of the POLST (Physician Orders for Life Sustaining Treatment), dated [DATE], indicated R38 chose to be a Full Code. Review of the updated POLST, dated [DATE], indicated R38 chose to have a natural death with no CPR given (DNR). Review of R38's Resident Profile section of the EMR indicated R38's code status was listed as Full Code. Review of the Medication Administration Record, dated February 2024 indicated R38's code status was listed as DNR. During an interview with the Social Service Director (SSD) on [DATE] at 9:41 AM, the SSD reviewed R38's EMR and confirmed that the code status for R38 did not match R38's Admission Record and Profile. During an interview with Licensed Practical Nurse (LPN) 1 on [DATE] at 9:00 AM, LPN 1 stated that if she were looking for the code status of a resident, she would check the POLST, the computer Medication Administration Record (MAR), or the Admission Record. During an interview with the Director of Nursing (DON) on [DATE] at 9:20 AM, the DON said she would expect the nurses would check a resident's Care Profile within the Dashboard of the EMR if they needed to find a resident's code status. The DON reviewed the sources for R38 and verified that not all the sources of the information for R 38's code status were correct. The DON stated it was her expectation was that the code status documentation in a resident record was accurate and consistent, according to resident wishes.

Based on record reviews, staff interviews, and review of the facility policy titled, RAI/Care Planning Management, the facility failed to implement the plan of care for baths and/or personal hygiene for four of six residents (R) (R#1, R#2, R#3, and R#4). The deficient practice had the potential to affect the quality of care provided for each dependent resident. Findings include: Review of the RAI/Care Planning Management revised August 2021under Standard. It is the practice of this facility to conduct a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity. Objective. 1. To identify resident's individual needs and care requirements. 1.Review of the Admission Record revealed that R#1 was admitted to the facility with diagnoses that include but not limited to morbid (severe) obesity, hypothyroidism, hypertension, schizoaffective disorder, and anxiety disorder. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed in Section G (Functional Status) that R#1 is total dependent on staff for personal hygiene and baths. Review of the care plan no date revealed R#1 has limited physical mobility and is at risk for a decline in ADLs related to obesity and non-weight bearing. Resident has limited range of motion bilateral upper extremity. Resident is dependent for showers/baths and requires a geriatric shower chair for bathing, Review of the bath schedule revealed that R#1 shower days were Monday, Wednesday, and Friday on the night shift. Review of the MDS Kardex report dated 11/16/2022 revealed Resident #1 is total dependent for baths with a two-person physical assist. And for personal hygiene, she is total dependent with one-person physical assist. Review of the Documentation Survey Report Dec-22 (December 1,2022 through December 31,2022) revealed no evidence that a bath was given. On 12/12/2022, 12/19/2022 and 12/26/2022 were coded 97 indicating not applicable. The other dates for December 2022 were marked with a X and there were no staff initials to indicate baths were given or refused. The personal hygiene section revealed no evidence that personal hygiene was performed for 12/5/2022, 12/6/2022, 12/14/2022, 12/23/2022, and 12/25/2022 on 7a-7p shift and 12/25/2022. 12/27/2022 for 7p-7a shift as indicated by a blank box. The monitor section-rejection of care revealed no evidence of refusal of care for 12/5/2022, 12/6/2022, 12/14/2022, 12/23/2022, and 12/25/2022 on 7a-7p shift and for 12/25/2023, and 12/27/2022 on 7p-7a shift as indicated by a blank box. Review of the documentation Survey Report Jan-23 (January 1, 2022, through January 31, 2022) revealed one bath was given on 1/16/2023. On 1/23/2023 coded 97 to indicate not applicable. The personal hygiene section revealed no evidence that personal hygiene was performed for 7a-7p shift on 1/1/2023, 1/2/2023, 1/6/2023, 1/9/2023, 1/12/2023, 1/21/2023, 1/22/2023 and for 7p-7a on 1/19/2023. The monitor- rejection of care revealed no evidence of rejection or refusal of care for 7a-7p shift on 1/1/2023, 1/2/2023, 1/6/2023, 1/9/2023, 1/12/2023, 1/21/2023, 1/22/2023 and for 7p-7a on 1/19/2023. 2. Admission Record revealed R#2 was admitted to the facility with diagnoses that include but not limited to Alzheimer's disease, schizophrenia, dementia, delusional disorders, vascular dementia with behaviors, psychotic disorder, bipolar disorder, and hallucinations. Review of the bath schedule revealed that R#2 shower days were Tuesday, Thursday, and Saturday on the night shift. Review of the MDS Quarterly assessment dated [DATE] revealed Section G (Functional Status) that resident is total dependent for baths and personal hygiene. He requires a two-person assist for baths, and one-person assist for personal hygiene. Review of the care plan no date revealed resident requires assistances with ADLs related to tremors and altered mental status. The resident can perform personal hygiene/oral care with limited assistance of supervision and cueing. Review of the bedside Kardex (CNAs) report dated 1/24/2023 revealed Bathing/Showering and Personal Hygiene/Oral Care that the resident can provide his own care with limited assistance of supervision and cueing. Staff is to encourage resident to change clothes as warranted related to excessive drooling. Review of the Documentation Survey Report Dec-22 (December 1, 2022, through December 31, 2022) revealed evidence that one bath was given on 12/1/2022 on 7p-7a shift. Review of the Documentation Survey Report Jan-23 (January 1/2023 through January 31,2023) revealed no evidence that the scheduled bath was given on 7p-7a shift for 1/3/2023 1/5/2023, 1/7/2023, 1/10/2023,1/12/2023, 1/14/2023, 1/17/2023, 1/19/2023, and 1/21/2023 as indicate of blank boxes. The monitor- rejection of care revealed no evidence that the resident refused on 1/3/2023, 1/5/2023, 1/12/2023, 1/17/2023, 1/19/2023 and 1/21/2023 for the 7p-7a shift. 3. Review of the Admission Record revealed R #3 was admitted to the facility with the following diagnoses that include but not limited to chronic obstructive pulmonary disease, convulsions, cardiac pacemaker, major depressive disorder, gastro-esophageal reflux disease, and colostomy. Review of the bath schedule revealed that R#3 shower days were Tuesday, Thursday, and Saturday on the day shift. Review of the MDS Annual assessment dated [DATE] revealed Section G (Functional Status) that resident requires supervision and oversight. Review of the care plan no date revealed resident has self-care deficit related to needs assist with bathing, grooming and personal hygiene related to weakness, inattention and easily distracted. Resident has interventions to be bath per bath schedule via staff and to shave daily and as needed. Review of the bedside Kardex report dated 1/24/2023 revealed that the ADLs/Bathing/Personal hygiene/oral care section that R #3 was to have assistance with oral care as need. And to attempt to educate resident in proper oral hygiene technique. The MDS Kardex report dated 1/24/2023 revealed that resident requires supervision for bathing and personal hygiene. Review of the progress noted dated 12 /25/2022 through 1/18/2023 revealed that Resident #3 did not have any refusal of baths or personal hygiene. Review of the Documentation Survey Report Dec-22 (December 1,2022 through December 31,2022) revealed no evidence that a bath was given on 12/3/2022, 12/6/2022, 12/8/2022, 12/10/2022, 12/13/2022, 12/15/2022, 12/17/2022, 12/20/2022 12/22/2022, 12/24/2022, 12/27/2022, 12/29/2022, and 12/31/2022. There was one bath noted on 12/12/2022. The personal hygiene section revealed no evidence that personal hygiene was performed for 7p-7a shift on 1/14/2022, 1/24/2022 and 1/27/2022 as indicated by a blank box. The monitor section-rejection of care revealed no evidence of refusal of care for 12/14/2022, 12/24/2023, and 12/27/2202 on 7p-7a shift as indicated by a blank box. Review of the Documentation Survey Report Jan-23 (January 1/2023 through January 31,2023) revealed no evidence that the scheduled bath was given on 7p-7a shift for 1/3/2023 1/5/2023, 1/7/2023, 1/10/2023,1/12/2023, 1/14/2023, 1/17/2023, 1/19/2023, and 1/21/2023 as indicated by blank boxes. The personal hygiene section revealed no evidence that personal hygiene was performed for 7p-7a shift on 1/19/2022 as indicated by a blank box. The monitor- rejection of care revealed no evidence that the resident refused on 1/3/2023, 1/5/2023, 1/7/2023, 1/12/2023, 1/10/2023, 1/12/2023 1/14/2023, 1/17/2023, and 1/21/2023 for the 7p-7a shift. 4. Review of the Admission Record revealed R#4 was admitted to the facility with the following diagnoses that include but not limited to multiple sclerosis, hypertension, atherosclerotic heart disease, major depressive disorder, diabetes mellitus, sedative, hypnotic or anxiolytic dependence, opioid dependence, and retention of urine and anxiety disorder. Review of the bath schedule revealed that R#4 shower days were Tuesday, Thursday, and Saturday on the night shift. Review of the MDS Quarterly assessment dated [DATE] revealed Section G (Functional Status) that resident is total dependent for baths and personal hygiene. He requires one-person to physical assist with ADLs. Review of the care plan no date revealed resident requires assistance with ADLs related to resident is not ambulatory, diagnosis of multiple sclerosis. He has an intervention to provide bathing/showerers on scheduled bath days and as needed. Review of the bedside Kardex report dated 1/24/2023 revealed ADLs/Bathing/Personal hygiene/oral care to provide bathing/showers on scheduled bath days and prn; provide oral care supplies and assist as needed. The Bathing section note provide sponge bath when a full bath or shower cannot be tolerated. Review the MDS Kardex report dated 1/24/2023 revealed resident is total dependent for bathing with two persons assist and personal hygiene total dependent with one-person physical assist. Review of the progress notes dated 12 /25/2022 through 1/21/2023 revealed no refusal of baths or personal hygiene. Review of the Documentation Survey Report Dec-22 (December 1,2022 through December 31,2022) revealed no evidence that a bath was given on 12/3/2022, 12/6/2022, 12/8/2022, 12/10/2022, 12/13/2022, 12/15/2022, 12/17/2022, 12/20/2022 12/22/2022, 12/24/2022, 12/27/2022, 12/29/2022, and 12/31/2022 for the 7p-7a shift. There was one bath noted on 12/19/2022. The personal hygiene section revealed no evidence that personal hygiene was performed for 7p-7a shift on 1/14/2022, 1/24/2022 and 1/27/2022 as indicated by a blank box. The monitor section-rejection of care revealed no evidence of refusal of care for 12/14/2022, 12/24/2023, and 12/27/2022 on 7p-7a shift as indicated by a blank box. Review of the Documentation Survey Report Jan-23 (January 1,2023 through January 31,2023) revealed no evidence that the scheduled bath was given on 7p-7a shift for 1/3/2023 1/5/2023, 1/7/2023, 1/10/2023,1/12/2023, 1/14/2023, 1/17/2023, and 1/21/2023 as indicated by blank boxes. The personal hygiene section revealed no evidence that personal hygiene was performed for 7p-7a shift on 1/19/2022 as indicated by a blank box. The monitor- rejection of care revealed no evidence that the resident refused on 1/3/2023, 1/5/2023, 1/7/2023, 1/12/2023, 1/10/2023, 1/12/2023 1/14/2023, 1/17/2023, and 1/21/2023 for the 7p-7a shift. Interview on 1/23/2023 at 12:57 p.m. Licensed Practical Nurse (LPN) GG revealed that if a resident refuses a bath the Certified Nurse Aide (CNA)s will tell her, and she will try to encourage the resident to bathe. Otherwise, she will just assume the bath was done. An interview on 1/25/2023 at 3:54 p.m. with the Administrator revealed that the facility does not currently have a MDS Coordinator and that the corporate is doing the MDS until a person is hired. Cross reference F677

Based on record review and staff interviews the facility failed to follow the care plan for one resident (R) #1 related to resident in solarium unsupervised for one of three residents reviewed for falls. Actual harm was identified to have occurred on 1/8/2020 when R#1 was left unsupervised in the solarium where he fell and suffered an [MEDICAL CONDITION]. Findings include: A review of the clinical records for R#1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed in Section C a Brief Interview for Mental Status (BIMS) coded as 99, which indicates cognitive impairment. R#1's balance during transitions and walking was not steady only able to stabilize with staff assistance when moving from a seated to standing position, walking with an assistive device if used, and surface to surface transfers. The mobility device used by R #1 was a wheelchair. Section J (Fall History) revealed, two or more falls with no injury and two or more falls with minor injury since admission/entry or reentry or the prior assessment (OBRA or Scheduled PPS). Review of care plans dated 7/11/2019 revealed R #1 At risk for Falls/injuries related to history of falls, poor safety awareness, [MEDICAL CONDITION] drug usage and unsteady gait. The care plan for R#1 was updated on 12/13/19 to reflect fall with no injury. A new intervention was documented for the resident not to be unsupervised in the solarium. Review of Nurses Notes dated 1/8/2020 revealed, R #1 was found by a Certified Nurse Assistant (CNA) lying face first in front of his Geri-chair and a small hematoma was noted to upper left forehead. Review of Post Fall Investigation report dated 1/8/2020 revealed R #1 had an unwitnessed fall on 1/8/2020 in the dining room/day room. At the time of the fall, he was alone and unattended. Interview conducted with CNA AA on 8/10/2020 revealed, she was sitting in the solarium with R #1 who was sitting in Geri-chair at the table. She stated she left the solarium to assist with another resident in a room nearby. She heard a loud noise and returned to the solarium where she found R #1 lying face down on the floor. Interview with the Director of Nursing (DON) on 8/11/2020 revealed that she stated in situations where it was warranted, residents are not to be left unsupervised.

Based on record review, staff interviews, and policy titled, Falls Management Standard the facility failed to provide adequate supervision to prevent an avoidable fall for one of three residents reviewed for falls (R#1). Actual harm was identified to have occurred on 1/8/2020 when R#1 was left unsupervised in the solarium where he fell and suffered an [MEDICAL CONDITION]. Findings include: The Facility's Fall Management Standards documents, they are also responsible for putting in place an intervention to prevent falls and implement interventions to reduce risk in residents with confusion. Interventions may include but are not limited to: Anticipate needs by monitoring resident. A review of the clinical records for R#1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C a Brief Interview for Mental Status (BIMS) coded as 99, which indicates cognitive impairment. In Section G Functional Status for self-performance and support provided with Activities of Daily Living (ADLs) revealed, he required limited-one-person physical assistance with bed mobility, transfers, walking in room and in corridor, locomotion on and off unit. R#1's balance during transitions and walking was not steady and R#1 was only able to stabilize with staff assistance when moving from a seated to standing position, walking with an assistive device if used, and surface to surface transfers. The mobility device used by R #1 was a wheelchair. Section J (Fall History) revealed, two or more falls with no injury and two or more falls with minor injury since admission/entry or reentry or the prior assessment. Review of care plans dated 7/11/2019 revealed R #1 had a care plan in place for: At risk for Falls/injuries related to history of falls, poor safety awareness, [MEDICAL CONDITION] drug usage and unsteady gait. Falls were recorded on the care plan for the following dates 7/9/19, 7/10/19,7/14/19, 10/8/19, 10/17/19, and 12/13/19 resulted with no injury. Falls recorded on care plan for 8/14/19, 9/28/19, 10/3/19, and 11/9/19 resulted with minor injuries. Fall on 1/8/2020 resulted with major injury. The care plan was updated on 12/13/19 to reflect fall with no injury. A new intervention was documented for R#1 not to be left unsupervised in the solarium. Review of Nurses Notes dated 1/8/2020 revealed, R #1 was found by a Certified Nurse Assistant (CNA) lying face first in front of his Geri-chair and a small hematoma was observed to R#1's upper left forehead. Review of Post Fall Investigation report dated 1/8/2020 revealed R #1 had an unwitnessed fall on 1/8/2020 in the dining room/day room. At the time of the fall, he was alone and unattended. Review of History & Physical from an acute care hospital dated 1/9/2020 revealed R#1was sent to a local acute care hospital. Review of a physician progress notes [REDACTED]. He (R#1) was reported to have fallen today from his wheelchair and struck his head. He was then taken to the local ER for evaluation and underwent radiographic workup. This showed some frontal IPH (Intraparenchymal Hemorrhage) and the patient was sent (from the local ER) to our ER in Florida for further evaluation. Review of a Consultant Note dated 1/8/2020 - CT head reviewed. Right frontal IPH consistent with recent traumatic injury. No other acute findings. Review of (TMH) physician progress notes [REDACTED]. This is a [AGE] year-old gentleman that transferred from an acute care hospital secondary to [MEDICAL CONDITION]. The patient has a history of dementia and [MEDICAL CONDITION]. He is cared for at a nursing facility. He is mostly in the bed or in a wheelchair. The patient needs assistance with any type of ambulation. He does not ambulate on his own. Apparently, he fell from his wheelchair and struck the left side of his head, in the forehead area. A workup, which included a CT of the head was done that showed frontal lobe intraparenchymal hemorrhage/contusion. Interview with CNA AA on 8/10/2020 at 11:30 a.m. revealed, she was sitting in the solarium with R #1 who was sitting in Geri-chair at the table. CNA AA stated she left the solarium to assist with another resident in a room nearby. CNA AA stated that she heard a loud noise and returned to the solarium where she found R #1 lying face down on the floor. Interview with CNA CC on 8/11/2020 at 2:00 p.m. revealed, she did not witness R #1 fall on 1/8/2020 because she was providing care in another resident's room at the time. Interview with LPN BB on 8/11/2020 revealed, he was working two CNA's the day R#1 fell . LPN BB stated CNA CC was making rounds and that CNA AA was sitting in the solarium with the residents. LPN BB stated he was in the hallway passing medications and was unaware CNA AA, had left the solarium leaving R #1 unattended. LPN BB stated he did not witness the fall and that CNA AA called out for him to assess R #1 after R#1 had fallen. LPN BB confirmed that R #1 should not have been left unsupervised. He stated CNA AA should have alerted him if she needed to step away from the solarium. Interview with the Director of Nursing (DON) on 8/11/2020 revealed, she ensures staff were implementing interventions during daily rounding and chart reviews in the morning meeting. The DON stated in situations, where it was warranted, some residents are not to be left unsupervised. The DON stated staff should always remain with or near and within plain view of the resident.

Based on record review, interviews, review of the policy titled. Notification of Resident Change in Condition, the Behavior Escalation and Crisis Management- Original Date: 02/2016, and the Behavior Management Psychoactive Medication Management Overview -Original Date: 02/2016 the facility failed to notify the Medical Doctor (MD) of a Psychiatrist recommendation for one (1) resident (R#7) and failed to notify three (3) responsible party/family member of alleged sexual assaults on the secure unit per the facility's written policies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 3/16/17 was seventy three (73) residents. The sample was twelve (12). On 3/20/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for [MEDICAL CONDITION] affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine [MEDICATION NAME] ([MEDICATION NAME]) to 100 mg by mouth twice a day; and orders were [MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet by mouth daily for maintenance; [MEDICATION NAME] sodium 250 mg delayed release tablets by mouth twice a day for maintenance; [MEDICATION NAME] 5 mg by mouth three times a day for maintenance; quetiapine ([MEDICATION NAME]) 100 mg by mouth twice a day for maintenance. However the facility failed to notify the attending physician, and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the policy titled, Notification of Resident Change in Condition Original Date: 03/2016 revealed that the clinical staff will notify the resident's Physician and family/responsible party immediately, if there is a change in the resident's clinical condition. The nurse collects all pertinent information prior to contacting the Physician. If the change is not significant, the resident's Physician and family/responsible party will be notified at the earliest convenient time during regular business hours. Notify the Physician and family/responsible party immediately if there is a significant change in condition, regardless of the time. Document in the Progress Notes the times notification was made and the names of the person(s) spoken to. Sign/date entry. Review of the Behavior Escalation & Crisis Management- Original Date: 02/2016 revealed: Complete an evaluation to include, but not be limited to: Changes in cognitive status, Changes in vital signs, Constipation, Evidence of infection, Medications for changes in dose, duration, or presence of side effects or adverse consequences, Presence of injury and Presence of pain or discomfort. Notify the following, as indicated: Supervisor, Physician, Family/responsible party and Psychiatric care provider. Review significant change in condition with a physician/pharmacist to evaluate medication regimen, as indicated. Evaluate circumstances preceding the behavior escalation/crisis to determine potential causes/triggers. Review of the Behavior Management Psychoactive Medication Management Overview -Original Date: 02/2016 revealed to confirm and document that the resident/patient and/or family/responsible party has been informed of the purpose and potential side effects of the psychoactive medication(s). 1. Review of the record dated 1/11/17 revealed R#7 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] Section I Active [DIAGNOSES REDACTED]. Review of psychiatric progress note dated 2/7/17 for R#7 revealed the psychiatrist plan of care was to increase [MEDICATION NAME] to 100 milligram (mg) twice a day, [MEDICATION NAME] 5 mg by mouth for maintenance, [MEDICATION NAME] sodium 250 mg by mouth twice a day for maintenance [MEDICATION NAME] sodium 500 mg for maintenance, [MEDICATION NAME] 5 mg by mouth three times a day and [MEDICATION NAME] 40 mg by mouth daily. An interview on 3/22/17 at 10:57 a.m., with the psychiatrist revealed that the facility had not sent any behavior information regarding behavior changes in R#7 and that R#7 was seen for intractable sobbing. When the psychiatrist was asked if he aware that his impression and plan was not implemented, he wanted to know why. The psychiatrist continued to state that the medications ordered was for mood and agitation. The psychiatrist stated that he had also sent copies of his progress notes and hard copy (written prescriptions) of the medications he ordered for R#7 to the facility. An interview on 3/20/17 at 9:23 a.m., the attending physician revealed that he was not aware of the psychiatrist recommendation to implement the added [MEDICAL CONDITION] drugs written from the consultation on 2/7/17. The physician revealed that the nursing staff are to call him with any recommendations from consulting physicians. (Cross refer to F223, F250) 2. R#8 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of nurse's note dated 3/10/17 revealed that R#7 had on a tee shirt and underwear with his penis out while attempting to get in bed with R#8. LPN BB notified the Medical Doctor (MD) however there is no evidence of notification of the family and/or responsible party. (Cross refer to F223 for details) An interview on 3/20/17 at 9:09 p.m. LPN BB revealed that she had not notified responsible party for R#8. Review of the social service progress notes dated 3/22/17 revealed the responsible party/family member were notified on 3/22/17. 3. R#1 was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Review of nurse's notes dated 3/15/17 revealed R#1 was heard yelling obscenities and when LPN BB arrived, R#7 was walking out of R#1 room. R#1 was documented as saying that R#7 was trying to get in bed with him and that he had swung at R#7 to stop him from getting in his bed. (Cross refer to F223 for details) Interview on 3/17/17 at 9:05 a.m. with R#1 confirmed that R#7 came through the bathroom and got in his bed on the left side. An interview on 3/20/17 at 9:09 p.m. LPN BB revealed that she did not notify the family member/responsible party because she saw R#7 already walking out the room and didn't see R#7 in R#1 bed. Review of the social service progress notes dated 3/22/17 revealed that the responsible party/family member was notified 3/22/17 which was seven (7) days after the incident. 4. R#11 was admitted to the facility with the following [DIAGNOSES REDACTED]. Interview on 3/20/17 at 9:09 p.m. LPN BB stated that the CNA EE reported to her that R#7 had went into R#11 room. When she got to R#11 room, she stated that she heard R#11 yelling I will kill you. LPN BB stated she did not report it or notified family member. (Cross refer to F223 for details) *****The facility implemented the following actions to remove the Immediate Jeopardy On 1/12/17 and 1/13/17, 16 nurses were in serviced out of 22 on payroll. Nurses were in serviced on notification of resident change in condition. Facility clinical staff will notify resident's Physician and family / responsible party immediately, if there is a change in the resident's clinical condition. The nurse will collect all pertinent information prior to contacting the physician. If the change is not significant, the resident's physicians and family/ responsible party will be notified at the earliest convenient time during regular business hours. On 3/20/17 at 11:30 a.m. in-service to nursing staff initiated for Change in Condition and notifying MD. There were 11 nurses out of 19 on payroll in-serviced. Nurses were in serviced on notification of resident change in condition. Facility clinical staff will notify resident's Physician and family/responsible party immediately, if there is a change in the resident's clinical condition. The nurse will collect all pertinent information prior to contacting the physician. If the change is not significant, the resident ' s physicians and family/responsible party will be notified at the earliest convenient time during regular business hours. Nurses were also educated on using change in condition tool. On 3/20/17 at 3:00 p.m. Quality Assurance Process Improvement, (QAPI) monitoring tool completed for Notification of Changes in Condition by Administrator and Director of Nurses. On 3/22/17 at 2:00 p.m. Mandatory Nurses meeting for training set for 3/22/17 for two shifts to cover licensed staff. Nurses will be in serviced on notification of resident change in condition. Facility clinical staff will notify resident ' s Physician and family/responsible party immediately, if there is a change in the resident's clinical condition. The nurse will collect all pertinent information prior to contacting the physician. If the change is not significant, the resident's physicians and family/ responsible party will be notified at the earliest convenient time during regular business hours. Nurses will also be in serviced on Abuse prevention program & reporting policy and Behavior management policy. There will be approximately 14 nurses in attendance. On 3/22/17 in-service to nursing staff continued for Change in Condition. Nurses were in serviced on notification of resident change in condition. Facility clinical staff will notify resident's Physician and family/responsible party immediately, if there is a change in the resident's clinical condition. The nurse will collect all pertinent information prior to contacting the physician. If the change is not significant, the resident's physicians and family/ responsible party will be notified at the earliest convenient time during regular business hours. On 3/20/17 Policy for Behavior Management and Change in Condition has been reviewed by the Administrator and Director of Nursing. Implementation of the Change in Condition Tool will occur on 3/21/17. Nurses were re-educated on 3/20/17, to the use of completion of this tool. The Administrator will audit the 24 hour report during morning Clinical Meeting and initial off on the form. If the administrator is not present Director of Nursing will review and initial off. On the weekends, the Weekend supervisor will audit and initial off on form. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: Review of the Staff inservice initiated on 3/20/17 through 3/23/17 on change in condition revealed that 100% of the nursing staff had been inserviced, including the Mandatory Nurses meeting conducted on 3/22/17. Interview on 3/28/17 at 11:32 a.m. Licensed Practical Nurse (LPN) TT revealed that she was given the information to read over because she did not attend the actual inservice and that she read the material provided to her by the ADON. At 11:37 a.m., LPN UU revealed that when she returned to work on 3/22/17 that the ADON provided her the reading material. And that the inservice is place in a book for nurses to read later. At 11:47 a.m., LPN CC revealed that she did not attended the inservice but was provided the information by ADON. The information regarding change of condition form. An interview on 3/28/17 at 12:27 p.m., the DON stated that 100% staff inservice was completed. The facility had two registered nurse to resign. The 24 Hour Report form is initialed by Administrator, DON and ADON each day for review. And that she is looking for falls, antibiotic therapy, medication changes, incidents and follow-ups. Review of two recent transfers to an acute care facility revealed that the change in condition form had been completed on 3/21/17, including notification of the MD and responsible parties.

Based on observation, record review, interviews and review of policy and procedures including, Abuse Prevention Program and Reporting Policy Resident to Resident Abuse, the facility failed to protect six (6) residents (R#1, R#2, R#3, R#4, R#8, and R#11) of thirty-three (33) residents that resided on a secure unit from sexual assault by R#7. This failure resulted in psychological harm to: R#8 who had history of childhood sexual abuse; R#1 who kept nail clippers in his pocket to protect himself; R#2 who is unable to speak words or make sound to call for help; R#3 who is total dependent on staff for all activities of daily living, and; R#4 who was pinned down in his bed requiring assistance of three staff to provide intervention. R#11 who was intruded in the bathroom was yelling I will kill you On 3/20/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for [MEDICAL CONDITION] affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine [MEDICATION NAME] ([MEDICATION NAME]) to 100 mg by mouth twice a day; and orders were [MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet by mouth daily for maintenance; [MEDICATION NAME] sodium 250 mg delayed release tablets by mouth twice a day for maintenance; [MEDICATION NAME] 5 mg by mouth three times a day for maintenance; quetiapine ([MEDICATION NAME]) 100 mg by mouth twice a day for maintenance. However the facility failed to notify the attending physician, and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: 1. Resident #2 (male) was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed in Section B, titled Hearing Speech Vision that R#2 has no speech and has the absence of spoken words. Review of Section G, titled Functional Status revealed R#2 requires limited assistance for ambulation and transfers. Interview on 3/23/17 at 10:36 a.m., Licensed Practical Nurse (LPN) CC revealed that she witnessed R#7 in bed with a male resident (R#2) during her shift in February 2017. She revealed the male resident's name as being R#2. She continued to briefly describe the incident that R#2 was laying on his side facing the wall and R#7 was sitting on the bed and looking toward the door. LPN CC stated that she thought this was on 2/27/17 because she remembered working the end of February 2017. LPN CC stated she did not write a nurse note or report the event to anyone. Review of nurse's notes dated 3/10/17 revealed that R#7 was found in R#2 bed wearing a tee shirt and underwear, with his penis out of his underwear. LPN BB escorted R#7 back to his room, and medicated him. Interview on 3/23/17 at 1:05 p.m., LPN BB revealed that she heard a Certified Nursing Assistant (CNA) holler for her. When she entered the room of R#2, she saw R#7 in bed with R#2. R#2 was laying on his right side. When they got R#7 out of R#2 bed, R#7 penis was hanging out from the boxers. She stated that R#2 does not talk and has a peg tube (tube inserted into the stomach to provide hydration and nutrition) and his eyes were wide, his mouth was open. R#2 was upset and refused to go back to bed. R#2 continue to pace the floor and didn't get back into the bed. LPN BB further revealed that she did not notify the Administrator or Director of Nursing because she had spoken with the medical doctor (MD). 2. Resident #8 (male) was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE], Section G, and titled Functional Status revealed that R#8 is total dependent on staff for transfers and he does not walk. Locomotion is via wheel chair with limited assistance. Review of the nurse's note dated 3/11/17 (no time listed) revealed that R#7 had on a tee shirt and underwear with his penis out while attempting to get in bed with R#8. LPN BB notified the Medical Doctor (MD) who gave an order to 1013 (CERTIFICATE AUTHORIZING TRANSPORT TO EMERGENCY RECEIVING FACILITY and REPORT of TRANSPORTATION. The 1013 revealed the following: In my opinion this Individual appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill and: (they either A or B) A. presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to other persons; or B. appears to be so unable to care for his/her own physical health and safety as to create an imminently life endangering crisis), to a behavioral facility. R#7 was sent to the emergency room (ER) for medical clearance for the 1013 on 3/16/17 (no time given), and R#7 was returned to the facility on the same date. Upon return to the facility, R#7 got naked and was attempting to urinate on R#8. LPN BB noted that R#7 again tried to get back in bed with R#8. An interview on 3/23/17 at 1:05 p.m., LPN BB revealed that she heard a noise and went into R#7 room and found him kneeling on the floor. R#7 right arm was resting on the mattress of R#8. When she and the CNA got him up, she saw his penis out. Later that day (3/11/17), LPN BB stated that a family member came to visit with R#7. Continued interview with the LPN revealed when R#7 family member left, he began to get upset, he would take his clothes off and walk into the hallway. LPN BB said she would take R#7 back to his room and redress him. About fifteen (15) minutes later she went to check on him and when she entered the room, she saw R#7 standing over R#8 bed with his penis in his hand. R#8 was laying on his back and looking up and watching R#7. LPN BB stated she assisted R#7 back to his bed and dressed him, then put him in a geri-chair in the hallway. Further interview with the LPN revealed that R#7 kept getting up out of the geri chair and going back in the room to get in bed with R#8. 3. Resident #1 (male) was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Review of the 30 day MDS assessment dated [DATE] Section G, titled Functional Status revealed that R#1 could transfer and ambulate with limited assist. His Brief Interview for Mental Status (BIMS) score was not completed. Review of nurse's notes dated 3/15/17 at 10:45 p.m. revealed R#1 was heard yelling obscenities and when LPN BB arrived to the room R#7 was walking out of R#1 room. R#1 was documented as saying that R#7 was trying to get in bed with him and that he had swung at R#7 to stop him from getting in his bed. Interview on 3/17/17 at 9:05 a.m., with R#1 revealed that a man came through the shared bathroom and got in his bed on the left side. R#1 said he was lying on the right side of the bed. He told the man (identified as R#7) to get out of his bed. R#1 continued to say that he had a nail clipper and was going to used it on R#7 to get him out of his bed. He also commented that he was not asleep and was not afraid, and glad that he was not sleep because the man would have put his hands on him. His last remarks was that the man should not have been here or come back here. An interview on 3/17/17 at 9:11 a.m., with R#9 who was the roomate of R#1 revealed that he saw the man (R#7) crawling on his hands and knees, then got up and got into R#1's bed. He told the man to get out of the room. Continued interview with R#9 revealed that the man (R#7) refused to leave and he was worried about R#1 because he could not help R#1 due to being paralyzed on the left side. R#9 stated that the curtain was open and he was watching from his bed. Review of the records revealed that R#9 had a BIMS score of 9 revealing that he had moderately impaired cognition. Observation/interview on 3/17/17 at 9:20 a.m. in the solarium on the secure unit, R#1 was sitting in a wheel chair in the hall near his room door entrance looking down the hall toward the solarium. Upon walking by R#1, stated that he was concerned that he saw the man (R#7) back in the building standing in the solarium. R#1 was reassured that the man was not in the building. He replied Good that man don't need to be here. He needs to be in jail. Interview on 3/20/17 at 11:44 p.m., CNA FF revealed that R#1 was yelling and cursing because R#7 was trying to get in his bed with him. CNA FF continued to state that she took R#7 back to his room. Interview on 3/23/17 at 1:05 p.m., LPN BB revealed that she was told by R#1 that he had swung at R#7 who was trying to get in his bed. 4. Resident #3 was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Review of the five-day MDS assessment dated [DATE] revealed in Section G, titled Functional Status revealed that R#3 is total dependent on staff for all activities of daily living (ADLs). Review of nurse's notes dated 3/15/17 at 11:30 p.m. revealed that LPN BB observed R#7 walking into R#3 (female) room, upon entering the room, LPN BB documented that she witnessed R#7 in the bed with R#3 whose shirt was unbuttoned, and trying to get away from R#7. LPN BB noted that R#7 was advised to get out of the bed, but he refused. LPN BB with the assistance of CNA FF removed R#7 from the bed. The responsible party and MD were notified. The MD gave an order to send R#3 to the ER for evaluation. Review of a local hospital report dated 3/16/17 revealed no obvious assault evidence available and chronic agitation. Interview on 3/20/17 at 11:44 p.m., CNA FF revealed that she was making rounds and passed by the room of R#3 and saw R#7 on top of R#3. CNA FF continued to state that R#3's shirt was unbutton and that R#7 was humping on R#3. CNA FF stated that she call for the nurse from the doorway and LPN BB came to assist her. R#7 was very difficult to get off R#3 who was crying and hollering. After R#7 was removed off R#3, he was taken back to his room and assisted to his bed. Interview on 3/23/17 at 11:54 a.m., LPN BB revealed that CNA FF had called for assistance in the room of R#3. CNA FF stated when she got to the room, she saw R#7 laying in the bed of R#3 face down. R#3 was hollering, making noise and was trying to swing her legs to the side of the bed. She also noticed that R#3 had a scared look on her face and her shirt was unbuttoned. Interview on 3/23/17 at 3:10 p.m., LPN AA revealed that she entered A-Hall (secure unit) and saw R#7 walking in the hall around 11:00 p.m. She reported to the assigned nurse on A-Hall that R#7 was walking the hall. When AA got ready to leave the A-Hall, she turned to be sure the door was going to lock and saw R#7 going into R#3's room. LPN AA stated she went back and knocked on the door of the nurse's office and informed LPN BB that she had seen R#7 going into another resident's room. When LPN AA and BB got to the room of R#3, LPN AA stated that R#7 was already crawling in bed with R#3. LPN AA stated that when one of the CNA's came into the room, she left the secure unit. LPN AA stated that R#3 was visible shaking, with the top three buttons of her top unfastened and she was making noise. 5. Resident #4 was admitting to the facility with the following but not limited [DIAGNOSES REDACTED]. Review of the nurse's notes dated 3/16/17 at 12:15 a.m. revealed LPN BB heard CNA FF yelling for her to come to the room of R#4. LPN BB noted that upon arriving to the room that she saw R#7 on top of R#4 (male), facing downward toward the mattress. R#7's left hand was wrapped around the left wrist of R#4, and R#7's forearm was pushed down on the neck of R#4. LPN BB noted that R#7 was moving his hip in an up and down motion on the buttocks of R#4. LPN BB stated with the assistance of CNA FF and CNA EE lifted R#7 off of R#4 and took R#7 back to his room. LPN BB notified MD (time not listed) and received order to send R#4 to ER for evaluation. At 1:15 a.m. R#7 was sent to the local hospital via ambulance on a 1013. Interview on 3/20/17 at 3:45 p.m. CNA EE revealed that she was across the hall from the room of R#4 when she heard CNA FF scream for help. When she entered the room of R#4, she saw R#4 lying face down with his eyes closed. R#7 had his head laying across the head of R#4, and R#7's right cheek was resting on the pillow. R#7 was holding the wrist of R#4 and R#7 was holding down the other hand of R#4 to prevent R#4 from moving. R#4 face was turning red. R#7 kept on humping R#4 like a dog. R#4 was trying to move out of the bed. It took all three (BB, EE, and FF) to get R#7 off R#4. Soon as R#7 was removed off of R#4, R#4 immediately got out of the bed and started pacing the floor, wringing his hands. Interview on 3/20/17 at 11:44 p.m. CNA FF revealed that she was passing by the room of R#4 and saw him with his eyes closed, R#7 was humping up and down like a dog. R#4 was pinned down and being choked by R#7. It took three (BB, EE and FF) of us to get R#7 off of R#4. R#7 was transferred from the building after midnight. Interview on 3/20/17 at 9:09 p.m. LPN BB revealed that R#4 was laying on his bed and R#7 was laying on top of R#4's back. R#7's left hand was holding the left hand of R#4 and neither resident's right hand was visible. The left forearm of R#7 had R#4 pinned down. 6. Resident #11 was admitted to the facility with the following but not limited to [DIAGNOSES REDACTED]. Interview on 3/20/17 at 3:45 p.m. CNA EE revealed that the room door was partial opened for R#11 (female). CNA FF stated she saw R#7 leaving the room of R#11 by going through the adjoining bathroom to the other female resident's room on 3/15/17. She stated that she went into room of R#11 and assist R#7 back to his room, then she left the secured unit to go to the laundry and get bed chucks (sheet protectors) from the dryer. Interview on 3/20/17 at 9:09 p.m. LPN BB stated that CNA EE reported to her that R#7 was going into other residents room and that R#7 had went into the room of R#11. LPN BB stated when she got to the room of R#11, she heard R#11 yelling I will kill you as R#7 was walking out of the shared bathroom of R#11. LPN BB stated she did not witness R#7 in the bed of R#11. Interview on 3/22/17 at 9:55 a.m. revealed that R#11 was speaking in English and her native language of Spanish. R#11 was not able to stay focus with one language or describe what happened in her room on 3/15/17. *****The facility implemented the following actions to remove the Immediate Jeopardy On 3/10/17 and 3/14/17 facility staff were in-serviced on abuse and neglect. On 3/10/17, 24 out of 60 employees were in-service which included: one administrator, seven nurses, 10 CNA's, four dietary staff, one maintenance staff and one activity staff. On 3/14/17, 42 out of 60 staff were in-serviced which included: 12 nurses, 14 CNAs, one central supply clerk, three dietary staff, one human resource staff, two therapist, five housekeeping staff, two agency staff and two activity staff An abuse in-service for all facility staff and contract staff will begin on 3/20/17 by 12:00 p.m. and will be complete by Friday 3/24/17 at 5:00 p.m. Staff will receive in-service training prior to returning to work. Effective 4/1/17, abuse in-service training for all facility and contract staff will be conducted quarterly, during facility orientation and as needed. The Hand In Hand Training will be used for quarterly education. The Social Services Director, the Activity Director or the Administrator will in-service current residents on abuse, how to whom to report abuse and prevention of abuse beginning on 03/21/17 by and will be 100% complete by Thursday, 03/23/17 at 5:00 p.m. On 3/16/17 and 3/21/17 social worker went around and conducted interviews with residents on the secured unit to determine any other at risk residents. The social worker will follow up with residents and report any psychological changes to the DON and the Administrator to determine if further intervention is needed. On 03/16/17 at approximately 12:30 a.m., R#7 was placed on immediate one on one supervision until police arrived. At approximately 1:15 a.m. Clinch County Police arrived and resident was 1013 out of facility. On 3/16/17 at approximately 1:20 a.m., R#3 and R#4 were taken to Clinch Memorial hospital and evaluated. Both residents were returned to the facility with no injuries noted. Referrals for tele- psych visit with United Behavioral Health Services was ordered. On 3/16/17 the social worker went around and interviewed six residents that may have witness the incident on 3/16/17. R#3 was unable to answer any questions. R#4 could not recall the incident on 3/16/17. The six other residents stated they were glad R#7 was gone. When residents were asked about the incident three out of six could not recall what happen that night (3/16/17). Two residents stated R#7 had been trying to get into their beds. One resident stated R#7 lied in his bed. 1 One resident stated he observed R#7 crawling on the floor like an animal and trying to get into his roommates bed but he and his roommate told R#7 to leave. Resident stated R#7 left their room when redirected. All of the residents interviewed stated R#7 seemed confused and was trying to lie down. The residents stated they told R#7 to leave and redirected R#7 out of their rooms. The residents that were interviewed revealed that R#7 did not touch them inappropriately. The social worker will follow up with R#3 and R#4 and report any psychological changes to the DON and the Administrator to determine if further intervention is needed. The Care Management Team reviewed residents on the secured unit on 3/17/17 and 3/21/17 to determine any other residents were at psychological risk from the incident on 03/16/17. An abuse in-service for all facility staff and contract staff will begin on 3/20/17 by 12:00 p.m. and will be 100% complete by Thursday 3/23/17 at 5:00 p.m. Effective 4/1/17, abuse in-service will be conducted quarterly for all facility staff and contract staff as well as in new employee orientation and as needed. The Hand In Hand Training will be used for quarterly education. In-services on Behavior Management and Preventing Difficult Behaviors for all facility staff and contract staff will begin on 03/20/17 by 12:00 p.m. and will be 100% complete by Friday 3/24/17 at 5:00 p.m. Effective 4/1/17, in-servicing for managing difficult behaviors for all facility staff and contract staff will be conducted semi-annual, during facility orientation and as needed. On 3/22/17 a Resident Council meeting was scheduled to review resident's rights and abuse and neglect. The Social Services Director, the Activity Director or the Administrator will in-service current residents on abuse, how and to whom to report abuse and prevention of abuse beginning on 03/21/17 by and will be 100% complete by Tuesday, 03/23/17 at 5:00 p.m. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: Interview on 3/28/17 at 11:15 a.m. with certified nurse aide (CNA) LL revealed that she had attended in-services on types of abuse and who to talk to about abuse. At 11:24 a.m., CNA RR revealed that she was in-service on abuse and what she needed to do (behavior interventions). At 11:29 a.m., CNA SS revealed that abuse was discussed and who to report abuse. At 11:41 a.m. CNA NN revealed that she was not aware of the meeting; however, when she returned to work on 3/21/17, she was educated by the Administrator and the Assistant Director of Nursing (ADON) about abuse and what should be done (behavior interventions). At 2:13 p.m., CNA FF revealed that the in-service was about abuse, notifying nurses of anything that happens on the unit and what to do (behavior interventions). Interviews on 3/28/17 at 11:32 a.m. Licensed Practical Nurse (LPN) TT revealed that she was given the information regarding abuse to read over because she did not attend the actual in-service. LPN TT stated that she did read the material provided to her by the ADON. At 11:37 a.m., LPN UU revealed that that when she returned to work on 3/22/17 that the ADON provided her the reading material regarding abuse which she did read. LPN UU stated that the in-service materials are placed in a book for nurses to read later. At 11:47 a.m., LPN CC revealed that she did not attended the in-service but was provided the information about abuse by ADON. LPN CC revealed she read the information which was regarding abuse, who to report it to, what to do when found. An interview on 3/28/17 at 12:27 p.m. with the DON stated that 100% staff in-service was completed on abuse, including reporting, interventions, documentation of, and notification. The facility had two registered nurse that had resigned. The DON revealed that newly hired nursing staff and non-nursing staff were in-service on types of abuse, how to identify abuse, who to report abuse. An interview on 3/28/17 at 2:00 p.m. with the Administrator revealed that she was reviewing and doing follow-up for concerns on the 24 Hour Report. The Administrator revealed she was checking for anything alarming and anything that needs to be reported, this also includes area of concerns that requires further investigation. Review of the records for R#3 and R#4 confirmed they had been evaluated at the hospital and there was no evidence of injury. Review of the record for R#7 confirmed that on 03/16/17 was placed on immediate one on one supervision, until R#7 was transported out of the facility via 1013. Interview with the acute care facility Administrator on 3/23/17 at 11:32 a.m. confirmed that R#7 was in the acute care facility. The acute care Administrator expressed the desire for R#7 to be readmitted back to the facility, and stated that the nursing home was dumping on the hospital as they could not continue to care for R#7. Review of the audits confirmed that the social worker did interview residents on the secured unit about abuse from R#7. Review of the audits, confirmed that some residents on the unit could not recall events, some of the residents could not recall specific details ie dates or times, and some of the residents did express concern related to the behaviors of R#7, however there were no occurrences reported.

Based on observation, interview, record review, review of policy and procedures, titled Abuse Prevention Program and Reporting Policy/Resident to Resident Abuse Procedure, review of the policy Behavior Escalation and Crisis Management, the facility failed to follow their policy to protect six residents (R#1, R#2, R#3, R#4, R#8,and R#11) of thirty three (33) residents on the secure unit from sexual abuse and physical assault; failed to identified the behaviors of two residents (R#7 sexual behaviors and R#12 physical behaviors); failed to assess the cause of behaviors for R#7 and R#12; failed to identify interventions to assist R#7 and R#12 in managing their behaviors; and failed to follow the facility policies including behavior management program. The resident sample was 12. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 3/16/17 was seventy three (73) residents. This failure resulted in psychological harm to (R#1, R#2, R#3, R#4, R#7, R#8, and R#12). On 3/20/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for [MEDICAL CONDITION] affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine [MEDICATION NAME] ([MEDICATION NAME]) to 100 mg by mouth twice a day; and orders were [MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet by mouth daily for maintenance; [MEDICATION NAME] sodium 250 mg delayed release tablets by mouth twice a day for maintenance; [MEDICATION NAME] 5 mg by mouth three times a day for maintenance; quetiapine ([MEDICATION NAME]) 100 mg by mouth twice a day for maintenance. However, the facility failed to notify the attending physician, and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the Abuse Prevention Program and Reporting Policy revealed the following: Ensure that prevention techniques are implemented in the facility including, but not limited to: Ongoing supervision of residents through visual observation; Recognition of signs of resident conflicts/aggressive behavior; identify, correct, and intervene in situations where resident to resident abuse is mostly like to occur. This includes, but is not limited to, identification/analysis of: Secluded areas of the facility; sufficient staffing on each shift to meet the needs of the residents; Assigned staff demonstrating knowledge of individual resident needs; Sufficient and appropriate supervisory staff to identify behaviors, and; Residents with needs and behaviors which might lead to conflict. Instruct staff they are to immediately report any incidents involving resident to resident conflict, aggressive behavior between residents and/or incidents of resident to resident abuse. Review of the policy Behavior Escalation and Crisis Management- Original Date: 02/2016 revealed that the interdisciplinary team works with the resident and family/responsible party to identify potential causes and triggers of behavior(s) in an effort to avoid a behavior escalation/crisis. Behavior escalation/crisis management may be required in the event a behavior escalates where the resident is at risk for harming themselves or others. If the behavior cannot be managed, the interdisciplinary team may determine that the resident requires transfer to an acute care facility. Facility leadership provides education and training to staff in response and management of a behavior crisis. Obtain additional staff assistance as needed. Avoid leaving the resident alone. Use minimal number of staff while maintaining safety to avoid crowding/frightening resident. Speak calmly to the resident in a quiet, firm voice. Respond to the expressed feelings in a reassuring manner. Initiate the following interventions which may include, but are not limited to: Removing resident from the situation to a safe, supervised environment. Identify and reduce/remove triggers of behavior. Remove others from the area. Refer to the Emergency Restraint Application procedure in the Restraint Prevention and Management Program. Remain with the resident until calm. Complete an evaluation to include, but not be limited to: Changes in cognitive status, Changes in vital signs, Constipation, Evidence of infection, Medications for changes in dose, duration, or presence of side effects or adverse consequences, Presence of injury and Presence of pain or discomfort. Notify the following, as indicated: Supervisor, Physician, Family/responsible party and Psychiatric care provider. Review significant change in condition with a physician/pharmacist to evaluate medication regimen, as indicated. Evaluate circumstances preceding the behavior escalation/crisis to determine potential causes/triggers. Document escalation/crisis, interventions, effectiveness of interventions, resolution of crisis and persons notified in the progress note. One-on-One (1:1) Observation includes observation may be implemented when a resident exhibits the following behavior that may include but is not limited to: Puts themselves or others in danger, increased agitation, Aggressive behavior, inappropriate sexual behavior, Suicidal verbalizations and increased anger. The Nursing Supervisor is responsible for identifying, implementing and assigning staff for one-on-one observation. If one-on-one observation is implemented, the Director of Nursing must be notified at that time. The Nursing Supervisor is responsible for providing direction and guidance to the staff involved in providing one-on-one observation. The Nursing Supervisor is responsible to verify the assigned nursing personnel completes all duties. Document change in condition in resident's medical record upon identification of a new behavior. Notify Physician of the resident's change in condition and the implementation of one-on-one observation. Notify the resident's family/responsible party of the change in condition and implementation of one-on-one observation. Resident must be in sight at all times. The assigned licensed nurse will determine the break schedule for the staff members assigned to the one-on-one observation. Document observations and interventions at least every two hours in the medical records. Ongoing frequency may be adapted by the Care Management team. Do not leave resident unattended or out of sight at any time. The Assigned Nurse will determine break schedules. Notify nurse immediately if resident's condition changes, (e.g., agitation increases or decreases). Document observations as instructed. Document care provided per routine expectations. 1. Review of the medical record dated 1/11/17 revealed R#7 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] Section I Active [DIAGNOSES REDACTED]. Review of the MDS Section E-Behavior indicated R#7 wandered daily and displayed behavioral symptoms occurring one to three days. Review of Section G Functional Status revealed that R#7 ambulates independently in room and corridor. Review of the admission/re-admission data collection and initial plan of care dated 1/11/17 revealed a plan of care for behaviors that were verbal and physical directed toward others and socially inappropriate behaviors. Resident #7 had been readmitted to the facility from an acute behavior unit after stabilization of medications, however the facility failed to implement all the medications on return to the facility which resulted in R#7's behaviors to escalate (see below and cross refer to F250 for details). The facility failed to have ongoing supervision of R#7 through visual observations, failed to identify the signs so that interventions and corrections of the behaviors could be implemented. The facility failed to analyze the areas of the secured unit and provide sufficient staffing to meet and/or un-meet needs of R#7 that caused the behaviors including supervisory staff. The staff failed to immediately report the incidents of R#7 to the Administrator and/or DON. Per review of the nursing notes on 3/11/17 the medical doctor wanted to know why the 1013 (CERTIFICATE AUTHORIZING TRANSPORT TO EMERGENCY RECEIVING FACILITY and REPORT of TRANSPORTATION) on 3/10/17, was not carried out as ordered. Further review of the physician's orders dated 3/10/17 revealed that R#7's needs cannot be met, and has ordered multiple 1013's. Review of the plan of care including Behavior Management revealed no changes to the care plan, and the facility continued to accept R#7 back into the facility, until 3/16/17 . The facility left R#7 alone even though they had identified the behaviors. The interdisciplinary team was working with the resident's family/responsible party to identify potential causes and triggers of behavior(s) in an effort to avoid a behavior escalation/crisis. Behavior escalation/crisis management may be required in the event a behavior escalates where the resident is at risk for harming themselves or others. 2. R#2 (male) was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Interview on 3/23/17 at 10:36 a.m. LPN CC revealed that she witnessed R#7 in bed with a male (R#2) she thinks this was on 2/27/17 because she remembered working the end of February. However did not write a nurse note or report it. (Cross refer to F223) An interview on 3/23/17 at 1:05 p.m. LPN BB revealed that she heard the CNA holler for her, she went to the room of R#2, and saw R#7 in R#2's bed and R#7's penis was hanging out from his boxers. LPN BB revealed that she did not notify the Administrator or Director of Nursing because she had spoken with the medical doctor (MD). 3. R#8 (male) was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of R#7 nurse's note dated 3/11/17 revealed that R#7 had his penis out while attempting to get in bed with R#8. R#7 was sent to the emergency room and returned to the facility. After re-admission, R#7 got naked and was attempting to urinate on R#8. (Cross refer to F223 for details of multiple occurrences on this day) 4. R#1 (male) was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Review of nurse's notes dated 3/15/17 revealed R#1 was heard yelling obscenities because R#7 was trying to get in bed with him. (Cross refer to F223 for details) An interview on 3/17/17 at 9:05 a.m. with R#1 confirmed the nurses note entry. Interview on 3/17/17 at 9:11 a.m. with R#9 confirmed that R#7 entered the room of R#1. (Cross refer to F223 for details) An interview on 3/20/17 at 11:44 a.m. CNA FF revealed that R#1 was yelling and cursing because R#7 was trying to get in his bed with him. 5. R#3 was admitted on [DATE] to the facility with the following [DIAGNOSES REDACTED]. Review of nurse's notes dated 3/15/17 at 11:30 p.m. revealed that LPN BB documented that she witnessed R#7 in the bed with R#3 and that R#3's shirt was unbuttoned. 6. R#4 was admitting to the facility with the following [DIAGNOSES REDACTED]. Reviewed nurse's notes dated 3/16/17 at 12:15 a.m. revealed LPN BB noted that R#7 was on top of R#4 (male) and R#7 was moving his hips in an up and down motion on R#4 buttocks. 7. R#11 was admitted to the facility with the following [DIAGNOSES REDACTED]. An interview on 3/20/17 at 3:45 p.m. CNA EE revealed that R#11 (female) room door was partial opened and she saw R#7 leaving R#11 room. Continued interview with the CNA revealed she left the secure unit to go to the laundry to get bed chucks from the dryer (this occurred on 3/15/17). An interview on 3/20/17 at 9:09 p.m. LPN BB confirmed that CNA EE notified her of the above, but did not document in R#11 chart nor report that on 3/15/17, R#7 had enter R#11 room. (Cross refer to F 223 for details) An interview on 3/22/17 at 12:00 p.m. the DON revealed that she was not aware of the incident on 3/10/17 of R#7 with his penis out in R#2 bed or the incident on 3/11/17 of R#7 with his penis out in R#8 bed. The DON continued to state that the nurse should have called her. The DON stated that she became aware of these incidents after the 3/15/17 incident involving multiple residents. An interview on 3/22/17 at 1:25 p.m. the Administrator revealed that she was not aware of the incident on 3/10/17 of R#7 with his penis out in R#2 bed or the incidents on 3/11/17 of R#7 with his penis out in R#8's room. She also said that the 24 hour report is reviewed during morning meetings and there were no indication of this type of behaviors. She stated that if she had been aware of R#7 behaviors, she would have placed him on 1:1 observation, and would have moved R#7 to a private room. The Administrator stated that she became aware of these incidents after the 3/15/17 incident involving multiple residents by reading R#7 nurse's notes. 8. Review of medical records for R#12 revealed they were readmitted to the facility on [DATE] with an original admitted [DATE]. R#12 had the following [DIAGNOSES REDACTED]. Review of nurse's notes revealed that R#12 hit and/or pushed another resident on 10/6/16, 10/13/16, 10/27/16, 11/19/16, 11/24/16, 12/4/16, 12/26/17, 1/26/17, 2/8/17, 2/9/17, 2/10/17, 3/8/17, and 3/21/17, a total of 13 times. Review of a geriatric behavior health report dated 2/15/17 revealed R#12 posed a danger to self and needed psychiatric hospitalization and stabilization. R#12 is currently pending placement to a behavioral facility as of 3/29/17. Review of the medical record revealed that despite the multiple altercations with other residents, the facility failed to ensure ongoing supervision of R#12 through visual observations, failed to recognize the signs and/or triggers that caused the aggressive behavior of R#12, failed to protect other residents from the behaviors of R#12 including the identification, analysis of the behaviors, and failed to ensure that R#12 was not left alone, or out of sight at any time. *****The facility implemented the following actions to remove the Immediate Jeopardy On 3/10/2017 and 3/14/17 facility staff were in-serviced on abuse and neglect. On 3/10/2017 24 out of 60 employees were in-service which included: one Administrator, seven nurses, 10 CNA's, four dietary staff, one maintenance staff and one activity staff. On 3/14/17, 42 out of 60 staff were in-serviced on abuse and neglect which included: 12 nurses, 14 CNAs, one central supply clerk, three dietary staff, one human resource staff, two therapist, five housekeeping staff, two agency staff, two activity staff. An abuse in-services for all facility staff and contract staff will begin on 3/20/17 by 12:00 p.m. and will be complete by Friday 3/24/17 at 5:00 p.m. Facility staff will receive in -service training prior to returning to work. Effective 4/1/17, abuse in-servicing for all facility and contract staff will be conducted quarterly, during facility orientation and as needed. The Hand In Hand Training will be used for quarterly education. The Social Services Director, the Activity Director or the Administrator will in-service current residents on abuse, how and to whom to report abuse, and prevention of abuse beginning on 03/21/17 and will be 100% complete by Thursday, 03/23/17 at 5:00 p.m. On 3/16/17 and 3/21/17 the social worker went around and interviewed residents on the unit to determine any other at risk residents. The social worker will follow up with residents at risk and report any psychological changes to the DON and the Administrator to determine if further intervention is needed. On 03/16/17 at approximately 12:30 a.m., R#7 was placed on immediate one on one supervision until police arrived. At approximately 1:15 a.m., Clinch County Police arrived and assisted with the resident's physician order of 1013 out of the facility to another facility to treat behaviors. On 3/16/17 at approximately 1:20 a.m., R#3 and R#4 were taken to Clinch Memorial hospital and evaluated. Both residents were returned to the facility with no injuries noted. Referrals for tele- psych visit with United Behavioral Health Services were ordered. On 3/16/17 the social worker went around and interviewed six residents that may have witness the incident on 3/16/17. R#3 was unable to answer any questions. R#4 can not recall the incident on 3/16/17. The six other residents stated they were glad R#7 was gone. When asked about the incident three out of six could not recall what happen that night. Two residents stated that R#7 had tried to get into their beds. One resident stated R#7 lied in his bed. Another resident revealed he observed R#7 crawling on the floor like an animal and trying to get into his roommates bed. This resident told R#7 to leave his room and R#7 did leave. All residents the social worker interviewed stated that R#7 seemed confused and was trying to lie down. The residents stated they told R#7 to leave and redirected R#7 out of their rooms. Out of the six residents interviewed they all stated R#7 did not touch them inappropriately. The social worker will follow up with R#3 and R#4 and report any psychological changes to the DON and the Administrator to determine if further intervention is needed. The Care Management Team reviewed residents on the secured unit on 3/17/17 and 3/21/17 to determine if any other residents were at psychological risk from the 03/16/17 incident. An abuse in-services for all facility staff and contract staff will begin on 3/20/17 by 12:00 p.m. and will be 100% complete by Thursday 3/23/17 at 5:00 p.m. Effective 4/1/17, abuse in-service will be conducted quarterly for all facility and contract staff as well as during facility orientation and as needed. The Hand In Hand Training will be used for quarterly education. In-services on Behavior Management and Preventing Difficult Behaviors for all facility staff and contract staff will begin on 03/20/17 by 12:00 p.m. and will be 100% complete by Friday 3/24/17 at 5:00 p.m. Effective 4/1/17, in-service for managing difficult behaviors will be conducted semi-annual for all facilty and contract staff as well as during facility orientation and as needed. On 3/22/17 a Resident Council meeting was scheduled to review resident's rights and abuse and neglect. The Social Services Director, the Activity Director or the Administrator will in-service current residents on abuse, how and to whom to report abuse and prevention of abuse beginning on 03/21/17 by and will be 100% complete by Tuesday, 03/23/17 at 5:00 p.m. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: Interview on 3/28/17 at 11:15 a.m. with certified nurse aide (CNA) LL revealed that she had attended in-services on types of abuse and who to talk to about abuse. At 11:24 a.m., CNA RR revealed that she was in-serviced on abuse and what she needed to do (behavior interventions). At 11:29 a.m., CNA SS revealed that abuse was discussed and who to report abuse. At 11:41 a.m. CNA NN revealed that she was not aware of the meeting, however; when she returned to work on 3/21/17, she was briefed by the Administrator and the Assistant Director of Nursing (ADON) about abuse and what should be done (behavior interventions). At 2:13 p.m., CNA FF revealed that the in-service was about abuse, notifying nurses of anything that happens on the unit and what to do (behavior interventions). Interviews on 3/28/17 at 11:32 a.m. Licensed Practical Nurse (LPN) TT revealed that she was given the information about abuse by the ADON to read over because she did not attend the actual inservice. Continued interview with LPN TT revealed that she did read the material provided to her by the ADON. At 11:37 a.m., LPN UU revealed that that when she returned to work on 3/22/17 the ADON provided her the reading material regarding abuse and she also reviewed the in-service materials that are placed in a book for nurses to read later. At 11:47 a.m., LPN CC revealed that she did not attended the in-service but was provided abuse information by ADON. LPN CC revealed the information was about to whom to report abuse, and what to do when found. An interview on 3/28/17 at 12:27 p.m. with the DON stated that 100% staff in-service was completed on abuse, including reporting, interventions, documentation of, and notification. The facility had two registered nurse that resigned and newly hired nursing staff and non-nursing staff were inservice on types of abuse, how to identify abuse, who to report abuse. An interview on 3/28/17 at 2:00 p.m. with the Administrator revealed that she was reviewing and doing follow-up regarding concerns on the 24 Hour Report. The Administrator revealed she is checking for anything alarming and anything that needs to be reported. This also includes area of concerns that requires further investigation. Review of the records for R#3 and R#4 confirmed they had been evaluated and there was no evidence of injury. Review of the record for R#7 confirmed that on 03/16/17 was placed on immediate one on one supervision, until R#7 was transported out of the facility via 1013. Interview with the acute care facility Administrator on 3/23/17 at 11:32 a.m. confirmed that R#7 was in the acute care facility. The acute care Administrator expressed the desire for R#7 to be readmitted to the facility, and stated that the nursing home was dumping on the hospital and they could not continue to care for R#7. Review of the audits confirmed that the social worker did interview residents on the secured unit about abuse from R#7. Review of the audits, confirmed that some residents on the unit could not recall events, some of the residents could not recall specific details ie dates or times, some of the residents did express concern related to the behaviors of R#7, however there were no occurrences reported.

Based on observation, interviews, and record review the facility failed to ensure medications, and a behavior consultant recommendations were implemented, failed to assess the cause of behaviors, failed to identify interventions to assist residents in managing their behaviors, medically-related social services to address the physical, mental and psychosocial needs of two residents (R7 and R#12) thus causing actual psychological harm to eight (8) residents (R#1, R#2, R#3, R#4, R#7 R#8, R#11 and R#12) of thirty three (33) residents on a secure unit. On 3/20/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for bipolar affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine fumarate (Seroquel) to 100 mg by mouth twice a day; and orders were olanzapine (Zyprexa) 5 mg tablet by mouth daily for maintenance; divalproex sodium 250 mg delayed release tablets by mouth twice a day for maintenance; diazepam 5 mg by mouth three times a day for maintenance; quetiapine (Seroquel) 100 mg by mouth twice a day for maintenance. However the facility failed to notify the attending physician, and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Review of the Job Description for the Social Service Worker signed and acknowledged by the Social Services Worker on 11/14/2016 revealed the following: The duties and responsibilities of the Social Worker include planning, developing, organizing, implementing, evaluating and directing the social services program to meet the needs of residents, determining the type of assistance required, assisting in obtaining benefits from agencies and organizations, completing necessary forms and involving families whenever possible and advisable. Also make arrangements for transportation to other institutions, clinics, etc., assists residents in identifying problems, formulating resolutions, and assists in utilizing community resources and preparing for discharge, in accordance with state and federal regulations and facility policies and procedures. Facilitate the coordination of the Social Services Department and other departments to maintain quality care for residents. Recognize and respond to changes in residents' social needs, and document observations, interventions and outcomes. Arrange transportation for residents to obtain medical consultations, outside appointments, etc. The following are skills needed to perform, with or without reasonable accommodation, the essential functions of the position of Social Worker. The ability to: recognize and respond to the social service needs of residents; effectively manage the Social Services Department with regard to residents, employees, families, visitors and the public; make prompt and accurate social service management judgments; effectively attend, aid, help, counsel and give support to residents and families; and communicate with residents, families, visitors and others; and convey a sense of caring; concern and dignity tolerate conflicts among and between staff, residents, visitors, and others, and; effectively manage time to perform the essential function of the job in a manner that benefits residents. 1. Review of the medical record dated 1/11/17 revealed R#7 was admitted to the facility on [DATE]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] Section I Active [DIAGNOSES REDACTED]. Review of the MDS Section E-Behavior indicated R#7 wandered daily and displayed behavioral symptoms occurring one (1) to three (3) days. Review of Section G Functional Status revealed that R#7 ambulates independently in room and corridor. Review of the admission/re-admission data collection and initial plan of care dated 1//11/17 revealed a plan of care for behaviors that were verbal and physical directed toward others and socially inappropriate behaviors. Review of a hospital discharge summary dated 12/22/16 revealed R#7's discharge medication was diazepam 5 mg by mouth three times a day for agitation for seven days; diphenhydramine HCL 50 mg by mouth every six hours as needed for anxiety for thirty days; fluoxetine HCL 20 mg capsule take 40 mg by mouth for 30 days; lacosamide (Vimpat) 50 mg take 100 mg by mouth every 12 hours for seizure for seven days; Lorazepam 1mg IM every six hours as needed for agitation; Quetiapine fumarate (Seroquel) 25 mg tablet take 100mg by mouth every evening for 30 days; quetiapine fumarate (Seroquel) 25 mg tablet take 50 mg by mouth daily for antipsychotic for 30 days, and; a referral to see a psychiatrist on 2/7/17 for bipolar affective disorder. Also on this discharge summary was a list of discontinued medication and specifically noted was to stop Valproic Acid (Depakote) 250 mg capsule take 750 mg by mouth every 12 hours for seizure. Review of the admission physician's order form dated 1/11/17 revealed that valproic acid (Depakote) 750 mg by mouth twice a day was written on the admission physician form, however there was no evidence valproic acid (Depakote) 750 mg by mouth was ordered. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine fumarate (Seroquel) to 100 mg by mouth twice a day; and orders were olanzapine (Zyprexa) 5 mg tablet by mouth daily for maintenance; divalproex sodium 250 mg delayed release tablets by mouth twice a day for maintenance; diazepam 5 mg by mouth three times a day for maintenance; quetiapine (Seroquel) 100 mg by mouth twice a day for maintenance. And a follow up appointment 4/6/17 was scheduled. Review of the physician order for [REDACTED]. An interview on 3/22/17 at 9:23 a.m., with the Medical Doctor (MD) revealed that he was not aware of the psychiatrist recommendation to implement changes to R#7 medications. And that the nurses are to call him with any consulting physician recommendation. MD stated that these medications ordered by the psychiatrist should have been implemented. An interview on 3/22/17 at 10:57 a.m., the Psychiatrist revealed that R#7 was seen in his office on 2/7/17 and that he sent to the facility a copy of his progress notes and written individual prescriptions for each medication for R#7 because R#7's pharmacy information was not in his system. The Psychiatrist stated that he was not aware that the recommendations for R#7 were not implemented. Continued interview revealed that R#7's medications ordered were for mood and agitation. An interview on 3/22/17 at 4:35 p.m. Licensed Practical Nurse (LPN) CC revealed that she put R#7 prescriptions in the facility pharmacy's gray bin for pick up and shredded the valium prescription that came with R#7 progress notes from the psychiatrist. In a later interview on 3/23/17 at 10:36 a.m. LPN CC stated that she could only recall the valium prescription. LPN CC continued to say that in the past, the Valium had been addressed with the MD to discontinue because the valium was causing R#7 to have increase anxiety and more agitation. LPN CC also revealed that the valium was replaced with Ativan in January 2017. She stated that the valium prescription was shredded to prevent having a written narcotic prescription in the R#7 medical records. Review of Physician's telephone orders dated 3/11/17 revealed to send to a behavior facility for evaluation when cleared sent to emergency room (ER) for 1013 (CERTIFICATE AUTHORIZING TRANSPORT TO EMERGENCY RECEIVING FACILITY and REPORT of TRANSPORTATION. In my opinion this Individual appears to be a mentally ill person requiring involuntary treatment in that he/she appears to be mentally ill and: (they either A or B) A. presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to other persons; or B. appears to be so unable to care for his/her own physical health and safety as to create an imminently life endangering crisis), to a behavioral facility. Further review of another phone order written on 3/12/17 revealed to send R#7 to a behavior facility as soon as a bed is available. Further investigation revealed that R#7 was sent to ER for medical clearance. R#7 was diagnosed with [REDACTED]. R#7 remained in the facility until 3/16/17 and was sent out of the facility after the multiple incidents involving other residents, as follows: on 3/10/17 revealed that R#7 was found in R#2 bed wearing a tee shirt and underwear, with his penis out of his underwear; on 3/11/17 revealed that R#7 entered the bed of R#8, with his penis out three times, attempted to urinate on R#8; on 3/15/17 at 10:45 p.m. R#1 was heard yelling obscenities at R#7 who was trying to get into the bed with him; on 3/15/17 at 11:30 p.m. R#7 entered the bed of R#3 (female) room, staff found the shirt of R#3 was unbuttoned, and she trying to get away from R#7; on 3/16/17 at 12:15 a.m. R#7 was on top of R#4 (male), pinning and humping the buttocks of R#4, and; on 3/20/17 at 9:09 p.m. during interview with LPN BB she stated she heard R#11 yelling I will kill you as R#7 was walking out of the shared bathroom of R#11. (Cross refer to F 223 for details) An interview on 3/22/17 at 1:25 p.m. the Administrator revealed that the behavior facility should have been called daily to check for an open bed. There was no evidence that social services had identified, and/or addressed the behaviors of the resident. 2. Review of medical records for R#12 revealed was readmitted to the facility on [DATE] with an original admitted [DATE] with the following but not limited to [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed in Section E, no behaviors, in Section G, titled Functional Status of independently transfers and ambulates. Review of nurse's notes dated 10/6/16 revealed R#12 hit another resident in the chest and shoulder four times. The MD gave an order to 1013 the resident to a behavior facility. R#12 was sent to the ER for medical clearance and returned to the facility. Review of nurse's notes dated 10/13/16 revealed R#12 hit his roommate after the roommate bumped him on the leg with his wheelchair. The MD ordered a 1013. R#12 was transfered to a behavioral facility. Review of nurse's notes dated 10/27/16 revealed R#12 was passing another resident and hit that resident. Zyprexa given. The MD ordered a 1013, however the behavior facility did not accept the resident due to not having a four day break in admission. Review of nurse's notes dated 10/28/16 revealed R#12 was placed on 15 minute monitoring. A later entry on the same day, revealed that R#12 had a room change related to arguing with his roommate. Review of nurse's notes dated 11/19/16 revealed R#12 hit a resident (roommate) in the face over a television channel. Geodon 10 mg IM was given as new dose and he was placed on 15 minutes watch. Review of nurse's notes dated 11/24/16 revealed R#12 had a confrontation with a female resident and hit her in the head. The MD gave a new order for 1013. R#12 was sent to the ER for medical clearance, then return back to the facility. Review of nurse's notes dated 12/4/16 revealed R#12 hit another resident and was placed on 15 minute watch. R#12 was not sent out of the facility. Review of nurse's notes dated 12/26/16 revealed R#12 was hitting a resident with a closed fist in the chest. R#12 was sent to the ER for medical clearance and to be placed in a behavior unit. Review of nurse's notes dated 12/28/16 revealed R#12 was returned to the facility due to the behavior unit was unable to find placement in a behavioral facility. R#12 was placed on fifteen (15) watch. Review of nurse's notes dated 1/26/17 revealed R#12 was striking out at other residents and being combative. The MD gave new order to increase Geodon to 40 mg by mouth twice a day and to give Seroquel 150 mg by mouth twice a day. Review of nurse's notes dated 2/8/17 revealed R#12 tried to hit a resident in front of him. He was redirected and monitored. Review of nurse's notes dated 2/9/17 revealed R#12 hit a resident on the arm and had to be separated from other residents. The nurse continue to monitor and the resident was placed on every 15 minutes checks. Review of nurse's notes dated 2/10/17 revealed R#12 punched a resident in the chest, and threw his tray across the room at another resident. He was placed on 15 minutes watch. The MD gave a new order to have R#12 arrested due to hitting other residents. The MD also order a 1013, one on one (1:1) until transfer to the hospital. Review of nurse's notes dated 3/8/17 revealed R#12 attempt to hit a female resident in the head. He had swung at her but missed. Review of the Doctor's Progress Notes dated 3/9/17 revealed that because of R#12 has dangerous behavior both to other patients and staff, he recommended that R#12 be placed under the criminal justice system and if necessary to be placed in a facility for the criminal insane. Review of Physician's Order dated 3/10/17 revealed that no behavior system will accept R#12 now- using dementia as an excuse. R#12 is dangerous and extreme caution should be used when dealing with R#12. The MD recommends that no one should attempt to deal with R#12 without a second staff member present. Review of nurse's notes dated 3/21/17 revealed R#12 pushed a resident down. The MD gave order to notify police and 1013 resident out of the facility. Review of nurse's notes dated 3/23/17 revealed R#12 was denied placement to a behavioral facility due to behavioral facility unable to meet resident needs. Review of a geriatric behavior health report dated 2/15/17 revealed R#12 posed a danger to self and needed psychiatric hospitalization and stabilization. R#12 is currently pending placement to a behavioral facility as of 3/29/17. Interview on 3/28/17 at 3:51 p.m. with Social Service revealed that this was her first Long Term Care Facility (LTC) and that her previous positions focused on marketing. She continued to reveal that she was not aware of the physician's order related to sending residents to the acute care facility for a 1013. She stated that she was not aware of the behaviors for R#7 or R#12 until 3/16/17 after the survey began and questions were being asked by the surveyor, including referrals for behaviors by the nursing department. She stated that when the physician writes an order for [REDACTED].e. an admission to a behavior unit, she faxes the information to the acute care facilities. She stated that the acute care behavior unit had no available beds. She further stated that a provider for psychiatric services is contracted with the facility. Continued interview with Social Service she stated that when they receive a referral for admissions, it usually comes via fax, once the fax is completed, it then goes to the Business Office. The business offices confirms payer sources. The nursing department reviews the information, request additional information and makes a decision on whether the needs of the resident can be met. If both the business office and nursing reply, yes, then a bed offer is made to the referring facility for admission to the facility. *****The facility implemented the following actions to remove the Immediate Jeopardy On 3/17/17 Medication Error report completed on incident. On 3/20/17 Residents with potential to be effected by this deficient practice were reviewed through a 100% audit on residents with an appointment within the last 30 days. No negative outcomes were identified. On 3/20/17 Director of Nursing initiated education to nurses on policy and procedure on residents returning from appointments and reconciliation of medication. Director of nursing will review in clinical morning meeting all residents who had an appointment the prior day to ensure new orders have been reconciled. 3/20/17 Root cause analysis completed on Medication error. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: Review of the Medication Error report verified it was completed on 3/17/17. Review of the education sign in sheets confirmed that the DON was educated the nurses on reconciliation of medications upon hospital return, and education was completed on 100% of the nursing staff by 3/23/17. The education included removing, ordering, reconciliation of orders, transcribing of the orders, the review of the policy and a memo with written instructions on the process. Review of the memo from the DON revealed that regardless of the admission type, each order was to be reviewed, and the nurse would initial indicating the review, the paperwork is to be placed in the front of the chart, so it can be reviewed in the morning meeting. Review of two recent admissions confirmed that the education had been implemented and that the nurses had completed the above process. Review of the 24 hour report revealed that returning residents were noted on the report and it was initialed by management staff. An interview on 3/28/17 at 12:27 p.m. the DON stated that 100% staff inservice was completed. The 24 Hour Report form is initialed by Administrator, DON and ADON each day and she verified that the charts were being brought to the morning meetings for review and follow ups. An interview on 3/28/17 at 2:00 p.m. the Administrator revealed that she is reviewing and doing follow-up for concerns on the 24 Hour Report, that it is being reviewed in the morning meetings. The administrator verified that the readmissions are being included in the morning meetings and they are being checked at that time, and that she is checking for any follow up actions. Post survey interview via telephone on 4/13/17 at 3:30 p.m. revealed that R#12 was still at the facility under 1:1 supervision, that the facility had reached out to numerous other behavior units without successful transfer.

Based on record review, and staff interview, and facility policy titled, Care Plan Development, the facility failed to develop comprehensive care plans for three (3) residents (R#7, R#1, and R#4) of the sampled twelve (12) residents. On 3/20/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for [MEDICAL CONDITION] affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine [MEDICATION NAME] ([MEDICATION NAME]) to 100 mg by mouth twice a day; and orders were [MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet by mouth daily for maintenance; [MEDICATION NAME] sodium 250 mg delayed release tablets by mouth twice a day for maintenance; [MEDICATION NAME] 5 mg by mouth three times a day for maintenance; quetiapine ([MEDICATION NAME]) 100 mg by mouth twice a day for maintenance. However the facility failed to notify the attending physician, and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings Include: Review of the facility policy titled, Care Plan Development revealed: An individualized, comprehensive care plan using the results of the Resident Assessment Instrument/Minimum data Set (RAI/MDS) assessment, resident/family/legal representative and interdisciplinary inputs will be developed for each resident in the facility with 21 days of admission or seven days after the completion date of a comprehensive MDS assessment. 1. Review of the medical record for R#7 revealed an admission date of [DATE], however there was no comprehensive care plan developed until 3/17/17. 2. R#1 was admitted on [DATE] however, review of the medical record revealed there was no comprehensive care plan developed until 3/20/17. 3. R#4 was admitted on [DATE] however, review of the medical record revealed there was no comprehensive care plan developed until 3/20/17. An interview on 3/16/17 at 4:00 p.m., with the Minimum Data Set (MDS) Coordinator revealed that she had not written the comprehensive care plan for R#1, R#4, R#7 and R#8 because she is being pulled to work in the facility as a CNA and was unable to finish her work. She further revealed that she has been working on R#7's comprehensive care plan all day. An observation on 3/20/17 at 4:15 p.m., the MDS coordinator was observed pushing the snack cart and passing snacks to residents on the halls. *****The facility implemented the following actions to remove the Immediate Jeopardy On 3/10/17 and 3/14/17 facility staff were in-serviced on abuse and neglect. On 3/10/17, 24 out of 60 employees were in-service which included: one administrator, seven nurses, 10 CNA's, four dietary staff, one maintenance staff and one activity staff. On 3/14/17, 42 out of 60 staff were in-serviced which included: 12 nurses, 14 CNAs, one central supply clerk, three dietary staff, one human resource staff, two therapist, five housekeeping staff, two agency staff and two activity staff An abuse in-service for all facility staff and contract staff will begin on 3/20/17 by 12:00 p.m. and will be complete by Friday 3/24/17 at 5:00 p.m. Staff will receive in-service training prior to returning to work. Effective 4/1/17, abuse in-service training for all facility and contract staff will be conducted quarterly, during facility orientation and as needed. The Hand In Hand Training will be used for quarterly education. The Social Services Director, the Activity Director or the Administrator will in-service current residents on abuse, how to whom to report abuse and prevention of abuse beginning on 03/21/17 by and will be 100% complete by Thursday, 03/23/17 at 5:00 p.m. On 3/16/17 and 3/21/17 social worker went around and conducted interviews with residents on the secured unit to determine any other at risk residents. The social worker will follow up with residents and report any psychological changes to the DON and the Administrator to determine if further intervention is needed. On 03/16/17 at approximately 12:30 a.m., R#7 was placed on immediate one on one supervision until police arrived. At approximately 1:15 a.m. Clinch County Police arrived and resident was 1013 out of facility. On 3/16/17 at approximately 1:20 a.m., R#3 and R#4 were taken to Clinch Memorial hospital and evaluated. Both residents were returned to the facility with no injuries noted. Referrals for tele- psych visit with United Behavioral Health Services was ordered. On 3/16/17 the social worker went around and interviewed six residents that may have witness the incident on 3/16/17. R#3 was unable to answer any questions. R#4 could not recall the incident on 3/16/17. The six other residents stated they were glad R#7 was gone. When residents were asked about the incident three out of six could not recall what happen that night (3/16/17). Two residents stated R#7 had been trying to get into their beds. One resident stated R#7 lied in his bed. 1 One resident stated he observed R#7 crawling on the floor like an animal and trying to get into his roommates bed but he and his roommate told R#7 to leave. Resident stated R#7 left their room when redirected. All of the residents interviewed stated R#7 seemed confused and was trying to lie down. The residents stated they told R#7 to leave and redirected R#7 out of their rooms. The residents that were interviewed revealed that R#7 did not touch them inappropriately. The social worker will follow up with R#3 and R#4 and report any psychological changes to the DON and the Administrator to determine if further intervention is needed. The Care Management Team reviewed residents on the secured unit on 3/17/17 and 3/21/17 to determine any other residents were at psychological risk from the incident on 03/16/17. An abuse in-service for all facility staff and contract staff will begin on 3/20/17 by 12:00 p.m. and will be 100% complete by Thursday 3/23/17 at 5:00 p.m. Effective 4/1/17, abuse in-service will be conducted quarterly for all facility staff and contract staff as well as in new employee orientation and as needed. The Hand In Hand Training will be used for quarterly education. In-services on Behavior Management and Preventing Difficult Behaviors for all facility staff and contract staff will begin on 03/20/17 by 12:00 p.m. and will be 100% complete by Friday 3/24/17 at 5:00 p.m. Effective 4/1/17, in-servicing for managing difficult behaviors for all facility staff and contract staff will be conducted semi-annual, during facility orientation and as needed. On 3/22/17 a Resident Council meeting was scheduled to review resident's rights and abuse and neglect. The Social Services Director, the Activity Director or the Administrator will in-service current residents on abuse, how and to whom to report abuse and prevention of abuse beginning on 03/21/17 by and will be 100% complete by Tuesday, 03/23/17 at 5:00 p.m. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: Interview on 3/28/17 at 11:15 a.m. with certified nurse aide (CNA) LL revealed that she had attended in-services on types of abuse and who to talk to about abuse. At 11:24 a.m., CNA RR revealed that she was in-service on abuse and what she needed to do (behavior interventions). At 11:29 a.m., CNA SS revealed that abuse was discussed and who to report abuse. At 11:41 a.m. CNA NN revealed that she was not aware of the meeting; however, when she returned to work on 3/21/17, she was educated by the Administrator and the Assistant Director of Nursing (ADON) about abuse and what should be done (behavior interventions). At 2:13 p.m., CNA FF revealed that the in-service was about abuse, notifying nurses of anything that happens on the unit and what to do (behavior interventions). Interviews on 3/28/17 at 11:32 a.m. Licensed Practical Nurse (LPN) TT revealed that she was given the information regarding abuse to read over because she did not attend the actual in-service. LPN TT stated that she did read the material provided to her by the ADON. At 11:37 a.m., LPN UU revealed that that when she returned to work on 3/22/17 that the ADON provided her the reading material regarding abuse which she did read. LPN UU stated that the in-service materials are placed in a book for nurses to read later. At 11:47 a.m., LPN CC revealed that she did not attended the in-service but was provided the information about abuse by ADON. LPN CC revealed she read the information which was regarding abuse, who to report it to, what to do when found. An interview on 3/28/17 at 12:27 p.m. with the DON stated that 100% staff in-service was completed on abuse, including reporting, interventions, documentation of, and notification. The facility had two registered nurse that had resigned. The DON revealed that newly hired nursing staff and non-nursing staff were in-service on types of abuse, how to identify abuse, who to report abuse. An interview on 3/28/17 at 2:00 p.m. with the Administrator revealed that she was reviewing and doing follow-up for concerns on the 24 Hour Report. The Administrator revealed she was checking for anything alarming and anything that needs to be reported, this also includes area of concerns that requires further investigation. Review of the records for R#3 and R#4 confirmed they had been evaluated at the hospital and there was no evidence of injury. Review of the record for R#7 confirmed that on 03/16/17 was placed on immediate one on one supervision, until R#7 was transported out of the facility via 1013. Interview with the acute care facility Administrator on 3/23/17 at 11:32 a.m. confirmed that R#7 was in the acute care facility. The acute care Administrator expressed the desire for R#7 to be readmitted back to the facility, and stated that the nursing home was dumping on the hospital as they could not continue to care for R#7. Review of the audits confirmed that the social worker did interview residents on the secured unit about abuse from R#7. Review of the audits, confirmed that some residents on the unit could not recall events, some of the residents could not recall specific details ie dates or times, and some of the residents did express concern related to the behaviors of R#7, however there were no occurrences reported.

Based on record review, observation, review of policy and procedures including, Abuse Prevention Program and Reporting Policy Resident to Resident Abuse and interviews, the facility failed to protect and follow the policy for six (6) residents (R#1, R#2, R#3, R#4, R#8, and R#11) of thirty three (33) residents on a secure unit from sexual assault from R#7. Specifically; The facility failed to implement [MEDICAL CONDITION] medication as ordered by a psychiatrist, failed to have adequate staffing to provide 1:1 observation and failed to notify the Medical Doctor (MD) of a Psychiatrist recommendation R#7; failed to develop interventions for R#12 with multiple resident to resident altercations; and failed to protect (R#1, R#2, R#3, R#4, R#8, and R#11) from sexual assaults by R#7 which resulted in psychological harm to all eight residents. On 3/20/17, determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for [MEDICAL CONDITION] affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine [MEDICATION NAME] ([MEDICATION NAME]) to 100 mg by mouth twice a day; and orders were [MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet by mouth daily for maintenance; [MEDICATION NAME] sodium 250 mg delayed release tablets by mouth twice a day for maintenance; [MEDICATION NAME] 5 mg by mouth three times a day for maintenance; quetiapine ([MEDICATION NAME]) 100 mg by mouth twice a day for maintenance. However the facility failed to notify the attending physician, and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: 1. Review of the admission record dated 1/11/17 revealed R#7 was admitted to the facility with no [DIAGNOSES REDACTED]. R#7 had benign [MEDICAL CONDITION] prostate, dementia non-Alzheimer, anxiety, depression, [MEDICAL CONDITIONS] and gastro [MEDICAL CONDITION] reflux disorder. Review of the nurse's notes dated 1/11/17 revealed R#7 ambulated to a female resident's room, speech was unclear and verbally resistant to redirection. R#7 placed a blanket and sheet on the female resident bed and attempted to climb in bed with her. R#7 was assisted by two person back to his room. A nurse's note dated 1/12/17 revealed R#7 was wandering in and out of female residents room and attempts to redirect R#7 was with very little success. The Director of Nursing (DON) was notified, resident moved to a different room for better supervision and 15 minutes checks. Review of nurse's notes dated 3/16/17 revealed that R#7 continued to enter other resident's room with inappropriate sexual behaviors. It's noted that R#7 entered into R#11's room and he was redirected back to his room, then R#7 went into R#1's room trying to get in his bed and was redirected, later R#7 went into R#3 room and was removed from her bed and placed on 15 minute staff watch, and finally R#7 went into R#4's room where he pinned down R#4 and had to be removed off R#4. LPN BB notified the Administrator and the Medical Doctor (MD) who gave an order to call the police for a 1013. R#7 was not placed on 1:1 observation until after he pinned down R#4 on 3/16/17, and the nurse was waiting for the police to arrive in the building. Review of the police report dated 3/16/17 revealed the type of incident was listed as sexual battery against three residents (R#1, R#3, and R#4). Review of the medical record revealed the following episodes of sexual assaults: on 3/10/17 revealed that R#7 was found in R#2's bed wearing a tee shirt and underwear, with his penis out of his underwear; on 3/11/17 revealed that R#7 entered the bed of R#8, with his penis out three times, attempted to urinate on R#8; on 3/15/17 at 10:45 p.m. R#1 was heard yelling obscenities at R#7 who was trying to get into the bed with him; on 3/15/17 at 11:30 p.m. R#7 entered the bed of R#3 (female) room, staff found the shirt of R#3 was unbuttoned, and she trying to get away from R#7; on 3/16/17 at 12:15 a.m. R#7 was on top of R#4 (male), pinning down and humping the buttocks of R#4, and; on 3/20/17 at 9:09 p.m. during interview with LPN BB she stated she heard R#11 yelling I will kill you as R#7 was walking out of the shared bathroom of R#11. (Cross refer to F 223 for details) Review of each of the above assaults revealed that R#7 was removed from the situation, at times every 15 minute checks were implemented, and one-to-one supervision, however the R#7 continued with the behaviors which placed all residents on the secured unit at risk. Interview on 3/22/17 at 9:23 a.m., the Medical Doctor (MD) revealed that he was not aware of the psychiatrist recommendation to implement changes to R#7's medications. Interview on 3/22/17 at 10:57 a.m., the Psychiatrist revealed that R#7 was seen in his office on 2/7/17 and he sent the facility a copy of his progress notes and written individual prescriptions for each medication for R#7 because R#7 pharmacy information was not in his system. The Psychiatrist stated that he was not aware that the recommendation for R#7 was not implemented. Continued interview revealed that medications ordered for R#7 was for mood and agitation. 2. Review of medical records revealed Resident #12 was readmitted to the facility on [DATE] with an original admitted [DATE]. R#12 had the following but not limited to diagnoses of paranoid [MEDICAL CONDITION], anxiety disorder, [MEDICAL CONDITION], major [MEDICAL CONDITIONS], mild intellectual disabilities, dementia, impulsive disorder, conduct disorder, violent behavior, restlessness and agitation, and presence of cardiac pacemaker. Review of physician's orders dated 3/9/17, the MD revealed that R#12 was a danger to other residents and staff and has attacked both previously. The MD continued to reveal that the facility was not able to provide adequate care for R#12. Review of physician's order dated 3/10/17, the MD revealed recommendation that if R#12 does attack any other patient or staff, that charges be pressed and he enter the legal/correction system. No behavior system will accept R#12 using dementia as an excuse. R#12 is dangerous and extreme caution should be used when dealing with him. Review of physician's telephone orders dated 3/21/17 revealed a 1013 to emergency room (ER) for evaluation and treat. R#12 had pushed a female resident on the floor. However, as of 3/29/17 R#12 remains in the facility. Review of the staffing hours revealed the following nursing hours per patient day (PPD): On 2/25/17 was 2.35 - the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse; On 2/26/17 was 2.28 -- the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse; On 3/4/17 was 2.44-- the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse; On 3/5/17 was 2.23-- the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse; On 3/6/17 was 2.44 -- the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse; On 3/11/17 was 2.37- on 3/11/17 revealed that R#7 entered the bed of R#8, with his penis out three times, attempted to urinate on R#8, and; the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse; On 3/12/17 was 2.21- the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse and; On 3/13/17 was 2.34-- the nurse scheduled for the secured unit also worked the C Hall-leaving the secured unit without a nurse. Review of the daily deployment sheets for February 2017 revealed that the MDS Coordinator worked as a certified nurse aide on 2/5/17, 2/15/17 and 2/20/17. Review of the daily deployment sheets revealed that on the 7 p.m. to 7 a.m. shift the secured unit Hall A nurse worked part of a Hall C leaving Hall A without a licensed nurse. On the following days; 1/11/17, 1/16/17, 1/17/17, 1/20/17, 1/21/17, 1/22/17, 1/24/17, 1/25/17, 1/26/17, 1/31/17, 2/1/17, 2/3/17, 2/4/17, 2/5/17, 2/6/17, 2/7/17, 2/8/17, 2/9/17, 2/20/17, 2/21/17, 2/22/17, 2/23/17, 2/24/17, 2/25/17, 2/26/17, 2/27/17, 2/28/17, 3/1/17, 3/2/17, 3/3/17, 3/4/17, 3/5/17, 3/6/17, 3/8/17, 3/9/17, 3/11/17, 3/12/17, 3/13/17, 3/14/17, 3/15/17, 3/16/17, 3/18/17, 3/19/17, 3/20/17, 3/21/17, 3/22/17, 3/23/17, 3/25/17, 3/27/17 and 3/28/17. An interview on 3/20/17 at 11:44 p.m., Certified Nurse Aide FF revealed that the licensed nurse goes to Hall C to pass medication and then comes back to Hall A. And that one CNA will be on Hall C and the other CNA will be giving showers. This sometimes leaves no one on Hall A for about 28-30 residents. An interview on 3/23/17 at 1:05 p.m., License Practical Nurse BB revealed that she will pass medication on Hall C first and do the blood sugars leaving Hall A without a licensed nurse. The LPN continued to state that sometime there is only one CNA or no CNA on the Hall A because one CNA will be on Hall C and the other CNA will be in the shower room. An interview on 3/28/17 at 10:13 a.m. with the Administrator revealed that she was aware of Hall A nurses leaving the unit and Hall A was without a licensed nurse. The Administrator continued to state that this has been the normal practice from her predecessors, however she has since requested approval for a third nurse on 7 p.m. to 7 a.m. shift. *****The facility implemented the following actions to remove the Immediate Jeopardy Daily staffing schedule reviewed for the month of March and April by Director of Nursing. Director of Nursing, weekend Supervisor and Administrator will review on a daily basis the staffing hours for the next seventy-two hours of staffing by using the Daily Deployment Sheets and manage staffing to meet resident acuity daily for three months. CNA and Nursing open positions advertised on Indeed and Facebook. Referral bonus for current employees referring new staff implemented. We have implemented a shift bonus for extra shifts that staff pick up that are open. We have had some staff from several facilities under the same management company that come and help out. We have a contract signed with an agency that is also filling open shifts. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: Review of the daily deployment form for 3/21/17 and 3/22/17 revealed that an additional staff was scheduled for 1:1 supervision. Review of the daily deployment forms dated 3/20/17 through 3/23/17 revealed that the nurse on the 7 pm to 7 am shift was being used on both the secured unit and the C hall, and that 2 nursing assistants were assigned to the secured unit. However, there was only one incident related to R#12 pushing another resident. R#12 was sent to the ER, and returned to the facility and is pending admission to a behavior facility. A Post survey telephone interview on 4/13/17 at 1:00 p.m. with the administrator revealed that they have hired an additional nurse to work the secured unit, who is currently on orientation. The administrator stated that staff are covering the unit and the needs of the unit with overtime. The administrator stated that they are using agency staff when they cannot cover the shift within the facility staff. Post survey telephone interview on 4/13/17 at 3:30 p.m. and review of additional documents revealed that a CNA came from the agency on 3/29/17, and a LPN worked from an agency on 3/30/17. Review of the additional documents revealed that from 4/1/17 through 4/12/17 a total of 13 agency staff have worked at the facility. The Administrator stated that staffing is being reviewed daily by her, the DON and the ADON. Review of the additional documentation sent from the Administrator revealed that from 3/20/17 through 3/31/17 a total of 23 Bonuses were paid for staff to work and 4 staff worked from sister facilities, from 4/1/17 through 4/9/17 a total of 10 bonuses were paid and 3 staff worked from sister facilities.

Based on record review and staff interview, it was determined that the facility failed to ensure it was administered in a manner that effectively implemented their policies related to behavior management including 15 minute checks and/or 1:1 monitoring, failed to ensure that a nurse was present on the secured unit and failed to ensure there was sufficient staff on the secured unit to prevent sexual abuse for six (6) residents (R#1, R#2, R#3, R#4, R#8,and R#11) by one (1) resident (R#7). The sample was 12. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on 3/16/17 was seventy three (73) residents. On 3/20/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for [MEDICAL CONDITION] affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine [MEDICATION NAME] ([MEDICATION NAME]) to 100 mg by mouth twice a day; and orders were [MEDICATION NAME] ([MEDICATION NAME]) 5 mg tablet by mouth daily for maintenance; [MEDICATION NAME] sodium 250 mg delayed release tablets by mouth twice a day for maintenance; [MEDICATION NAME] 5 mg by mouth three times a day for maintenance; quetiapine ([MEDICATION NAME]) 100 mg by mouth twice a day for maintenance. However the facility failed to notify the attending physician, and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: 1. Review of the medical record revealed that R#7 was admitted to the facility on [DATE]. Further review of the record revealed the following episodes of sexual assaults: on 3/10/17 revealed that R#7 was found in R#2 bed wearing a tee shirt and underwear, with his penis out of his underwear; on 3/11/17 revealed that R#7 entered the bed of R#8, with his penis out three times, attempted to urinate on R#8; on 3/15/17 at 10:45 p.m. R#1 was heard yelling obscenities at R#7 who was trying to get into the bed with him; on 3/15/17 at 11:30 p.m. R#7 entered the bed of R#3 (female) room, staff found the shirt of R#3 unbuttoned, and she was trying to get away from R#7; on 3/16/17 at 12:15 a.m. R#7 was on top of R#4 (male), pinning down and humping the buttocks of R#4, and; on 3/20/17 at 9:09 p.m. during interview with LPN BB she stated she heard R#11 yelling I will kill you as R#7 was walking out of the shared bathroom of R#11. (Cross refer to F 223 for details) Review of each of the above assaults revealed that R#7 was removed from the situation, at times 15 minute checks were implemented, and 1:1 monitoring, however R#7 continued to have behaviors. 2. Review of nurse's notes revealed that on the following dates R#12 had a resident to resident altercation: on 10/6/16, 10/13/16, 10/27/16, 10/28/16, 11/19/16, 11/24/16, 12/4/16, 12/26/16, 12/28/16, 1/26/17, 2/8/17, 2/9/17, 2/10/17, 3/8/17, 3/21/17 and 3/23/17. Review of the daily deployment sheets revealed that on the 7 p.m. to 7 a.m. shift the secured unit Hall A nurse worked part of a Hall C leaving Hall A without a licensed nurse. The following days, Hall A was periodically without licensed nurse; 1/11/17, 1/16/17, 1/17/17, 1/20/17, 1/21/17, 1/22/17, 1/24/17, 1/25/17, 1/26/17, 1/31/17, 2/1/17, 2/3/17, 2/4/17, 2/5/17, 2/6/17, 2/7/17, 2/8/17, 2/9/17, 2/20/17, 2/21/17, 2/22/17, 2/23/17, 2/24/17, 2/25/17, 2/26/17, 2/27/17, 2/28/17, 3/1/17, 3/2/17, 3/3/17, 3/4/17, 3/5/17, 3/6/17, 3/8/17, 3/9/17, 3/11/17, 3/12/17, 3/13/17, 3/14/17, 3/15/17, 3/16/17, 3/18/17, 3/19/17, 3/20/17, 3/21/17, 3/22/17, 3/23/17, 3/25/17, 3/27/17 and 3/28/17. An interview on 3/28/17 at 10:13 a.m. with the Administrator revealed that she was aware of Hall A nurses leaving the secured unit and Hall A was without a licensed nurse. The Administrator continued to state that this had been the normal practice from her predecessors; however, she has since requested approval for a third nurse on 7 p.m. to 7 a.m. shift. (Cross refer to F223, F226, F250, F353) *****The facility implemented the following actions to remove the Immediate Jeopardy Daily staffing schedule reviewed for the month of March and April by Director of Nursing. Director of Nursing, weekend Supervisor and Administrator will review on a daily basis the staffing hours for the next seventy-two hours of staffing by using the Daily Deployment Sheets and manage staffing to meet resident acuity daily for three months. CNA and Nursing open positions advertised on Indeed and Facebook. Referral bonus for current employees referring new staff implemented. We have implemented a shift bonus for extra shifts that staff pick up that are open. We have had some staff from several facilities under the same management company that we are that come and help out. We have a contract signed with an agency that is also filling open shifts. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) Jeopardy Removal as follows: Review of the daily deployment form for 3/21/17 and 3/22/17 revealed that additional staff were scheduled for 1:1 monitoring. Review of the daily deployment forms dated 3/20/17 through 3/23/17 revealed that the nurse on the 7 p.m. to 7 a.m. shift was being used on both the secured unit and the C hall, and that two nursing assistants were assigned to the secured unit. However, there was only one incident related to R#12 pushing another resident. R#12 was sent to the ER, and returned to the facility and is pending admission to a behavior facility. A Post survey telephone interview on 4/13/17 at 1:00 p.m. with the Administrator revealed that they have hired an additional nurse to work on the secured unit and who is currently in orientation. The Administrator stated that staff are covering the secured unit and the needs of the unit with overtime. The Administrator stated that they are using agency staff when they cannot cover the shift with the facility staff. Post survey telephone interview on 4/13/17 at 3:30 p.m. with the Administrator and review of additional documents revealed that a CNA came from the agency on 3/29/17, and a LPN worked from an agency on 3/30/17. Review of the additional documents revealed that from 4/1/17 through 4/12/17 a total of 13 agency staff have worked at the facility. The Administrator stated that staffing is being reviewed daily by her, the DON and the ADON. Review of the additional documentation sent from the Administrator revealed that from 3/20/17 through 3/31/17 a total of 23 bonuses were paid for staff to work and four staff worked from sister facilities, from 4/1/17 through 4/9/17 a total of 10 bonuses were paid and three staff worked from sister facilities.

Based on observation, record review and staff interviews, it was determined that the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed and implemented corrective action plans to correct a problem of inadequate staffing, and the sexual inappropriate behavior of one (1) resident (R#7). Review of the form CMS-672, Resident Census and Conditions of Residents, the census was seventy three (73) residents and the sample size was twelve (12). On 3/20/17, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The Administrator, Director of Nursing (DON) and Assistant Director of Nursing (ADON) for Clinch Healthcare Center were notified on 3/20/17 at 10:17 a.m. that Immediate Jeopardy (IJ) existed. The Immediate Jeopardy is outlined as follows: On 1/17/17 R#7 was admitted to the facility with a referral to see a psychiatrist on 2/7/17 for [MEDICAL CONDITION] affective disorder. Review of the psychiatric progress note dated 2/7/17 revealed that impression and plan was to increase quetiapine [MEDICATION NAME] ([MEDICATION NAME]) to 100 mg by mouth twice a day; and orders were [MEDICATION NAME] (Zyprexia) 5 mg tablet by mouth daily for maintenance; [MEDICATION NAME] sodium 250 mg delayed release tablets by mouth twice a day for maintenance; [MEDICATION NAME] 5 mg by mouth three times a day for maintenance; quetiapine ([MEDICATION NAME]) 100 mg by mouth twice a day for maintenance. However, the facility failed to notify the attending physician and the recommendations for the increase and changes in medications were never implemented. In addition, R#7's behavior escalated resulting in actual psychological harm not only to R#7 who was experiencing uncontrollable crying, anxiety and aggressive behaviors but also to six other residents (R#1, R#2, R#3, R#4, R#8,and R#11) from sexual assault by R#7. The sample was twelve (12), and the census was seventy three (73) residents. The noncompliance related to the immediate jeopardy was identified to have existed on 2/7/17. The immediate jeopardy continued through 3/23/17. An acceptable Allegation of Compliance (AoC) was received on 3/27/17. Based on the validation of the AoC, the State Survey Agency determined the deficient practice was corrected on 3/23/17. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the AoC, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/23/17. The facility remained out of compliance at a lower scope and severity of E at F157, F223, F226, F250, F353, F490 and F520, while the facility continued management level staff oversight of resident to resident abuse including supervision of the residents at risk and/or with behavior concerns, medication management, review of the physician orders and consultant recommendations including medication adjustments and/or therapeutic interventions, education of the staff and/or staffing based on the identified needs of the residents. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the accurate acquiring of the necessary care and services including resident medication/behavior therapy, and the necessary steps to ensure the continuity of care. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures. Findings include: Immediate Jeopardy related to the facility's noncompliance with the program requirements at 42 C.F.R. was identified to have existed on 2/7/17 the first date verified that R#7 had not received the [MEDICAL CONDITION] medications ordered by the psychiatrist and inadequate staffing to provide 1:1 monitoring to prevent sexual assault for six (6) residents on 3/10/17, 3/11/17, 3/13/17, 3/14/17, 3/15/17 and 3/16/17. Review of the facility's QAA Committee's Quarterly Meeting sign-in sheets revealed that the Medical Director, Administrator, DON and several department heads met on 12/21/16, 1/27/17 and 2/28/17. An interview with the Administrator on 3/29/17 at 11:53 a.m., revealed that the QAA committee meets monthly and quarterly and consisted of the Medical Director, Administrator, Director of Nursing, and the department heads. Continued interview revealed that open staffing positions had been an on-going concern because of qualified applicants in the local community. Further interview revealed that during morning meeting a review of the 24 Hour Report did not indicate any unusual behavior for R#7 nor did the License Practical Nurse (LPN) report the sexual occurrence for 3/10/17. The Administrator stated that she had not been notified of R#7 sexual inappropriateness until 3/16/17 and after reading R#7 medical chart. The Administrator revealed had she known, she would have immediately implemented 1:1 monitoring and moved R#7 to a private room. The Administrator stated the nurse did not follow facility policy for the consultant physician order for [REDACTED]. Interview with the Medical Director on 3/20/17 at 10:37 a.m. revealed that he visited the facility to see his residents every other week. He stated that he did not discuss R#7 with the Administrator on 3/10/17 because his intentions were that the nurse would inform the Administrator and the DON of R#7's behaviors. At the time of exit on 3/29/17 an acceptable Allegation of Compliance (AoC) had been received therefore the IJ was abated on 3/23/17. *****The facility implemented the following actions to remove the Immediate Jeopardy Daily staffing schedule reviewed for the month of March and April by Director of Nursing. Director of Nursing, weekend Supervisor and Administrator will review on a daily basis the staffing hours for the next seventy-two hours of staffing by using the Daily Deployment Sheets and manage staffing to meet resident acuity daily for three months. CNA and Nursing open positions will be advertised on Indeed and Facebook. Referral bonus for current employees referring new staff implemented. The facility had implemented a shift bonus for extra shifts that staff pick up that are open. The facility had some staff from several sister facilities under the same management company come and help out. The facility had a contract signed with an agency that is also assisting with filling open shifts. **** The State Survey Agency (SSA) validated the Allegation of Compliance (AoC) and Immediate Jeopardy removal as follows: Review of the daily deployment form for 3/21/17 and 3/22/17 revealed that an additional staff was scheduled for 1:1 monitoring in the secured unit. Review of the daily deployment forms dated 3/20/17 through 3/23/17 revealed that the nurse on the 7 p.m. to 7 a.m. shift were being used on both the secured unit and the Hall C, and that two nursing assistants were assigned to the secured unit. However, there was only one incident related to R#12 pushing another resident. R#12 was sent to the emergency room (ER), and returned to the facility and is pending admission to a behavior facility. A Post survey telephone interview on 4/13/17 at 1:00 p.m. with the Administrator revealed that they have hired an additional nurse to work on the secured unit and who is currently in orientation. The Administrator stated that staff were covering the unit and the needs of the unit with overtime. The Administrator stated that they are using agency staff when they cannot cover the shift with the facility staff. Post survey telephone interview on 4/13/17 at 3:30 p.m. with the Administrator and review of additional documents revealed that a CNA came from the agency on 3/29/17, and a LPN worked from an agency on 3/30/17. Review of the additional documents revealed that from 4/1/17 through 4/12/17 a total of 13 agency staff have worked at the facility. The Administrator stated that staffing is being reviewed daily by her, the DON and the ADON. Review of the additional documentation sent from the Administrator revealed that from 3/20/17 through 3/31/17 a total of 23 bonuses were paid for staff to work and four staff worked from sister facilities, from 4/1/17 through 4/9/17 a total of 10 bonuses were paid and three staff worked from sister facilities.

Based on record review and staff interview, it was determined that the facility failed to ensure the following: that licensed nursing staff followed physician's orders [REDACTED].#5, #12 and #16); that licensed nursing staff followed up promptly with the physician about abnormally low or high laboratory test results for four residents (#2, #6, #12 and #13) of 11 residents, who were given medications that required titration to obtain and/or maintain therapeutic levels and; that licensed nursing staff promptly notified the physician about the need to revise the drug therapy for one resident (#5) with a urinary tract infection [MEDICAL CONDITION] from a total sample of 19 residents. Licensed nursing staff failed to notify the Director of Nursing that laboratory tests were not being obtained as ordered. The DON denied being aware that laboratory tests were not being done as ordered or that the physicians were not being promptly notified of the test results. Supervisory nursing staff failed to ensure that licensed nursing staff had obtained laboratory tests as ordered and followed up with their physicians about abnormal laboratory test results for residents #2, #5, #6, #12, #13 and #16. Resident #2 returned from the hospital on [DATE] with physician's orders [REDACTED]. Licensed nursing staff did not follow the order or notify the Director of Nursing or the physician that it was not done. The nursing staff's failure to obtain [MEDICATION NAME] levels twice a week as ordered for resident #2 resulted in the physician not having the laboratory test results necessary to review the appropriateness of the ordered drug therapy. After receiving the laboratory report that resident #2's [MEDICATION NAME] level was low on 4/27/10 at 4:06 p.m., nursing staff did not attempt to notify his/her physician until 21 hours later. Resident #2, who had a history of [REDACTED]. Therefore, it was determined that the likelihood of an immediate and serious threat to resident health and safety existed from 4/15/10 until 4/30/10 when a plan of correction was implemented to remove the jeopardy situation. Findings include: According to the Sections 43-26-3 and 43-26-32 of the Georgia Nursing Practice and Regulations Act, licensed nurses' responsibilities included the communication and consultation with other health team members. The nursing staff was responsible for obtaining laboratory test results and for consulting with the residents' physician about abnormal levels. On 4/30/10 at 2:00 p.m., the Director of Nursing stated that she was responsible for ensuring that licensed nursing staff obtained laboratory tests as ordered and followed up with the physician promptly about abnormal test results. She stated, however, that she was unaware that licensed nursing staff had failed to obtain laboratory tests and/or failed to follow up with the physician about abnormal laboratory test results for residents #2, #5, #6, #12, #13 and #16. The DON said that, although she was ultimately responsible to ensure that laboratory tests were obtained as ordered and the doctor notified about them, a floor nurse had been assigned those tasks about 2 to 3 months ago instead of the ADON, who had been previously assigned to do them. At 2:30 p.m. on 4/30/10, floor nurse "LL", who had been given responsibility to do the laboratory audits, said that she had told the DON and ADON that she did not know how to do it. The nurse said that she had later been told that she would only be responsible for the labs (audits) on her hall. She said that it was difficult to give medications to residents all day and then have to keep up with labs and notifying the physicians (lab audits). 1. According to the 4/5/10 hospital history and physical, Resident #2 had a history of [REDACTED]. The resident was readmitted to the facility on [DATE] with physician's orders [REDACTED]. The resident had care plan interventions since 4/15/10 for licensed nursing staff to administer medication as ordered to prevent [MEDICAL CONDITION] and to obtain laboratory tests as ordered by the physician to monitor the blood level of the [MEDICAL CONDITION] medication. However, licensed nursing staff failed to obtain a [MEDICATION NAME] level twice weekly between 4/15/10 and 4/27/10. Although licensed nursing staff had documented on the 4/22/10 nurse's notes that the laboratory technician had been unable to draw a blood sample from the resident for testing, there was no evidence that the licensed nurse had notified the physician or supervisory nursing staff that the [MEDICATION NAME] level was not obtained on 4/22/10. There was no indication that nursing staff made any further attempts to obtain the [MEDICATION NAME] level test as ordered twice a week. Licensed nursing staff failed to obtain a [MEDICATION NAME] level until 4/27/10 (12 days after the 4/15/10 order). Licensed nursing staff had documented on the Medication Administration Record (MAR) that the resident had refused his/her 9:00 p.m. medications, including [MEDICATION NAME], on 4/27/10. However, there was no indication that the resident's physician had been notified that the resident had refused any of the medications including [MEDICATION NAME]. When the facility obtained the laboratory test results report on 4/27/2010, the resident's [MEDICATION NAME] level was recorded as being low at 1.0 ug/ml (normal range was between 10 and 20). Although the facility had received the faxed laboratory test results on 4/27/10 at 4:06 p.m., the licensed nurse failed to notify the physician about that abnormally low test result until 4/28/10. Licensed nursing staff documented on the 4/28/10 from 1:00 p.m. to 4:45 p.m. nurse's notes that the results were faxed and called into the offices of the resident's urologist and neurologist. However, there was no indication that licensed nursing staff had followed-up for a physicians' response. According to the 4/28/10 at 6:00 p.m. nurses notes, the resident had a [MEDICAL CONDITION] that lasted about 45 seconds, and was sent to the hospital emergency room for treatment. On 4/30/10 at 2:10 p.m., licensed nurse "LL" stated that the office for the resident's attending physician was closed on Wednesdays and that was why he/she had not followed up with the attending physician regarding the abnormally low [MEDICATION NAME] level on 4/28/10 (Wednesday). "LL" stated that, in the past, the resident's attending physician had instructed him/her to notify the residents' urologist of any abnormal laboratory test results when the attending physician was unavailable. "LL" stated that he/she was also responsible for administering medications to the residents and had gotten behind on the afternoon of 4/28/10. "LL" stated that he/she did not follow up with any physician about the abnormally low [MEDICATION NAME] level until she called the emergency room after the resident had a [MEDICAL CONDITION] at 6:00 p.m. on 4/28/10. See F309 for additional information regarding resident #2. 2. Resident #5 had [DIAGNOSES REDACTED]. There was a 3/2/10 laboratory test results form with a high [MEDICATION NAME] time (PT) level of 24.1 seconds (normal 11-13) and a critical high international ratio (INR) level of 4.44 seconds (normal 0.90-1.20). On 3/2/10, there was a physician's orders [REDACTED]. However there was no evidence that the licensed nursing staff had obtained the PT/INR as ordered on [DATE] or notified the physician that it had not been done. During an interview on 4/29/10 at 8:55 a.m., the Director of Nursing (DON) stated that the 3/7/10 PT/INR tests were not obtained. The DON said that the licensed nurse, who had received the order, failed to put the order for that test in the laboratory book as "to be drawn". However, that licensed nurse documented in the nurse's notes on 4/5/10 at 2:10 a.m. that the resident had refused to have the laboratory tests drawn. During an interview on 4/29/10 at 8:55 a.m., the DON stated the licensed nurse had not notified the resident's physician that the resident had refused to have blood drawn for the PT/INR tests on 4/5/10. On 4/28/10 after surveyor inquiry, when the resident's physician's assistant (PA) was notified about the ordered PT/INRs not being done, he ordered that a PT/INR be drawn "now". The results of the resident's PT/INR obtained on 4/28/10 were reported as being abnormal. His/her PT was high at 23.7 seconds and INR was "critical high" at 3.72 seconds. During an interview on 4/29/10 at 4:20 p.m., the PA stated that the resident's physician had not been in the office since at least December 2009. He stated that the facility staff had not informed him until 4/28/10 that the resident's previously ordered (3/7/10 and 4/5/10 PT/INR) laboratory tests had not been done. After reviewing the abnormal PT/INR levels, the PA ordered licensed nursing staff to hold the resident's [MEDICATION NAME] for two days then restart it at 2 milligrams (mg) on 5/2/10 and to recheck the PT/INR levels on 5/3/10. The licensed nurse documented in the 2/25/10 nurse's notes for resident #5 that the physician's assistant (PA) had ordered 500 milligrams (mg) of [MEDICATION NAME] twice a day for seven days because of an urinary tract infection [MEDICAL CONDITION]. The licensed nurse documented in the 2/26/10 nurse's notes that the pharmacy had called and told them not to give the [MEDICATION NAME] to the resident because, the resident was allergic to [MEDICATION NAME]. The pharmacy told the nursing staff to contact the physician for a different antibiotic. The licensed nurse documented in the 2/26/10 (Friday) nurse's notes that he/she had called the physician's office but, it was closed until Monday. There was no evidence that the licensed nurses attempted to contact the physician again until Monday 3/1/10 which delayed starting antibiotic therapy for the resident's urinary tract infection for four days. Upon being notified about the resident's allergy on 3/1/10, the physician's assistant (PA) changed the order to giving [MEDICATION NAME] DS twice a day to the resident for seven days. During an interview on 4/30/10 at 12:00 p.m., the DON confirmed that the resident did not receive antibiotic therapy for his/her urinary tract infection from 2/25/10 to 3/1/10 because, the physician's office was closed until Monday 3/1/10. 3. Resident #6 had a history of [REDACTED]. The 12/7/09 laboratory test results form reported that the resident's [MEDICATION NAME] level was low at 3.8 mg/ml (normal 4-12). According to the 3/4/10 laboratory test results form, his/her [MEDICATION NAME] level was lower at less than 0.1 mg/ml. The licensed nurse documented on both of those laboratory test results forms that the results had been faxed to the resident's physician. However despite the resident's low Tegretal titration levels, there was no evidence that licensed nursing staff followed up with the resident's physician after faxing either of those reports. During an interview on 4/29/10 at 4:20 p.m., the physician's PA stated that the physician had not been in the office since at least December 2009. The PA said that he/she had not seen either the 12/7/09 nor 3/4/10 abnormal laboratory test results until 4/29/10 (after surveyor inquiry). After reviewing the abnormal laboratory tests on 4/29/10, the PA ordered licensed nursing staff to increase the amount of [MEDICATION NAME] given to the resident to 300 milligrams (mg) twice a day and to recheck his/her [MEDICATION NAME] level in two weeks. 4. Resident #12 had a [DIAGNOSES REDACTED]. He/She had a 3/19/10 order for a PT/INR level to be drawn on 3/20/10, 3/21/10 and 3/22/10. There was a 3/21/10 PT/INR laboratory test results report of a high [MEDICATION NAME] time (PT) of 22.9 seconds (normal 11-13) and a critical high international ratio (INR) of 3.49 seconds (normal 0.90-1.23). The licensed nurse documented on the test results form that it had been faxed to the emergency room and to the physician's office on 3/21/10 (Sunday). There was undated documentation on the test results form from the physician's assistant (PA) "to hold the [MEDICATION NAME] on today only, then follow up with the resident's attending physician tomorrow." The licensed nurse documented on a "Clinch Healthcare Lab Form" that the resident had refused to have the blood draw on 3/22/10 but, the lines on the form for the notification of the physician and the time were blank. There was no evidence that licensed nursing staff notified the physician about the resident's critical high INR or about his/her refusal to have blood drawn on 3/22/10. During an interview on 4/30/10 at 9:45 a.m., the DON stated that the resident's attending physician was not notified on 3/22/10 about the residents's refusal to have blood drawn for the PT/INR on 3/22/10 or about the critical high INR level on 3/21/10. When the resident's attending physician was notified about the critical high INR level on 3/23/10, he ordered nursing staff to change the dosage of [MEDICATION NAME] and to recheck the residents's PT/INR levels on 3/26/10. However there was no evidence on 3/26/10 that nursing staff obtained a PT/INR for resident #12 or notified the physician or the DON that it was not done. During an interview on 4/30/10 at 9:45 a.m., the DON stated that the ordered 3/26/10 laboratory tests had not been obtained as ordered. According to the order sheet, the physician had discontinued the order for [MEDICATION NAME] on 4/13/10. 5. Resident #13 had a [DIAGNOSES REDACTED]. There were care plan interventions since 1/26/10 for licensed nursing staff to schedule laboratory tests as ordered by the physician and notify the physician when the results were received. Licensed nursing staff had documented on the 2/26/10 nurse's notes that the resident had a [MEDICAL CONDITION] that lasted two minutes and that the emergency room physician was notified. The resident's attending physician assessed the resident on 3/4/10 and ordered licensed nursing staff to obtain a [MEDICATION NAME] level for the resident. On 3/8/10, the [MEDICATION NAME] level was reported as having been low at 8.0 ug/ml (normal range was between 10 and 20). Although licensed nursing staff had documented on the 3/8/10 laboratory test results form that the results were faxed to the resident's attending physician, there was no evidence that licensed nursing staff had followed up with the physician about that low [MEDICATION NAME] level. 6. Resident #16 had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. There was a physician's orders [REDACTED]. However, a review of the resident's clinical record revealed no evidence that licensed nursing staff had obtained the residents's PT/INR in February 2010. There was no evidence that the DON or physician had been notified that the PT/INR had not been obtained as ordered. During an interview on 4/30/10 at 9:00 a.m., the Assistant Director of Nursing (ADON) confirmed that the resident's February 2010 PT/INR levels were not obtained as ordered. The immediate and serious threat to resident health and safety was determined to have been removed on 4/30/10 but the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining laboratory tests as ordered and physician notification; nursing staff obtains laboratory tests ordered by the physicians: to review the effectiveness and implementation of the facility's lab tickler system for tracking laboratory tests; supervisory nursing monitors to ensure that ordered laboratory tests are obtained; that physicians are notified promptly about laboratory test results; nursing staff monitors to ensure physicians received faxed reports or ensure physician notification; supervisory nursing staff supervises nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; that the Quality Assurance committee monitors the implementation of the facility's interventions to ensure that laboratory testing is done as ordered, and that the laboratory test results are communicated to the physicians promptly and revises the plan as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility had consulted with the residents' physicians about the laboratory tests that were not obtained as ordered. Completed 4/29/10. 2. The facility notified residents' physicians about all laboratory test results that were abnormal. Completed 4/29/10. 3. All residents who had critical laboratory test results were assessed by the physician on 4/29/10. The Medical Director came to the facility to examine any residents whose attending physician had not seen them, and reviewed their laboratory test results. Completed 4/29/10. 4. The facility conducted an audit of all residents' orders for laboratory tests and the evidence of those laboratory tests having been done. Completed 4/29/10. 5. The facility in-serviced all licensed nursing staff (not on leave) about the facility's policy and procedures regarding laboratory tests and results, the medications that required laboratory tests, the monitoring of levels to ensure therapeutic levels were maintained, and the notification of physicians regarding laboratory test results. Completed 4/29/10. Other staff would be in-serviced before returning to work. 6. The facility implemented a plan for the Director of Nursing/ADON to audit physicians' orders daily for any new laboratory test orders. Implemented 4/29/10. 7. A list of medications requiring therapeutic drug levels was done for each hall of the facility and was to be reviewed daily by the Director of Nursing for laboratory test orders and test results. Implemented 4/29/10. 8. The facility implemented a Lab Tracking Form to be completed for all residents and filed in the Lab Tickler notebook. The form included the residents' names, physician, birthdates, diagnosis, Medicare/Medicaid/social security numbers, and the physician's order for laboratory tests. Implemented 4/29/10. 9. The facility implemented the use of a Laboratory Log that included the date due, resident name, tests to be done, when done, initial by staff, reason if not done, and when report received and placed on residents' charts. Implemented 4/29/10. 10. The Director of Nursing/ADON/Charge nurse will check the Lab Log daily to ensure laboratory tests are done as scheduled. She will retrieve all laboratory results and notify the physician via telephone and fax. She will document that the physician was notified of the laboratory test results. Implemented 4/29/10. 11. The facility developed a procedure for the licensed nursing staff to follow if a laboratory test result was critical. The physician was to be notified by telephone. If the physician did not return the call within 15 minutes, the nursing staff was to re-phone the physician every 15 minutes for three times then, call the Medical Director. If the Medical Director did not return the call within 15 minutes, the nursing staff was to re-phone him every 15 minutes for three times then, notify the Director of Nursing, Administrator and transfer the resident to the emergency room . Implemented 4/29/10.

Based on record review and staff interview, it was determined that the facility failed to ensure that plans of care were implemented for the following: obtaining and/or monitoring laboratory tests, and/or for notifying the attending physician about the laboratory test results timely for six residents (#2, #5, #9, #12, #13 and #16) of 11 residents, who received medications requiring titration; for administering medication as ordered for two residents (#3 and #9) and; to provide a protein supplement for one resident (#9) with a pressure sore from a total sample of 19 residents. The facility's failure to obtain and/or monitor laboratory tests as ordered by the physician for residents, who received medications requiring titration and to follow up with physician's regarding abnormal laboratory test results, resulted in the potential for serious injury to residents #2, #5, #9, #12, #13 and #16. On 4/15/2010, resident #2 returned from the hospital where his/her admission [DIAGNOSES REDACTED]. However, the facility failed to obtain his/her [MEDICATION NAME] level until 4/27/10. This failure resulted in the his/her physician being unable to monitor the ordered drug therapy. After receiving the report of the resident's low [MEDICATION NAME] level on 4/27/10 at 4:06 p.m., the facility failed failed to promptly notify the physician prior to resident #2 having a [MEDICAL CONDITION] on 4/28/10 at 6 p.m. The resident was transferred to the emergency room for treatment. Therefore, it was determined that the likelihood of an immediate jeopardy existed for those residents from 4/15/10 until 4/30/2010 when the immediate jeopardy was removed after the facility implemented a plan of correction to remove the jeopardy situation. Findings include: 1. Resident #2 had a [DIAGNOSES REDACTED]. The resident was readmitted from the hospital on [DATE] with a physician's orders [REDACTED]. The resident had a care plan intervention since 4/15/10 for licensed nursing staff to obtain laboratory tests as ordered by the physician to monitor the blood level of the [MEDICAL CONDITION] medication. However, licensed nursing staff failed to obtain a [MEDICATION NAME] level twice weekly. Although licensed nursing staff had documented on the 4/22/10 nurse's notes that the laboratory technician had been unable to draw a blood sample from the resident, there was no indication that the physician had been notified that the [MEDICATION NAME] level was not obtained. There was no evidence that nursing staff made any further attempts to obtain the laboratory test until 4/27/10 (12 days later after the order). Nursing staff failed to ensure that the physician was promptly notified about the laboratory report of the low [MEDICATION NAME] level received on 4/27/10 at 4:06 p.m. Prior to ensuring the the physician had the laboratory report, the resident had a [MEDICAL CONDITION] on 4/28/10 at 6 p.m. which required his/her transfer to the emergency room for treatment. See F309 for additional information regarding resident #2. 2. Resident #5 had a 3/2/10 care plan intervention to repeat laboratory tests (PT/INR) as ordered. On 3/2/10, the physician ordered a decrease in the resident's [MEDICATION NAME] dose to 2.5 milligrams (mg) daily and to repeat the PT/INR laboratory tests on 3/7/10. However, there was no evidence that licensed nursing staff had repeated the resident's PT/INR on 3/7/10. During an interview on 4/29/10 at 8:55 a.m., the Director of Nursing confirmed that the 3/7/10 PT/INR was not obtained. According to the 3/21/10 laboratory test results form, resident #5 had a high [MEDICATION NAME] time (PT) level of 24.1 seconds (normal 11-13) and a critical high internation ratio (INR) level of 4.44 seconds (normal 0.90-1.20). See F309 for additional information regarding resident #5. 3. Resident #12 had a care plan problem since 3/16/10 to address his/her risk for abnormal bleeding related to anticoagulant therapy. On 4/13/10, facility staff handwrote on the care plan that the resident received medication with anticoagulant properties. There were care plan interventions since 3/16/10 for nursing staff to monitor labs as ordered and notify when results are in and, to notify the physician as/if warranted. The resident had a 3/19/10 order for a PT/INR to be drawn on 3/20/10, 3/21/10, and 3/22/10. The resident was reported on his/her 3/21/10 laboratory test results to have a high [MEDICATION NAME] time (PT) of 22.9 seconds (normal 11-13) and a critical high international ratio (INR) of 3.49 seconds (normal 0.90-1.23). The licensed nurse documented on the test results form that on 3/21/10 it had been faxed to the emergency room and to the physician's office. There was documentation (undated) on the test results form from the physician's assistant (PA) "to hold the [MEDICATION NAME] on today only, then follow up with the resident's attending physician tomorrow." There was no evidence that licensed nursing staff followed up with the residents's physician on 3/22/10. Staff documented on a lab form that on 3/22/10 the resident had refused to have blood drawn for the PT/INR but, there was no evidence the physician was notified. During an interview on 4/30/10 at 9:45 a.m., the DON stated that on 3/22/10, the resident's attending physician was not notified about the residents's refusal to have blood drawn for the PT/INR on 3/22/10 or the critical high INR level reported on 3/21/10. The resident's attending physician was notified about the critical high INR level on 3/23/10 and ordered nursing staff to recheck the PT/INR levels on 3/26/10. However, there was no evidence that licensed nursing staff obtained it. In an interview on 4/30/10 at 9:45 a.m., the DON confirmed that the ordered 3/26/10 laboratory tests were not obtained. See F309 for additional information regarding resident #12. 4. Resident #16 had a care plan since 2/25/10 to address his/her risk for abnormal bleeding related to being on anticoagulant therapy for [MEDICAL CONDITION] and a history of [MEDICAL CONDITION] embolism. There was a care plan intervention since 2/25/10 for nursing staff to monitor labs as ordered and notify when results were in. Resident #16 had a physician's orders [REDACTED]. However there was no evidence that nursing staff has obtained them in February 2010. During an interview on 4/30/10 at 9:00 a.m., the Assistant Director of Nursing (ADON) confirmed that the resident's February 2010 PT/INR laboratory tests were not obtained as ordered. See F309 for additional information regarding resident #16. 5. Resident #3 had a care plan since 2/10/10 to address his/her risk for alteration in comfort related to [DIAGNOSES REDACTED]. There was an intervention for licensed nursing staff to administer pain medication according to the physician's orders [REDACTED]. However, review of the resident's March 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. See F309 for additional information regarding resident #3. 6. Resident #13 had a [DIAGNOSES REDACTED]. The resident had a care plan intervention since 1/26/10 for licensed nursing staff to schedule laboratory tests as ordered by the physician and notify the physician when the results were received. Licensed nursing staff had documented on the 2/26/10 nurse's notes that the resident had a [MEDICAL CONDITION] two minutes. The physician ordered on [DATE] that licensed nursing staff to obtain a [MEDICATION NAME] level on the resident. On 3/8/10, the [MEDICATION NAME] level was reported as low at 8.0 (normal range was between 10 and 20). Although licensed nursing staff had documented on the 3/8/10 laboratory test results form that the report of the low [MEDICATION NAME] level was faxed to the resident's attending physician, there was no indication that licensed nursing staff had followed up with the physician to ensure notification. See F309 for additional information regarding resident #13. 7. Resident #9 had an indwelling catheter and a history of recurrent urinary tract infections. The resident had a care plan intervention since 3/18/10 for licensed nursing staff to obtain laboratory tests as ordered. There was a physician's orders [REDACTED]. However, licensed nursing staff failed to obtain the urinalysis as ordered until after surveyor inquiry on 4/29/10. See F502 for additional information regarding resident #9. There was also a care plan intervention since 3/18/10 for licensed nursing staff to administer medications as ordered by the physician. On 3/18/10, the resident's urologist ordered licensed nursing staff to administer Uroquid (an antiseptic and urinary acidifier used in the prevention and treatment of [REDACTED]. However, licensed nursing staff failed to administer the medication for 13 of 13 days in March 2010. See F309 for additional information regarding resident #9. Resident #9 had a Stage IV pressure sore on his/her coccyx since his/her admission on 9/3/09 and a low [MEDICATION NAME] level of 2.2 (normal range was between 3.5 and 4.8) reported on 2/8/10. The resident had a care plan problem since 3/19/10 to address his/her impaired skin integrity and risk for further impaired skin integrity. There was an intervention to administer medications, vitamins and supplements as warranted. On 3/10/10, the registered dietician recommended that licensed nursing staff increase the [MEDICATION NAME] powder (a protein supplement to promote wound healing ) from one scoop three times a day to four times a day. The resident's physician accepted that recommendation on 3/17/10. However, licensed nursing staff failed to increase the supplement to four times a day as ordered until after surveyor inquiry on 4/29/10. See F314 for additional information regarding resident #9. The immediate and serious threat to resident health and safety was determined to have been removed on 4/30/10 but the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining laboratory tests as ordered and physician notification; nursing staff obtains laboratory tests ordered by the physicians: to review the effectiveness and implementation of the facility's lab tickler system for tracking laboratory tests; supervisory nursing monitors to ensure that ordered laboratory tests are obtained; that physicians are notified promptly about laboratory test results; nursing staff monitors to ensure physicians received faxed reports or ensure physician notification; supervisory nursing staff supervises nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; that the Quality Assurance committee monitors the implementation of the facility's interventions to ensure that laboratory testing is done as ordered, and that the laboratory test results are communicated to the physicians promptly and revises the plan as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility had consulted with the residents' physicians about the laboratory tests that were not obtained as ordered. Completed 4/29/10. 2. The facility notified residents' physicians about all laboratory test results that were abnormal. Completed 4/29/10. 3. All residents who had critical laboratory test results were assessed by the physician on 4/29/10. The Medical Director came to the facility to examine any residents whose attending physician had not seen them, and reviewed their laboratory test results. Completed 4/29/10. 4. The facility conducted an audit of all residents' orders for laboratory tests and the evidence of those laboratory tests having been done. Completed 4/29/10. 5. The facility in-serviced all licensed nursing staff (not on leave) about the facility's policy and procedures regarding laboratory tests and results, the medications that required laboratory tests, the monitoring of levels to ensure therapeutic levels were maintained, and the notification of physicians regarding laboratory test results. Completed 4/29/10. Other staff would be in-serviced before returning to work. 6. The facility implemented a plan for the Director of Nursing/ADON to audit physicians' orders daily for any new laboratory test orders. Implemented 4/29/10. 7. A list of medications requiring therapeutic drug levels was done for each hall of the facility and was to be reviewed daily by the Director of Nursing for laboratory test orders and test results. Implemented 4/29/10. 8. The facility implemented a Lab Tracking Form to be completed for all residents and filed in the Lab Tickler notebook. The form included the residents' names, physician, birthdates, diagnosis, Medicare/Medicaid/social security numbers, and the physician's order for laboratory tests. Implemented 4/29/10. 9. The facility implemented the use of a Laboratory Log that included the date due, resident name, tests to be done, when done, initial by staff, reason if not done, and when report received and placed on residents' charts. Implemented 4/29/10. 10. The Director of Nursing/ADON/Charge nurse will check the Lab Log daily to ensure laboratory tests are done as scheduled. She will retrieve all laboratory results and notify the physician via telephone and fax. She will document that the physician was notified of the laboratory test results. Implemented 4/29/10. 11. The facility developed a procedure for the licensed nursing staff to follow if a laboratory test result was critical. The physician was to be notified by telephone. If the physician did not return the call within 15 minutes, the nursing staff was to re-phone the physician every 15 minutes for three times then, call the Medical Director. If the Medical Director did not return the call within 15 minutes, the nursing staff was to re-phone him every 15 minutes for three times then, notify the Director of Nursing, Administrator and transfer the resident to the emergency room . Implemented 4/29/10.

Based on record review and staff interview, it was determined that the facility failed to follow physicians' orders to obtain laboratory tests that monitored medications requiring titration levels for four residents (#2, #5, #12 and #16) and failed to follow up on the physician's response regarding abnormally high or low laboratory test results for four residents (#2, #6, #12 and #13) of 11 residents, who received medications requiring titration levels, and failed to administer medications as ordered for three residents (#3, #8, and #9) from a total sample of 19 residents. The facility's failure to obtain laboratory tests as ordered by the physician for six of 11 residents who received medications requiring titration and the facility's failure to follow up to ensure the physician's notification and response regarding abnormally high or low laboratory test results resulted in actual harm to resident #2 and had the likelihood of resulting in serious injury to residents #5, #6, #12, #13 and #16. The facility's failure to obtain [MEDICATION NAME] levels (laboratory tests) for resident #2, who had a history of [REDACTED]. Therefore, it was determined that the likelihood of an immediate jeopardy existed for those six (#2, #5, #6, #12, #13 and #16) residents from 4/15/10, when resident #2 was readmitted from the hospital with a physician's orders [REDACTED]. Findings include: 1. According to the 1/15/10 nurses notes, resident #2 had jerking movements and had several episodes of [MEDICAL CONDITION] before being sent to emergency room . The [MEDICATION NAME] level that the physician ordered to be done immediately was reported to have been low (6.9). Resident #2 was hospitalized between 4/5/10 and 4/15/10 for [MEDICATION NAME] toxicity, severe kidney insufficiency and dehydration. The resident was readmitted from the hospital on [DATE] with physician's orders [REDACTED]. The resident had care plan interventions since 4/15/10 for licensed nursing staff to administer medication as ordered to prevent [MEDICAL CONDITION] and to obtain laboratory tests as ordered by the physician to monitor the blood level of the [MEDICAL CONDITION] medication. However, licensed nursing staff failed to obtain a [MEDICATION NAME] level until 12 days later on 4/27/10. There was no evidence of any further attempts to obtain the laboratory test until 4/27/10. Licensed nursing staff had documented on the 4/10 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. However, there was no indication that the resident's physician had been notified that the resident had refused the medications, including the [MEDICATION NAME]. The [MEDICATION NAME] level obtained on 4/27/2010 was reported by the laboratory to have been low at 1 (normal range was between 10 and 20). Although the facility had received the faxed laboratory report on 4/27/10 at 4:06 p.m., there was no evidence that the facility had attempted to notify the physician about abnormally low results until 4/28/10 at 1 p.m. (21 hours later). The licensed nurse wrote in the 4/28/10 (1 p.m.) note that the resident was not eating or drinking well that shift. Licensed nursing staff had documented on the 4/28/10 at 1:00 p.m. to 4:45 p.m. nurse's notes that the laboratory report was faxed and called into the offices of the resident's urologist and neurologist. However, there was no indication that licensed nursing staff had followed up on the physicians' response after 4:45 p.m. when the offices were noted to have been closed. According to the 4/28/10 at 6:00 p.m. nurses notes, the resident had a [MEDICAL CONDITION] that lasted about 45 seconds. The resident was sent to the hospital emergency room for treatment (intravenous [MEDICATION NAME]). On 4/30/10 at 2:10 p.m., licensed nursing staff "LL" explained that the resident's attending physician's office was closed on Wednesdays so, that was why she had not followed up with the attending physician regarding the abnormally low [MEDICATION NAME] level on 4/28/10 (Wednesday). "LL" stated that in the past the resident's attending physician had instructed him/her to notify the residents' urologist of any abnormal laboratory test results when the attending physician was unavailable. "LL" stated that he/she was also responsible for administering medications to the residents and had gotten behind during the medication pass on the afternoon of 4/28/10. When there had not been a response from the physician to the faxed reports and the resident appeared to be "OK", she continued to administer medications to the residents. Before she had the opportunity to follow up with any physician about the abnormally low [MEDICATION NAME] level, the resident had a [MEDICAL CONDITION] at 6:00 p.m. 2. Resident #5 had [DIAGNOSES REDACTED]. There was a 3/2/10 laboratory test results form that reported a high [MEDICATION NAME] time (PT) level of 24.1 seconds (normal 11-13) and a critical high international ratio (INR) level of 4.44 seconds (normal 0.90-1.20). There was a physician's orders [REDACTED]. However there was no evidence nursing staff obtained that ordered PT/INR. During an interview on 4/29/10 at 8:55 a.m., the Director of Nursing (DON) confirmed that the 3/7/10 PT/INR tests were not obtained. The DON stated that the licensed nurse, who had received the order, failed to put the test in the laboratory book as "to be drawn" on 3/7/10. There was a 4/5/10 nurses note at 2:10 a.m. that the resident had an order for [REDACTED]. During an interview on 4/29/10 at 8:55 a.m., the DON stated that the resident's physician was not notified by the licensed nurse that the resident had refused to have blood drawn for the PT/INR tests on 4/5/10. On 4/28/10 after surveyor inquiry, the resident's physician's assistant (PA) was notified and he ordered that a PT/INR be drawn "now". On 4/28/10, the resident's PT was reported as high at 23.7 seconds and the INR was critical high at 3.72 seconds. During an interview on 4/29/10 at 4:20 p.m., the PA stated that the resident's physician had not been in the office since at least December 2009. He stated that he had not been informed until 4/28/10 that the resident's 3/7/10 and 4/5/10 PT/INR laboratory tests had not been done. On 4/29/10, the PA ordered licensed nursing staff to hold the resident's [MEDICATION NAME] for two days then restart it at 2 milligrams (mg) on 5/2/10 and to recheck the PT/INR levels on 5/3/10. Resident #5 was on a regular diet. His/her diet card did include information about the resident being on [MEDICATION NAME] (an anti-coagulant). Green leafy vegetables are high in Vitamin "K" which helps blood make clots. However, resident #5 was observed at the lunch meal to on 4/28/10 at 1:00 p.m. to have been served greens on his/her tray. On 4/29/10 at 1:10 p.m. staff served cole slaw made from cabbage to him/her. The licensed nurse documented in the 2/25/10 nurse's notes for resident #5 that the physician's assistant (PA) ordered 500 milligrams (mg) of [MEDICATION NAME] twice a day for seven days because of an urinary tract infection [MEDICAL CONDITION]. The licensed nurse documented in the 2/26/10 nurse's notes that the pharmacy called and told them not to administer the [MEDICATION NAME] because the resident was allergic to [MEDICATION NAME]. The pharmacy told them to contact the physician for a different antibiotic. The licensed nurse documented in the 2/26/10 (Friday) nurse's notes that he/she had called the physician's office but, it was closed. There was no evidence that nursing staff attempted to contact the physician again until Monday 3/1/10. On 3/1/10, the physician's assistant (PA) ordered [MEDICATION NAME] DS twice a day for seven days. During an interview on 4/30/10 at 12:00 p.m., the DON confirmed that the resident did not receive antibiotic therapy for the urinary tract infection from 2/25/10 to 3/1/10 because of the physician's office being closed until Monday 3/1/10. 3. Resident #6 had a history of [REDACTED]. On the 12/7/09 laboratory test results form, the resident's [MEDICATION NAME] level was low at 3.8 mg/ml (normal 4-12). On the 3/4/10 laboratory test results form, his/her [MEDICATION NAME] level was reported low at less than 0.1 mg/ml. The licensed nurse documented on both of those laboratory test results forms that the results had been faxed to the resident's physician. However, there was no evidence that nursing staff followed up with the resident's physician about the low [MEDICATION NAME] levels. During an interview on 4/29/10 at 4:20 p.m., the PA stated that the physician had not been in the office since at least December 2009 and that the PA had not seen the resident's 12/7/09 nor 3/4/10 abnormal laboratory test results until 4/29/10, after surveyor inquiry. On 4/29/10, the PA ordered nursing staff to increase the [MEDICATION NAME] to 300 milligrams (mg) twice a day and to recheck the [MEDICATION NAME] level in two weeks. 4. Resident #12 had a [DIAGNOSES REDACTED]. He/She had a 3/19/10 order for a PT/INR level to be drawn on 3/20/10, 3/21/10 and 3/22/10. There was a 3/21/10 laboratory test results form which reported a high [MEDICATION NAME] time (PT) of 22.9 seconds (normal 11-13) and a critical high international ratio (INR) of 3.49 seconds (normal 0.90-1.23). The licensed nurse documented on the test results form that it had been faxed to the emergency room and to the physician's office on 3/21/10. There was documentation (undated) on the test results form from the physician's assistant (PA) "to hold the [MEDICATION NAME] on today only, then follow up with the resident's attending physician tomorrow." There was a " Clinch Health Care Lab Form" with nursing staff's documentation that the resident had refused to have his/her blood drawn on 3/22/10 but, the lines on the form for the notification of the physician and time were blank. During an interview on 4/30/10 at 9:45 a.m., the DON stated that on 3/22/10, the nursing staff had not notified the resident's attending physician about the residents's refusal to have blood drawn for the PT/INR on 3/22/10 or about the critical high INR level on 3/21/10. The resident's attending physician was not notified about the critical high INR level until 3/23/10. He ordered a change in the [MEDICATION NAME] to 7.5 milligrams (mg) every day and to recheck the PT/INR levels on 3/26/10. There was no evidence that nursing staff had the PT/INR rechecked on 3/26/10 or had notified the physician about the resident's refusal. During an interview on 4/30/10 at 9:45 a.m., the DON confirmed that the ordered 3/26/10 laboratory tests were not obtained. 5. Resident #16 had [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. There was a physician's orders [REDACTED]. However, a review of the resident's clinical record revealed no evidence that nursing staff obtained the resident's PT/INR in February 2010. During an interview on 4/30/10 at 9:00 a.m., the Assistant Director of Nursing (ADON) confirmed that the resident's February 2010 PT/INR levels were not obtained as ordered. 6. Resident #13 had a [DIAGNOSES REDACTED]. There were care plan interventions since 1/26/10 for licensed nursing staff to schedule laboratory tests as ordered by the physician and notify the physician when the results were received. Licensed nursing staff had documented on the 2/26/10 nurse's notes that the resident had a [MEDICAL CONDITION] two minutes and that the emergency room physician was notified. The resident's attending physician assessed the resident on 3/4/10 and ordered licensed nursing staff to obtain a [MEDICATION NAME] level for the resident. On 3/8/10, the [MEDICATION NAME] level was reported as being low at 8.0 mg/ml (normal range was between 10 and 20). Although licensed nursing staff had documented on the 3/8/10 laboratory test results form that the results were faxed to the resident's attending physician, there was no evidence that licensed nursing staff had followed up with the physician for a response regarding that low [MEDICATION NAME] level. 7. Resident #3 had a 2/23/10 physician's orders [REDACTED]. However, review of the resident's March 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 4/30/10 at 1:00 p.m., licensed nurse "LL" confirmed that nursing staff had not administered [MEDICATION NAME] on those dates because, the nursing staff had failed to get an order from the physician to refill the prescription. The pharmacy could not provide [MEDICATION NAME] ER for the resident without an order. The resident was given [MEDICATION NAME] as needed for pain during that time. 8. Resident #8 had [DIAGNOSES REDACTED]. The physician wrote an order on 11/27/09 for the resident's medication [MEDICATION NAME] to be increased to 10 milligrams three times daily. However, a review of the resident's MARs for January, February, March, and April, 2010 revealed that licensed nurses failed to transcribe the order for [MEDICATION NAME] so, they did not give it to the resident. There was no evidence that [MEDICATION NAME] had been discontinued by the physician. In an interview on 4/29/10 at 1:10 p.m., the Director of Nursing said that the resident should have been given [MEDICATION NAME]. 9. Resident #9 had an indwelling catheter and a history of recurrent urinary tract infections. On 3/18/10, the resident's urologist ordered licensed nursing staff to administer Uroquid (an antiseptic and urinary acidifier used in the prevention and treatment of [REDACTED]. However, licensed nursing staff had failed to administer the medication to the resident for 13 of 13 days in March 2010. The immediate and serious threat to resident health and safety was determined to have been removed on 4/30/10 but the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining laboratory tests as ordered and physician notification; nursing staff obtains laboratory tests ordered by the physicians: to review the effectiveness and implementation of the facility's lab tickler system for tracking laboratory tests; supervisory nursing monitors to ensure that ordered laboratory tests are obtained; that physicians are notified promptly about laboratory test results; nursing staff monitors to ensure physicians received faxed reports or ensure physician notification; supervisory nursing staff supervises nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; that the Quality Assurance committee monitors the implementation of the facility's interventions to ensure that laboratory testing is done as ordered, and that the laboratory test results are communicated to the physicians promptly and revises the plan as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility had consulted with the residents' physicians about the laboratory tests that were not obtained as ordered. Completed 4/29/10. 2. The facility notified residents' physicians about all laboratory test results that were abnormal. Completed 4/29/10. 3. Residents with critical laboratory test results were assessed by the physician on 4/29/10. The Medical Director came to the facility to examine any residents whose attending physician had not seen them, and reviewed their laboratory test results. Completed 4/29/10. 4. The facility conducted an audit of the medical records of all residents' orders for laboratory tests and the evidence that those laboratory tests had been done. Completed 4/29/10. 5. The facility in-serviced all licensed nursing staff about the facility's policy and procedures regarding laboratory tests and results, the medications that required laboratory tests, the monitoring of levels to ensure therapeutic levels were maintained, and the notification of physicians regarding laboratory test results. Completed 4/29/10. 6. The facility implemented a plan for the Director of Nursing/ADON to audit physicians' orders daily for any new laboratory test orders. Implemented 4/29/10. 7. A list of medications requiring therapeutic drug levels was done for each hall of the facility and was to be reviewed daily by the Director of Nursing for laboratory test orders and test results. Implemented 4/29/10. 8. The facility implemented a Lab Tracking Form to be completed for all residents and filed in the Lab Tickler notebook. The form included the residents' names, physician, birthdates, diagnosis, Medicare/Medicaid/Social Security numbers, and the physician's orders [REDACTED]. 9. The facility implemented the use of a Laboratory Log that included the date due, resident name, tests to be done, when done, initial by staff, reason if not done, and when report received and placed on residents' charts. Implemented 4/29/10. 10. The Director of Nursing/designee will check the Lab Log daily to ensure laboratory tests are done as scheduled. She will retrieve all laboratory results and notify the physician via telephone and fax. She will document that the physician was notified of the laboratory test results. Implemented 4/29/10. 11. The facility developed a procedure for the licensed nursing staff to follow if a laboratory test result was critical. The physician was to be notified by telephone. If the physician did not return the call within 15 minutes, the nursing staff was to re-phone the physician every 15 minutes for three times then, call the Medical Director. If the Medical Director did not return the call within 15 minutes, the nursing staff was to re-phone him every 15 minutes for three times then, notify the Director of Nursing, Administrator and transfer the resident to the emergency room . Implemented 4/29/10.

Based on record review and staff interview, it was determined that the facility failed to be administered in a manner to ensure that laboratory tests were obtained as ordered and that physicians were promptly notified about abnormally low or high laboratory test results for six of 11 residents who received medications requiring titration from a total sample of 19 residents. The nursing staff failed to identify and report to the Administrator and Director of Nurses that laboratory tests for residents on medications requiring titration were not obtained and that the six residents' physicians were not promptly consulted about their abnormal laboratory test results. The facility's failure to obtain laboratory tests as ordered by the physician for six of 11 residents, who received medications requiring titration levels, and the facility's failure to follow up for the physician's response regarding abnormally high or low laboratory test results resulted in actual harm to resident #2 and had the likelihood of causing serious injury to residents #5, #6, #12, #13 and #16. The facility failed to obtain [MEDICATION NAME] levels as ordered for resident #2, who had a history of [REDACTED]. Resident #2 had been admitted to the hospital on [DATE] with a [DIAGNOSES REDACTED]. Therefore, it was determined that the likelihood of an immediate jeopardy existed for those residents from 4/15/10, when resident #2 was readmitted from the hospital with a physician's orders [REDACTED]. Findings include: When licensed nursing staff failed to obtain laboratory tests as ordered by the physicians and failed to obtain prompt responses to abnormal laboratory test results from physicians for six residents who received medications requiring titration, they failed to report those problems to supervisory staff. The DON denied being aware of those problems, their cause, or extent. There was no evidence of the facility's identification of the problems despite their being on-going since at least 4/15/10. The administrative staff was not aware of the facility's systemic failure to obtain the laboratory test results for residents who were on drugs requiring titration. Therefore, the administrative staff were not able to address any corrective measures to prevent the actual harm for resident #2, and the potential likelihood of serious harm for residents #5, #6, #12, #13, and #16. See F281 and F309 for additional information regarding residents #2, #5, #6, #12, #13 and #16. The immediate and serious threat to resident health and safety was determined to have been removed on 4/30/10 but the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining laboratory tests as ordered and physician notification; nursing staff obtains laboratory tests ordered by the physicians: to review the effectiveness and implementation of the facility's lab tickler system for tracking laboratory tests; supervisory nursing monitors to ensure that ordered laboratory tests are obtained; that physicians are notified promptly about laboratory test results; nursing staff monitors to ensure physicians received faxed reports or ensure physician notification; supervisory nursing staff supervises nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; that the Quality Assurance committee monitors the implementation of the facility's interventions to ensure that laboratory testing is done as ordered, and that the laboratory test results are communicated to the physicians promptly and revises the plan as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility consulted with the residents ' physicians about the laboratory tests that were not obtained as ordered. Completed 4/29/10. 2. The facility notified residents ' physicians about all laboratory test results that were abnormal. Completed 4/29/10. 3. Residents with critical laboratory test results were assessed by the physician on 4/29/10. The Medical Director came to the facility to examine any residents whose attending physician had not seen them, and reviewed their laboratory test results. Completed 4/29/10. 4. The facility conducted an audit of all residents ' orders for laboratory tests and the evidence of those laboratory tests having been done. Completed 4/29/10. 5. The facility in-serviced all licensed nursing staff about the facility ' s policy and procedures regarding laboratory tests and results, the medications that required laboratory tests, the monitoring of levels to ensure therapeutic levels were maintained, and the notification of physicians regarding laboratory test results. Completed 4/29/10. 6. The facility implemented a plan for the Director of Nursing/ADON to audit physicians' orders daily for any new laboratory test orders. Implemented 4/29/10. 7. A list of medications requiring therapeutic drug levels was done for each hall of the facility and was to be reviewed daily by the Director of Nursing for laboratory test orders and test results. Implemented 4/29/10. 8. The facility implemented a Lab Tracking Form to be completed for all residents and filed in the Lab Tickler notebook. The form included the residents' names, physician, birthdates, diagnosis, Medicare/Medicaid/social security numbers, and the physician's order for laboratory tests. Implemented 4/29/10. 9. The facility implemented the use of a Laboratory Log that included the date due, resident name, tests to be done, when done, initial by staff, reason if not done, and when report received and placed on residents' charts. Implemented 4/29/10. 10. The Director of Nursing/ADON/Charge nurse will check the Lab Log daily to ensure laboratory tests are done as scheduled. She will retrieve all laboratory results and notify the physician via telephone and fax. She will document that the physician was notified of the laboratory test results. Implemented 4/29/10. 11. The facility developed a procedure for the licensed nursing staff to follow if a laboratory test result was critical. The physician was to be notified by telephone. If the physician did not return the call within 15 minutes, the nursing staff was to re-phone the physician every 15 minutes for three times then, call the Medical Director. If the Medical Director did not return the call within 15 minutes, the nursing staff was to re-phone him every 15 minutes for three times then, notify the Director of Nursing, Administrator and transfer the resident to the emergency room . Implemented 4/29/10.

Based on record review and staff interview, it was determined that the facility failed to obtain laboratory tests as ordered by the attending physician for four residents ( #5, #9, #12 and #16) from a total sample of 19 residents. Three of the four residents (#5, #12 and #16) received medications that required titration to obtain therapeutic levels. The facility's failure to obtain laboratory tests as ordered by the physician for residents who received medications requiring titration resulted in the likelihood for serious injury to residents #5, #12, and #16. Therefore, it was determined that the likelihood of an immediate jeopardy existed for those residents from 4/15/10 until 4/30/2010 when the immediate jeopardy was removed after the facility implemented a plan of correction to remove the jeopardy situation. Findings include: 1. Resident #5 had a 3/2/10 high [MEDICATION NAME] time (PT) level of 24.1 seconds (normal 11-13) and a critical high internation ratio (INR) level of 4.44 seconds (normal 0.90-1.20). On 3/2/10, the physician ordered nursing staff to decrease the resident's [MEDICATION NAME] dose to 2.5 milligrams (mg) daily and repeat the PT/INR laboratory tests on 3/7/10. However, there was no evidence that nursing staff had obtained the PT/INR levels as ordered on [DATE]. During an interview on 4/29/10 at 8:55 a.m., the Director of Nursing confirmed that the 3/7/10 PT/INR levels were not obtained. The DON stated that the licensed nurse, who received the order had not put that order in the laboratory book "to be drawn." See F309 for additional information regarding resident #5. 2. Resident #12 had a high [MEDICATION NAME] time (PT) of 22.9 seconds (normal 11-13) and a critical high international ratio (INR) of 3.49 seconds (normal 0.90-1.23) reported on 3/21/10. On 3/21/10, the licensed nurse contacted the physician's assistant (PA) and he ordered the nurses to hold the [MEDICATION NAME] on 3/21/10 only, then follow up with the resident's attending physician on 3/22/10. However, the resident's attending physician was not notified about the critical high INR level until 3/23/10. He/She ordered a change in the resident's [MEDICATION NAME] to 7.5 milligrams (mg) every day and to recheck the PT/INR levels on 3/26/10. However, there was no evidence that nursing staff obtained the PT/INR levels as ordered on [DATE]. During an interview on 4/30/10 at 9:45 a.m., the DON confirmed that the ordered 3/26/10 laboratory tests were not obtained. See F309 for additional information regarding resident #12. 4. Resident #16 had a physician's orders [REDACTED]. He/She had a physician's orders [REDACTED]. However, there was no evidence that the PT/INR levels were obtained in February 2010. During an interview on 4/30/10 at 9:00 a.m., the Assistant Director of Nursing (ADON) confirmed that the resident's February 2010 PT/INR levels were not obtained as ordered. See F309 for additional information regarding resident #16. Resident #16 also had a physician's orders [REDACTED]. However there was no evidence that the CBC was done as ordered in January 2010. During an interview on 4/29/10 at 3:00 p.m., the ADON stated that the January 2010 CBC was not obtained as ordered. 5. Resident #9 had an indwelling catheter. The resident had a physician's orders [REDACTED]. However, as of 4/28/10, licensed nursing staff had failed to obtain the urinalysis as ordered. The immediate and serious threat to resident health and safety was determined to have been removed on 4/30/10 but the associated noncompliance continues. The noncompliance continues in order to ensure that the following are maintained by the facility: all licensed nursing staff are in-serviced on obtaining laboratory tests as ordered and physician notification; nursing staff obtains laboratory tests ordered by the physicians: to review the effectiveness and implementation of the facility's lab tickler system for tracking laboratory tests; supervisory nursing monitors to ensure that ordered laboratory tests are obtained; that physicians are notified promptly about laboratory test results; nursing staff monitors to ensure physicians received faxed reports or ensure physician notification; supervisory nursing staff supervises nursing staff to ensure implementation of the plan of correction to remove the jeopardy and; that the Quality Assurance committee monitors the implementation of the facility's interventions to ensure that laboratory testing is done as ordered, and that the laboratory test results are communicated to the physicians promptly and revises the plan as necessary to assure compliance. Therefore, the scope and severity of the deficiency is reduced from a 'K' to an 'E' level when the facility implemented the following plan of correction: 1. The facility consulted with the residents ' physicians about the laboratory tests that were not obtained as ordered. Completed 4/29/10. 2. The facility notified residents' physicians about all laboratory test results that were abnormal. Completed 4/29/10. 3. Residents with critical laboratory test results were assessed by the physician on 4/29/10. The Medical Director came to the facility to examine any residents whose attending physician had not seen them, and reviewed their laboratory test results. Completed 4/29/10. 4. The facility conducted an audit of all residents' orders for laboratory tests and the evidence of those laboratory tests having been done. Completed 4/29/10. 5. The facility in-serviced all licensed nursing staff about the facility ' s policy and procedures regarding laboratory tests and results, the medications that required laboratory tests, the monitoring of levels to ensure therapeutic levels were maintained, and the notification of physicians regarding laboratory test results. Completed 4/29/10. 6. The facility implemented a plan for the Director of Nursing/ADON to audit physicians' orders daily for any new laboratory test orders. Implemented 4/29/10. 7. A list of medications requiring therapeutic drug levels was done for each hall of the facility and was to be reviewed daily by the Director of Nursing for laboratory test orders and test results. Implemented 4/29/10. 8. The facility implemented a Lab Tracking Form to be completed for all residents and filed in the Lab Tickler notebook. The form included the residents' names, physician, birthdates, diagnosis, Medicare/Medicaid/Social Security numbers, and the physician's orders [REDACTED]. 9. The facility implemented the use of a Laboratory Log that included the date due, resident name, tests to be done, when done, initial by staff, reason if not done, and when report received and placed on residents' charts. Implemented 4/29/10. 10. The Director of Nursing/ADON/Charge nurse will check the Lab Log daily to ensure laboratory tests are done as scheduled. She will retrieve all laboratory results and notify the physician via telephone and fax. She will document that the physician was notified of the laboratory test results. Implemented 4/29/10. 11. The facility developed a procedure for the licensed nursing staff to follow if a laboratory test result was critical. The physician was to be notified by telephone. If the physician did not return the call within 15 minutes, the nursing staff was to re-phone the physician every 15 minutes for three times then, call the Medical Director. If the Medical Director did not return the call within 15 minutes, the nursing staff was to re-phone him every 15 minutes for three times then, notify the Director of Nursing, Administrator and transfer the resident to the emergency room . Implemented 4/29/10.