Every finding on record at Riverside Health Care Center

Based on staff interviews, record review, and review of policies titled, Preadmission Screening PASARR/PASSR, the facility failed to refer one of 10 residents (R)(R7) for level two pre-admission screening and resident review (PASARR) out of 10 residents identified with level two PASARR. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life. Findings include:Review of the policy titled Preadmission Screening (PASSAR/PASSR) dated June 2025 revealed the policy of the facility was to follow the Federal and State regulations with regards to prescreening residents with a mental disorder and individuals with intellectual disability for individuals requiring more than 30 days in the Center, with the Procedure: 1. A level II PASSR must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, or a suspicion or diagnosis of serious mental illness, intellectual disability, or both. A PASRR level II may only be terminated by a PASSR Level II Evaluator.Review of the electronic medical record (EMR) revealed R7 was admitted to the facility on [DATE], and pertinent diagnoses included, but were not limited to, anxiety disorder, major depressive disorder, recurrent moderate mixed obsessional thoughts and acts, bipolar, and schizoaffective disorder. Review of R7's quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 01/22/2026 revealed a Brief Interview for Mental Status (BIMS)score of 13, which indicates R7's cognition is intact. Section E (behavior) revealed no potential indicators of psychosis. Section N (medications) revealed high-risk medications taken with an indication noted as antidepressant and antipsychotic. Review of R7's care plan indicated a focus on mood problems related to diagnoses of depression, schizoaffective disorder, suicidal ideations, and anxiety. Goals included, but were not limited to, improved mood state. Interventions included, but were not limited to, administering medications as ordered, behavioral health consults as needed, monitoring/recording/reporting to the MD as needed, mood patterns, signs and symptoms of depression, anxiety, change in suicide attempt, or sad mood. An interview with the admission Coordinator (AC) on 05/14/2026 at 9:45 AM revealed that she was responsible for verifying if a new admission had a PASARR level one. The Social Services Director (SSD) was responsible for reviewing PASARR level one and determining whether a resident needed a PASARR level 2, if not already done, and uploading it into GAMMIS (Georgia Medicaid Management Information System) and the EMR upon completion. She verified that R7 did not have a PASARR level two screening. An interview with the Social Services Director (SSD) on 05/14/2026 at 10:00 AM revealed that she was responsible for verifying that a resident had a psychiatric disorder diagnoses, after reviewing PASARR level one to determined whether it triggers and determining whether the resident needed a PASARR level two screening. She also verified that R7 did not have PASARR level two in his chart and did have the diagnoses that met the criteria for a PASARR level two assessment. The SSD stated that a negative outcome of R7 not having a PASARR level two assessment done could result in him missing out on treatments.Interview with the Director of Nursing (DON) on 05/14/2026 at 2:08 PM .The DON verified that R7 had qualifying diagnoses for a PASARR level two, that an assessment should have been conducted, and that no PASARR level two assessment was conducted for R7. She stated that the negative outcomes could be R7 not receiving proper care, medication, or benefits.

Based on observations, interviews with staff, record review and review of the facility policies titled, Activities of Daily Living and Prevention of Pressure Injuries, the facility failed to ensure one of six sampled residents (R13), who required assistance with repositioning, was repositioned in accordance with the resident's turning schedule and interventions. This deficient practice placed the resident at risk for poor hygiene, decreased quality of life, and worsening pressure ulcers.Review of the facility's policy titled, Activities of Daily Living revised December, 2025 revealed the following: 1. Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that the resident's abilities in activities of daily living do not diminish unless circumstances of the individual's condition demonstrate that such diminution was unavoidable. 2. The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. 3. The facility will provide care and services for the following activities of daily living: a. Hygiene. b. Mobility.c. Elimination.d. Dining.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the facility's policy titled. Prevention of Pressure Injuries revised April 2020 revealed a section: 3. e. Reposition resident as indicated on the care plan.Mobility/Repositioning. 1. Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. 2. Choose a frequency for repositioning based on the resident's risk factors and current clinical practice guidelines. 3.Provide support devices and assistance as needed .Review of the electronic medical records (EMR) revealed R13 resident admitted to the facility on [DATE] with diagnoses including traumatic cerebral hemorrhage, obstructive hydrocephalus, epilepsy, dysphagia following cerebral infarction, dysphagia, rheumatoid arthritis, osteoarthritis, esophageal dyskinesia, cognitive communication deficit, generalized muscle weakness, muscle wasting/atrophy, lack of coordination, sarcopenia, and pressure ulcers including sacral pressure ulcers stage 4.Review of the Brief Interview for Mental Status (BIMS) revealed a score of 2, indicating severe cognitive impairment. Section GG (Functional Abilities and Goals) revealed functional limitations with bilateral impairment of both upper and lower extremities. The resident was dependent on staff for oral hygiene, toileting, showering/bathing, upper body dressing, and personal hygiene. Section M (Skin Conditions) revealed R13 had a pressure ulcer and was assessed as being at risk for developing pressure ulcers. The assessment further revealed the use of pressure-reducing devices for bed and chair, nutritional and hydration interventions to manage skin problems, and pressure ulcer/injury care.Review of the care plan for R13 revealed interventions related to activities of daily living (ADL) care, repositioning every two hours and as needed, keeping body in good alignment and maintaining clean and dry skin and linens.On 05/12/2026 at 9:20 AM, an observation and interview of R13 revealed the resident resided in a semi-private room, with her bed positioned near the window. A Turning Schedule sign was posted above the resident's bed with instructions for repositioning every two hours as follows: back (left) from 12 to 2, left side from 2 to 4, right side from 4 to 6, back (right) from 6 to 8, left side from 8 to 10, and right side from 10 to 12. The sign further instructed staff not to position the resident flat on their back and to slightly elevate either side of the buttocks using a pillow or wedge.On 05/12/2026 at 10:05 AM, wound care was observed being performed by Licensed Practica Nurse (LPN) AA. In an interview following the dressing change observation, Wound Nurse LPN AA stated residents were care planned for wound and ADL care, and interventions were implemented based on individual needs, including low air loss mattresses, wedges, protein supplements, vitamins, and repositioning interventions. She stated nurses and CNAs were responsible for implementing interventions and reporting changes in skin condition.On 5/12/2026 from 11:18 AM through 2:22 PM, a continuous three-hour observation was conducted from the hallway across from the resident's room. The room door remained open and the privacy curtain was partially closed, allowing observation of the resident from the hallway. At 11:18 AM, R13 observed lying on her back with the head of the bed elevated and covered with multiple blankets.In an interview conducted with CNA DD on 05/12/2026 at 2:07 PM in the hallway, she stated she reviewed the care plans and received report from other staff to determine the resident's care needs. She stated R13 was a total care resident and she provided the resident's care, the CNA stated, Yes, I turn her every two hours. When asked when the resident was last repositioned, the CNA stated, Two hours ago. CNA DD then went into the room and located two wedges in R13's closet. CNA DD confirmed she had not repositioned R13 that day and stated she thought the wound nurse would reposition the resident earlier during wound care. On 05/13/2026 at 8:48 AM, observation of R13 in her room revealed the resident lying on her back (not on her left side, as per Turning Schedule) with the head of the bed elevated and tube feeding was in progress.In an interview conducted with LPN FF, assigned to R13, on 05/13/2026 at 8:50 AM, she confirmed R13 was lying on her back and not positioned on her left side as indicated on the resident's turning schedule. When asked why the turning schedule was not being followed, the LPN stated she had just started the resident's tube feeding and wanted the resident to remain propped up.In an interview conducted with the Wound Nurse LPN AA on 05/13/2026 at 9:00 AM, she stated any nursing staff member could reposition the R13 and that residents were repositioned during wound care. She stated R13 prefered to remain on her back and staff assisted with side positioning by using the resident's other leg to help maintain the position. The Wound Nurse stated she asked nursing staff if the resident had been repositioned prior to the dressing change on 05/12/2026. In an interview conducted with MDS Coordinator LPN GG , on 05/13/2026 at 11:15 AM, she stated the facility does not document resident turning and repositioning in the Electronic Medical Records (EMR). She stated it is the facility's policy that all residents unable to reposition themselves are to be turned and repositioned every two hours. She further stated the facility uses a Turning Schedule to assist staff in identifying the side to which the resident should be repositioned.In an interview conducted with the Director of Nursing (DON) on 05/13/2026 at 11:46 AM, she stated she expected nursing staff to assist dependent residents with turning and repositioning every two hours. The DON was unable to find documentation indicating R13 had refused care prior to 05/13/2026.In an interview conducted with Unit Manager LPN CC on 05/13/2026 at 4:10 PM, she stated she expected CNAs to round on residents and reposition them every two hours.

Based on observations, interviews with staff, record review and review of the facility policy titled, Activities of Daily Living, the facility failed to follow physician orders related to diet by failing to provide a meal tray to one of 150 residents on an oral diet (R13). This deficient practice placed the resident at risk for decreased quality of life.Findings include:Review of the facility's policy titled, Activities of Daily Living revised December 2025 revealed the following: 3. The facility will provide care and services for the following activities of daily living: d. Dining-eating, including meals and snacks.4. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.Review of the Electronic Medical Records (EMR) revealed R13 iresident admitted to the facility on [DATE] with diagnoses including traumatic cerebral hemorrhage, obstructive hydrocephalus, epilepsy, dysphagia following cerebral infarction, dysphagia, rheumatoid arthritis, osteoarthritis, esophageal dyskinesia, cognitive communication deficit, generalized muscle weakness, muscle wasting/atrophy, lack of coordination, sarcopenia, and pressure ulcers including sacral pressure ulcers stage 4.Review of the Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a BIMS score of 2, indicating severed cognitive impairment. Section GG (FunctioGoals) revealed functional limitations with bilateral impairment of both upper an lower extremities. The resident was dependent on staff for oral hygiene, toileting, showering/bathing, upper body dressing, and personal hygiene. Section K (Swallowing/ Nutritional Status) revealed the resident received nutrition through a feeding tube and a mechanically altered therapeutic diet. The assessment further revealed the resident was not observed holding food in the mouth or coughing or choking when swallowing medications.Review of the care plan for R13 revealed interventions related to nutrition, including tube feeding via PEG ( percutaneous esophageal gastrostomy) tube, providing diet as prescribed and offering pleasure tray, staff assisting with all meals.Review of the physician orders related to nutrition for R13 revealed orders for a controlled carbohydrate no added salt (CCD NAS) diet with puree texture and thin liquids consistency; Jevity 1.5 via Percutaneous Endoscopic Gastrostomy (PEG) tube at 60 cc/hr for 20 hours daily; 150 cc water flushes every 4 hours; 30 cc water flushes before and after medication administration; checking gastric residuals and tube placement prior to feeding; elevating the head of bed 30-45 degrees during and after feeding; monitoring for PEG tube complications; and daily PEG site care with cleansing and dressing changes.An observation and interview of R13 on 05/12/2026 at 9:20 AM revealed R13 was observed lying on her back in bed with the head of the bed elevated. Tube feeding was observed infusing at 60 milliliters per hour (mL/hr). On 05/12/2026 at 12:48 PM, Certified Nursing Assistant (CNA) HH was observed passing meal trays on the 400 Hall but did not provide a tray to R13. At that time, R13 continued to receive tube feeding.On 05/12/2026 at 1:03 PM, CNA DD, who was assigned to R13, was observed conducting rounds from room to room. When asked why R13 had not received a meal tray, CNA DD stated the resident did not receive meal trays because she was tube-fed.On 05/13/2026 at 8:48 AM, observation of R13 in her room revealed the resident lying on her back with the head of the bed elevated and tube feeding was in progress. In an interview conducted with Licensed Practical Nurse (LPN) FF, assigned to the 400 Hall and caring for R13, on 05/13/2026 at 8:50 AM, when asked why the resident had not received a meal tray, the LPN stated R13 did not take anything by mouth because she received continuous tube feeding. In an interview conducted with the Director of Nursing (DON) on 05/13/2026 at 11:46 AM, she stated R13 received a pleasure tray and staff assisted her with all meals and did not know why the resident had not been offered one. She stated she expected the physician's orders to be followed. The DON was unable to provide documentation indicating R13 had refused the meal trays prior to 05/13/2026.In an interview conducted with the Dietary Manager on 05/13/2026 at 3:50 PM, she stated R13 had an active order to receive meal trays and that trays were always sent as ordered.

Based on observations, staff interviews, record review, and review of the facility policy titled, Respiratory Therapy Equipment, the facility failed to ensure proper maintenance and monitoring of oxygen equipment in accordance with professional standards of practice for two of 28 sampled residents (R) (R109 and R1) reviewed for respiratory care related to maintaining a clean oxygen concentrator and filter. This deficient practice had the potential to result in decreased oxygen delivery, increased risk of respiratory compromise, and exposure to contaminants, which could adversely affect the residents' health and safety.Findings include:Record review of the facility policy titled Respiratory Therapy Equipment, which was undated, revealed procedure guidelines for oxygen administration directing staff to wash oxygen concentrator filters weekly, rinse the filters, and squeeze dry prior to reuse.1. Review of the EMR revealed R109 had diagnoses including, but not limited to, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, congestive heart failure (CHF), shortness of breath (SOB), and pneumonia, and had active physician orders for oxygen therapy.Observation conducted on 05/11/2026 at 12:15 PM, revealed R109 receiving oxygen therapy via oxygen concentrator with visible dust and debris accumulation present on the concentrator exterior and filter while the equipment remained in use.Follow-up observations conducted on 05/11/2026 at 3:26 PM, revealed that the oxygen concentrator filter remained visibly soiled, with continued dust and debris accumulation, while oxygen therapy remained in progress.Follow-up observations conducted on 05/12/2026 at 12:25 PM, revealed that the oxygen concentrator filter remained visibly soiled, with continued dust and debris accumulation, while oxygen therapy remained in progress.During an interview on 05/12/2026 at 1:00 PM, Certified Medication Aide (CMA) (CMA) KK, stated that staff monitored oxygen cannula placement, verified oxygen flow rates, and assessed concentrators for equipment issues when alarms occurred. She stated oxygen tubing was routinely changed by night shift staff and concentrators were generally serviced by central supply personnel.During an interview on 05/12/2026 at 1:10 PM, Licensed Practical Nurse (LPN) JJ, stated that residents receiving oxygen therapy were routinely monitored to ensure oxygen was administered as ordered and oxygen equipment was functioning properly. She stated staff monitored oxygen saturation levels, verified oxygen flow rates, and routinely changed oxygen supplies in accordance with facility practice.During an interview on 05/12/2026 at 1:15 PM, Unit Manager Licensed Practical Nurse (LPN) II, stated staff monitored residents receiving oxygen therapy, including oxygen saturation levels, tubing changes, and concentrator functioning. She stated an outside company was reportedly responsible for concentrator filter maintenance; however, when shown the concentrator in use, she confirmed the filter was visibly soiled with dust and debris.During an interview on 05/12/2026 at 1:20 PM, the Director of Nursing (DON) confirmed that the oxygen concentrator filters in use were visibly dirty and did not meet facility cleanliness and maintenance standards. She stated that her expectation was that the concentrators should be routinely monitored to ensure proper functioning to ensure resident health and safety and noted that the facility used an outside company for concentrator maintenance.2. Review of the EMR for R1 revealed admission to the facility with diagnoses of Alzheimer's Disease, cerebral infarction, congestive heart failure, chronic respiratory disease with hypoxia.Review of the physician orders revealed that oxygen was to be administered at 2 liters per minute via nasal cannula continuous, change and date all respiratory supplies and tubing weekly *if oxygen concentrator is present, clean filter*.Review of the care plan revealed the following interventions and goal: RI is on oxygen therapy related to hypoxic-respiratory failure, R1 will have no signs and symptoms of poor oxygen absorption.Observation conducted on 05/11/2026 at 10.20 AM, revealed R1 receiving oxygen therapy via oxygen concentrator with visible dust and debris accumulation present on the concentrator exterior and filter while the equipment remained in use.Follow-up observations conducted on 05/11/2026 at 3:24 PM of R1, revealed that the oxygen concentrator filter remained visibly soiled, with continued dust and debris accumulation, while oxygen therapy remained in progress.Follow-up observations conducted on 05/12/2026 at 12:25 PM of R1, revealed that the oxygen concentrator filter remained visibly soiled, with continued dust and debris accumulation, while oxygen therapy remained in progress.

Based on observations, staff interviews, and review of the facility policy titled, Hand Hygiene, the facility failed to perform appropriate hand hygiene while passing lunch meal trays between each resident on one of three units. The deficient practice had the potential to place residents at risk of cross-contamination and the transmission of infectionsFindings include:Review of the facility policy titled, Hand Hygiene, dated February, 2026, revealed that handwashing /hand hygiene shall be regarded by this Center as a means of preventing the spread of infections. The subsection titled, Policy Interpretation and Implementation revealed under number 2. e. stated, Associates must perform appropriate handwashing procedures under the following conditions, between passing out meal trays at lunch.Observations made on 05/11/2026 at 12:33 AM in the Unit 2 dining hall revealed two employees, Certified Nursing Assistants (CNAs) PP and QQ, not performing proper hand hygiene between passing out lunch meal trays.In an interview on 05/11/2026 at 12:33 PM with Licensed Practical Nurse (LPN) FF, the employee stated that employees who passed out lunch trays were supposed to sanitize their hands before grabbing a new tray and confirmed CNAs PP and QQ were not performing appropriate hand hygiene between tray passes.In an interview on 05/11/2026 at 12:35 PM, CNA QQ stated that she knew to hand-sanitize after each tray pass and acknowledged that she sanitized her hands only before the first tray she passed out.During an interview with the Assistant Director of Nursing (ADON) on 05/11/2026 at 12:41 PM, she stated she expected handwashing/hand sanitizing to be done between tray passes, that residents were kept safe, and that residents had proper assistance with feeding.

Based on observations, family, resident and staff interviews, record review, and review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, the facility failed to provide adequate supervision to prevent accidents for one of three residents (R) (R1) reviewed for falls with major injury. Actual harm occurred on 8/17/2025 when Certified Nursing Assistant (CNA) AA transferred R1 unassisted from his bed to the wheelchair resulting in R1 sustaining a fall during transfer that resulted in a closed displaced spiral fracture of the right femur. Findings include:A review of the facility's policy titled, Care Plan- Comprehensive, dated September 2025 under Policy revealed: A comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs shall be developed for each resident. Under the section Policy Interpretation and Implementation number 2 (e) identify the professional services that are responsible for each element of care and (h) ensure care plan is individualized and person-centered and reflects the resident's goals for admission and desired outcomes.A review of the electronic medical record (EMR) revealed R1 was admitted to the facility with a diagnosis that included but was not limited to, displaced spiral fracture of shaft of right femur (thigh bone) subsequent encounter for closed fracture with routine healing, flaccid hemiplegia affecting right dominant side (weakness on right side of the body), encountering for other specified surgical aftercare, unspecified fall, pain in right knee, and difficulty in walking not specified elsewhere classified.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] for R1 revealed Section GG (Functional Abilities and Goals) revealed, R1 was dependent on staff for chair/bed-to chair or wheelchair transfer indicating the assistance of two or more helpers required for the resident to complete the activity.A review of the care plan dated 11/1/2021 revealed R1 had potential for injury from falls related to right hemiparesis, episodes of weakness with interventions to use two persons for transfers.A review of the EMR under the Kardex Report the section Safety revealed R1 required two persons for transfers.In an interview on 10/27/2025 at 1:36 pm with CNA AA confirmed she transferred R1 alone and stated she never looks at his point of care in the EMR and is familiar with R1 mobility transfers based on observations from other staff on the unit transferring R1.In an interview on 10/27/2025 at 1:47 pm with CNA EE stated R1 has always been a two-person transfer.In an interview on 10/27/2025 at 2:24 pm with the Care Plan Coordinator (CPC) stated if there is an intervention on the most updated care plan the staff are expected to follow them. The CPC continued to state the Kardex reflects the resident care plan, and this is the information that shows up on the Plan of Care (POC) for their task. While looking at R1 care plan she stated the staff should be following the two-person assistance for R1 transfers.In an interview on 10/27/2025 at 2:39 pm with the Director of Nursing (DON) stated the CNAs should follow the Kardex while working on the floor. She stated under the section titled Safety is defined as keeping the resident safe so there is no harm and confirmed R1 is a two person assist. The DON further stated her expectations are that the Kardex should match the care plan and when a fall occurs the care plan should be updated immediately.In an interview on 10/28/2025 at 12:38 pm with the Administrator stated she expects the staff to follow the care plans and the Kardex.[Cross Reference - F689]

Based on observations, family, resident and staff interviews, record review, and review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, the facility failed to provide adequate supervision to prevent accidents for one of three residents (R) (R1) reviewed for falls with major injury. Actual harm occurred on 8/17/2025 when Certified Nursing Assistant (CNA) AA transferred R1 unassisted from his bed to the wheelchair resulting in R1 sustaining a fall during transfer that resulted in a closed displaced spiral fracture of the right femur. Findings include:A review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, dated July 2025 under Purpose: To ensure a safe environment for all residents by minimizing accidents hazards, providing adequate supervision and assistive devices, and implementing a proactive and systematic approach to preventing, investigating, and mitigating accidents and incidents in accordance with federal regulations (F689), facility policies, and resident- centered care principles. Under Policy Statement: The facility is committed to ensuring adequate supervision and appropriate use of assistive devices to reduce the risk of accidents and incidents. A review of the Electronic Medical Record (EMR) revealed R1 was admitted to the facility with a diagnosis that included but was not limited to, displaced spiral fracture of shaft of right femur (thigh bone) subsequent encounter for closed fracture with routine healing, flaccid hemiplegia affecting right dominant side (weakness on right side of the body), encountering for other specified surgical aftercare, unspecified fall, pain in right knee, and difficulty in walking not specified elsewhere classified.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R1 revealed, Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderate cognitive impairment and Section GG (Functional Abilities and Goals) revealed, R1 was dependent on staff for chair/bed-to chair or wheelchair transfer indicating the assistance of two or more helpers required for the resident to complete the activity.A review of the care plan dated 11/1/2021 revealed R1 had potential for injury from falls related to right hemiparesis, episodes of weakness with interventions to use two persons for transfers. A review of the Nurse's Note dated 8/17/2025 documented tech called me into patient (pt) room to notify me of fall that occur previously during care. Pt was seen sitting on commode asking to be put back in bed, pt was assisted back to bed, vital signs (vs) taken and documented, family called and notified, clinician orders to transport pt to emergency department (ED) for follow up treatment (tx). (Sic)A review of the EMR under the Kardex Report the section Safety revealed R1 requires two persons for transfers.In a telephone interview on 10/23/2025 at 3:57 pm with CNA AA confirmed she transferred R1 without assistance while preparing him for a shower from his bed to his wheelchair. CNA AA stated while transferring R1 he grabbed the bedrails which caused both of them to become unsteady and caused her fall back on R1 and into the wheelchair. She continued to state she called for assistance from another CNA and the nurse to assess R1 post fall because he was complaining of leg pain. Continued interview also revealed that CNA AA stated she never looks at his point of care in the EMR and is familiar with R1 mobility transfers based on observations from other staff on the unit transferring R1.In an interview on 10/27/2025 at 1:15 pm with the family member of R1 revealed she was informed by the CNA that she was caring for R1 alone and while transferring him to his wheelchair she fell on top of him resulting in R1 having a broken leg.In an interview on 10/27/2025 at 1:18 pm with R1 revealed he does not remember much from the fall other than falling. However, he stated there is usually one staff assisting him with transfers.In an interview on 10/27/2025 at 1:47 pm with CNA EE revealed that R1 had always been a two-person transfer.In an interview on 10/27/2025 at 1:50 pm with Licensed Practical Nurse (LPN) FF stated the CNA on the floor should be looking at the policy, asking questions to the nurses on the floor, and looking at the residents EMR to determine the type of care that should be provided for the residents.In an interview on 10/27/2025 at 2:39 pm with the Director of Nursing (DON) stated she was informed about R1 fall occurring during a transfer from the bed to the wheelchair by CNA AA. During the interview it was disclosed that the DON expects for the nursing staff to follow the residents plan of care when care is provided. [Cross Reference - F656]

Based on observations, record review, resident and staff interviews, and review of the facility's policy titled, Self-Administration of Medication, the facility failed to ensure one of 56 sampled residents (R) (R150) was assessed for self-administration of medications prior to leaving medications at her bedside. This deficient practice had the potential to place R150 at risk of medical complications and a diminished quality of life. Findings Include: A review of the facility's policy titled, Self-Administration of Medication, dated April 2022, revealed the General Guidelines section included, 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. A review of R150's electronic health record (EHR) for R150 revealed diagnoses including, but not limited to, chronic respiratory failure with hypoxia, acute chronic diastolic congestive heart failure (CHF), acute pulmonary edema, asthma, chronic obstructive pulmonary disease (COPD) with acute exacerbation, and bronchitis. A review of R150's admission Minimum Data Set (MDS) dated [DATE] revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of nine (indicating moderate cognitive impairment). A review of R150's care plan, with a start date of 2/10/2025, revealed no care areas or interventions for self-administration of medications. A review of R150's Physicians Orders revealed an order dated 3/21/2025 for Breztri Aerosphere inhalation aerosol 160-9-4.8 microgram (MCG)/actuator (ACT), two puffs inhaled orally two times a day (a medication used to treat COPD). Further review revealed an order dated 2/10/2025 for albuterol sulfate high flow aerosol (HFA) solution 108 (90 base) MCG/ACT, two puffs orally every four hours as needed (a medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing). A review of R150's EMR revealed that no self-administration of medication assessments were completed. In a concurrent observation and interview on 3/31/2025 at 11:17 am, in R150's room, observation revealed one medicated oral inhaler on the bedside table and one medicated oral inhaler on her bed. In an interview, R150 stated the facility had left the medications at her bedside and stated the inhalers had been in her room for a month. R150 stated the facility staff told her she could administer the medications on her own. R150 further stated that a nurse could be down the hall, and she might need the medications immediately, and staff might not be around all the time. In an interview on 3/2/2025 at 3:13 pm, Certified Nursing Assistant (CNA) HH stated she was aware that R150 had medicated inhalers in her room and was unsure if there was an order to leave the inhalers at the bedside. CNA HH stated the facility protocol for medications at the bedside was that residents were allowed to have medications at the bedside if they were competent enough. In a concurrent observation and interview on 3/2/2025 at 3:13 pm, Licensed Practical Nurse (LPN) II stated R150 has an order for the inhalers at the bedside. LPN II stated that the facility procedure was that medications were not allowed at the bedside, but they made an exception for R150 because she has respiratory issues. LPN II stated R150 had been assessed to have medications at the bedside, but was unsure of how many inhalers. LPN II verified R150's physician's orders and confirmed that R150 did not have a physician's order for the medicated inhalers to be kept at the bedside and self-administered. In an interview on 4/2/2025 at 4:17 pm, the Director of Nursing (DON) stated that if a resident desired to self-administer a medication, the physician would provide the order, and the facility would assess the resident's ability to self-administer the medication. She stated the resident must demonstrate the ability to self-administer the medication before the medication would be left at the bedside. The DON further stated her expectations were for nurses to be aware of what residents are allowed to have medications at the bedside. She stated risks of having unauthorized medications at the resident's bedside were overuse of the medication, the wrong resident could use it, and further stated it was against the five rights of medication administration.

Based on observations, staff interviews, record review, and review of the facility's policy titled Care Plan Policy, the facility failed to develop a comprehensive person-centered care plan for one of 12 residents (R) (R120) with an indwelling urinary catheter and one of 26 R (R147) receiving oxygen (O2). This deficient practice had the potential to place R120 and R147 at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Care Plan Policy, revised 11/15/2022, revealed the Policy Statement included, Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Standards of Practice section included, . 9. A comprehensive plan of care will be developed by the interdisciplinary team, resident and/or resident representative as applicable. The plan of care will address the resident's status in triggered CAA [Care Area Assessments] areas, a rationale for deciding whether to proceed with care planning and provide evidence that the facility considered the development of care planning interventions for all CAA's triggered by the Minimum Data Set 3.0. 1. Review of R120's Admission Minimum Data Set (MDS) dated [DATE] revealed Section H (Bowel and Bladder) revealed R120 had an indwelling urinary catheter. Review of R120's comprehensive care plan dated 2/15/2025 revealed there was no focus area or interventions for an indwelling urinary catheter. Observations on 3/31/2025 at 11:45 am and 4/2/2025 at 2:28 pm revealed R120 had an indwelling urinary catheter. During an interview on 4/3/2025 at 2:50 pm, the Director of Nursing (DON) stated that the MDS Coordinator was responsible for updating care plans, and nurses could also update care plans as needed. During an interview on 4/3/2025 at 3:58 pm, the MDS Coordinator revealed she updated care plans based on information during morning clinical meetings, information in resident charts, and discussion with other staff members. She further stated that indwelling catheters should be included in the care plan. 47947 2. Review of R147's clinical record for R147 revealed he was admitted to the facility on [DATE] with diagnoses including, but not limited to, pneumonia and cough. Review of the Admission MDS, dated [DATE], Section O (Special Treatments, Procedures, and Programs) documented R147 received oxygen while a resident. Review of R147's care plan revealed there was no care plan focus area or interventions addressing oxygen therapy. Observations on 3/31/2025 at 10:30 am and on 4/1/2025 at 11:07 am and 2:20 pm revealed R147 receiving oxygen via a nasal cannula at 2.5 liters per minute. During observation and interviews on 4/1/2025 at 3:20 pm, Licensed Practical Nurse (LPN) AA confirmed that R147 was receiving oxygen via nasal cannula. LPN BB verified that there was no care plan area or interventions for O2 on R147's care plan for oxygen administration. In an interview on 4/1/2025 at 3:00 pm, the DON stated oxygen administration should be included on a resident's care plan.

Based on observations, staff interviews, and a review of the facility's, Care Plan policy, the facility failed to revise the comprehensive care plan to include a new sacral pressure injury with measurable goals and interventions for one of three residents (R) (R206) reviewed with pressure ulcers. The facility also failed to update the care plan for R47, whose oxygen treatment had been discontinued but was still listed on the care plan. Findings include: Review of the facility policy titled, Care plan policy updated 11/15/2022 revealed the policy statement: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how facility staff will provide services to attain or maintain the resident highest practicable physical, mental and psychosocial wellbeing. Further review of the Policy revealed under Standard of Practice number 1. Each resident will be assessed by the interdisciplinary team on admission, quarterly, annually, and with a significant change in status 5 .Upon a resident's readmission to facility, the care plan will be updated as indicated 10. Areas of concern or potential concern and residents strengths will be addressed with measurable goals and specific person-centered approaches to promote attainment or maintenance of the goal(s) .12. The plan of care is to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident reprehensive party if so desired. Record review for R 206 revealed resident was admitted to the facility on [DATE] following a transfer from a local hospital, where she underwent a right hip hemiarthroplasty (hip repair surgery), for physical/occupational therapy and assistance with activities of daily living (ADLs). At the time of admission, she was alert and oriented to person, place, and time, able to express her needs, and capable of following simple commands. Initial and ongoing skin assessments through 10/31/2024 documented an intact sacrum. Continued record review revealed R206 had a hospital return on 11/1/2024, nursing staff identified a new deep tissue injury (DTI) to the sacrum and initiated treatment. However, the care plan was not updated upon her return to reflect the new skin integrity concerns. Care plan review did not reveal interventions related to the newly developed deep tissue injury (DTI) on the sacrum. Interview on 4/1/2025 at 2:25 pm with the treatment nurse, LPN EE revealed that when a resident develops a pressure ulcer, she notifies the nurse practitioner or physician, documents any new orders, informs the family, updates the care plan, and provides treatment as prescribed. The treatment nurse confirmed that she could not locate an updated care plan addressing the sacral wound for the resident; only the surgical incision was included in the care plan. A subsequent interview on 4/1/ 2025, at 3:15 pm, with the Director of Nursing (DON) indicated that care plans are expected to be revised when a resident experiences a change in condition. The DON acknowledged that the facility failed to update resident R206's care plan to reflect the presence of a sacral wound. Interview on 4/3/2025 at 3:58 pm with LPN and MDS Coordinator LL revealed that she updates care plans based on information shared during morning clinical meetings. She added that if a resident develops a new wound, it would be care planned accordingly. 47947 2. Record review for R254 revealed resident was admitted to the facility on [DATE] with diagnoses that include but not limited to Alzheimer's disease, sequelae of cerebral infarction, and unspecified convulsions. Review of R47 electronic medical records revealed physician order for oxygen therapy at 2 liters per minute with start date of 3/29/2024 and end date of 5/30/2024. Review of Cerebral Vascular Accident care plan dated 2/14/2025 revealed an intervention in place to give oxygen as ordered. Interview on 4/3/2025 at 4:50 pm with LPN, MDS Coordinator LL revealed that the care plan should be updated if oxygen order is discontinued. LPN LL confirmed that intervention for oxygen administration was in R47's current care plan and stated that this intervention should be resolved. LPN LL continued stating that she and MDS Director are responsible for updating care plans, and all nurses have access to care plans updates.

Based on observations, staff interviews, records reviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure a physicians order for oxygen administration was obtained for one residents R (R147), the facility also failed to ensure two of 26 residents (R254 and R69) oxygen was administered as ordered by the physician. Findings include: Review of undated facility policy titled Oxygen Administration revised date of October 2010 revealed under Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 1.Review of the Electronic Medical Record (EMR) for R147 revealed resident was admitted to the facility with diagnoses of but not limited to pneumonia, anxiety, and cough. Continued review of the residents' physicians' orders did not reveal an order for oxygen therapy administration. Review of the 5-day Admission Minimum Data Set (MDS) dated [DATE] documented R147 had a Brief interview for Mental Status (BIMS) score of 4 indicating resident had severe cognitive impairment. Observation on 3/31/2025 at 11:30 am revealed R147 was receiving oxygen via nasal cannula at 2.5 liters per minute (L/M). Observation on 4/1/2025 at 11:07 am revealed R147 was receiving oxygen via nasal cannula at 2.5 (L/M). Observation and Interview on 4/1/2025 at 2:20 pm revealed R147 was receiving oxygen via nasal cannula at 2.5 (L/M). Interview on 4/1/2025 at 2:20 pm with Licensed Practical Nurse (LPN) AA confirmed the oxygen concentrator was set at 2.5 L/M. LPN AA checked R147's electronic medical records and was not able to locate a physician order for oxygen administration. Interview on 4/1/2025 at 2:22 pm with Unit Manager, LPN BB she stated that she was not able to find a physician order of oxygen for R147. 2. Review of the EMR for R254 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, and pneumonia. Review of the 5-day MDS dated [DATE] for R254 documented a BIMS score of 15 indicating little to no cognitive impairment. Review of the physician order dated 3/27/2025 for R254 revealed an order for oxygen at three liters (3L) per minute via nasal canula (NC). Observation on 3/31/2025 at 1:15 pm of the oxygen concentrator for R254 revealed a rate of delivery at four liters. Observation on 4/1/2025 at 11:03 am of the oxygen concentrator for R254 revealed a rate of delivery at four liters. Observation with LPN AA on 4/1/2025 at 2:20 pm of the oxygen concentrator for R254 confirmed the rate of delivery at four liters. LPN AA reviewed R254 medical records and confirmed that physician order was for 3 liters per minute. Interview with Director of Nursing (DON) on 4/1/2025 at 3:00 pm confirmed that all residents receiving oxygen therapy should have a physician order and care plan, and physician order must match oxygen concentrator setting. 52212 3. Review of the EMR for R69 revealed resident was admitted to the facility with diagnoses of but not limited to, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, and dependence on supplemental oxygen. Review of R69's Quarterly MDS assessment dated [DATE] revealed a BIMS of 14, which indicated R69 had little to no cognitive impairment. Section O, Special Treatments, indicate oxygen therapy. Review of care plan for R69 revealed focus for R69 is on oxygen therapy related to chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), ineffective gas exchange, oxygen dependency, recent history of acute respiratory failure with hypoxia. Outcome of R69 will have no signs and symptoms of poor oxygen absorption through the review date. Interventions, include but not limited to, the resident has oxygen (O2) via nasal prongs at two to three liters continuously, give oxygen as ordered by the physician. Review of the Physician's Orders for R69 included but was not limited to: Order dated for 5/30/2024 oxygen three liters (L) per minute by way of nasal cannula for shortness of breath (sob) intermittent use or pulse oximeter <92%. Observation and interview on 3/31/2025 at 2:06 pm of R69 stated she uses oxygen continuously. Oxygen concentrator noted at bedside with flow meter below 2 liters via nasal canula. Observation on 4/1/2025 at 9:31 am on R69 revealed resident lying in bed with O2 NC in place, oxygen flow rate was just below two liters. Observation on 4/1/2025 at 2:53 pm revealed R69 Oxygen setting on two liters. An interview on 4/1/2025 at 2:57 PM with LPN WW confirmed status of oxygen concentrator in the room of R69 was set at two liters and that the order for residents' oxygen was for three liters. An interview on 4/1/2025 at 3:00 pm with DON revealed that all residents receiving oxygen therapy should have physician order and care plan, and physician order must match oxygen settings.

Based on observations, staff interview, and review of the facility's policy titled, Medication Storage, the facility failed to ensure all medication labels were legible and that expired medications were disposed of after expiration date on one of five medication carts and in two of three medication storage rooms on (100 Hall and 300 Hall). Findings include: A review of the facility's policy titled, Medication Storage, revision date of November 2020 revealed under policy statement, the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation: 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Observation on 4/2/2025 at 9:36 am Certified Medication Aide (CMA) GG was observed during medication administration. An audit of the medication cart revealed two boxes of expired glucagon injection syringes. Each box contained 1 ready to use rescue pen for low blood sugar emergencies and were dated March 2025. CMA GG confirmed that the injections of glucagon were expired. She stated that no expired medications should have been on the cart. She also confirmed that the process is to take expired medication out the cart and put them in the return bin. Observation and interview on 4/2/2025 at 1:43 pm with Licensed Practical Nurse (LPN) FF of medication storage room on hall 100 revealed two boxes of expired pneumococcal vaccines dated September 2024 and December 2024 and one box of sodium chloride inhalation solution expired in October 2021. LPN FF confirmed that pneumococcal vaccines and the sodium chloride inhalation solution was expired. Observation and interview on 4/2/2025 at 2:09 pm with LPN AA of medication storage room on hall 300 revealed expired 1 bottle of Ketamine dated February 2025. There was a medication bottle in the locked narcotic box in the refrigerator that had an unreadable label. LPN AA verified and confirmed that the Ketamine was expired and confirmed and verified that second bottle of medication label was not legible and that it was no way to determine what the medication was or who it belonged to. LPN AA stated she was a new employee and revealed she did not know the process for the expired and discontinued medications. She also stated she did not know the process to follow when a label is not legible. Interview on 4/2/2025 at 1:58 pm an with LPN II revealed that he was a unit manager, and stated he did not know who was responsible for auditing medication rooms for expired drugs and supplies. He further revealed he did not know the process for removal of expired medications. Interview on 4/3/2025 at 11:08 am with the Director of Nursing (DON) revealed that usually the night staff checks for expired medications on the medication carts and in the medication storage rooms. She also confirmed that pharmacy comes once a month to pick up the discontinued and expired items, and all medications are scanned and recorded in an electronic system. She stated over the counter medications are checked for expiration dates by the central supply clerk during her restocking process. The DON stated her expectations were for the staff to remove expired medications from the medication carts and the medication storage rooms. She also revealed that staff should not administer medications that are expired. Observation and interview on 4/2/2025 at 2:09 pm with LPN AA of medication storage room on hall 300 revealed expired 1 bottle of Ketamine dated February 2025. There was a medication bottle in the locked narcotic box in the refrigerator that had an unreadable label. LPN AA verified and confirmed that the Ketamine was expired and confirmed and verified that second bottle of medication label was not legible and that it was no way to determine what the medication was or who it belonged to. LPN AA stated she was a new employee and revealed she did not know the process for the expired and discontinued medications. She also stated she did not know the process to follow when a label is not legible. Interview on 4/2/2025 at 1:58 pm an with LPN II revealed that he was a unit manager, and stated he did not know who was responsible for auditing medication rooms for expired drugs and supplies. He further revealed he did not know the process for removal of expired medications. Interview on 4/3/2025 at 11:08 am with the Director of Nursing (DON) revealed that usually the night staff checks for expired medications on the medication carts and in the medication storage rooms. She also confirmed that pharmacy comes once a month to pick up the discontinued and expired items, and all medications are scanned and recorded in an electronic system. She stated over the counter medications are checked for expiration dates by the central supply clerk during her restocking process. The DON stated her expectations were for the staff to remove expired medications from the medication carts and the medication storage rooms. She also revealed that staff should not administer medications that are expired.

Based on staff interviews, record review, and review of facility's policy titled Abuse Prevention Policy, the facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) Fingerprint check was conducted for two [Certified Nursing Assistant (CNA) BB and CNA CC] of ten employee files selected for review. The facility census was one hundred and forty-eight residents. Findings include: Review of the policy titled Abuse Prevention Policy dated 11/1/2021 under the section titled Employee Screening revealed, Background, reference, and credentials' checks should be conducted on employees prior to or at the time of employment by the facility administration, in accordance with applicable state and federal regulations. During a record review of the employee files there was no documentation that a fingerprint records check was conducted on CNA BB and CNA CC. An interview on 1/17/2024 at 10:30 am with the Administrator stated the facility follows the State and Federal requirements for conducting fingerprint checks. The Administrator confirmed CNA BB and CNA CC did not have a fingerprint check conducted. An interview on 1/24/2024 at 1:40 pm with the Human Resources Director (HRD) stated she was responsible for background checks, fingerprints check, reference check and maintaining the employee's files. She stated she was aware CNA BB did not have a fingerprint check conducted. She stated I didn't follow through with the fingerprint check for the employee. The HRD stated she had not completed an audit of the employees' files to ensure that a GCHEXS fingerprint check was conducted on the required employees. The HRD stated she was sure that CNA BB was the only one that had not been performed.

Based on record review, document review, and interviews, the facility failed to ensure a Registered Nurse (RN) was on duty eight consecutive hours per day seven days a week. This had the potential to affect all 134 residents residing in the facility. Findings include: Review the [NAME] Payroll Based Journal (PBJ) dated July 1, 2022, through September 30, 2022 revealed during the fourth quarter reporting, the facility was identified as not having a RN working on the dates of 7/3/2022 and 8/21/2022, for 8 consecutive hours each day. Interview on 1/18/2023 at 4:14 p.m., Human Resource (HR) confirmed that eight consecutive hours of RN coverage was not provided for the dates of 7/3/2202 and 8/21/2022. Interview on 1/19/2023 at 1:35 p.m., the Staffing Coordinator (SC), revealed they have not been without RN coverage. She stated the ADON will come in and work when RN coverage is needed. The SC stated she gave the information to HR as a missed punch and stated it must have not gotten entered. Interview on 1/19/2023 at 1:47 p.m., both the Administrator and Director of Nursing (DON), state neither remember not ever having RN coverage. The DON indicated there was nothing on the schedule without an RN. She stated she remembers on 8/21/2022 a nurse getting sick and having to leave, but stated another RN was called in to assist. During further interview, she stated I'm thinking the Staffing Coordinator forgot to add to the shift and put it into the system to be pulled over. The DON indicated the facility does not have an RN staffing policy but follows state and federal regulations.

Based on observations, record review, interview, policy review and review of Centers for Disease Control (CDC) guidelines and Quality Safety and Oversight Group (QSO) memo, the facility failed to implement an effective Infection Control Program to prevent the spread of infections, including COVID-19 virus by not posting signage related to the current COVID-19 outbreak upon entering the facility. In addition, the facility failed to ensure staff changed gloves during wound care for one resident (R) (R#60) of 10 residents reviewed for infection control. Findings include: 1. Review of the CDC guidelines in Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic include: Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias). These alerts should include instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations. Review of the QSO 20-39-NH indicated, Facilities should provide guidance (e.g., posted signs at entrances) about recommended actions for visitors who have a positive viral test for COVID-19, symptoms of COVID-19, or have had close contact with someone with COVID-19. Visitors with confirmed COVID-19 infection or compatible symptoms should defer non-urgent in-person visitation until they meet CDC criteria for healthcare settings to end isolation. For visitors who have had close contact with someone with COVID-19 infection, it is safest to defer non-urgent in-person visitation until 10 days after their close contact if they meet criteria described in CDC healthcare guidance (e.g., cannot wear source control) . Instructional signage throughout the facility and proper visitor education on COVID- 19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene). Observation on 1/16/2023 at 9:30 a.m. upon entering the facility, there was no signage posted informing the public of the facility's current COVID-19 outbreak status. Interview on 1/16/2023 at 10:02 a.m. during the entrance conference, the Administrator stated they currently had one resident who tested positive for COVID-19. Observation on 1/19/2023 at 4:20 p.m., the front receptionist area and glass window did not include a posting informing people who enter the building they had a COVID-19 outbreak. Interview on 1/19/2023 at 4:23 p.m. the receptionist was observed sitting at the front desk. She was asked how people who enter the facility were informed of the facility's COVID-19 outbreak status. She stated she verbally informs all people who entered the facility that they had a positive COVID-19 person in the building. During further interview, she stated there are two shifts at the front desk. She stated she works the second shift and her shift ends at 8:00 p.m. She stated after that time, they relied on the nurses to inform people who enter after hours that the facility had residents and/or staff members that tested positive for COVID in the building. The receptionist was asked if there was a posting or signage about the COVID positive status of the facility and she replied No. Interview on 1/19/2023 at 4:49 p.m., the Infection Preventionist (IP) was asked about the requirement to post signage upon entering the facility informing all persons of the COVID-19 outbreak status in the building. She stated No she wasn't aware. She stated she thought the signage was supposed to be posted on the COVID unit. 2. Review of the clinical record revealed R#60 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, cerebral infarction due to thrombosis of right middle cerebral artery, cerebral infarction due to thrombosis of left cerebellar artery, and unspecified severe protein calorie malnutrition. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/2022, revealed a Brief Interview for Mental Status (BIMS) score of four out of 15, which indicated the resident was severely cognitively impaired. Section G revealed resident was dependent on two staff for bed mobility and had functional limitation on the upper and lower extremities. Section M revealed resident had one stage IV pressure ulcer. Review of the care plan revised 11/16/2022 indicated resident has a potential for pressure ulcer development and has pressure ulcer to right heel and pressure ulcer to right lateral ankle. Interventions to care include follow facility policies/protocols for the prevention/treatment of skin breakdown. Observation on 1/18/2023 at 9:04 a.m., Licensed Practical Nurses (LPN) NN and LPN AA performed wound care for R#60's pressure ulcers. LPN AA washed her hands and donned gloves. She removed the old dressings. She cleaned the right lateral ankle pressure ulcer with cotton gauze soaked in normal saline. Without changing her gloves and sanitizing her hands, LPN AA then obtained a new cotton gauze pad soaked in normal saline and cleaned the right heel pressure ulcer. She then doffed her gloves, washed her hands, donned gloves, and completed the dressing changes. Interview on 1/18/2023 at 10:09 a.m., LPN NN and LPN AA were asked what the facility's policy was for changing gloves and sanitizing hands between cleaning different ulcers. LPN NN stated the policy was to change gloves and sanitize the hands. LPN NN confirmed that LPN AA did not change her gloves and sanitize her hands between cleaning the two pressure ulcers. Interview on 1/18/2023 at 1:16 p.m., the Director of Nursing (DON) stated she did not know if the facility had a specific policy regarding changing gloves and sanitizing hands between cleaning different pressure ulcers, but stated that it was a current standard of practice to do so. During further interview, she stated she thought it would be best practice to doff gloves and sanitize hands when going between two pressure ulcers. Interview on 1/19/2023 at 9:41 a.m., the DON stated the reason for doffing gloves and sanitizing between cleaning pressure ulcers was to prevent cross contamination and infection. She stated even with the proximity of the pressure ulcers, it could be possible to have infection in one ulcer and not in the other.

Based on observations, interviews, and document review, the facility failed to ensure an effective pest control program was in place to maintain the facility free of pests. The census was 134. Findings include: Review of the policy titled, Pest Control Policy, revised 11/2022 indicated this facility ensures that, as far as possible, pests (rats, mice, roaches, ants, fruit flies, silver fish, etc.) within the premises are kept to an absolute minimum with the ideal being eradication but due to the resilience and persistence of some species this ideal is impossible to achieve. Review of the contract to provide pest elimination services revealed on 10/23/2020, the facility entered a contract with [name of provider] to provide pest elimination services to the facility for the control of cockroaches, ants, rodents, silverfish, drain flies, and other structural pest infestations, by periodic treatment using appropriate products according to approved label procedures. Review of [provider] service records revealed the exterminator had been to the facility and treated 10 resident rooms on 400 hall on 8/9/2022; on 9/13/2022 set roach baits in six rooms on 100 hall; on 10/12/2022 treated four resident rooms with granules; on 11/10/2022 treated 32 resident rooms with power spray and on 12/4/2022 treated four resident rooms. Review of the Resident Grievance/Complaint Log showed a resident's family complained of roaches on 12/7/2022, and the exterminator was notified. There was no record that the exterminator treated after the grievance. Observation on 1/16/2023 at 11:30 a.m., two live roaches on the floor of R#132's room, and the resident stated that the roaches have been here since he has, and it is worse now. Observation on 1/17/2023 at 8:46 a.m., two live roaches on the wall of R#32's bathroom, and one dead roach near his bed. Certified Nursing Assistant (CNA) OO was assisting R#32 and stated roaches was an ongoing problem in several rooms in the facility. Observation on 1/18/2023 at 10:51 a.m. a live roach was observed in R#96's room and (CNA) DD killed it. R#96 stated that there were issues with roaches and the exterminator comes once a month. She stated the issue has been bad for a while. Interview on 1/18/2023, at 12:02 p.m., Licensed Practical Nurse (LPN) MM stated that roaches have been seen in the residents' rooms, for at least the last two months. Interview on 1/18/2023, at 12:34 p.m., the Maintenance Director (MD) stated that the facility has an exterminator that has been coming once a month. He stated the exterminator and his assistant also check for rodents during room rounds. During further interview, he stated residents and family members are advised to bring food in closed containers, and not have food in the room.

Based on observations, record review, interviews, and document review, the facility failed to provide comfortable water temperatures in the residents' bathrooms and shower rooms in 11 of 38 rooms, and one broken shower head. The census was 134. Findings include: Review of the facility's Maintenance Log History from 8/1/2022 - 1/19/2023 revealed the following rooms had reported issues with water temperatures: *On 10/4/2022 in room [ROOM NUMBER]-A, resident complained to family that her hot water is not working in her room. *On 10/7/2022 on Unit 300 H, reports of having no hot water in several rooms on the unit. *On 10/24/2022 in room [ROOM NUMBER], no hot water. *On 11/2/2022, shower room unit 2 with shower head reported to be broken, CNA [Certified Nursing Assistant] reported it is leaking everywhere like it has been dropped. *On 11/18/2022, Unit 300 H hot water is not working. *On 1/5/2023 in room [ROOM NUMBER]-A, no water in bathroom. *On 1/16/2023 in room [ROOM NUMBER], water is not working in the bathroom. Interview on 1/18/2023 at 9:03 a.m. with CNA CC, stated the water in room [ROOM NUMBER]'s bathroom doesn't get hot, and the shower room doesn't always get hot either. She stated she goes to another room for hot water. CNA CC stated the facility had a water issue in which a pipe leaked in October or November 2022. Observation on 1/18/2023 at 9:12 a.m. in room [ROOM NUMBER]/308 hot water was observed by the surveyor to feel cold to the touch after running for two minutes. Observation on 1/18/2023 at 9:14 a.m., room [ROOM NUMBER] hot water was also cold to the touch. Observation on 1/18/2023 at 9:30 a.m., CNA DD was observed with a pink basin filled with water. At this time, CNA DD stated room [ROOM NUMBER] doesn't have hot water. room [ROOM NUMBER]'s bathroom sink water was checked and was 100 degrees Fahrenheit (F). Interview on 1/18/2023 at 9:41 a.m. with CNA CC, stated she reported the cold water to the Maintenance Director and to the Director of Nursing (DON) in November 2022. Interview on 1/18/2023 at 10:49 a.m., DON stated staff did complain that the shower room was temping at 106 degrees F and that maintenance stated that the temperature was within code. The DON stated she hadn't heard any reports of residents' rooms without hot water and had not seen any CNAs taking the water in a basin from room to room. The DON stated that if she had, she would have done something about it. Observation on 1/18/2023 at 10:50 a.m. the DON felt with her hand the hot water in room [ROOM NUMBER]/308 and stated, it's cold. Interview on 1/18/2023 at 10:50 a.m. with Licensed Practical Nurse (LPN) EE, stated that the hot water is not hot, but it is warm. Interview on 1/18/2023 at 11:10 a.m. with CNA FF, stated that the facility staff know about the issue with the hot water. She stated that room [ROOM NUMBER] does not have hot water and that this morning the resident in this room stated cold, cold, no when she tried to wash her face. CNA FF stated she reported it to the Maintenance Director and told the Administrator about the water being cold. Interview on 1/18/2023 at 11:19 a.m. with CNA DD, stated the hot water problems started when the pipes froze. She indicated that room [ROOM NUMBER] has no hot water, only cold water for about a year and a half, Interview on 1/18/2023 at 12:14 p.m. with the Maintenance Director, stated that nobody had ever reported any cold water in the resident bathrooms. He stated that there's a maintenance tracker that staff can use to enter issues. Observation on 1/18/2023 at 12:21 p.m. of water temperatures with the Maintenance Director (using an infrared thermometer) in room [ROOM NUMBER]/308 shared bathroom had a water temperature of 90 degrees F. At this time, the Maintenance Director stated, if they haven't run water in the room in a while, they have to wait for it to circulate to get warm. At 12:23 p.m. the water temperature was 96 degrees F. At 12:25 p.m., the water temperature was 99-100 degrees F. Observation on 1/18/2023 at 12:26 p.m. room [ROOM NUMBER]'s bathroom had a water temperature of 98 degrees F. Observation on 1/18/2023 at 12:28 p.m. room [ROOM NUMBER]'s bathroom had a water temperature of 94 degrees F. Observation on 1/18/2023 at 12:30 p.m. room [ROOM NUMBER]'s bathroom had a water temperature of 101 degrees F. Interview on 1/19/2023 at 10:35 a.m. with the Maintenance Director, stated he goes through the maintenance log three times a day. He stated if staff put concerns in maintenance care and was completed, it would be closed out. He indicated that there are no issues with water at the facility.

Based on observations, interviews, record review and policy review, the facility failed to ensure two residents (R) (R#60 and R#101) were treated with dignity. Specifically, staff failed to sit while feeding R#60, and served R#101 meals on Styrofoam plates with plastic silverware. The sample size was 33. Findings include: Review of the facility policy titled, Resident Rights, revised 10/20/22, indicated, . The resident has the right to a dignified existence . 1. Review of the clinical record for R#60 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to Alzheimer's, cerebral infarction, and unspecified severe protein calorie malnutrition. The resident's most recent Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 4, which indicated severe cognitive impairment. Section G revealed resident was dependent on staff for eating. Observation on 1/16/23 at 12:46 p.m. Licensed Practical Nurse (LPN) AA was feeding R#60 while he was lying in bed. LPN AA stood on the right side of the resident's bed and reached over the end of the overbed table with each bite of food she gave the resident. A chair was observed in the resident's room, between the bathroom door and the resident's privacy curtain. Interview on 1/18/23 at 10:16 a.m. LPN AA stated there were no chairs available to sit while she assisted R#60 with his meal. The surveyor informed LPN AA that there had been a chair in the room. LPN AA stated the facility's policy was to sit while assisting a resident with their meal so the staff could interact with the resident. Interview on 1/18/23 at 2:02 p.m. the Director of Nursing (DON) stated the policy of the facility was for staff to sit while feeding a resident, to be at eye level, and engage with the resident during the meal. She stated it was a dignity issue. 2. Review of the clinical record for R#101 revealed she was admitted to the facility on [DATE], with diagnosis that include unspecified dementia, unspecified schizophrenia, and anxiety disorder. The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was no coded, therefore unable to determine cognition. Observation on 1/16/23 at 1:38 p.m. R#101 was fed lunch by MDS Coordinator (MDSC) from a three compartment Styrofoam plate with a plastic spoon. The MDSC was questioned about the Styrofoam plate. The MDSC stated that she could not explain why residents' meals are served this way, but stated it was on her care plan. Interview on 1/16/23 at 2:40 p.m., the MDSC stated R#101 meals are served on Styrofoam plates because she would throw her plate across the room. Interview on 1/18/23 at 10:35 a.m., the Psychiatric Nurse (PN) BB revealed that she has not had any issues or complaints about R#101 throwing her meal plate. She stated that there were no new behaviors or psychiatric concerns. During further interview, she stated if there are concerns the social worker, or the nurse would let her know. Interview on 1/18/23 at 11:08 a.m., the MDSC stated that she spoke with some the certified nursing assistants (CNA), and they informed her that it has been some time since R#101 had thrown a tray at someone. Interview on 1/19/23 at 11:36 a.m., the DON stated she was not sure how long R#101 has been receiving her meals on the Styrofoam plate with a plastic spoon, but replied it has been some years.

Based on observation, record review, interview, and review of the policy titled Social Service - Respect and Dignity Policy, the facility failed to ensure that one resident (R) (R#125) was free from misappropriation of resident's property of 33 sampled residents. Findings include: Review of the facility's policy titled Social Service - Respect and Dignity Policy revised November 2022 revealed respecting resident's private space and property, not moving, or inspecting resident's personal possessions without permission; Process: Residents are encouraged to have and to use personal possessions. Review of the clinical record revealed R#125 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 10/15/2022 documented a BIMS score of 7, indicating severe cognitive impairment and no signs of delirium present at time of assessment. Interview on 1/16/2023 at 3:50 p.m. R#125 stated that she had some items that were broken or missing since she's been at the facility, specifically a DVD player was found broken, a thermos, a fleece blanket, and a plastic tote box. R#125 stated that her daughter called several people to report it. She indicated that the items went missing over the past six months. Interview on 1/17/2023 at 9:16 a.m. R#125's family member stated that she reported the missing items to the DON, the Social Worker (SW), and a staff member in the business office and was told they would look into it, but nothing came of it. Interview on 1/18/2023 at 6:04 p.m. the SW stated that she remembered the resident's items going missing. She stated the DVD player was broken when the resident was moved from one room to another. The SW indicated that the process is that they first try to find the item, or the facility will replace it for them. The SW stated she was going to replace it the DVD player. Interview on 1/18/2023 at 6:04 p.m. the Business Office Staff stated that she went to speak to R#125 yesterday as the resident inquired about how much money was in her patient account. The resident brought up the missing items, but the Business Office Staff stated she was unaware anything was missing or broken. The process is that normally a grievance is written up, then the facility lets her know to go ahead and reimburse the family for the missing items.

Based on record review, interviews, and review of the policy titled Care Plan Policy, the facility failed to develop a person-centered comprehensive care plan related to behaviors for one resident (R) (R#58) of 33 sampled residents. Findings include: Review of the policy titled Care Plan Policy, reviewed 11/15/2022 revealed policy statement is each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Review of the clinical record for R#58 revealed she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, chronic obstructive pulmonary disease (COPD), diabetes, hypertension (HTN), depression, and schizophrenia. Resident's most recent annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/4/2022, revealed Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment. Section E revealed R#58 had physical and verbal behaviors towards others one to three days during the preceding seven days. Review of Patient at Risk Progress Note dated 11/1/2022 at 3:26 p.m. indicated resident was having increased behaviors and aggression. The note also indicated resident had an order for a urinalysis (urine test), which she refused to allow staff to collect, and that her medications were reviewed. There was no documentation of interventions attempted to reduce the resident's behaviors. Review of Nurses Note dated 11/1/2022 at 11:09 p.m. documented as a late entry, indicated the resident had scratched a certified nurse assistant (CNA) and called her derogatory names, refused to have her nails trimmed, and was combative during care but was redirected and calmed down. Review of Nurses Note dated 11/3/2022 at 3:14 p.m. indicated resident was combative, refused care, and would not let staff change her gown. The resident was given Haldol two milligram (mg). There was no documentation or evidence to show that interventions were attempted to reduce the resident's behaviors prior to the administration of Haldol. Review of Electronic Medication Administration Record (EMAR), dated 11/7/2022 at 4:03 a.m. revealed resident was combative with staff, called staff derogatory names, and was making inappropriate comments. It was documented redirection was attempted without success. Review of the Care Plan revised on 11/7/2022 indicated resident had the potential to demonstrate physical behaviors, specifically scratching another person related to dementia. The outcome was documented as R#58 would not harm herself or others through the review date. Interventions/Tasks were listed as medication review; analyze key times, places, circumstances, triggers, and what de-escalates behavior and document; cognitive assessment; and monitor each shift and document observed behavior and attempted interventions in behavior log. The care plan did not address any individualized care interventions to attempt to aid in decreasing or preventing any behaviors. Interview on 1/18/2023 at 2:22 p.m., the MDS Coordinator (MDSC), stated staff generally worked together to develop interventions for a resident's care plan. She confirmed the interventions listed on the care plan for the focus problem of behaviors were not individualized for the resident. Interview on 1/18/2023 at 7:03 p.m., Licensed Practical Nurse (LPN) GG stated staff tried distractions, giving a snack, and providing activities when R#58 was exhibiting behaviors. She stated she knew what to do when resident exhibited behaviors, because she had known her for a long time. LPN GG stated she was not involved in the care plan meetings but stated specific interventions should be listed on resident's care plan.

Based on record review, review of the policy titled Preadmission Screening and Resident Review (PASARR) Policy, and staff interviews, the facility failed to follow through with recommendations for Level II PASARR for evaluation and determination for specialized services for one of 16 sampled residents (R)(R#1), who experienced worsening behaviors and had a known history of wrapping the call light, linen, and curtains around their body. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 3:50 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when R#1 was found deceased in her room with a window blind cord wrapped around her neck. The IJ is outlined as follows: Record review revealed that R#1 was found in her room near the window by the air conditioning unit with the blind cord wrapped around her neck. The resident was assessed to have no pulse, no respirations, pupils fixed and dilated with signs of lividity. The resident was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was severely cognitively impaired and had a known history of wrapping call lights, sheets, and curtains around her body. The facility failed to remove a blind cord from the resident's room and failed to adequately supervise the resident which resulted in her death on [DATE]. In addition, R#1 was seen by the Psychiatric Nurse Practitioner on [DATE] for worsening behaviors including safety concerns with call lights and curtains. A suicidal assessment was conducted, and the resident was identified as low risk for suicide. However, for further evaluation, recommendations were made to obtain medical records from the resident's previous inpatient psychiatric stay; or to file PASARR (Preadmission Screening & Resident Review) Level II for extensive psychiatric care. The recommendations for R#1 were not followed. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.20(k)(1)-(3) PASARR Screening for MD & ID (F 645 Scope and Severity (S/S): J) C.F.R. 483.21(b)(1) Develop/implement Comprehensive Care Plan (F 656 S/S: J) C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J) C.F.R. 483.40 Behavioral Health Services (F 740 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J). An acceptable Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to accident hazards and behavioral health needs of residents. Findings include: Review of the policy titled, Preadmission Screening & Annual Resident Review (PASARR) Policy dated [DATE]: Policy Statement: Annually and with any significant change of status, the facility will complete the PASARR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. Objective: The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASARR will be evaluated annually and upon any significant change for those individuals identified. Review of the Annual Minimum Data Set (MDS) for R#1 dated [DATE] revealed she was admitted to the facility on [DATE]. Section A revealed R#1 had not been evaluated for a Level II PASARR. Section I revealed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Nurse's Notes from [DATE] through [DATE] revealed R#1 exhibited behaviors which included wrapping the call light and curtains around her body. Staff were concerned for resident's safety. Review of Nursing Note dated [DATE] revealed R#1 was discussed with the Psychiatric Nurse Practitioner regarding the resident's need for more extensive psych care. Discussed resident behaviors including poor safety awareness with call lights and curtains. The writer reported to the Nurse Practitioner (NP) that SS (Social Services) had been notified. Review of Psychiatry Progress Note dated [DATE] revealed R#1 with referral to psych eval (psychiatric evaluation) and medication management. R#1 had behaviors including but not limited to climbing over her bed, wandering in and out of other rooms, and unable to follow redirection. The curtain in room was tied because the patient is noted to have tried wrapping it around self. Continue to monitor for suicide risk. Treatment Plan/ Recommendations included: 1. Discussed with SW (social worker), medical records from (name- psychiatric inpatient facility) are needed for further evaluation or file PASARR level II for extensive psych care. There was no evidence that the above psychiatric recommendations, including to file PASARR level II, was followed. Review of Psychiatry Progress Note dated [DATE] revealed R#1 has an ongoing and worsening behavior of wrapping the curtain and pull cord (call light) around her body. The facility may not be an appropriate placement for the resident. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #1 has an ongoing and worsening behavior wraps her body in the in curtain or call button cord. Because of the resident's worsening behaviors, the Physician recommended that the resident be seen by the Psychiatrist. Review of Nursing Note dated [DATE] at 12:20 p.m. revealed the DON found R#1 with the window blind cord wrapped around her neck. The resident was assessed, no heartbeat noted on auscultation, no respirations, pupil fixed and dilated, skin cool to touch. The NP was present and determined that resident was deceased . An interview on [DATE] at 11:19 a.m. with the Social Services Director (SSD) revealed she was aware of R#1's worsening behaviors as it was discussed in the Behavioral Management Meeting in July and [DATE]. The SSD confirmed the last visit from Psychiatric Services was on [DATE]. The SSD stated she was not aware that the physician requested that the resident be seen by a psychiatrist. She stated she did not complete a PASARR screening for R#1. The SSD stated she did not know that PASARR should be evaluated upon any significant change in a resident's behavior. An interview was conducted on [DATE] at 2:26 p.m. with the Psychiatric NP confirmed that she requested that a PASSAR Level II screening to be completed due to the resident significant changes in behaviors. She stated the request was made to determine if the resident could receive extensive psychiatric services. Cross refer to F740. The facility implemented the following actions to remove the IJ: 1. [DATE], Resident #1 expired in facility, Riverside Health Care Center. 2. [DATE], an Ad Hoc QAPI meeting was held with the QAPI Committee (Administrator, Chief Director of Clinical Operations (CDCO), Maintenance Director, Social Services Director, and the Medical Director) to discuss the incident involving Res #1. 3. [DATE], the MDS Director audited care plans for all 40 of 40 residents on the Memory Care Unit with behaviors. No other residents were identified to require a completed PASARR. 4. [DATE], an Ad Hoc QAPI meeting was held with the QAPI Committee (Administrator, Chief Director of Clinical Operations, QA Nurse, and Regional Director of Clinical Operations) to discuss the root cause analysis of the PASARR and Behavioral Health Services Immediate Jeopardy citations. 5. [DATE], the policies for Preadmission Screening and Annual Resident Review and Secure Memory Care Unit were reviewed by the Administrator and Medical Director with no revisions made. 6. [DATE], the current eight residents with PASARR Level II services have been reviewed. Individualized interventions have been verified on their care plans. 7. [DATE], the Vice President of Clinical Operations in-serviced the IDT, which consists of CDCO, Social Services Director, MDS Director, SDC (Staffing Development Coordinator), Activity Director, and Rehab Director on instructions for significant changes in behavior and treatment plans (how staff will identify, report, develop treatment plans-interventions). 8.[DATE], SDC and Infection Control Preventionist, in-serviced clinical staff how to access psych consult progress notes electronically. RN: 9 of 9 LPN: 17 of 19 C.N.A: 22 of 26 Therapy: 11of 12 Agency: 13 of 15 C.N.A Agency: 2 of 5 LPN Total: 86% 9. [DATE], the Vice President of Clinical Operations in-serviced the CDCO, Social Services Director, MDS Director, and SDC, on the PASARR Level II Screening (referral process, treatment plans). 10. [DATE], the CDCO and SDC in-serviced staff on how to access Psych consult progress notes electronically, instructions for significant changes in behavior and treatment plans (how staff will identify, report, develop treatment plans-interventions). RN: 9 of 9 LPN: 17 of 19 Agency: 2 of 5 LPN Total: 85% 11. Social Services, CDCO, Unit Manager review PCC 24-hour report (includes new Psych Progress Notes) and update care plan interventions as needed 7 times a week x 4 weeks. 12. The CDCO performed a Quality Improvement Monitoring (PASARR) Audit of care plans for residents on the Memory Care Unit and other Nursing Units to identify any other residents recommended for PASARR. No other residents were identified. This audit will be completed by Social Services Director and/or Nursing Supervisor 7 times a week x 4 weeks. 13. As of [DATE], 108 of 125 staff were in-serviced on instructions for significant changes in behavior and treatment plans (how staff will identify, report, develop treatment plans-interventions). RN: 9 of 9 LPN: 17 of 19 C.N.A: 22 of 26 Agency: 13 of 15 C.N.A Agency: 2 of 5 LPN Therapy: 11 of 12 Housekeeping: 6 of 7 Laundry: 2 of 3 Dietary: 9 of 12 Maintenance: 2 of 2 Administration: 15 of 15 Total: 108 of 125 86% 14. The remaining 17 staff will be in-serviced by the CDCO/SDC on the next scheduled workday prior to beginning their shift. New hires, contract workers, and employees on LOA (leave of absence) (1 RN, 1 LPN and 1 C.N.A for total of 3) will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of a Transfer/Discharge Report revealed R#1 was discharged on [DATE] to the funeral home. A phone interview on [DATE] at 11:00 a.m. with the facility's Medical Director revealed he was made aware of R#1's death on [DATE] by the Administrator. 2. Review of the Quality Assessment and Assurance/QAPI Committee Attendance Sheet dated [DATE] revealed the Administrator, Chief Director of Clinical Operations, Maintenance Director, Social Services Director, and the Medical Director were in attendance. An interview was conducted on [DATE] at 11:00 a.m. with the Administrator, DON, and Medical Director (via telephone). The Medical Director stated after the DON spoke with the staff on Unit 3 (Memory Care) regarding the incident with R#1, an AD HOC meeting was conducted on [DATE]. Review of the QAPI Root Cause Analysis (RCA) Worksheet dated [DATE] revealed an RCA was completed by the DON. The Unit Manager (UM), and charge nurse for R#1 were not aware of the resident's behavior of playing with the window blinds. The team identified that the new behavior was not identified, and the care plan was not personalized enough to change the outcome. Changes to correct the issue was to educate the staff to report behaviors and care plan. The staff will be educated on the care plan process. 3. Record review revealed a PASARR Assessment (Level I & II) audit was completed by the MDS-Coordinator on [DATE], which included 40 of 40 residents on the memory care unit. The following residents were reviewed for PASARR and care plans: Record review revealed R#19 had a care plan for mood problems with revision date of [DATE] and an updated Behavior Kardex. R#20 had a care plan for inappropriate public display with revision date of [DATE] and an updated Behavior Kardex. R#21 had a care plan for PASARR Level II with a revision date of [DATE] and an updated Behavior Kardex. 4. Review of the AD HOC QAPI Meeting Attendance Sheet dated [DATE] revealed signature of the Administrator, DON, Medical Director, Maintenance Director, and Social Services. Four areas were discussed for the RCA: risk management, trends noted, root cause, and action taken. Actions Taken: Pull 24-hour report timely and read recommendations. Coordinate with our Medical Director to check on the changing process. Request psych list when NP/MD visit facility. Behaviors reported will be care planned immediately. Activities to help with individualized need with activity implementation. 5. Review of the undated policies for Preadmission Screening and Resident Review and Secure Memory Care Unit was signed by the Administrator. A phone interview was conducted on [DATE] at 11:00 a.m. with the Medical Director. The Administrator and DON were present during the interview. The Medical Director stated the Care Plan Policy and Notification of Resident's Change of Condition were emailed to him. A phone conference was conducted with the Administrator and DON all the policies were reviewed and no changes were made. 6. Record review revealed a PASARR Assessment (Level I & II) audit was completed by the MDS-Coordinator on [DATE] for the eight residents with PASARR Level II. This was confirmed by record review as follows: Review of the clinical record revealed R#21 has a care plan for PASARR Level II. Review of the Georgia Collaborative ASO Treatment Service PASARR Level II dated [DATE]. R#21 was approved for placement in a skilled nursing facility, recommend specialized services for serious mental illness. The resident is being followed by psychiatric services, last seen on [DATE]. Review of the clinical record revealed R#22 has a care plan for PASARR Level II. APS Healthcare State of Georgia PASARR Review Outcome Notification dated [DATE] approved resident for nursing facility eligible for psychiatric services, if needed. Review of the clinical record revealed R#23 has a care plan for PASARR Level II. Georgia Collaborative ASO Treatment Service PASARR Level II dated [DATE]. R#23 was approved for placement in a skilled nursing facility and does not need specialized services. The resident is being followed by psychiatric services last seen on [DATE]. Receiving Psychotherapy last seen on [DATE]. 7. Review of the facility in-service record dated [DATE] revealed the Administrator, CDCO/DON, Social Services Director, MDS Director, Staff Development Coordinator (SDC), Activity Director, and Rehab Director were educated on instructions for significant changes in behavior and treatment plans (how staff will identify, report, develop treatment plans-interventions). This was confirmed by interview with the Vice President of Clinical Operations on [DATE] at 4:44 p.m. 8. Review of facility in-service records dated [DATE] revealed 9 of 9 RN's, 17 of 19 LPN's, 22 of 26 CNA's, 11 of 12 Therapy, 13 of 15 agency CNA's and 2 of 5 agency LPN's received instruction on how to access psych consult progress notes electronically. Also verified via the following staff interviews on [DATE]: 2:44 p.m. with LPN UU, 3:08 p.m. with RN Infection Control Preventionist, 4:00 p.m. with LPN OO, 4:05 p.m. with LPN NN, 4:10 p.m. with LPN PP, 4:15 p.m. with CNA ZZ, and 4:23 p.m. with CNA VV; on [DATE]: 7:50 a.m. with LPN RR, 8:10 a.m. with CNA AAA, 8:14 a.m. with CNA YY, 8:17 a.m. with CNA XX, 8:20 a.m. with LPN SS, and 9:33 a.m. with RN MM, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 9. Review of the facility in-service record dated [DATE] revealed the CDCO/DON, Social Services Director, MDS Director, and Staff Development Coordinator (SDC) on the referral process and treatment plans for PASARR Level II screening. This was confirmed by interview with the Vice President of Clinical Operations on [DATE] at 4:44 p.m. 10. Review of facility in-service records dated [DATE] revealed 9 of 9 RN's, 17 of 19 LPN's, and 2 of 5 agency LPN's received instruction on how to access Psych consult progress notes electronically, instructions for significant changes in behavior and treatment plans and how staff will identify, report, develop treatment plans and interventions. There have been no new hires. Also verified via the following staff interviews on [DATE]: 2:44 p.m. with LPN UU, 3:08 p.m. with RN Infection Control Preventionist, 4:00 p.m. with LPN 00, 4:05 p.m. with LPN NN, 4:10 p.m. with LPN PP; on [DATE]: 7:50 a.m. with LPN RR, 8:20 a.m. with LPN SS, and 9:33 a.m. with RN MM, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 11. An interview on [DATE] at 10:34 a.m. with the DON revealed she and the SDC in-serviced the licensed staff on obtaining the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated the nursing staff were educated on looking at the 24-hour report that obtains any documentation completed in the past 24-hours. They were also in-serviced on utilizing the 24-hour communication (communication nurse to nurse). 12. Record review revealed a PASARR Assessment (Level I & II) audit was completed by the MDS-Coordinator on [DATE] and [DATE]. No other residents were identified. An interview was conducted on [DATE] at 10:30 a.m. with the DON and SSD. The DON stated a facility wide audit was conducted by the MDS Coordinator. The DON stated this Audit will be completed daily based on admission paperwork, behaviors discussed in the clinical meeting, progress notes and physician orders. The SSD stated she will obtain a list from psych service on each visit she will review notes and look for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The updated/new information will be entered the Georgia Medicaid Management Information System (MMIS) portal system. The facility will follow up based on the recommendations. The SSD stated the PASARR assessments will also be completed annually and with any significant change. 13. Review of facility in-service records dated [DATE] revealed 9 of 9 RN's, 17 of 19 LPN's, 22 of 26 CNA's, 11 of 12 Therapy, 13 of 15 agency CNA's and 2 of 5 agency LPN's received instruction on how staff will identify, report, and develop treatment plans for significant changes in behavior. Also verified via the following staff interviews on [DATE]: 2:44 p.m. with LPN UU, 3:08 p.m. with RN Infection Control Preventionist, 4:00 p.m. with LPN OO, 4:05 p.m. with LPN NN, 4:10 p.m. with LPN PP, 4:15 p.m. with CNA ZZ, and 4:23 p.m. with CNA VV; on [DATE]: 7:50 a.m. with LPN RR, 8:10 a.m. with CNA AAA, 8:14 a.m. with CNA YY, 8:17 a.m. with CNA XX, 8:20 a.m. with LPN SS, and 9:33 a.m. with RN MM, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Review of facility in-service records dated [DATE] revealed 6 of 7 Housekeeping, 2 of 3 Laundry, 9 of 12 Dietary, 2 of 2 Maintenance, and 15 of 15 Administration received instruction on how staff will identify, report, and develop treatment plans for significant changes in behavior. Also verified via the following staff interviews on [DATE]: 1:56 p.m. with Housekeeper DDD, 2:02 p.m. with Maintenance Staff FFF, 2:04 p.m. with Maintenance Director, 2:10 p.m. with Housekeeper/Laundry EEE, 2:16 p.m. with Dietary Staff BBB, 2:19 p.m. with Dietary Staff CCC, and 2:28 p.m. with Business Office Assistant KK, 2:38 p.m. with Laundry Staff GGG, and 3:11 p.m. with Admissions Staff LL, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 14. Review of the daily staffing sheets and additional facility in-service records from [DATE] through [DATE] revealed the remaining staff have not worked prior to receiving the in-service education. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE].

Based on record review, review of the facility policy titled Care Plan Policy, and staff interview, the facility failed to implement care plan interventions to monitor the safety of one of 16 sampled residents (R) (R#1), who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 3:50 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when R#1 was found deceased in her room with a window blind cord wrapped around her neck. The IJ is outlined as follows: Record review revealed that R#1 was found in her room near the window by the air conditioning unit with the blind cord wrapped around her neck. The resident was assessed to have no pulse, no respirations, pupils fixed and dilated with signs of lividity. The resident was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was severely cognitively impaired and had a known history of wrapping call lights, sheets, and curtains around her body. The facility failed to remove a blind cord from the resident's room and failed to adequately supervise the resident which resulted in her death on [DATE]. In addition, R#1 was seen by the Psychiatric Nurse Practitioner on [DATE] for worsening behaviors including safety concerns with call lights and curtains. A suicidal assessment was conducted, and the resident was identified as low risk for suicide. However, for further evaluation, recommendations were made to obtain medical records from the resident's previous inpatient psychiatric stay; or to file PASARR (Preadmission Screening & Resident Review) Level II for extensive psychiatric care. The recommendations for R#1 were not followed. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.20(k)(1)-(3) PASARR Screening for MD & ID (F 645 Scope and Severity (S/S): J) C.F.R. 483.21(b)(1) Develop/implement Comprehensive Care Plan (F 656 S/S: J) C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J) C.F.R. 483.40 Behavioral Health Services (F 740 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J). An acceptable Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to accident hazards and behavioral health needs of residents. Findings include: Review of the policy titled, Care Plan Policy dated ,d+[DATE]: Policy Statement: Each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standards of Practice. 7. Areas of concern or potential concern and residents' strengths will be addressed with measurable goals and specific person-centered approaches to promote attainment or maintenance of the goal(s). 9. The plan of care is to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident representative party if so desired. A review of the Admission Record (face sheet) for R#1 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) interview not conducted, resident rarely/never understood, which indicated severe cognitive impairment. Section E revealed other behavioral symptoms not directed toward others occurred one to three days of the seven-day assessment period; and that the behavior put the resident at significant risk for physical injury. The Care Area Assessment (CAA) Summary triggered behavioral symptoms to be addressed in the care plan. Review of the care plan initiated [DATE] and updated [DATE] revealed that R#1 has a behavior problem, observed wrapping the call light and privacy curtains around her body. Interventions to be implemented included to keep privacy curtain tied when not in use and minimize potential for behaviors including wrapping herself in the call light, curtain . by offering tasks which divert attention. The care plan did not address the risk related to the window blind cord in the room or the need to monitor the resident more frequently. Review of Nursing Note dated [DATE] at 12:20 p.m. revealed the DON found R#1 with the window blind cord wrapped around her neck. The resident assessed, no heartbeat noted on auscultation, no respirations, pupil fixed and dilated, skin cool to touch. The Nurse Practitioner (NP) was present and determined that resident was deceased . An interview on [DATE] at 10:31 a.m. with the MDS coordinator revealed she observed R#1 in her room wrapping the curtains around her body. Because of the behaviors, the care plan was updated but only included interventions to remove linen from bed when the resident gets up for the day and secure curtains but did not include the window blind cord. Cross refer to F689. The facility implemented the following actions to remove the IJ: 1. [DATE], Resident #1 expired in the facility, Riverside Health Care Center. 2. [DATE], a root cause analysis was completed and presented to the Ad Hoc QAPI Committee. 3. [DATE], an Ad Hoc QAPI meeting was held with the QAPI Committee (Administrator, Chief Director of Clinical Operations (CDCO), Maintenance Director, Social Services Director, and· the Medical Director) to discuss incident involving Resident #1. 4. [DATE], the policies for Care Plan and Notification of Resident's Change of Condition were reviewed by the Administrator, Medical Director and the Ad Hoc QAPI Committee with no revisions made. 5. [DATE], the MDS Director completed an audit of care plans for all 40 of 40 Memory Care Unit (Unit 3) residents for self-harming behaviors. Care plans were updated with appropriate monitoring interventions. 6. [DATE], CDCO and MDS Director completed a 100 % Care Plan and Kardex Audit for residents on Memory Care Unit (Unit 3). 40 of 40 residents care plans and Kardex were audited for behavior interventions and accident interventions. No deficient practices noted in individualized care plan interventions. This audit tool will continue weekly x 4 weeks. 7. [DATE], Vice President of Clinical Operations in-serviced the IDT, which consists of Chief Director of Clinical Operations (CDCO), Social Services Director, MDS Director, Staff Development Coordinator (SDC), Activity Director, and Rehab Director on instructions for care plans (resident centered related to behavioral health monitoring, reporting- individualized interventions for behavior). 8. [DATE], the Chief Director of Clinical Operations (CDCO) and Staff Development Coordinator (SDC}, in-serviced licensed nursing staff on instruction for care plans (resident centered related to behavioral health monitoring, reporting- individualized interventions for behavior). RN: 9 of 9 LPN: 17 of 19 Agency: 2 of 5 LPN Total: 85% 9. [DATE], the CDCO and SDC in-serviced clinical staff on how to access Care Plan/Kardex/Maintenance Care to identify interventions for behavior and identified accidental hazards. 10. As of [DATE],74 of 86 clinical staff were in-serviced how to access Care Plan/Kardex/Maintenance Care to identify interventions for behavior and identified accidental hazards. RN: 9 of 9 LPN: 17 of 19 C.N.A: 22 of 26 Therapy: 11 of 12 Agency: 13 of 15 C.N.A Agency: 2 of 5 LPN Total: 86% 11. [DATE], the CDCO and SDC in-serviced non-clinical staff on how to report observed behaviors or identified accidental hazards to the Administrator, CDCO, and/or Maintenance Director. 12. As of [DATE], 34 of 39 non-clinical staff were in-serviced how to report observed behaviors or identified accidental hazards to the Administrator, CDCO, and/or Maintenance Director. Housekeeping: 6 of 7 Laundry: 2 of 3 Dietary: 9 of 12 Maintenance: 2 of 2 Total: 87% 13. The Social Services Director and/or Nursing Supervisor to perform Quality Improvement Monitoring (PASARR) Audit of care plans for residents on the Memory Care Unit and other Nursing Units 7 times a week x 4 weeks. 14. As of [DATE], 28 of 33 licensed nurses were in-serviced on care plan interventions for individualized behaviors and behavior monitoring tool and instruction for care plan (resident centered related to behavioral health monitoring, reporting - individualized interventions for behaviors). RN: 9 of 9 LPN: 17 of 19 Agency: 2 of 5 LPN Total: 85% 15. The remaining 12 clinical and 5 non-clinical staff will be in-serviced by the CDCO/SDC on the next scheduled workday prior to beginning their shift. New hires, contract workers, employees on LOA (leave of absence) (1 RN, 1 LPN and 1 C.N.A for total of 3} will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of a Transfer/Discharge Report revealed R#1 was discharged on [DATE] to the funeral home. A phone interview on [DATE] at 11:00 a.m. with the facility's Medical Director revealed he was made aware of R#1's death on [DATE] by the Administrator. 2. Review of the Quality Assessment and Assurance/QAPI Committee Attendance Sheet dated [DATE] revealed the Administrator, Chief Director of Clinical Operations, Maintenance Director, Social Services Director, and the Medical Director were in attendance. An interview was conducted on [DATE] at 11:00 a.m. with the Administrator, DON, and Medical Director (via telephone). The Medical Director stated after the DON spoke with the staff on Unit 3 (Memory Care) regarding the incident with R#1, an AD HOC meeting was conducted on [DATE]. Review of the QAPI Root Cause Analysis (RCA) Worksheet dated [DATE] revealed an RCA was completed by the DON. The RCA revealed: The Unit Manager (UM), and charge nurse for R#1 were not aware of the resident's behavior of playing with the window blinds. The team identified that the new behavior was not identified, and the care plan was not personalized enough to change the outcome. Changes to correct the issue was to educate the staff to report behaviors and care plan. The staff will be educated on the care plan process. 3. Review of the AD HOC QAPI Meeting Attendance Sheet dated [DATE] revealed the signatures of the Administrator, DON, Medical Director, Maintenance Director, and Social Services. Four areas were discussed; risk management, trends noted, root cause, and action taken. Trends Noted: No trends noted. Root Cause: Accidental. Action Taken: Unit three blinds will be replaced with cordless blinds. Maintenance team is working on this project until completed. The project will expand facility wide once unit three has been completed. Immediate action: All cords on blinds have been secured to prevent reoccurrence. 4. Review of the Care Plan Policy and Notification of Resident's Change of Condition with a date of [DATE] was signed by the Administrator. A phone interview was conducted on [DATE] at 11:00 a.m. with the Medical Director. The Administrator and DON were present during the interview. The Medical Director stated the Care Plan Policy and Notification of Resident's Change of Condition were emailed to him. A phone conference was conducted with the Administrator and DON all the policies were reviewed and no changes were made. 5. Review of a Daily Census of the Memory Care Unit dated [DATE] revealed 40 of 40 residents were reviewed for appropriate care plan interventions for behaviors. An interview on [DATE] at 12:30 p.m. with the Minimum Data Set (MDS) Coordinator revealed a facility wide audit was completed for care plans, residents with new behaviors, and PASARR. She stated she reviewed the residents care plan and made sure the care plan reflected what services were being received. The residents on Unit 3 (Memory Care) were reviewed to make sure that behaviors were care planned and individualized. The Kardex was also audited for the residents' behavior. Any new behaviors identified/discussed during the weekly Patient at Risk Meeting (PAR), the CP and Kardex will be updated during the meeting. 6. Review of 40 resident's behavior care plans and Kardex with a print date of [DATE] revealed audits for behavior interventions and accident interventions with no further deficient practice identified. Record review revealed R#19 had a care plan for mood problems with revision date of [DATE] and an updated Behavior Kardex. R#20 had a care plan for inappropriate public display with revision date of [DATE] and an updated Behavior Kardex. R#21 had a care plan for PASARR Level II with a revision date of [DATE] and an updated Behavior Kardex. 7. Review of the facility in-service record dated [DATE] revealed the Administrator, CDCO/DON, Social Services Director, MDS Director, Staff Development Coordinator (SDC), Activity Director, and Rehab Director were educated on instructions for care plans to be resident centered related to behavioral health monitoring, reporting, and to include individualized care plan interventions for behaviors. This was confirmed by interview with the Vice President of Clinical Operations on [DATE] at 4:44 p.m. 8. Review of facility in-service records dated [DATE] revealed 9 of 9 RN's, 17 of 19 LPN's, and 2 of 5 agency LPN's received instruction on resident centered care plans related to behavioral health monitoring. There have been no new hires. Also verified via the following staff interviews on [DATE]: 2:44 p.m. with LPN UU, 3:08 p.m. with RN Infection Control Preventionist, 4:00 p.m. with LPN 00, 4:05 p.m. with LPN NN, 4:10 p.m. with LPN PP; on [DATE]: 7:50 a.m. with LPN RR, 8:20 a.m. with LPN SS, and 9:33 a.m. with RN MM, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 9. - 10. Review of facility in-service records dated [DATE] revealed 9 of 9 RN's, 17 of 19 LPN's, 22 of 26 CNA's, 11 of 12 Therapy, 13 of 15 agency CNA's and 2 of 5 agency LPN's received instruction on how to access care plans, Kardex, and maintenance care to identify behavior interventions and accident hazards. There have been no new hires. Also verified via the following staff interviews on [DATE]: 2:44 p.m. with LPN UU, 3:08 p.m. with RN Infection Control Preventionist, 4:00 p.m. with LPN OO, 4:05 p.m. with LPN NN, 4:10 p.m. with LPN PP, 4:15 p.m. with CNA ZZ, and 4:23 p.m. with CNA VV; on [DATE]: 7:50 a.m. with LPN RR, 8:10 a.m. with CNA AAA, 8:14 a.m. with CNA YY, 8:17 a.m. with CNA XX, 8:20 a.m. with LPN SS, and 9:33 a.m. with RN MM, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 11. - 12. Review of facility in-service records dated [DATE] revealed 6 of 7 Housekeeping, 2 of 3 Laundry, 9 of 12 Dietary, and 2 of 2 Maintenance received instruction on how to report observed behaviors or identified accident hazards. There have been no new hires. Also verified via the following staff interviews on [DATE]: 1:56 p.m. with Housekeeper DDD, 2:02 p.m. with Maintenance Staff FFF, 2:04 p.m. with Maintenance Director, 2:10 p.m. with Housekeeper/Laundry EEE, 2:16 p.m. with Dietary Staff BBB, 2:19 p.m. with Dietary Staff CCC, and 2:38 p.m. with Laundry Staff GGG, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 13. Record review revealed a PASARR Assessment (Level I & II) audit was completed for all residents on the memory care unit on [DATE] and [DATE]. An interview was conducted on [DATE] at 10:30 a.m. with the DON and SSD. The DON stated a facility wide audit was conducted by the MDS Coordinator. The DON stated this Audit is completed daily based on admission paperwork, behaviors discussed in the clinical meeting, progress notes and physician orders. 14. Review of facility in-service records dated [DATE] and [DATE] revealed 9 of 9 RN's, 17 of 19 LPN's, and 2 of 5 agency LPN's received instruction on care plan interventions for individualized behaviors and the behavior monitoring tool. There have been no new hires. Also verified via the following staff interviews on [DATE]: 2:44 p.m. with LPN UU, 3:08 p.m. with RN Infection Control Preventionist, 4:00 p.m. with LPN 00, 4:05 p.m. with LPN NN, 4:10 p.m. with LPN PP; on [DATE]: 7:50 a.m. with LPN RR, 8:20 a.m. with LPN SS, and 9:33 a.m. with RN MM, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 15. Review of the daily staffing sheets and additional facility in-service records from [DATE] through [DATE] revealed the remaining staff have not worked prior to receiving the in-service education. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE].

Based on record review and staff interviews, the facility failed to ensure a safe environment for one of 16 sampled residents (R) (R#1). Specifically, the facility failed to remove a blind cord from the resident's room and failed to adequately supervise the resident with a known history of wrapping call lights, sheets, and curtains around her body. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 3:50 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when R#1 was found deceased in her room with a window blind cord wrapped around her neck. The IJ is outlined as follows: Record review revealed that R#1 was found in her room near the window by the air conditioning unit with the blind cord wrapped around her neck. The resident was assessed to have no pulse, no respirations, pupils fixed and dilated with signs of lividity. The resident was a [AGE] year-old female with diagnoses including dementia with behavioral disturbances, [CONDITION(S)], anxiety, depression, and [CONDITION(S)]. The resident was severely cognitively impaired and had a known history of wrapping call lights, sheets, and curtains around her body. The facility failed to remove a blind cord from the resident's room and failed to adequately supervise the resident which resulted in her death on [DATE]. In addition, R#1 was seen by the Psychiatric Nurse Practitioner on [DATE] for worsening behaviors including safety concerns with call lights and curtains. A suicidal assessment was conducted, and the resident was identified as low risk for suicide. However, for further evaluation, recommendations were made to obtain medical records from the resident's previous inpatient psychiatric stay; or to file PASARR (Preadmission Screening & Resident Review) Level II for extensive psychiatric care. The recommendations for R#1 were not followed. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.20(k)(1)-(3) PASARR Screening for MD & ID (F 645 Scope and Severity (S/S): J) C.F.R. 483.21(b)(1) Develop/implement Comprehensive Care Plan (F 656 S/S: J) C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J) C.F.R. 483.40 Behavioral Health Services (F 740 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J). An acceptable Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to accident hazards and behavioral health needs of residents. Findings include: A review of the Admission Record (face sheet) for R#1 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to dementia with behavioral disturbances, [CONDITION(S)], specified anxiety disorders, major depressive disorder, [CONDITION(S)], and unspecified [CONDITION(S)] not due to a substance or known physiological condition. Review of Nursing Note dated [DATE] revealed R#1 is requiring 1:1 supervision for safety and care. The resident has no safety awareness. The curtain and call lights must be placed out of the resident's reach. Review of Nursing Note dated [DATE] revealed R#1 was placed in a highly visible area of the unit and was monitored closely by all staff. The resident is being closely monitored by all staff every 15 minutes and as needed. Review of Nursing Note dated [DATE] revealed R#1 has been noted to wrap herself in the curtains. Staff concern for resident safety regarding the call light, curtains, and bedside table. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) interview not conducted, resident rarely/never understood, which indicated severe cognitive impairment. Section E revealed other behavioral symptoms not directed toward others occurred one to three days of the seven-day assessment period; and that the behavior put the resident at significant risk for physical injury. The Quarterly MDS dated [DATE] revealed R#1 continued to be severely cognitive impairment. Review of Nursing Note dated [DATE] revealed R#1 was discussed with the Psychiatric Nurse Practitioner (NP) regarding the resident's behavior including poor safety awareness with call lights and curtains. The writer reported to the Nurse Practitioner that SS (Social Services) had been notified. Will continue to monitor resident closely. Review of Psychiatry Progress Note dated [DATE] revealed a suicidal risk assessment was conducted and R#1 was at a low risk for suicide, per staff . continue to monitor resident. The Progress Note documented to continue to monitor for suicide risk. The curtain in room was tied because the patient is noted to have tried wrapping it around self. Review of Psychiatry Progress Note dated [DATE] revealed R#1 has an ongoing and worsening behavior of wrapping the curtain and pull cord (call light) around her body. They (the facility) do not think this is appropriate placement for her. Treatment plan/recommendations included to continue supportive cares and behavioral approaches. Review of the Nursing Progress Note- COMS Skilled Evaluation dated [DATE] revealed that R#1's mood and behavior is anxious. The resident has a chronic behavior, potentially causing harm to self or others. Review of Physician Progress Note dated [DATE] revealed R#1 has ongoing and worsening behaviors. Unsafely wraps her body in the curtain or call button cord. Review of facility documented timeline revealed R#1 was last seen by a Certified Nursing Assistant (CNA) on [DATE] around 11:35 a.m. after returning from lunch, resident was observed in her room walking. During nursing rounds at 11:30 a.m., the resident was seen walking around in her room. Review of Nursing Note dated [DATE] at 12:20 p.m. revealed the DON found R#1 with the window blind cord wrapped around her neck. The resident was assessed, no heartbeat noted on auscultation, no respirations, pupil fixed and dilated, skin cool to touch. The NP was present and determined that resident was deceased . Review of the Coroner's Death Investigation Report dated [DATE] revealed R#1 died as a result of an accidental hanging in room 404 at (the facility). It was known that she would twirl in the curtain in her room . It was reported by staff that the resident suffers from [CONDITION(S)], dementia, depressive disorders, amongst other disorders. She has a habit of twirling in curtains and items hanging from heights. The staff would move the curtain to an area were she could not get to it. She has never twirled in this cord before to their knowledge. The coroner spoke with the administrator and made a recommendation that the corded blinds be removed from every room. An interview on [DATE] at 11:30 a.m. with Licensed Practical Nurse (LPN) GG revealed R#1 had a behavior of wrapping her body in the curtains and call light cord. The LPN stated the curtains had to be pulled back out of the resident's reach. The call bell had to be tied as a precaution. The LPN stated on [DATE], she was called to bring the scissors to the resident's room. Upon arriving to the room, the blind cords were cut, and R#1 was assisted from the floor to the bed. The LPN stated the cord around R#1's neck was removed. The NP was in the room and determined that resident was deceased . An interview on [DATE] at 12:51 p.m. with CNA YY revealed if you do not see R#1 walking in the hall she should be checked on every 15 minutes. An interview on [DATE] at 1:43 p.m. with LPN TT revealed the residents on the memory care unit, including R#1, should be checked by staff every 15 minutes. An interview on [DATE] at 2:12 p.m. with CNA AAA revealed R#1 should be checked every 15 minutes. An interview on [DATE] at 10:41 a.m. with Registered Nurse (RN) AA revealed R#1 had a history of the wrapping her body in call lights and curtains. She stated the resident required constant supervision. The RN stated she had discussed one to one supervision for R#1 with the Administrator and Medical Director. An interview on [DATE] at 12:15 pm with the Administrator revealed he was aware of R#1's behavior during PAR (Patient at Risk) and the daily Clinical Meeting. The Administrator was aware of the resident's behavior in [DATE]. He stated some of the behaviors were crawling over the furniture in the room and getting entangled in the curtains in her room. He stated several interventions were put in place including padding on the bed, securing the privacy curtains, and removing the linen off the bed after the resident gets up for the day. The Administrator stated he makes daily rounds to verify what is going on with the resident and did not see anything in R#1's room that she could harm herself with. An interview on [DATE] at 2:24 p.m. with CNA DD revealed the memory care unit is her regular assigned unit. She stated on [DATE] she was reassigned to the other end of the hall (,d+[DATE]). She stated the person that was assigned to her side of the hall asked to work room ,d+[DATE] because she was more familiar with the residents. She stated when assigned to R#1 she brings her out of her room so she can see her. If the resident was in the room, she would stay in the room with her. The facility implemented the following actions to remove the IJ: 1. [DATE], Resident #1 expired in the facility, Riverside Health Care Center. 2. [DATE], a root cause analysis was completed and presented to the Ad Hoc QAPI Committee. 3. [DATE], an Ad Hoc QAPI meeting was held with the QAPI Committee (Administrator, Chief Director of Clinical Operations (CDCO), Maintenance Director, Social Services Director, and the Medical Director) to discuss incident involving Resident #1. 4. [DATE], the policies for Secure Memory Care Unit and Incident Report-Documentation, Investigation, and Reporting were reviewed by the Administrator, Medical Director and the Ad Hoc QAPI Committee with no revisions made. 5. [DATE], The Administrator and Department Heads began completing daily written Environmental Quality Improvement Monitoring Audit for Unit 1, Unit 2, Unit 3 (Memory Care Unit)- including the Activity Room and Dining Room, Rehab Gym, Main Dining Room, and Lobby Area. The Administrator, CDCO and/or Nursing Supervisor to perform Quality Improvement Monitoring of residents who reside on the Memory Care Unit 7 times a week for 4 weeks. The Administrator reviews these Environmental QI Monitoring Audits weekly. The results will be reviewed with the QA Committee during QAPI monthly. 6. [DATE], CDCO and MDS (Minimum Data Set) Director completed a Care Plan and Kardex Audit for behavior interventions and accident interventions. This audit tool will continue weekly x 4 weeks. 7. [DATE], Maintenance replaced 124 window blinds accessible to residents throughout the facility (resident rooms, dining areas, front lobby, rehab gym) with cordless blinds. 8. [DATE], the Vice President of Clinical Operations in-serviced the IDT, which consists of Chief Director of Clinical Operations (CDCO), Social Services Director, MDS Director, Staff Development Coordinator (SDC), Activity Director, and Rehab Director on how to identify, report and intervene when accidental hazards are identified. 9. Beginning [DATE] the CDCO in-serviced staff regarding accidents and injuries and completed on [DATE] as the Chief Director of Clinical Operations (CDCO) and Staff Development Coordinator (SDC) in-serviced staff on how to identify, report, intervene and monitor, including all window blinds must be cordless or cords secured, reporting any issues in resident room/facility that may cause injury to residents, and reporting any behavior that may cause self-injury or injury to someone else. When accidental hazards are identified. RN: 9 of 9 LPN: 17 of 19 C.N.A: 22 of 26 Agency: 13 of 15 C.N.A Agency: 2 of 5 LPN Rehab: 11 of 12 Housekeeping: 6 of 7 Laundry: 2 of 3 Dietary: 9 of 12 Maintenance: 2 of 2 Administration: 15 of 15 Total: 108 of 125 86% 10. The remaining 17 staff will be in-serviced by the CDCO/SDC on the next scheduled workday prior to beginning their shift. New hires and employees on LOA (leave of absence) (1 LPN and 1 C.N.A for a total of 2) will not be placed on the schedule and/or will not be allowed to return to work until in-services are completed. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of a Transfer/Discharge Report revealed R#1 was discharged on [DATE] to the funeral home. A phone interview on [DATE] at 11:00 a.m. with the facility's Medical Director revealed he was made aware of R#1's death on [DATE] by the Administrator. 2. Review of the Quality Assessment and Assurance/QAPI Committee Attendance Sheet dated [DATE] revealed the Administrator, Chief Director of Clinical Operations, Maintenance Director, Social Services Director, and the Medical Director were in attendance. An interview was conducted on [DATE] at 11:00 a.m. with the Administrator, DON, and Medical Director (via telephone). The Medical Director stated after the DON spoke with the staff on Unit 3 (Memory Care) regarding the incident with R#1, an AD HOC meeting was conducted on [DATE]. Review of the QAPI Root Cause Analysis (RCA) Worksheet dated [DATE] revealed an RCA was completed by the DON. The Unit Manager (UM), and charge nurse for R#1 were not aware of the resident's behavior of playing with the window blinds. The team identified that the new behavior was not identified, and the care plan was not personalized enough to change the outcome. Changes to correct the issue was to educate the staff to report behaviors and care plan. The staff will be educated on the care plan process. 3. Review of the AD HOC QAPI Meeting Attendance Sheet dated [DATE] revealed signature of the Administrator, DON, Medical Director, Maintenance Director, and Social Services. Four areas were discussed; risk management, trends noted, root cause, and action taken. Trends Noted: No trends noted. Root Cause: Accidental. Action Taken: Unit three blinds will be replaced with cordless blinds. Maintenance team is working on this project until completed. The project will expand facility wide once unit three has be completed. Immediate action: All cords on blinds have been secured to prevent reoccurrence. 4. Review of the undated policies for Secure Memory Care Unit and Incident Report-Documentation, Investigation, and Reporting was signed by the Administrator. A phone interview was conducted on [DATE] at 11:00 a.m. with the Medical Director. The Administrator and DON were present during the interview. The Medical Director stated the policies for Secure Memory Care Unit and Incident Report-Documentation, Investigation, and Reporting were emailed to him. A phone conference was conducted with the Administrator and DON all the policies were reviewed and no changes were made. 5. Review of the Environmental Quality Audit revealed audits were conducted daily on Unit 1, Unit 2, and Unit 3 (memory care) from [DATE] through [DATE] to monitor window blind cords secure, electrical outlets not in use secures, call bell cords secured, unit doors are in proper working order, and all housekeeping carts are locked when unattended. Audits were signed by the Administrator. An observation was conducted daily from [DATE] through [DATE] and found that all blinds in the resident rooms had been changed to cordless. No safety/environmental issues were identified. 6. Review of 40 resident's behavior care plans and Kardex with a print date of [DATE] revealed audits for behavior interventions and accident interventions with no further deficient practice identified. Record review revealed R#19 had a care plan for mood problems with revision date of [DATE] and an updated Behavior Kardex. R#20 had a care plan for inappropriate public display with revision date of [DATE] and an updated Behavior Kardex. R#21 had a care plan for PASARR Level II with a revision date of [DATE] and an updated Behavior Kardex. An interview on [DATE] at 12:30 p.m. with the Minimum Data Set (MDS) Coordinator revealed a facility wide audit was complete for care plans, resident with new behaviors, and PASARR. She stated she reviewed the residents care plan and made sure the care plan reflected what services were being received. The residents on Unit 3 (Memory Care) were reviewed to make sure that behaviors were care planned and individualized. The Kardex was also audited for the residents' behavior. Any new behaviors identified/discussed during the weekly Patient at Risk Meeting (PAR), the CP and Kardex will be updated during the meeting. 7. An observation was conducted daily from [DATE] through [DATE]. All blinds in the resident rooms, dayrooms, rehab, front lobby, and dining rooms had been changed to cordless. 8. Review of the facility in-service record dated [DATE] revealed the Administrator, CDCO/DON, Social Services Director, MDS Director, Staff Development Coordinator (SDC), Activity Director, and Rehab Director were educated on how to identify, report and intervene when accidental hazards are identified. This was confirmed by interview with the Vice President of Clinical Operations on [DATE] at 4:44 p.m. 9. Review of facility in-service records dated [DATE] revealed 9 of 9 RN's, 17 of 19 LPN's, 22 of 26 CNA's, 11 of 12 Therapy, 13 of 15 agency CNA's and 2 of 5 agency LPN's received instruction on how to identify, report, intervene and monitor any issues in resident's room/facility that may cause injury to residents, and reporting any behavior that may cause self-injury or injury to someone else, including all window blinds must be cordless or cords secured and when accidental hazards are identified. Also verified via the following staff interviews on [DATE]: 2:44 p.m. with LPN UU, 3:08 p.m. with RN Infection Control Preventionist, 4:00 p.m. with LPN OO, 4:05 p.m. with LPN NN, 4:10 p.m. with LPN PP, 4:15 p.m. with CNA ZZ, and 4:23 p.m. with CNA VV; on [DATE]: 7:50 a.m. with LPN RR, 8:10 a.m. with CNA AAA, 8:14 a.m. with CNA YY, 8:17 a.m. with CNA XX, 8:20 a.m. with LPN SS, and 9:33 a.m. with RN MM, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. Review of facility in-service records dated [DATE] revealed 6 of 7 Housekeeping, 2 of 3 Laundry, 9 of 12 Dietary, 2 of 2 Maintenance, and 15 of 15 Administration received instruction on how to identify, report, intervene and monitor any issues in resident's room/facility that may cause injury to residents, and reporting any behavior that may cause self-injury or injury to someone else, including all window blinds must be cordless or cords secured and when accidental hazards are identified. Also verified via the following staff interviews on [DATE]: 1:56 p.m. with Housekeeper DDD, 2:02 p.m. with Maintenance Staff FFF, 2:04 p.m. with Maintenance Director, 2:10 p.m. with Housekeeper/Laundry EEE, 2:16 p.m. with Dietary Staff BBB, 2:19 p.m. with Dietary Staff CCC, and 2:28 p.m. with Business Office Assistant KK, 2:38 p.m. with Laundry Staff GGG, and 3:11 p.m. with Admissions Staff LL, the staff confirmed that they received the in-service information and were able to demonstrate an understanding of the education information provided. 10. Review of the daily staffing sheets and additional facility in-service records from [DATE] through [DATE] revealed the remaining staff have not worked prior to receiving the in-service education. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE].

Based on record review, review of the facility policy titled Behavioral Assessment, Intervention, and Monitoring, and staff interviews, the facility failed to ensure one of 16 sampled residents (R) (R#1) received necessary behavior health services to address significant worsening behaviors including safety concerns with the call lights, curtains, and linen. On [DATE] a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on [DATE] at 3:50 p.m. The noncompliance related to the IJ identified to have existed on [DATE] when R#1 was found deceased in her room with a window blind cord wrapped around her neck. The IJ is outlined as follows: Record review revealed that R#1 was found in her room near the window by the air conditioning unit with the blind cord wrapped around her neck. The resident was assessed to have no pulse, no respirations, pupils fixed and dilated with signs of lividity. The resident was a [AGE] year-old female with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was severely cognitively impaired and had a known history of wrapping call lights, sheets, and curtains around her body. The facility failed to remove a blind cord from the resident's room and failed to adequately supervise the resident which resulted in her death on [DATE]. In addition, R#1 was seen by the Psychiatric Nurse Practitioner on [DATE] for worsening behaviors including safety concerns with call lights and curtains. A suicidal assessment was conducted, and the resident was identified as low risk for suicide. However, for further evaluation, recommendations were made to obtain medical records from the resident's previous inpatient psychiatric stay; or to file PASARR (Preadmission Screening & Resident Review) Level II for extensive psychiatric care. The recommendations for R#1 were not followed. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.20(k)(1)-(3) PASARR Screening for MD & ID (F 645 Scope and Severity (S/S): J) C.F.R. 483.21(b)(1) Develop/implement Comprehensive Care Plan (F 656 S/S: J) C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J) C.F.R. 483.40 Behavioral Health Services (F 740 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices (F 689 S/S: J). An acceptable Removal Plan was received on [DATE]. Based on the validation of the Removal Plan, the State Survey Agency determined that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of facility Policies and Procedures related to accident hazards and behavioral health needs of residents. Findings include: Review of the policy titled, Behavioral Assessment, Intervention, And Monitoring dated [DATE] revealed Policy Statement: 2. Behavioral symptoms will be managed appropriately. Management: 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. 6. If the resident lacks decision-making capacity and does not have effective family support, the IDT (Interdisciplinary Team) will contact social services to provide assistance to the resident. Review of the Admission Record (face sheet) for R#1 revealed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) interview not conducted, resident rarely/never understood, which indicated severe cognitive impairment. Section E revealed other behavioral symptom not directed toward others occurred one to three days of the seven-day assessment period; and that the behavior put the resident at significant risk for physical injury. The resident was administered antipsychotic and antidepressant medications for seven days during the seven-day assessment period and received no psychological therapy. Review of the Quarterly MDS for R#1 dated [DATE] revealed during this seven-day assessment period, the resident continued to be severely cognitively impaired. Section E revealed no behavioral symptoms during the seven-day assessment period. The resident was administered antipsychotic and antidepressant medications for seven days during the seven-day assessment period and received no psychological therapy. Review of the Physician's Orders for R#1 initiated on [DATE] revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no evidence that R#1 was seen by the outside behavioral health service. Review of Nursing Note dated [DATE] revealed R#1 has been noted to wrap herself in the curtains. Staff concern for resident safety regarding the call light, curtains, and bedside table. Social service was made aware of resident's behavior. Review of Nursing Note dated [DATE] revealed R#1 was discussed with the Psychiatric Nurse Practitioner (NP) regarding the resident's need for more extensive psych care. Discussed resident behaviors including poor safety awareness with call lights and curtains. The writer reported to the NP that SS (Social Services) had been notified. Review of Social Service assessment dated [DATE] revealed no documentation related to worsening behaviors related to poor safety awareness with call lights and curtains. There was not another Social Service Assessment until [DATE] which revealed no documentation of the worsening behaviors. Review of Psychiatry Progress Note dated [DATE] revealed R#1 with referral to psych eval (psychiatric evaluation) and medication management. R#1 had behaviors including but not limited to climbing over her bed, wandering in and out of other rooms, and unable to follow redirection. The curtain in room was tied because the patient is noted to have tried wrapping it around self. A suicidal risk assessment was conducted, and R#1 was at a low risk for suicide, per staff . continue to monitor resident. Continue to monitor for suicide risk. Treatment Plan/ Recommendations included: 1. Discussed with SW (social worker), medical records from the resident's previous psychiatric inpatient facility are needed for further evaluation or file PASARR (Preadmission Screening & Resident Review) Level II for extensive psych care. Further review of the clinical record revealed R#1 was an inpatient at a psychiatric facility from [DATE] through [DATE]. There was no evidence that the above psychiatric recommendations were followed. Review of Psychiatry Progress Note dated [DATE] revealed R#1 has an ongoing and worsening behavior of wrapping the curtain and pull cord around her body. They (the facility) do not think this is appropriate placement for her. There was no evidence that the facility made any attempt to pursue alternate placement for R#1. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] #1 wraps her body in the curtain or call button cord. Because of the worsening behaviors, recommended that the resident be seen by the Psychiatrist. There was no evidence that the resident was seen by a psychiatrist following the above [DATE] Physician recommendation. Review of the Physician's Orders for R#1 from [DATE] through [DATE] revealed there were no documented orders for behavior monitoring/documenting for safety concerns with call light, curtains, or climbing on top of the furniture. Review of Nursing Note dated [DATE] at 12:20 p.m. revealed the DON found R#1 with the window blind cord wrapped around her neck. The resident assessed, no heartbeat noted on auscultation, no respirations, pupil fixed and dilated, skin cool to touch. The NP was present and determined that resident was deceased . An interview on [DATE] at 11:19 a.m. with the Social Service Director (SSD) revealed she was aware of R#1's worsening behaviors as it was discussed in the Behavioral Management Meeting on [DATE], [DATE], [DATE], and [DATE]. The SSD stated R#1 was not seen by the outside behavioral health service per the physician order. The SSD stated she did not complete a PASARR screening for R#1. The SSD stated she did not know that PASARR should be evaluated upon any significant change in a resident's behavior. An interview on [DATE] at 2:26 p.m. with the Psychiatric NP revealed she was familiar with R#1. The NP stated that the resident did not verbally communicate and would pace in the hallways. She stated she did request the resident's inpatient records from the psychiatric hospital or a PASSAR Level II to be completed by the Social Service department. She stated she never received the records, and a Level II was not completed. She stated she is not sure if an alternative service would have benefited R#1, but she wanted to try. She always reviewed the residents with the psychiatrist and was aware that an alternative placement was suggested for R#1. The facility implemented the following actions to remove the IJ: 1. [DATE], Resident #1 expired in the facility, Riverside Health Care Center. 2. [DATE], an Ad Hoc QAPI meeting was held with the QAPI Committee (Administrator, Chief Director of Clinical Operations, Maintenance Director, and Social Services Director) and the Medical Director to discuss incident involving Resident #1. 3. [DATE], an Ad Hoc QAPI meeting was held with the QAPI Committee (Administrator, Chief Director of Clinical Operations, QA Nurse, and Regional Director of Clinical Operations) to discuss the root cause analysis of the PASARR and Behavioral Health Services Immediate Jeopardy citations. 4. [DATE], the policies for Preadmission Screening and Annual Resident Review, Secure Memory Care Unit, and Mood and Behavior were reviewed by the Administrator, Medical Director and the Ad Hoc QAPI Committee with no revisions made. 5. [DATE], the Vice President of Clinical Operations in-serviced the Chief Director of Clinical Operations (CDCO), Social Services Director, MDS Director, Staff Development Coordinator (SDC), Activity Director, and Rehab Director on Behavior Health Services overview (Behavior management meeting program, PASARR Level II Screening process, process for psychiatric care recommendations to prevent complications for residents with worsening behaviors). 6. The CDCO performed a Quality Improvement Monitoring (PASARR} Audit of care plans for residents on the Memory Care Unit and other Nursing Units to identify any other residents recommended for PASARR. No other residents were identified. This audit will be completed by Social Services Director and/or Nursing Supervisor 7 times a week x 4 weeks. 7. A list of residents seen by the Psych Nurse Practitioner, including recommendations, will be given to the Social Services Director (SSD) and/or CDCO during each exit to follow up with any recommendations. 8. CDCO and Social Services Director reviewed psych recommendations and no other residents were identified for psych services. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of a Transfer/Discharge Report revealed R#1 was discharged on [DATE] to the funeral home. A phone interview on [DATE] at 11:00 a.m. with the facility's Medical Director revealed he was made aware of R#1's death on [DATE] by the Administrator. 2. Review of the Quality Assessment and Assurance/QAPI Committee Attendance Sheet dated [DATE] revealed the Administrator, Chief Director of Clinical Operations, Maintenance Director, Social Services Director, and the Medical Director were in attendance. An interview was conducted on [DATE] at 11:00 a.m. with the Administrator, DON, and Medical Director (via telephone). The Medical Director stated after the DON spoke with the staff on Unit 3 (Memory Care) regarding the incident with R#1, an AD HOC meeting was conducted on [DATE]. Review of the QAPI Root Cause Analysis (RCA) Worksheet dated [DATE] revealed an RCA was completed by the DON. The Unit Manager (UM), and charge nurse for R#1 were not aware of the resident's behavior of playing with the window blinds. The team identified that the new behavior was not identified, and the care plan was not personalized enough to change the outcome. Changes to correct the issue was to educate the staff to report behaviors and care plan. The staff will be educated on the care plan process. 3. Review of the AD HOC QAPI Meeting Attendance Sheet dated [DATE] revealed signature of the Administrator, DON, Medical Director, Maintenance Director, and Social Services. Four areas were discussed as part of the RCA: risk management, trends noted, root cause, and action taken. Actions Taken: Pull 24-hour report timely and read recommendations. Coordinate with our Medical Director to check on the changing process. Request psych list when NP/MD visit facility. Behaviors reported will be care planned immediately. Activities to help with individualized need with activity implementation. 4. Review of the undated policies for Preadmission Screening and Resident Review, Secure Memory Care Unit and Mood and Behavior was signed by the Administrator. A phone interview was conducted on [DATE] at 11:00 a.m. with the Medical Director. The Administrator and DON were present during the interview. The Medical Director stated the policies for Preadmission Screening and Resident Review, Secure Memory Care Unit and Mood and Behavior were emailed to him. A phone conference was conducted with the Administrator and DON all the policies were reviewed and no changes were made. 5. Review of the facility in-service record dated [DATE] revealed the Administrator, CDCO/DON, Social Services Director, MDS Director, Staff Development Coordinator (SDC), Activity Director, and Rehab Director were educated on the behavior management meeting program, PASARR Level II Screening process, and process for psychiatric care recommendations to prevent complications for residents with worsening behaviors. This was confirmed by interview with the Vice President of Clinical Operations on [DATE] at 4:44 p.m. 6. Record review revealed a PASARR Assessment (Level I & II) audit was completed on [DATE] and [DATE]. No other residents were identified as requiring PASARR. An interview was conducted on [DATE] at 10:30 a.m. with the DON and SSD. The DON stated a facility wide audit was conducted by the MDS Coordinator. The DON stated this Audit will be completed daily based on admission paperwork, behaviors discussed in the clinical meeting, progress notes and physician orders. The SSD stated she will obtain a list from psych service on each visit she will review notes and look for diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The updated/new information will be entered the Georgia Medicaid Management Information System (MMIS) portal system. The facility will follow up based on the recommendations. The SSD stated the PASARR assessments will also be completed annually and with any significant change. 7. An interview was conducted on [DATE] at 10:30 a.m. with the DON and SSD. The SSD stated psych service and an outside behavioral health service are in the facility weekly. She stated prior to them exiting the facility, a list will be provided to her with the resident seen and any recommendation or orders. In the SSD absent, the list will be provided to the assistant and/or the DON. The SSD stated the psych progress notes are entered into the electronic health record within 48 hours. 8. An interview was conducted on [DATE] at 10:30 a.m. with the DON and SSD. The DON stated a list was pulled from the electronic medical record of all 32 residents seen by psych services with recommendations. She stated all the progress notes and recommendations were reviewed and orders were checked to make sure they were followed through. R#6, R#21, and R#23 were reviewed for psychiatric services and recommendations. No issues noted. All corrective actions were completed on [DATE]. The facility alleges that the IJ is removed on [DATE].

Based on observations, interviews, record reviews, and review of the facility's infection control policies, the facility failed to: 1. ensure an effective Infection Prevention Control Program (IPCP) was implemented including timely and accurate COVID-19 testing for residents to be consistently aware of the COVID status of all residents to prevent the spread of [MEDICAL CONDITION] in the facility, 2. designate a single entrance to the facility to properly screen staff and contractors allowed inside the building to reduce the spread of COVID-19 within the facility, 3. provide and maintain adequate supplies of soap for proper hand hygiene for residents and staff, 4. properly don/doff and appropriately use Personal Protective Equipment (PPE) on the COVID-19 Unit, 5. appropriately quarantine and change PPE when providing care for Resident (R) #1, and R#6. quarantine and cohort newly admitted residents (R#3 and R#5) as Persons Under Investigation (PUIs) for 14 days to confirm their COVID-19 status. As a result of these facility failures the facility has had an ongoing COVID-19 outbreak with a cumulative 101 residents and 40 staff who have tested positive for COVID-19. Additionally, the facility reports 27 resident deaths from COVID-19. The sample was 27 residents. On August 17, 2020, in consultation with DCH, a determination was made that the facility's noncompliance had resulted in an Immediate Jeopardy. On August 18, 2020 and August 19, 2020, additional Immediate Jeopardy concerns were identified, and the facility was made aware. The Immediate Jeopardy was identified to exist on July 15, 2020. The facility's Administrator and Interim Director of Nursing (IDON) were informed of this Immediate Jeopardy on August 17, 2020 at 8:39 p.m. and was identified to have existed on August 11, 2020. On August 18, 2020 at 6:19 p.m. the facility's Administrator was informed of additional Immediate Jeopardy concerns and was identified to have existed on August 3, 2020. On August 19, 2020 at 6:18 p.m. further Immediate Jeopardy concerns were identified to have existed on July 15, 2020 and the facility's Acting Administrator/ Regional Director of Clinical Services and Vice President of Clinical Operations were informed. The immediate jeopardy situations are outlined as follows: 1. Medical record reviews revealed that 19 COVID-19 tests were rejected by the lab on July 15, 2020 and the facility failed to retest timely to confirm resident's COVID status for appropriate care and to reduce the spread of [MEDICAL CONDITION] until August 2, 2020. Of the 19 test that were repeated on August 2, 2020, one resident was not retested , one resident was hospitalized on [DATE] and found to be COVID-19 positive on admission, and eight additional residents tested positive on August 2, 2020. Poor infection prevention and control due to unknown COVID status for residents in the facility, increased the risks of illness from COVID-19 for residents and staff; and increased the potential risk of spreading [MEDICAL CONDITION] in the facility and the community. 2. The facility failed to designate an entrance/exit to the facility to ensure staff and visitors/surveyors were properly screened prior to entering the facility. 3. There were infection control/ PPE concerns on the positive COVID unit. Staff were not wearing the required PPE to include hair and shoe covers on the COVID unit. 4. Resident #1 was unnecessarily exposed to COVID-19 by facility staff failing to change PPE after treating COVID-19 positive residents. 5. It was discovered that all but two soap dispensers in the facility were empty. The serious concern regarding a lack of soap/hand hygiene supplies for staff and residents was relayed to the Administrator and Director of Nursing on August 18, 2020 at 11:00 a.m. after the tour and after confirming interviews with staff. 6. The facility failed to cohort and properly isolate newly admitted residents (Residents (R)#3 and R#5) who were considered Persons Under Investigation (PUI). These residents were admitted to the general population without quarantine for 14 days to determine COVID-19 status. R#5 was cohorted with R#8 (who was negative for COVID-19) putting R#8 at risk. The Immediate Jeopardy was identified on August 17, 2020, August 18, 2020 and August 19, 2020 and determined to exist on July 15, 2020 in the area of 42 CFR §483.80 infection control regulations, F880 which was cited at a Scope and Severity of L. At the time of exit on August 20, 2020, an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains ongoing. Findings include: 1. Review of the facility policy titled Laboratory Testing, dated September 1, 2018, revealed, Diagnostic test will be completed according to facility laboratory schedule and/or as ordered by the primary care physician, physician assistant, nurse practitioner .Any labs not obtained as scheduled will be rescheduled and the ordering physician will be notified . Review of the policy titled Covid19 Testing and Resident and Staffing Requirements dated 5/5/2020 revealed Definitions: Nasal and Oral-Pharyngeal samples will be collected by a licensed nurse after completion of training. Action: Step 1-a facility will require a Nasal and Oral-Pharyngeal test sample for COVID19. Step 2-Residents-COVID19 testing will be conducted per Physician Order. Medical record reviews, including Electronic Medical Records (EMR) and hard copy charts, revealed that 19 residents had COVID-19 tests ordered for July 15, 2020 and July 16, 2020. The specimens were collected and sent to the lab. Review of the lab results revealed that the specimens were rejected by the lab because the specimen tubes were not labeled. The lab reports stated, Rejection Reason: Tube was not labeled, will need to be recollected. Continued record reviews revealed no evidence that the specimens were recollected timely to execute the Physician's Order when the facility was notified that the initial specimens had not been properly processed. The EMR reviews revealed the next collection/test results available for the rejected specimens were as follows: R#7-8/2/2020 positive results R#9 -no retest documented R#10-8/2/2020 positive result R#11-8/7/2020 negative result R#12-8/2/2020 positive result R#13-8/2/2020 negative result R#14-8/6/2020 negative result R#15-8/2/2020 positive result R#16-8/2/2020 positive result R#17-8/2/2020 positive result R#18-8/2/2020 negative result R#19-8/2/2020 positive result R#20-8/2/2020 negative result R#21-8/2/2020 positive result R#22-8/2/2020 negative result R#23-8/2/2020 positive result R#24-8/2/2020 negative result R#25-7/24/2020 positive result when hospitalized R#26-8/2/2020 negative result In an interview with the Medical Director (MD) on 8/17/2020 at 2:22 p.m., the MD stated that he has had concerns with the facility not following Physician's Orders as written. The MD stated that he has received credible reports from his Nurse Practitioners (NPs) and facility nurses that the facility is aware of the MD's preference for nasopharyngeal specimen collection due to increased reliability of the test result. The nurses have reported to the NPs and to the MD that they were instructed by the Director of Nurses (DON) and the Administrator to collect and send oral samples instead. The MD also stated that due to sample collection and reporting concerns with the facility, the contracted provider of lab services had terminated their contract with the facility effective 8/14/2020. The named lab provider called the surveyor about lab results inquiries on 8/18/2020 at 4:49 p.m. and confirmed the named lab had terminated their contract with the facility on 8/14/2020. A call was placed to confirm the details of the contract termination with a lab representative and a voice mail was left requesting a return call on 8/20/2020 at 8:50 a.m. The call was not returned prior to exiting the survey. In a subsequent phone interview with the MD on 8/19/2020 at 12:10 p.m., the MD stated that if labs were ordered and not processed due to a facility error, then it was certainly his expectation that the sample be recollected that day. In an interview on 8/18/2020 at 10:40 a.m., RN II stated that she had been specifically instructed by her managers to collect oral specimens rather than nasopharyngeal specimens. RN II confirmed managers referred to the Administrator and DON. In an interview with the Interim DON (ID) and the Administrator on 8/18/2020 at 10:50 a.m., the Administrator stated she was aware that the MD wanted nasopharyngeal specimens for testing, but that corporate made a decision that oral specimens were less traumatic for the residents and confirmed that oral samples were collected When asked if the MD was notified that the specimens were being collected orally and not by the nasopharyngeal method, the Administrator stated, I'm not sure . but we have to do what corporate says. In an interview with the Regional Director of Clinical Operations (RDCO) on 8/18/2020 at 11:50 a.m., the RDCO stated he was now the Acting Administrator. He stated he has been working with the facility on COVID issues for a couple of months. He was asked if a corporate directive should be followed instead of a Physician's Order and he stated . we have to do what corporate directs . When asked if he was aware of the MD's preference for nasopharyngeal specimens he said .yes, but the order says COVID test, so we are doing oral tests. When asked if the MD should have been notified that the lab specimens were oral and not nasopharyngeal, he stated, yes, he probably should have. In a phone interview with the former facility DON on 8/19/2020 at 12:30 p.m,, she confirmed that the facility did not recollect the specimens when the facility was notified the specimens had been rejected. In an interview with the Vice President of Clinical Operations (VPOC) on 8/19/2020 at 1:30 p.m., the VPOC confirmed the facility was aware the specimens had been rejected and not recollected. She confirmed the MD order had not been followed. When asked how the resident care should have been managed by the facility while the test results were unknown, and the VPOC said, they should have been treated as potentially positive or PUIs (Person Under Investigation) until we knew different. When asked if this had happened, she said no. In an interview with the RDCO on 8/19/2020 at 2:00 p.m., he was asked about the July 15, 2020 and July 16, 2020 testing errors and he confirmed he was aware the specimens had been rejected and were not recollected. The RDCO was asked if the Physician Orders had been followed and he replied, no, not in this case. The RDCO was asked to provide documentation that the MD had been notified of the rejected COVID tests although the documentation had not been presented by the survey exit on 8/20/2020. 2. Review of the facility's policy titled, Pandemic Event Emergency Procedure Coronavirus (COVID-19) Respiratory Disease Infection, revised 07/02/2020, revealed This facility has taken measures to prepare for a pandemic event. With the globally spreading of a new respiratory disease- Coronavirus Disease 2019 (COVID-19) . The facility will adhere to recommendation from the Center for Disease Control .All Employees-Screen all employees by obtaining temperatures and assessing for coughing, and sore throat symptoms, chest discomfort or shortness of breath . Observation on 8/17/20 at 8:43 a.m. revealed the receptionist came to the front door, used a temporal thermometer, and took two surveyors' temperatures and two Georgia Department of Public Health (GDPH) employees' temperatures. Continued observation revealed the receptionist did not screen any of the four visitors for signs and symptoms of COVID-19 and did not record any of the four visitors' names for contact tracing. Interview on 8/17/2020 at 9:30 a.m. with the receptionist revealed when we (surveyors and GDP) came into the facility she was supposed to ask screening questions and record our names. Observation on 8/17/2020 at 9:31 a.m. revealed Licensed Practical Nurse (LPN) AA preparing to enter R #1's room on the COVID positive unit. When asked if she had entered the unit through the designated entry/don/doff area she stated, No, I came in through that door, and pointed to an exit door at the other end of the hallway. When asked if she was screened prior to starting her shift LPN AA stated, I took my temperature. When asked to see where she logged her temperature LPN AA stated, I didn't write it down. The DON was present during this interview and confirmed the staff on the COVID unit are required to enter through the PPE don/doff area. An interview on 8/17/2020 at 2:05 p.m. with Certified Nursing Assistant (CNA) FF, revealed she was employed by agency staffing and had been assigned to this facility for two weeks. Continued interview revealed CNA FF confirmed she was not screened or had her temperature taken before starting her shift today. CNA FF stated she had not been screened or had her temperature taken since being assigned to the facility. Continued interview revealed she was assigned to Unit 2 today. An interview on 8/17/2020 at 2:34 p.m. with CNA GG, revealed she was an agency CNA and today was her first day. Continued interview revealed she had been in the building since approximately 6:55 a.m. and has not been screened or had her temperature taken. Review of the facility's COVID-19 screening form for Unit 2 titled, Riverside Healthcare Register, dated 08/17/2020, revealed no documented evidence CNA FF and CNA GG were screened for signs and symptoms of COVID-19 including having their temperature taken. Unit 2 was the designated unit for COVID-19 negative residents. Interview on 8/17/2020 at 3:20 p.m. with CNA HH revealed she did take her own temp when coming in the Unit 3 door this morning, but she did not document. Continued interview with CNA HH revealed she went to the Unit 3 nurses' station for screening and to have her temperature taken again; however, no one was at the nurses' station, no paper was there to sign, and she was in a rush to start her shift. CNA HH worked the 7:00 a.m. to 3:00 p.m. shift on 8/17/2020 without having been screened for signs and symptoms of COVID-19. Interview on 8/17/2020 at 9:46 a.m. with CNA DD revealed she entered the building from the outside side door of Unit 3, donned (put on) her PPE and then walked up to the nurses' station, through the unit's resident area, and was screened and her temperature was taken. Interview on 8/17/2020 at 9:48 a.m. with LPN EE revealed she was the nurse for Unit 3. Continued interview revealed the normal process for all staff who work on Unit 3 was to enter the side door at the end of the unit's hall, don PPE, and then come through the resident area to have her temperature taken and to be screened. LPN EE stated staff should take their own temperature when they don PPE and if no elevated temperature then they could come up to nurses' station where it was then confirmed the employee did not have a temperature. Review of the facility's COVID-19 screening form for Unit 3 titled, Riverside Healthcare Register, dated 8/17/2020, revealed no documented evidence CNA HH was screened for signs and symptoms of COVID-19 including having her temperature taken. Unit 3 was designated as the recovery unit where residents who previously had COVID-19 were monitored for additional signs or symptoms. Interview on 8/17/2020 at 2:54 p.m., the Medical Director revealed it was his expectation staff were screened upon entrance of the building and not after they have entered a resident area. In an interview on 08/17/2020 at 5:33 p.m., the Administrator stated there was no policy regarding designated entrances or exits for COVID screening. 3. Review of the facility policy titled Handwashing/Hand Hygiene dated November 2016, revealed, This facility considers hand hygiene the primary means to prevent infections .3. Hand hygiene products and supplies (sinks, soap, towels, alcohol- based hand rub, etc.) shall be readily accessible and convenient for staff use .6. Wash hands with soap .and water for the following situations: a. When hands are visibly soiled . Observations on 8/17/2020 and 8/18/2020 revealed the facility failed to ensure adequate handwashing supplies be available to residents and staff for proper hand hygiene during a pandemic. Observation 8/17/2020 at 4:10 p.m. revealed the restroom at the Unit 2 (designated as COVID negative hall) nurses' station had no soap in the bathroom for hand hygiene. The dispenser was empty and there was a bottle of (Brand) Shampoo & Bodywash on the sink. On 8/18/2020 at 10:10 a.m. at the Unit 2 nurses' station, a tour was initiated with the DON of all hand washing stations for staff use on each resident care areas/hallways. It was discovered that all but two soap dispensers in the staff handwashing areas were empty. At the Unit 2 nurses' station the restroom had no soap in the dispenser and had a scant amount of bodywash in a bottle on the sink. In the Unit 2 pantry there was no soap available, but there was a half full bottle of shampoo/bodywash. The DON stated that hand sanitizer was available for use in the facility. When asked what to do when hands were visibly soiled, or after using the rest room the DON stated .we have to do the best we can with what we have. On 8/18/2020 at 10:24 a.m. at the Unit 3 nurses' station, there was a pantry and an employee restroom with sinks for staff handwashing per the DON. There was neither soap nor bodywash available at either sink. There was no hand hygiene agent at all other than water. There was an 8 oz bottle of hand sanitizer on the nurse's station desk. The housekeeping closet on Unit 3 had no soap available at the sink. The DON confirmed the observations. Unit 3 was the recovery unit for the facility. On 8/18/2020 at 10:38 a.m., Registered Nurse (RN) II was interviewed and stated that she brings her own soap to work because it was not available in the facility. RN II stated that as a nurse she did not feel the shampoo/bodywash supplied by the facility was adequate for hand hygiene during resident care. On 8/18/2020 at 10:44 a.m., Unit 1, the COVID unit, was entered. In the donning/doffing area there was a bottle with a hand-written label hand sanitizer. There was no handwashing station at the entry/exit point to the COVID-19 unit. The restroom at the COVID unit nurses' station had no soap, only a bottle of shampoo/bodywash. In the COVID unit staff breakroom there was a sink but no hand hygiene agents available. Continued observation of the COVID unit revealed four of the 10 resident rooms were found to be without soap or any type of hand hygiene agent, only a sink. On 8/18/2020 at 11:21 a.m., CNA FF stated that soap had been unavailable in the facility for awhile. She stated that she brought her own soap to wash her hands. On 8/18/2020 at 11:45 a.m., CNA JJ was interviewed and stated that hand soap had not been available for staff or residents to use. On 8/18/2020 at 12:12 p.m., CNA KK also stated the facility had been out of soap for over a month. On 8/18/2020 at 12:45 p.m., the Infection Preventionist (IP) Registered Nurse was interviewed. She stated the soap dispenser refills had been on back order since before she was out of work for two weeks due to COVID-19 illness. On 8/18/2020 at 12:56 p.m. the Central Supply (CS) staff was interviewed. She confirmed that soap had been on back order for over a month. On 8/18/2020 at 1:00 p.m. the DON was interviewed about the soap shortages. The DON confirmed the tour with the surveyor and the empty soap dispensers. The DON confirmed that hand washing is key to infection control and the facility should have soap available for staff and resident use. The Acting Administrator (AA) was interviewed on 8/18/2020 at 1:16 p.m. revealed that he has been involved with this facility for a little over two months. He stated he was not aware that there was no actual soap available for staff and resident use. 4. Observation on 8/17/2020 at 9:09 a.m. revealed Restorative Certified Nurse Aid (RCNA) exiting the positive COVID unit in the PPE don/doffing area. The RCNA had ungloved hands as she removed her used/dirty gown. The RCNA then used her ungloved hands to place the used gown in a trash can and push the contents down with bare hands so the lid would close. The trash can that she used was clearly labeled No PPE. The RCNA was exiting the unit to work on Unit 3 that was not a positive COVID unit. Observation on 8/17/2020 at 9:31 a.m. revealed LPN AA preparing to enter R#1's room, on the positive COVID unit and LPN AA was not in full PPE. The PPE requirements on the COVID unit were mask, gloves, face shield, hair cover, gowns, and shoe covers. When questioned why she was not wearing the required hair and shoe covers, LPN AA stated, the hair net doesn't fit my hair, so I don't wear it, and I didn't put on shoe covers this morning. LPN AA stated she has worked in the facility for five days. When asked if she was aware full PPE was required on the COVID Unit LPN AA stated, yes. The DON was present during this interview and confirmed that the staff on the COVID unit are required to enter through the don/doff area and .staff are required to wear full PPE, at all times, on the COVID-19 hall inclusive of hair and shoe coverings, which is the facility's requirement. The DON stated that all residents on Unit 1 are positive for COVID-19. 5. Review of the Admission Criteria for COVID-19 policy, dated July 24, 2020, revealed the policy did not address residents admitted as PUI (Person Under Investigation) which are recommended infection control practices that include 14-day quarantine separated from residents negative for COVID-19 and from residents who are positive for COVID-19. This applies to PUI/newly admitted residents to determine COVID-19 status. In an interview on 8/17/2020 at 5:30 p.m., the Administrator stated that testing is the determining factor for determining Persons Under Investigation (PUI) versus COVID positive, but all hospital admits are considered PUIs, until testing confirmed positive or negative. Record review revealed that R#1 was admitted to the facility on [DATE] to a room on the COVID positive unit and remained so through the survey exit on 8/20/2020. Record review of the COVID Admission Criteria dated 08/10/2020 revealed R #1 tested negative for COVID-19 on 08/12/2020. The negative results are documented as received by the facility on 08/15/2020. On 8/17/2020 at 9:37 a.m., LPN AA was observed to enter the room of R#1. The LPN did not change PPE after caring for the resident next door to R#1 who is positive for COVID. An interview on 8/17/2020 at 11:10 a.m., LPN AA stated she was the nurse caring for R#1 and .up until 20 minutes ago I was not aware that I needed to change PPE between residents because (R#1) was PUI and not COVID positive. I thought they (residents on the unit) were all positive. Interview on 8/17/2020 at 11:15 a.m., CNA BB stated she was caring for R#1 and has worked with him since his admission last week. The CNA then stated that she has never changed PPE prior to entering R#1's room because until a few minutes ago she did not know R#1 was a PUI and not COVID positive. An interview with the ICP nurse on 08/17/2020 at 4:00 p.m. confirmed the negative resident (R#1) continues on the COVID positive unit, .but I'm going to move him. 6. Review of the facility's policy titled, Admission Criteria for COVID-19, dated 07/24/2020, revealed This facility shall admit and re-admit residents who are no longer acutely ill with the COVID-19 virus from acute care settings .COVID-19 testing is not required as a consideration for admission to the Skilled Nursing Facility .Practice Guidelines . 2. During a pandemic event all residents admitted or readmitted to the Skilled nursing Facility will be considered as having been exposed to Covid-19; therefore, transmission-based precaution will be initiated. They should be quarantined for 14 days . a. Review of R#3's undated Admission Record, located in the resident's electronic medical record (EMR) under the profile tab, revealed the resident was admitted to the facility on [DATE]. Continued review of the resident's EMR, specifically the census tab, revealed the resident was admitted to room [ROOM NUMBER]A and then on 8/12/2020 was moved to room [ROOM NUMBER]A. Unit 2 was designated as the negative unit meaning all residents on that unit are presumed to be negative for COVID-19. Review of R#3's Progress Note, dated 08/10/2020, located under the progress notes tab, revealed the Speech Therapist (ST) LL assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Interview on 8/18/2020 at 2:49 p.m. with R #3 revealed she was in room [ROOM NUMBER] when she was first admitted and then moved to room [ROOM NUMBER] a few days after she was admitted . Continued interview with the resident revealed she did not know if she was admitted as a PUI. The resident stated when she was in room [ROOM NUMBER] and room [ROOM NUMBER], the staff did sometimes have gowns on, but not all of the time. The resident also stated she had not been tested for COVID-19 since she was admitted to the facility. Interview on 8/18/2020 at 10:38 a.m. with Registered Nurse (RN) II revealed she did not find out that R#3 was supposed to be in quarantine until on 8/17/20. RN II stated she was not given a reason why the resident was now on Transmission Based Precautions (TBP). RN II stated R#3 had been in her current room since 8/12/20 and was not on any type of TBP for PUI. The RN also stated to her knowledge, the only PPE that had been worn in the resident's room for provided care was a mask and gloves. Further interview with RN II revealed when she left the facility last night (8/17/2020) R#3 was in room [ROOM NUMBER]; however, when she came on duty this morning, the resident had been moved to Unit 3 which was now the facility's PUI unit. Interview on 8/18/2020 at 11:21 a.m. with CNA FF revealed she was assigned to R#3 on 8/14/2020 and 8/17/2020 and was not told the resident was on any type of TBP. CNA FF stated she did wear a gown and face shield both days she was the resident's CNA; however, she wore the same PPE all day and did not change the PPE after providing care to R#3 and before providing care to other residents. The CNA also stated she had been told by the facility she did not have to wear any PPE while she was working on Unit 2 because it was a COVID-19 free unit, but she wore PPE because she felt more comfortable doing so. An interview on 8/18/2020 at 12:30 p.m. was held with the Infection Preventionist (IP).When asked if there was any potential for a negative outcome for the resident or other residents from staff providing care without PPE or wearing same PPE all day after providing care to R #3, the IP stated, Yes. It could have caused another outbreak. b. Review R#5's undated Admission Record, located in the resident's EMR under the profile tab, revealed the resident was readmitted to the facility on [DATE] to room [ROOM NUMBER]A and then on 8/12/2020 (nine days post admission) was moved to room [ROOM NUMBER]B. Interview on 8/18/2020 at 10:38 a.m. with RN II revealed R#5 was placed in room [ROOM NUMBER] when she was readmitted and then moved to room [ROOM NUMBER] (previous room prior to hospital stay) and had not been under any TBP or considered a PUI. Continued interview with RN II revealed the resident does currently have a roommate in room [ROOM NUMBER], R#8. Review of R#8's undated Admission Record, located in the resident's EMR under the profile tab, revealed the resident was readmitted to the facility on [DATE] to room [ROOM NUMBER]A. Review of R#8's COVID-19 lab results, with a report date of 07/09/2020 revealed a test result of Not Detected (negative). Interview on 8/18/2020 at 11:45 a.m. CNA JJ revealed she was familiar with R#5 and was regularly assigned to the resident. Continued interview revealed the resident had resided in rooms [ROOM NUMBERS] and there was never any signage or communication from the facility that the resident was on TBP. CNA JJ stated she would wear a gown when going into the resident's room to provide care; however, she would not change the gown before going to provide care to other residents. Interview on 8/18/2020 at 12:12 p.m. with CNA KK revealed she was frequently assigned to R#5 and revealed there has never been any signage on the resident's door to indicate the resident was ever on isolation or TBP. CNA KK stated she has not worn any PPE gowns when going into the resident's room to provide care. Interview 8/18/2020 at 12:30 p.m. with the IP revealed after reviewing R#5's record, the resident should have been readmitted to the facility from the hospital on [DATE] as a PUI on 14-day TBP. Continued interview revealed the resident should have never been moved back to her original room on 8/12/2020 with a roommate who was a confirmed negative resident. The IP stated, if R #5 had anything (COVID) the roommate would have been exposed. The IP also stated the resident not being quarantined as a PUI created a potential for an outbreak. Interview on 8/18/2020 at 1:01 p.m. with the DON revealed R#3 was never placed in quarantine when she was admitted to the facility and should have been considered a PUI. Continued interview revealed R#5 should have also been considered a PUI with 14-day TBP. The DON stated it was important both residents would have been considered a PUI because a resident could be negative for COVID one day and positive the next. Interview on 8/18/2020 at 1:10 p.m. with the Regional Director of Clinical Operations who was now the Interim Administrator revealed it was his expectation both R#3 and R#5 would have been admitted to the facility as PUIs with TBPs.