Every finding on record at Rocky Top Care Center

Based on facility documentation, observations, and interviews, the facility failed to ensure 2 of 3 microwaves for resident use were maintained in a clean and sanitary condition. The findings include:Review of the facility Daily/Weekly Cleaning Logs dated 2/1/2026 - 2/28/2026, revealed the Nourishment Rooms which included microwaves were not listed on the Daily/Weekly cleaning schedule. During an observation and interview on 3/2/2026 at 9:45 AM, with Regional Certified Dietary Manager (Regional CDM) L, Certified Dietary Manager (CDM) A, and Regional CDM M revealed, the microwave in Nourishment room [ROOM NUMBER] was observed with brown, tan, and orange substances splattered on the top, sides, and bottom of the interior. Gray and white crusty substances and food debris were observed on the right side of the interior and on the glass plate. [NAME] crumbs and food debris were observed on the bottom of the microwave's interior. CDM A confirmed the microwave was dirty. During an observation and interview on 3/2/2026 at 9:47 AM, with Regional CDM L, CDM A, and Regional CDM M revealed, the microwave in Nourishment room [ROOM NUMBER] was observed with orange, tan, and yellow substances splattered on the top, sides, and bottom of the interior. A brown, sticky substance and orange and tan crumbs were observed on the bottom of the microwave's interior. Regional CDM L confirmed the microwave was dirty. During an interview on 3/2/2026 at 3:37 PM, Regional CDM L, stated, .We don't have cleaning logs for the nourishment rooms .we just wipe down as we go . During an observation on 3/4/2026 at 11:12 AM, with Regional CDM L and Regional CDM M present, the microwave in Nourishment room [ROOM NUMBER] was observed to have brown, tan, and orange substances splattered on the top, sides, and bottom of the interior. Gray and white crusty substances were observed on the right side of the interior and on the glass plate. [NAME] crumbs and food debris were observed on the bottom of the microwave's interior. During a second observation and interview on 3/4/2026 at 11:15 AM, with Regional CDM L and Regional CDM M present, the microwave in Nourishment room [ROOM NUMBER] continued to be observed with orange, tan, and yellow substances splattered on the top, sides, and bottom of the interior. A brown, sticky substance and orange and tan crumbs were continued to be observed on the bottom of the microwave's interior. Regional CDM L confirmed, .the microwaves are dirty . During an interview on 3/4/2026 at 11:16 AM, Licensed Practical Nurse (LPN) F stated, .we [facility staff] would heat the residents' food in there [Nourishment room [ROOM NUMBER] microwave] if we need to . During an interview on 3/4/2026 at 11:18 AM, LPN H stated, .if we [facility staff] need to heat resident meals, we do it in that [Nourishment room [ROOM NUMBER]] microwave . During an interview on 3/4/2026 at 11:19 AM, Certified Nursing Assistant (CNA) I stated, .we heat resident food in the nourishment room microwave . During an interview on 3/4/2026 at 11:19 AM, CNA K stated, .[Nourishment room [ROOM NUMBER] microwave] is where we heat the residents' food if we need to . During an interview on 3/4/2026 at 2:41 PM, Regional CDM L confirmed, .we have no set policy, but dietary should be checking them [microwaves] daily and should be cleaning them as needed .they are an extension of our kitchen .we should be wiping them out .

Based on facility policy review, medical record review, observations, and interviews, the facility failed to ensure safety requirements were met for food storage for 2 residents (Resident #40 and Resident #17) of 10 resident refrigerators observed. The findings include: Review of the facility's policy titled, Use & Storage of Food from Outside Sources, dated 11/1/2016, revealed .due to the potential for foodborne illness or interference with nutritional treatment, family members and/or visitors who bring food in from the outside will be educated on safe food handling practices .Food .brought in from the outside will be monitored by nursing staff for spoilage, contamination and safety .Food .items may be stored in .resident's personal room refrigerators .Foods that do not require refrigeration may be stored in a resident's room .Food .in the original container that is past the manufacturer's expiration date will be discarded by nursing staff .All cooked or prepared food brought in for a resident and stored in the .personal room refrigerator will be dated when accepted for storage and discarded after 24 hours .Nursing staff will monitor resident's room .and refrigeration units for food .disposal . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Neurocognitive Disorder with Lewy Bodies, Bipolar Disorder, Dementia with Agitation, and Diabetes. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment. During an observation and interview on 3/2/2026 at 11:14 AM and on 3/3/2026 at 2:48 PM, 2 black plastic food containers with transparent lids were observed inside Resident #40's personal refrigerator. Neither container had a label or indication of the discard or expiration date. Resident #40 stated he did not know what was in the containers or how long the containers had been in the refrigerator. During an interview on 3/3/2026 at 2:50 PM, Certified Nursing Assistant (CNA) J stated, .we have to check their refrigerators every day, and everything in them has to be dated . During an interview on 3/3/2026 at 2:52 PM, Licensed Practical Nurse (LPN) G stated, .Resident #40's family brought those containers in on Sunday .we check the dates daily . During an interview on 3/4/2026 at 2:35 pm, the Regional Director of Clinical Services stated, .our expectation would be that the food would be dated . Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Diabetes Mellitus, Muscle Weakness, and Vascular Dementia. Review of Resident #17's comprehensive care plan revised on 11/14/2024, revealed .impaired cognitive function/dementia or impaired thought processes . Review of the annual MDS assessment dated [DATE], revealed Resident #17 scored a 7 on the BIMS assessment which indicated the resident had severe cognitive impairment. During an observation on 3/2/2026 at 11:49 AM, in Resident #17's room, the resident's personal refrigerator contained a whole sandwich and 2 half sandwiches in unsealed plastic bags that were unlabeled and undated. During an observation on 3/3/2026 at 2:32 PM, in Resident #17's room, revealed a loaf of white bread on top of Resident #17's personal refrigerator with a .BEST IF USED BY .JAN [January] 19 26 [2026] . Inside Resident #17's personal refrigerator there was 1 whole sandwich and 2 half sandwiches in unsealed plastic bags that were unlabeled and undated. During an observation and interview on 3/3/2026 at 2:40 PM, in Resident #17's room, with CNA E, revealed a loaf of white bread on top of Resident #17's personal refrigerator with a .BEST IF USED BY .JAN [January] 19 26 [2026] . Inside Resident #17's personal refrigerator there was 1 whole sandwich and 2 half sandwiches in unsealed plastic bags that were unlabeled and undated. CNA E confirmed the loaf of white bread was expired and available for resident use and the sandwiches in the refrigerator were unsealed, unlabeled, undated, and available for resident use. CNA E stated the sandwiches were the sandwiches provided by the facility for snacks. CNA E confirmed she was unaware when the sandwiches needed to be discarded because they were not dated. CNA E stated CNAs were responsible to check resident personal refrigerators .I would say like once a week . for expired items. Items placed in the refrigerator were to be labeled and dated and discarded within .2 days . of being placed in the refrigerator and items with an expiration date were to be discarded by the expiration date. CNA E was unaware when Resident #17's personal refrigerator was last checked. During an interview on 3/4/2026 at 9:53 AM, the Infection Preventionist revealed the facility had not had any cases of food borne illness in the past year. During an interview on 3/4/2026 at 2:59 PM, the Administrator stated resident personal refrigerators were checked .daily . by nursing for temperatures and spot checked for cleanliness and dated/expired items. The Administrator confirmed that outside food items brought in by a resident's family were to be labeled, dated, and discarded within .3 days . and foods with an expiration date were to be discarded by the expiration date.

Based on facility policy review, medical record review, and interviews, the facility failed to provide resident and resident representative notice of quarterly care plan conferences for 1 resident (Resident #8) of 14 residents and resident representatives interviewed for participation in care plan conferences. The findings include: Review of the facility's policy titled, Care Conference Guideline, dated 11/2017, revealed .involve residents .and their representatives with goals and preferences of care, and to integrate with those of the interdisciplinary team (IDT) .should be completed at the time of admission, regular intervals .Attendees .Resident .Resident/Patient Representative .Pre-Conference .Social Services Director or Designee distributes care conference invitation to resident .and/or their representative prior to the scheduled care conference .During the Conference .Interdisciplinary team, resident, and/or resident representative reviews the current plan of care and if necessary .physical, mental, and psychosocial problems, strengths, goals, life history, preferences, discharge planning .Ask resident .or their representative for any other identified needs of care for potential inclusion on the care plan .The interdisciplinary care plan is reviewed on a quarterly basis and/or with significant changes .to evaluate effectiveness, revise and update and to address needs in accordance with the most current assessment .After the Conference .Document that the care conference occurred and who attended . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychotic Disturbance, Diabetes Mellitus, and Generalized Anxiety Disorder. Review of the comprehensive care plan initiated on 7/11/2024 and revised on 1/7/2025, revealed .generalized anxiety disorder, dementia with behavioral disturbances . Review of the care plan conference documentation dated 10/14/2024, revealed a care plan conference was held with Resident #8's responsible party via telephone. Review of the medical record revealed no other documented care plan conferences for Resident #8. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #8 scored a 4 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #8 revised on 3/14/2025, revealed .impaired cognitive function/dementia . Continued review revealed no documentation the resident's representative was involved or notified of the revision. Review of the quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Social Services note dated 6/9/2025 at 11:18 AM, revealed .Discussed with daughter about resident's exit seeking behavior. Daughter was asked if she would be willing to let resident transfer to [secure unit] for resident's safety, daughter in agreement at this time but does not want this to be a permanent placement. Daughter was told resident would be evaluated quarterly for criteria . Review of the Social Services note dated 6/9/2025 at 2:40 PM, revealed .Follow up with daughter regarding room change daughter would prefer that resident stay in room .until UA [urinalysis] results are back, resident has not shown exit seeking behavior today SS [Social Services]/staff agreed resident is safe at this point and would revisit possible room change if needed . Review of the annual MDS assessment dated [DATE], revealed the Resident #8 scored a 2 on the BIMS assessment which indicated the resident had severe cognitive impairment. During a telephone interview on 3/2/2026 at 11:10 AM, Resident #8's responsible party stated she had not attended or been invited to care plan conferences for Resident #8. During an interview on 3/4/2026 at 2:55 PM, the Administrator stated the Social Services Director (SSD) was responsible for scheduling and inviting residents or resident representatives to care plan meetings. Care plan meetings were to be conducted on admission, quarterly, with any significant changes, and when requested by residents or resident representatives. The Administrator confirmed residents, resident representatives, and members of the Interdisciplinary Team were to be invited to care plan meetings and care plan meetings were to be documented including all attendees of the meeting. The Administrator was unaware if there had been any care plan meetings for Resident #8 or if the family had been invited. During an interview on 3/4/2026 at 3:04 PM, the SSD stated care plan meetings were conducted quarterly and as needed with the IDT team and the resident and/or resident representative. The SSD confirmed care plan meetings were scheduled by the SSD and resident representatives were invited via telephone. The SSD confirmed care plan meetings were to be documented and should include all attendees of the care plan meeting. The SSD stated a care plan meeting was held with Resident #8's representative on 10/14/2024 and 6/9/2025. The care plan meeting held on 6/9/2025 was a conversation with Resident #8's representative documented as a Social Services note and confirmed the note did not include all attendees of the meeting. The SSD confirmed she was unsure if there were any other care plan meetings for Resident #8 other than 10/14/2024 and 6/9/2025 because there was no care plan meeting documentation and no records the resident's representative was invited to a care plan meeting. The SSD stated she was .getting to know the process . and had not been .keeping up with care plan meetings .when they needed to be scheduled .I wasn't keeping a schedule .

Based on facility policy review, facility assessment review, Centers for Disease (CDC) recommendations and guidance review, facility documentation review, medical record review, observations, and interviews, the facility failed to ensure residents' personal laundry was stored in a sanitary condition, and failed to ensure practices to prevent or mitigate the potential spread of infection and communicable disease were maintained through the process of handling, storing, processing, and transporting residents' personal laundry. The facility's non-compliance had the potential to affect 85 of 90 residents who resided in and whose laundry service was provided by the facility. The facility failed to ensure COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the CDC to control the exposure and spread of the COVID-19 virus during the facility's COVID-19 outbreak from 6/18/2024-8/7/2024 placing 22 residents (Resident #1, #2, #20, #33, #36, #42, #46, #53, #57, #71, #72, #78, #82, #340, #341, #3, #11, #27, #43, #12, #30, and #79) in an Immediate Jeopardy (IJ) situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The facility's failure to exclude COVID-19 positive employees from work had the potential to cause a serious adverse outcome for all 90 residents in the facility. The facility failed to ensure 3 resident rooms (Resident #8, #39, and #60) had Enhanced Barrier Precautions (EBP) signage posted on the doors. The facility census was 90. The Administrator, Director of Nursing Services, Regional [NAME] President, and Regional Director of Clinical Operations Q were informed of the Immediate Jeopardy for F-880 on 8/20/2024 at 9:27 PM, in the Administrator's office. The facility was cited IJ at F-880 at a scope and severity of L. An Extended survey was conducted onsite from 8/20/2024 through 8/21/2024. The IJ began on 5/1/2024 and continued through 8/21/2024. The IJ ended on 8/21/2024 and was removed on site. An acceptable removal plan, which removed the immediacy of the jeopardy, was provided by the facility on 8/21/2024 at 9:48 PM for F-880. The corrective actions were validated onsite by the surveyors on 8/22/2024 for F-880. Noncompliance continues at F-880 at a scope and severity of F. The facility is required to submit a Plan of Correction (POC). The findings include: 1. Review of the facility policy titled, Linen Handling Guidelines, effective date 11/1/2017, revealed .the purpose of this procedure is to provide a process for the safe and aseptic handling, processing, transporting, and storage of linen .consider all soiled linen to be potentially infectious .anyone who handles soiled laundry must wear protective gloves .and other .protective equipment .staff will bag contaminated laundry .to be picked up and processed by commercial means . Review of the CDC Guidelines titled, Environmental Infection Control in Health-Care Facilities, Section G Laundry and Bedding, revised 1/8/2024, revealed .OSHA [Occupational Safety and Health Administration] defines contaminated laundry as .laundry which has been soiled with blood or other potentially infectious materials .The laundry facility in a health-care setting should be designed for efficiency in providing hygienically clean textiles [a type of cloth or woven fabric], fabrics, and apparel for patients .Guidelines for laundry .for health-care facilities, including nursing facilities .Laundry workers should wear appropriate personal protective equipment ([example] gloves and protective garments) while sorting soiled fabrics and textiles .Fabrics .textiles, and clothing used in health-care settings are disinfected during laundering and generally rendered free of .pathogens .Laundering cycles consist of .main wash, bleaching, rinsing .The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors .Hot water provides an effective means of destroying microorganisms. A temperature of at least 160 .F [Fahrenheit] .for a minimum of 25 minutes .for hot water washing. The use of chlorine bleach assures an extra margin of safety. Chlorine alternatives .[example] activated oxygen-based laundry detergents .provide added benefits for fabric and color safety in addition to antimicrobial activity . Health-care workers should note the cleaning instructions of textiles, fabrics .Low-temperature laundry cycles rely heavily on the presence of chlorine- or oxygen-activated bleach to reduce the levels of microbial contamination . Review of a facility document titled, [Named] Management Services Position Descriptions, dated 5/1/2024, revealed Position Title .Laundry Aide .Facility .[name of facility] .Accountability Objective .Loads and unloads washers/dryers, sorts clothing .distributes throughout the facility .Key Responsibilities .Washes linens/personal clothing using proper chemicals .follows proper infection control techniques .Handles chemicals .and follows instructions for type and amount . Review of the facility assessment, titled Center Assessment Tool, updated 7/28/2024, revealed .Infection prevention and control .Identification and containment of infections, prevention of infections .PPE [Personal Protective Equipment] utilization .services .Laundry . During an observation and interview with Housekeeper R and the Regional Director of Clinical Operations P in a building behind the facility on 8/16/2024 at 9:03 AM, a large green bin was observed filled with a large stack of residents' uncontained soiled clothing items. Multiple clothing items had a dried brown substance on the clothing, smelled of urine, was stiff/rigid, and difficult to unfold. Other clothing items had a white and greenish/black unidentified substance on them and had a musty smell. Housekeeper R stated she had not observed residents' personal clothes in the large green bin prior to 8/16/2024. She stated the clothes might have gotten mixed with the facility linen and sent back to the facility from the linen company who provided the facility's linen laundry service. Housekeeper R stated the linen company did not provide cleaning of the residents' personal clothing. She also stated the former Housekeeping Supervisor was responsible to ensure the residents' personal laundry was taken off-site to be laundered, and she no longer worked at the facility (Housekeeping Supervisor's last date of employment was 8/8/2024). Housekeeper R stated the former Housekeeping Supervisor (or designee) loaded the laundry in the facility van, took it to a local laundromat and washed it but was unsure how often the laundry had been taken to be washed. After the Housekeeping Supervisor quit, Housekeeper V was responsible for taking the residents' personal laundry to the laundromat. The Regional Director of Clinical Operations P stated the residents' personal clothing in the large green bin was in .horrible condition . During an observation on 8/16/2024 at 9:22 AM, in a building behind the facility where dirty clothes were stored, revealed Certified Nursing Assistant (CNA) T drove the facility van and parked the van near the storage area. CNA T stated she was asked by the Administrator to bring the van around so it could be loaded with the residents' personal laundry. CNA T stated she had not been asked by the Administrator to bring the van to the back of the facility prior to 8/16/2024 for the soiled laundry. During an interview and observation on 8/16/2024 at 9:30 AM, CNA U stated the process of the residents' personal laundry was as follows: 1a) After a resident's clothing was changed, the dirty clothes were placed in a white plastic top community rolling hamper, and a disposable plastic bag could be attached and detached as need. The rolling hamper was labeled Personal Laundry. 1b) At the end of the shift, the bag with residents' personal clothes was removed, taken to a building at the back of the facility, and placed in a blue plastic container. There was a sign over the blue containers which identified the residents' personal laundry. CNA U stated the residents did not have personal laundry containers in their individual rooms and all the residents' personal clothing was placed in the same white community linen container together. Observation with CNA U of the outside building laundry storage area revealed 2 large blue plastic containers with several plastic bags stored in them. The observation revealed a sign over the blue containers which identified the containers as the residents' personal laundry. During an observation of the laundry storage area (located behind the facility) and interview on 8/16/2024 at 9:41 AM, the Administrator and CNA T removed the soiled clothes from the large green bin and placed them in plastic bags. The Administrator stated he had called Housekeeper V to see if she could work today (8/16/2024) and take the clothes to be washed at the local laundromat. The Administrator further stated, if Housekeeper V was unable to come to work, he would contact the sales manager of the contracted commercial linen service (the linen service who laundered the facility's linens) to inquire if the linen company could wash the residents' personal laundry today. The Administrator and CNA T was asked to remove the plastic bags from the 2 blue plastic containers which had the residents' personal laundry stored for surveyor observation. The observation revealed 12 closed plastic bags which contained the residents' soiled laundry. The Administrator confirmed the residents' personal laundry had not been contained or maintained in a sanitary condition. During a telephone interview on 8/16/2024 at 11:19 AM, the former Housekeeping Supervisor stated she worked at the facility for 3 years and had resigned from her position on 8/8/2024. The former Housekeeping Supervisor stated Housekeeper V and herself were responsible for taking the residents' personal laundry to a local laundromat. The former Housekeeping Supervisor stated the facility initiated a new laundry process approximately 1 week prior to 5/1/2024 [date unknown], after the new management company had taken over. She stated the new process for residents' personal laundry was as follows: 1c) After the CNAs bathed the residents, the residents' soiled clothes were changed, placed in a white plastic top community rolling hamper, and the container was marked personal laundry. 1d) At the end of the shift, the soiled clothes were bagged, taken to an outside storage building, and placed in a blue plastic container. There was a sign posted on the wall hanging over the containers which identified the containers as the residents' personal laundry. 1e) Housekeeper V took the soiled laundry to the local laundromat .Coin Laundry . 3 times a week. The laundry was not separated, and the residents' laundry was washed together. Sometimes the laundry would be brought back to the facility .smelling like urine and stained with poop [feces] . after it had been washed. The former Housekeeping Supervisor also stated if Housekeeper V was unable to get the laundry clean, the laundry was placed separately from the clean clothes, brought back to the facility in plastic bags, placed back in the blue plastic containers to rewash. If a resident was on isolation precautions, the personal clothing items were placed in a yellow biohazard bag identified as .infectious . and washed at the local laundromat. The former Housekeeping Supervisor stated washing the residents' clothes at the laundromat was not .a good idea . because the water was not hot enough to get the clothes clean and certain chemicals had to be used. The facility purchased [named household laundry detergent] and no bleach, bleach alternatives, or chemicals were used (to ensure proper sanitization). Former Housekeeping Supervisor had expressed her concern to the Administrator with no solution to the concern. The former Housekeeping Supervisor stated she had educated Housekeeper V on the proper handling of the residents' contaminated personal laundry to include the process of handling, storing, processing, and transporting residents' personal laundry, which included wearing gloves and a gown to cover her clothing when handling the soiled laundry to mitigate the spread of infection and communicable diseases. During an interview on 8/16/2024 at 11:51 AM, the Administrator stated the contracted commercial linen services was contacted by the facility on 8/16/2024 and had agreed to wash the residents' personal laundry effective Monday, 8/19/2024. The Administrator also stated, .we did not know there was molded clothes [residents'] in the storage shed .this has never happened before . During an interview on 8/16/2024 at 3:05 PM, the Regional [NAME] President (RVP) stated the new management company started managing the facility on 5/1/2024. During a telephone interview on 8/16/2024 at 8:22 PM, Housekeeper V stated she was responsible for washing the residents' personal laundry at the local laundromat and she had taken the first load on 5/1/2024. The housekeeper stated the clothes were not being cleaned sufficiently because the water was not hot enough to clean the laundry. The residents' soiled personal laundry was bagged together and placed in blue plastic containers in a storage building at the back of the facility. When she transported the residents' personal laundry to the laundromat, the 2 blue plastic containers were placed in the back of the facility van and transported to the laundromat. Housekeeper V stated she donned gloves prior to placing the residents' clothing in the washer but did not wear an apron or gown to protect her clothing. The laundry detergent used was [named household laundry detergent] and there were no other chemical products, bleach, or bleach alternatives used. Housekeeper V stated the laundry was not separated by individual residents, was washed all together, and she was unsure of what temperature the water was or needed to be [to ensure proper sanitization]. Housekeeper V further stated after she emptied the blue plastic containers, she sanitized the containers with sanitizing wipes before she placed the clean clothes back in the plastic containers. When the laundry was dried, some of the clothing still smelled of urine and had .poop stains . She stated isolation laundry was to be placed in red or yellow bags but did not remember washing any personal clothing that was in red or yellow bags. Housekeeper V stated .not sure where the isolation laundry went . (The facility had a COVID-19 outbreak from 6/2024-8/2024). Housekeeper V denied receiving formal education by the former Housekeeping Supervisor on how to process and handle residents' personal or soiled laundry to mitigate the spread of communicable or infectious diseases. Review of an email dated 8/16/2024, authored by the Infection Prevention Specialist 2 with the Tennessee Department of Health revealed .If heavily soiled/contaminated laundry was taken to a laundromat, there is a concern that temperatures and chemicals would not be sufficient to kill bacteria, viruses, fungi, or even parasites and could lead to exposure .to organisms .One of the concerns that come to mind is C [clostridium] difficile [a highly contagious bacteria that causes diarrhea] and could be spread through this avenue .If offsite laundry services are used, the laundry should be safely transported and taken to a commercial laundry facility that is knowledgeable on proper healthcare laundry processes to include temperatures and chemicals to ensure the laundry is rendered safe and sanitary . During a telephone interview on 8/19/2024 at 10:33 AM, the owner of a local Coin Laundry (another area laundromat, not the one used by the facility) stated he previously worked for a (Named) commercial company with expertise in infection prevention services prior to purchasing his own laundromat. He also stated laundromat water did not get hot enough for nursing home residents' personal clothing (temperature should be at least 160 degrees Fahrenheit), and there were certain chemicals needed to ensure the clothes were clean and to reduce contamination. The hot water for washing machines at the laundromats were typically set between 140-142 degrees Fahrenheit. Nursing home residents' personal clothing would need to be washed at a higher temperature with pre-oxygenated bleach. The laundromat owner also stated if a long-term care facility reached out to him to provide laundry services, he would decline because the laundromat washers were not equipped to process this type of clothing to mitigate the spread of infection. During an interview on 8/19/2024 at 4:17 PM, the Administrator stated he was in charge of laundry and housekeeping services in the absence of the housekeeping supervisor. During an interview on 8/19/2024 at 7:13 PM, CNA G stated residents did not have personal laundry containers in their rooms. The residents' personal laundry was placed in a white community linen container and the container was marked personal laundry. At the end of the shift, the soiled clothes were bagged together, taken to a building at the back of the facility, and placed in a blue plastic container. During a telephone interview on 8/20/2024 at 9:04 AM, the Production Manager (PM) at the facility's contracted commercial linen service stated the company laundered the facility's linens and if resident's personal clothing was found mixed in with the linen, the clothes were tossed in a bin and sent back to facility on the next delivery date (deliveries were made twice a week to the facility). The PM stated the company would not have waited until the large bin was filled with the residents' clothing before sending it back to the facility. The PM stated the linen company was TRSA certified (the certification verifies that processes used in the facility meet appropriate hygienically clean standards). The linen service had been contacted by the facility's Administrator to provide laundry services for the facility residents' personal laundry, the first .batch . would be completed today [8/20/2024]. The PM stated, .I was shocked to learn the facility was taking items to a laundromat to wash .certain chemicals have to be used . During an interview on 8/20/2024 at 11:00 AM, the Administrator stated he was aware certain chemicals and water temperatures were to be used when washing resident's personal laundry .I don't know what the temperatures were at the laundromat . During an interview on 8/20/2024 at 4:46 PM, the Business Office Manager (BOM) stated the facility purchased laundry detergent to wash the residents' personal laundry. The laundry detergent purchased was (named household laundry detergent) and there were no bleach products purchased. During an interview on 8/21/2024 at 12:00 PM, the Administrator stated he was informed on 4/28/2024 the facility would no longer have a linen service to wash the residents' personal laundry effective 4/30/2024. The facility had to .put something in place . It was decided the residents' personal laundry would be washed at the local laundromat and the process started 5/1/2024. 2. Review of the facility policy titled, COVID [COVID-19] Comprehensive Guide, dated 5/2023, revealed .Team Members Return to Work Criteria .with COVID Infection .should be restricted from work and follow recommended practices .Team members with mild to moderate symptoms .not .immunocompromised [weakened immune system] .At least 7 days have passed since symptoms first appeared .or 10 days if testing is not performed .At least 24 hours have passed since last fever without the use of .medications and symptoms .have improved .HCP [Healthcare Personnel] should have a negative test obtained on day 5 and again 48 hours later .Team members .asymptomatic .not .immunocompromised .At least 7 days have passed since the date of their first positive viral test .negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) .HCP should follow all recommended infection prevention and control practices including wearing well-fitting source control .not reporting to work when ill or if testing positive for SARS-CoV-2 [COVID-19] infection .Contingency and crisis strategies .Work Restrictions for Team Members with COVID Infection .Crisis .No work restrictions .asymptomatic . (outdated guidance (5/2023) the facility was following during the COVID-19 outbreak). Review of the CDC's guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 [COVID-19] Pandemic, updated 3/18/2024, revealed .Return to Work Criteria for HCP [healthcare personnel] with SARS-CoV-2 Infection [COVID-19] .HCP with mild to moderate illness [fever, cough, sore throat, malaise, headache, muscle pain without shortness of breath, dyspnea, or abnormal chest imaging] could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g.,[example] cough, shortness of breath) have improved .HCP who were asymptomatic throughout their infection .could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test* is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7) .HCP with severe to critical illness [respiratory failure, septic shock, and/or multiple organ dysfunction] .could return to work after the following criteria have been met: At least 10 days and up to 20 days have passed since symptoms first appeared, and At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved .HCP who are moderately to severely immunocompromised may produce replication-competent virus beyond 20 days after symptom onset or, for those who were asymptomatic throughout their infection, the date of their first positive viral test . HCP who are not symptomatic could return to work after the following criteria are met: Results are negative from at least two consecutive respiratory specimens collected 48 hours apart (total of two negative specimens) tested using an antigen test or NAAT [Nucleic Acid Amplification Test] . (This CDC guidance was published 3/18/2024 and this was the guidance the facility should have followed for the 6/18/2024-6/23/2024 outbreak). Review of the CDC ' s guidance titled, Viral Respiratory Pathogens Toolkit for Nursing Homes, dated 3/28/2024, revealed .When an acute respiratory infection is identified in a resident or HCP, it is important to take rapid action to prevent the spread to others in the facility .Implement universal masking for source control on affected units or facility-wide, including for residents around others (e.g., out of their room) and for HCP when in the facility . Consult with the local or state public health department about additional interventions . Review of the CDC's guidance titled, Infection Control Guidance: SARS-CoV-2, dated 6/24/2024, revealed, .The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency [5/11/2023] .To provide the greatest assurance that someone does not have SARS-CoV-2 infection, if using an antigen test .facilities should use 3 tests, spaced 48 hours apart .testing should be repeated every 3-7 days until no new cases are identified for at least 14 days .Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection .Ensure everyone is aware of recommended IPC [infection prevention and control] practices in the facility .Source control is recommended for individuals in healthcare settings who: Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure .Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible .Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5 . (The CDC published this recommendation on 6/24/2024 and this was the guidance the facility should have followed from 6/24/2024 to present). The following residents who resided on the 300 and 500 Hallways tested positive for COVID-19 during the COVID-19 outbreak in the facility from 6/18/2024-8/7/2024. (The last resident to test positive was on 7/24/2024, the outbreak ended on 8/7/2024). 2a) Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Chronic Obstructive Pulmonary Disease, and Schizoaffective Disorder. Review of the medical record revealed Resident #1 resided in room [ROOM NUMBER]B on the 500 Hallway at the time of the COVID-19 outbreak. Review of an annual [NAME] Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 9 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the Nurse's Notes for Resident #1 dated 6/26/2024, revealed .Covid [COVID-19] test positive. Resident congested with cough .Notified .resident daughter . Review of the Physician's Orders for Resident #1 dated 6/26/2024, revealed .Molnupiravir [an antiviral medication used to treat mild to moderate COVID-19 in adults who are at high risk of developing severe COVID-19 symptoms] .200 mg [milligrams] .Give 4 capsule [capsules] by mouth two times a day for COVID until 7/02/2024 . 2b) Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, and Seizures. Review of the medical record revealed Resident #2 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak. Review of an annual MDS assessment dated [DATE], revealed Resident #2 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the Nurse's Notes for Resident #2 dated 6/24/2024, revealed .Resident tested for Covid due to high fever .headache .tested positive . Review of the Physician's Orders for Resident #2 dated 6/24/2024, revealed .Molnupiravir .200 mg .Give 4 capsule by mouth two times a day for COVID until 6/29/2024 . 2c) Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Atrial Fibrillation, Depression, and Weakness. Review of the medical record revealed Resident #20 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak. Review of a quarterly MDS assessment dated [DATE], revealed Resident #20 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Nurse's Notes for Resident #20 dated 6/26/2024, revealed .Resident tested positive COVID .notified resident and left message for son .denies .distress . Review of the Physician's Orders for Resident #20 dated 6/26/2024, revealed .Molnupiravir .200 mg .Give 4 capsule by mouth two times a day for COVID for 5 days . 2d) Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Autistic Disorder, Adult Failure to Thrive, Dementia, Transient Ischemic Attack, and Cerebral Infarction. Review of the medical record revealed Resident #33 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak. Review of a quarterly MDS assessment dated [DATE], revealed Resident #33 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the Nurse's Notes for Resident #33 dated 6/19/2024, revealed .resident notified of testing positive for COVID .denies symptoms at this time except for slightly 'not feeling well' .residents [resident's] brother/POA [Power of Attorney] notified . Review of the Physician's Orders for Resident #33 dated 6/19/2024, revealed .Molnupiravir .800 mg .two times a day for COVID for 5 days . 2e) Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, History of Falling and Dementia. Review of the medical record revealed Resident #36 resided in room [ROOM NUMBER]A on the 300 Hallway at the time of the COVID-19 outbreak. Review of an annual MDS assessment dated [DATE], revealed Resident #36 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the Nurse's Notes for Resident #36 dated 6/26/2024, revealed .Resident tested positive for Covid [COVID-19] .Resident notified as well as son .Resident denies .distress . Review of the Physician's Orders for Resident #36 dated 6/26/2024, revealed .Molnupiravir .200 mg .Give 4 capsule by mouth two times a day for COVID for 5 days . 2f) Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, Need for Assistance with Personal Care, and Difficulty Walking. Review of the medical record revealed Resident #42 resided in room [ROOM NUMBER]A on the 300 Hallway at the time of the COVID-19 outbreak. Review of an admission MDS assessment dated [DATE], revealed Resident #42 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the Nurse's Notes for Resident #42 dated 6/22/2024, revealed .Spoke with family .notified of positive C0vid 19 [COVID-19] test today .Resident Complains [complains] of feeling tired . Review of the Physician's Orders for Resident #42 dated 6/24/2024, revealed .Molnupiravir .Give 4 capsule by mouth two times a day for COVID 19 for 5 Days . 2g) Review of the medical record revealed Resident #46 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dependence on Supplemental Oxygen, and Chronic Respiratory Failure. Review of the medical record revealed Resident #46 resided in room [ROOM NUMBER]B on the 300 Hallway at the time of the COVID-19 outbreak. Review of a quarterly MDS assessment dated [DATE], revealed Resident #46 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of the Nurse's Notes for Resident #46 dated 6/26/2024, revealed .Resident tested positive for COVID this shift .Resident is self responsible and notified of results .resident denies any distress .has some sinus drainage . Review of the Physician's Orders for Resident #46 dated 6/26/ [TRUNCATED]

Based on facility policy review, job description review, facility assessment review, Quality Assurance and Performance Improvement (QAPI) Plan review, QAPI Meeting Minutes review, facility documentation review, and interviews, the facility's QAPI program failed to ensure an effective QAPI program that identified quality deficiencies, implement performance improvement activities to address quality concerns, and perform a root cause analysis related to poor infection control practices. The facility's QAPI committee failed to develop and implement effective processes or initiate action plans for performance improvement, when the committee failed to recognize the facility's poor infection control practices and to have an effective infection control program to mitigate the spread of disease when the residents' personal laundry was not handled, stored, processed, or transported in a safe and sanitary manner which had the potential to expose infectious pathogens to residents whose laundry service was provided by the facility. The facility's QAPI program failed to recognize and provide to the staff the updated Centers for Disease Control (CDC) Guidelines for the isolation and quarantine time of COVID-19 positive employees which allowed COVID-19 positive employees to work and provide care for vulnerable and COVID-19 negative residents of the facility exposing the residents to the COVID-19 infection. The facility census was 90. The facility's failure to have an effective QAPI program, implement proper infection control practices and ensure the proper handling of soiled and contaminated laundry resulted in an Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) which had the potential or likelihood to impact all 90 residents of the facility. The facility's QAPI committee failed to develop and maintain an effective QAPI program, which resulted in continued non-compliance and a repeated deficiency of F-600 related to abuse after the facility had previously been cited abuse on the last recertification survey conducted on 6/23/2021; a complaint survey conducted on 5/18/2022, which resulted in a harm level deficiency; a revisit and complaint survey conducted on 8/4/2022; and a complaint survey conducted on 5/1/2024. The facility census was 90. The Administrator, Director of Nursing Services (DNS), Regional [NAME] President (RVP), Regional Director of Clinical Operations (RDCO) Q were notified of the Immediate Jeopardy (IJ) for F-867 on 8/20/2024 at 9:27 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-867 at a scope and severity of L. The facility was cited Immediate Jeopardy at F-835, F-837, and F-880 at a scope and severity of L. An Extended survey was conducted onsite from 8/21/2024 through 8/22/2024. The IJ began on 5/1/2024 and continued through 8/21/2024. The IJ ended on 8/21/2024 and was removed on site. An acceptable Removal Plan which removed the immediacy was provided by the facility on 8/21/2024 at 9:48 PM for F-867. The corrective actions were validated on site by the surveyors on 8/22/2024 for F-867. Noncompliance continues at F-867 at a scope and severity of F. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, revised on 2/2017, revealed .The activities of QAPI involve team members at all levels of the organization to identify opportunities for improvement .address gaps in systems or processes .develop and implement an improvement or corrective action plan . Review of the Administrator's Job Description signed and dated by the Administrator on 5/1/2024, revealed .Directs, oversees and manages the 24/7 [24 hours per day, 7 days a week] day to day operations of the .post-acute care center .key responsibilities .ensure compliance with State and Federal regulations .ensure the quality of care and services is provided to all .residents .lead an effective [QAPI] program . Review of the Director of Nursing's (DNS') Job Description signed and dated by the DNS on 5/1/2024, revealed .manages the department of nursing in accordance with policy and procedure .state and federal regulations .responsibilities .implements policies/procedures with follow-up and supervision to staff to ensure compliance .ensures safe working practices are developed and adhered to .ensures proper infection control techniques are utilized . Review of the RVP's Job Description signed and dated by the RVP on 5/3/2024, revealed .Directs, oversees and manages the 24/7 day to day operations .essential job duties .ensures compliance with State and Federal regulations .ensure the quality of care and services is provided to all .residents .leads an effective [QAPI] program .supports, provides guidance and manages the administrators .collaborates with team members on risk mitigation and event management . During an interview on 8/16/2024 at 3:05 PM, the RVP stated the new management company started managing the facility on 5/1/2024. The new management company was unable to reach an agreement with the contracted commercial linen service used by the facility. The new management company contracted with another commercial linen service, but the linen service was unable to wash the residents' personal laundry. Further interview revealed an architect was hired to remodel or build an area at the facility to provide laundry services. RVP stated until the area was completed, the facility laundered the residents' personal laundry at a local laundromat. During an interview on 8/20/2024 at 11:00 AM, the Administrator stated he was aware the facility laundered the residents' personal laundry at the local laundromat. The Administrator stated he was also aware certain chemicals and water temperatures were to be used when washing residents' personal laundry and confirmed .I don't know what the temperatures [water] were at the laundromat . The facility had a COVID-19 outbreak from 6/18/2024-8/7/2024. During the outbreak 22 residents and 13 employees tested positive for COVID-19. The facility allowed 7 of the 13 COVID-19 positive employees to return to work before the required isolation time frame recommended by the CDC guidelines. During an interview on 8/20/2024 at 12:36 PM, the DNS confirmed (7) employees returned to work before their quarantine time was complete per the CDC recommended guidelines for COVID-19 positive staff in a long-term care facility. Refer to F880 Review of the QAPI meeting minutes dated 6/25/2024 and 7/23/2024, revealed no documentation the facility's QAPI program identified or reported quality deficiencies, performed a root cause analysis which identified serious outcomes, developed or implemented processes or corrective action plans related to the facility's infection control program and practices with the recent COVID-19 outbreak (6/18/2024-8/7/2024), and laundry services. Continued review of the meeting minutes revealed no documentation or root cause analysis which identified, addressed, or discussed, the repeated deficiencies related to abuse. The facility Administration failed to address in QAPI the facility's widespread problem of unsafe and unsanitary handling, storing, and processing of the residents' contaminated and potentially hazardous personal laundry and ensuring COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the Centers of Disease Control (CDC) to control the exposure and spread of COVID-19. During an interview on 8/20/2024 at 7:35 PM, the Administrator stated the facility had some areas of improvement to address regarding infection prevention and control practices. When the Administrator was asked by the surveyor if he felt the QAPI Program was effective, the Administrator relied, Yes. Refer to F-835 Review of a recertification survey statement of deficiencies (SOD) conducted on 6/23/2021, revealed the facility was cited F-600 for abuse related to a resident-to-resident altercation. Review of a complaint survey SOD conducted on 5/18/2022, revealed the facility was cited F-600 for abuse related to a resident-to-resident altercation and had an occurrence of staff to resident abuse which was cited at a harm level. Review of a revisit and complaint survey SOD conducted on 8/24/2022, revealed the facility was cited F-600 for abuse related to a resident-to-resident altercation. Review of a complaint survey SOD conducted on 5/15/2024, revealed the facility was cited F-600 for abuse related to multiple resident-to-resident altercations and had an occurrence of staff to resident abuse which was at a harm level. During the current recertification and complaint survey conducted on 8/12/2024-8/22/2024, revealed abuse was identified regarding multiple resident-to-resident altercations and F-600 was again cited. The QAPI committee failed to maintain oversight and implement policies and procedures to address patterns of continued abuse. Refer to F-600 Validation of the Allegation of Compliance (AOC) Removal Plan to remove the immediacy of the Jeopardy (IJ) was conducted on 8/22/2024 through review of facility documentation, medical record reviews, and interviews. On 8/20/2024, the Administrator and DNS were educated on Infection Control Policies, COVID-19 Guidelines from the Infection Control Manual and CDC Recommendations, Transmission Based Precautions, Enhanced Barrier Precautions, QAPI, and Handling Soiled Linen by Regional [NAME] President, Regional Director of Clinical Operations, and Senior Director of Clinical Quality and Education. On 8/20/2024-8/21/2024, staff education was started by the DNS, or designee, with all staff on duty regarding isolation precautions for infection control including transmission- based precautions, hand hygiene, and enhanced barrier precautions, in-service on COVID-19 testing and guidelines related to safe care and prevention of COVID-19. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. On 08/20/24, [named commercial laundry service] agreed to a contract revision with Administrator to provide personal laundry services twice per week (refer to exhibit 5). The personal laundry will be removed from the resident's area in bags and placed in labeled bin for [named commercial laundry service] pickup which is located in the laundry storage building. All personal laundry will be returned from [named commercial laundry service] in lined clean bin folded or layered flat and covered with protective sheeting on the south station administrative hall. Housekeeping services will sort, hang, and deliver to residents upon return. Administrator and DNS began educating staff on duty on 8/21/2024 regarding removal of personal laundry, placement in bin for transport to [named commercial laundry service] and return to residents upon return from [named commercial laundry service] on 8/21/24. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. Facility adopted a new policy titled, Handling Soiled Linen, on 8/21/2024. The policy was reviewed and approved in an Ad Hoc QAPI meeting held on 8/21/24. Review of the sign in sheet revealed the Administrator, Director of Nursing Services, Medical Director, and Regional Director of Clinical Operations Q were in attendance. Education was started on 8/21/2024, by DNS, or designee, with all staff on duty regarding policy on Handling Soiled Linen. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. On 8/21/24, Administrator and DNS conducted environmental rounds audit utilizing the environmental rounds tool and handling of soiled linens with no issues identified. Starting 8/21/2024 the following guidelines, recommended by cdc.gov titled Infection Control Guidelines: SARS-CoV-2 dated 6/24/2024, were initiated. The following steps will be: HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and, At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Current employees are required to test twice a week during COVID-19 outbreak and as needed with development of any signs or symptoms (e.g., those with runny nose, cough, sneezing, shortness of breath). If current employee tests positive while at work, employee will notify Administrator, DNS, and/or ADNS (Assistant Director of Nursing Services), and the employee will be sent home immediately and will remain off work according to current CDC guidelines. In the possibility of a staffing crisis, facility will initiate the following: Call all off duty staff including cross-trained staff Offer incentives Offer shift swaps or bonus day off Offer split shifts Call all licensed administrative staff that can come in and work under any capacity. If above points unsuccessful involve Corporate Regional Support Team for further guidance. An Ad Hoc QAPI meeting was conducted on 8/21/2024 with the Administrator, DNS, Director of Clinical Operations, Infection Preventionist, Minimum Data Set Coordinator, Director of Care Coordination, and Medical Director to discuss, address, and review the deficient practice identified during the survey related to infection control practices and guidance to mitigate the spread of COVID-19 to staff and residents and infection control concerns identified with the handling of residents' personal laundry. All corrective actions will continue until a Plan of Correction is developed. Refer to F835, F837, F867, and F880

Based on facility policy review, job description review, facility documentation review, and interview, the facility's Governing Body failed to address the facility's widespread problem of unsafe and unsanitary handling, storing, and processing of the residents' contaminated and potentially hazardous personal laundry, which had the potential to expose infectious pathogens to 85 of 90 residents that utilized the facility provided laundry service. The facility's Governing Body failed to provide effective leadership and oversight of the facility's Administration to ensure COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the Centers of Disease Control (CDC) to control the exposure and spread of COVID-19. The facility allowed COVID-19 positive staff to work with Non-COVID-19 residents which exposed vulnerable residents to the COVID-19 infection, leaving the potential to cause a serious adverse outcome to 90 of 90 residents in the facility. The Governing Body's failure to provide adequate leadership to oversee and maintain safe and effective infection control practices had the potential or likelihood to impact all the residents in the facility, which placed the residents in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The Administrator, Director of Nursing Services (DNS), Regional [NAME] President (RVP), Regional Director of Clinical Operations (RDCO) Q were notified of the IJ for F-837 on 8/20/2024 at 9:27 PM, in the Administrator's office. The facility was cited Immediate Jeopardy at F-837 at a scope and severity of L. The facility was cited Immediate Jeopardy at F-835, F-867, and F-880 at a scope and severity of L. An Extended survey was conducted onsite from 8/21/2024 through 8/22/2024. The IJ began on 5/1/2024 and continued through 8/21/2024. The IJ ended on 8/21/2024 and was removed on site. An acceptable Removal Plan which removed the immediacy was provided by the facility on 8/21/2024 at 9:48 PM for F-837. The corrective actions were validated on site by the surveyors on 8/22/2024 for F-837. Noncompliance continues at F-837 at a scope and severity of F. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Plan, revised on 2/2017, revealed .The activities of QAPI involve team members at all levels of the organization to identify opportunities for improvement .address gaps in systems or processes .develop and implement an improvement or corrective action plan . Review of the facility's policy titled, Governing Body, dated 2023 (exact date unknown), revealed .The Governing Body is responsible for identifying and prioritizing problems .ensuring that corrective actions address gaps in the system and are evaluated for effectiveness .setting clear expectations for safety, quality, rights, choice, and respect .ensuring adequate resources exist .ensuring contingency plans for program sustainability during times of leadership transition . Further review revealed the Governing Body members are the RVP, Administrator, and the DNS. Review of the Administrator's Job Description signed and dated by the Administrator on 5/1/2024, revealed .Directs, oversees and manages the 24/7 (24 hours per day, 7 days a week) day to day operations of the .post-acute care center .key responsibilities .ensure compliance with State and Federal regulations .ensure the quality of care and services is provided to all .residents .lead an effective [QAPI] program . Review of the DNS' Job Description signed and dated by the DNS on 5/1/2024, revealed .manages the department of nursing in accordance with policy and procedure .state and federal regulations .responsibilities .implements policies/procedures with follow-up and supervision to staff to ensure compliance .ensures safe working practices are developed and adhered to .ensures proper infection control techniques are utilized . Review of the RVP's Job Description signed and dated by the RVP on 5/3/2024, revealed .Directs, oversees and manages the 24/7 day to day operations .essential job duties .ensures compliance with State and Federal regulations .ensure the quality of care and services is provided to all .residents .leads an effective [QAPI] program .supports, provides guidance and manages the administrators .collaborates with team members on risk mitigation and event management . During an interview on 8/16/2024 at 3:05 PM, the RVP stated the new management company started managing the facility on 5/1/2024. The new management company was unable to reach an agreement with the contracted commercial linen service used by the facility to launder the residents' personal clothing items. The new management company contracted with another commercial linen service, but the linen service was unable to wash the residents' personal laundry. Further interview revealed an architect was hired to remodel or build an area at the facility to provide laundry services. RVP stated until the area was completed, the facility laundered the residents' personal laundry at a local laundromat. The RVP stated the Governing Body (also members of the QAPI committee) consisted of the Administrator, the DNS, and himself (RVP) and met routinely. The RVP stated the facility was following the CDC's guidelines (outdated) for COVID-19 to address the spread of COVID-19. The facility had a COVID-19 outbreak from 6/18/2024-8/7/2024. During the outbreak 22 residents (Resident #1, #2, #20, #33, #36, #42, #46, #53, #57, #71, #72, #78, #82, #340, #341, #3, #11, #27, #43, #12, #30, and #79) and 13 employees tested positive for COVID-19. During an interview on 8/20/2024 at 12:36 PM, the DNS confirmed (7) employees returned to work before their quarantine time was complete per the CDC recommended guidelines for COVID-19 positive staff in a long-term care facility. Refer to F880 Review of the QAPI meeting minutes dated 6/25/2024, revealed the facility's QAPI program failed to identify quality deficiencies, report, perform a root cause analysis to identify serious outcomes, develop and implement processes or corrective plans related to the facility ' s infection control program and laundry services. Refer to F867 Review of the QAPI meeting minutes dated 6/25/2024 and 7/23/2024, revealed no documentation the facility's QAPI program identified or reported quality deficiencies, performed a root cause analysis which identified serious outcomes, developed or implemented processes or corrective action plans related to the facility's infection control program and practices with the recent COVID-19 outbreak (6/18/2024-8/7/2024), and laundry services. Continued review of the meeting minutes revealed no documentation or root cause analysis which identified, addressed, or discussed, the repeated deficiencies related to abuse. The facility Administration and Governing Body failed to address in QAPI the facility's widespread problem of unsafe and unsanitary handling, storing, and processing of the residents' contaminated and potentially hazardous personal laundry and ensuring COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the Centers of Disease Control (CDC) to control the exposure and spread of COVID-19. During an interview on 8/20/2024 at 7:35 PM, the Administrator stated the facility had some areas of improvement to address regarding infection prevention and control practices. Refer to F-835 Validation of the Allegation of Compliance (AOC) Removal Plan to remove the immediacy of the Jeopardy (IJ) was conducted on 8/22/2024 through review of facility documentation, medical record reviews, and interviews. On 8/20/2024, the Administrator and DNS were educated on Infection Control Policies, COVID-19 Guidelines from the Infection Control Manual and CDC Recommendations, Transmission Based Precautions, Enhanced Barrier Precautions, QAPI, and Handling Soiled Linen by RVP, Regional Director of Clinical Operations, and Senior Director of Clinical Quality and Education. On 8/20/2024-8/21/2024, staff education was started by the DNS, or designee, with all staff on duty regarding isolation precautions for infection control including transmission- based precautions, hand hygiene, and enhanced barrier precautions, in-service on COVID-19 testing and guidelines related to safe care and prevention of COVID-19. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. On 08/20/24, (named commercial laundry service) agreed to a contract revision with Administrator to provide personal laundry services twice per week (refer to exhibit 5). The personal laundry will be removed from the resident ' s area in bags and placed in labeled bin for (named commercial laundry service) pickup which is located in the laundry storage building. All personal laundry will be returned from (named commercial laundry service) in lined clean bin folded or layered flat and covered with protective sheeting on the south station administrative hall. Housekeeping services will sort, hang, and deliver to residents upon return. Administrator and DNS began educating staff on duty on 8/21/2024 regarding removal of personal laundry, placement in bin for transport to (named commercial laundry service) and return to residents upon return from (named commercial laundry service) on 8/21/24. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. Facility adopted a new policy titled, Handling Soiled Linen, on 8/21/2024. The policy was reviewed and approved in an Ad Hoc QAPI meeting held on 8/21/24. Review of the sign in sheet revealed the Administrator, Director of Nursing Services, Medical Director, and Regional Director of Clinical Operations Q were in attendance. Education was started on 8/21/2024, by DNS, or designee, with all staff on duty regarding policy on Handling Soiled Linen. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. On 8/21/24, Administrator and DNS conducted environmental rounds audit utilizing the environmental rounds tool and handling of soiled linens with no issues identified. Starting 8/21/2024 the following guidelines, recommended by cdc.gov titled Infection Control Guidelines: SARS-CoV-2 dated 6/24/2024, were initiated. The following steps will be: Healthcare Providers (HCP) who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and, At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Current employees are required to test twice a week during COVID-19 outbreak and as needed with development of any signs or symptoms (e.g., those with runny nose, cough, sneezing, shortness of breath). If current employee tests positive while at work, employee will notify Administrator, DNS, and/or ADNS (Assistant Director of Nursing Services), and the employee will be sent home immediately and will remain off work according to current CDC guidelines. In the possibility of a staffing crisis, facility will initiate the following: Call all off duty staff including cross-trained staff Offer incentives Offer shift swaps or bonus day off Offer split shifts Call all licensed administrative staff that can come in and work under any capacity. If above points unsuccessful involve Corporate Regional Support Team for further guidance. An Ad Hoc QAPI meeting was conducted on 8/21/2024 with the Administrator, Director of Nursing Services, Director of Clinical Operations, Infection Preventionist, Minimum Data Set Coordinator, Director of Care Coordination and Medical Director to discuss, address, and review the deficient practice identified during the survey related to infection control practices and guidance to mitigate the spread of COVID-19 to staff and residents and infection control concerns identified with the handling of residents ' personal laundry. All corrective actions will continue until a Plan of Correction is developed Refer to F835, F837, F867, and F880

Based on facility policy review, Centers for Disease Control (CDC) recommendations and guidance review, job description review, facility assessment review, Activities of Daily Living (ADL) documentation review, facility staffing schedule review, facility staff time punch records review, medical record review, observations, and interviews, the facility's Administration failed to ensure the residents' personal laundry was handled, stored, processed, and transported in a safe and sanitary manner which had the potential to expose infectious pathogens to 85 of 90 residents whose laundry service was provided by the facility. The facility's Administration failed to provide effective leadership and oversight to ensure COVID-19 positive employees were excluded from work for the required isolation time frame recommended by the CDC. The facility allowed COVID-19 positive staff to work with Non-COVID-19 residents exposing the vulnerable residents to the COVID-19 infection, which had the potential to cause a serious adverse outcome to all 90 residents in the facility. The Administration's failure to maintain effective leadership and oversight related to infection prevention and control practices for the facility, placed the residents in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident). The facility's Administration failed to maintain adequate staffing levels to ensure 2 residents (Residents #9 and #83) were provided transportation to scheduled outpatient physician appointments of 4 residents reviewed for transportation needs and failed to ensure there was sufficient staffing to meet the ADL needs of scheduled showers for 5 residents (Residents #33, #39, #49, #77, and #84) of 24 residents reviewed for ADL needs. The Administrator, Director of Nursing Services (DNS), Regional [NAME] President (RVP), Regional Director of Clinical Operations (RDCO) Q were notified of the Immediate Jeopardy for F-835 on 8/20/2024 at 9:27 PM in the Administrator's office. The facility was cited Immediate Jeopardy at F-835 at a scope and severity of L. The facility was cited Immediate Jeopardy at F-837, F-867, F-880 at a scope and severity of L. An Extended survey was conducted onsite from 8/21/2024 through 8/22/2024. The IJ began on 5/1/2024 and continued through 8/21/2024. The IJ ended on 8/21/2024 and was removed on site. An acceptable Removal Plan which removed the immediacy was provided by the facility on 8/21/2024 at 9:48 PM for F-835. The corrective actions were validated on site by the surveyors on 8/22/2024 for F-835. Noncompliance continues at F-835 at a scope and severity of F. The facility is required to submit a Plan of Correction (POC). The findings include: Review of the facility's policy titled, Linen Handling Guidelines, dated 11/1/2017, revealed .The purpose of this procedure is to provide a process for the safe and aseptic handling, processing, transporting, and storage of linen .consider all soiled linen to be potentially infectious . Review of the facility's policy titled, COVID Comprehensive Guide, dated 5/2023, revealed .Team Members Return to Work Criteria for .with COVID Infection .should be restricted from work and follow recommended practices .Contingency and crisis strategies .Work Restrictions for Team Members with COVID Infection .Crisis .No work restrictions .asymptomatic . (outdated guidance the facility was following during the COVID-19 outbreak from 6/2024-8/2024). Review of the CDC Guidelines titled, Environmental Infection Control in Health-Care Facilities, Section G Laundry and Bedding, revised 1/8/2024, revealed .OSHA [Occupational Safety and Health Administration] defines contaminated laundry as .laundry which has been soiled with blood or other potentially infectious materials .Laundering cycles consist of .main wash, bleaching, rinsing .The antimicrobial action of the laundering process results from a combination of mechanical, thermal, and chemical factors .Hot water provides an effective means of destroying microorganisms. A temperature of at least 160 .F [Fahrenheit] .for a minimum of 25 minutes .for hot water washing. The use of chlorine bleach assures an extra margin of safety. Chlorine alternatives .[example] activated oxygen-based laundry detergents .provide added benefits for fabric and color safety in addition to antimicrobial activity .Health-care workers should note the cleaning instructions of textiles, fabrics .Low-temperature laundry cycles rely heavily on the presence of chlorine- or oxygen-activated bleach to reduce the levels of microbial contamination . Review of the CDC's guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 3/18/2024, revealed .Return to Work Criteria for HCP [healthcare personnel] with SARS-CoV-2 [COVID-19] Infection . (The guidance published in this CDC recommendation on 3/18/2024 was the guidance the facility should have followed for the COVID-19 outbreak that occurred from 6/18/2024-6/23/2024.) Review of the Administrator's Job Description signed and dated by the Administrator on 5/1/2024, revealed .Directs, oversees and manages the 24/7 (24 hours per day, 7 days a week) day to day operations of the .post-acute care center .key responsibilities .ensures the safety of all residents .ensure compliance with State and Federal regulations .ensure the quality of care and services is provided to all .residents .lead an effective [QAPI] program . Review of the DNS' Job Description signed and dated by the DNS on 5/1/2024, revealed .manages the department of nursing in accordance with policy and procedure .state and federal regulations .responsibilities .implements policies/procedures with follow-up and supervision to staff to ensure compliance .ensures safe working practices are developed and adhered to .ensures proper infection control techniques are utilized . Review of the CDC's guidance titled, Infection Control Guidance: SARS-CoV-2, dated 6/24/2024, revealed, .The recommendations in this guidance continue to apply after the expiration of the federal COVID-19 Public Health Emergency .To provide the greatest assurance that someone does not have SARS-CoV-2 infection .Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection .Ensure everyone is aware of recommended IPC [infection prevention and control] practices in the facility . (The CDC published this recommendation on 6/24/2024 was the guidance the facility should have followed from 6/24/2024 to present). Review of the facility's assessment dated [DATE], revealed .The administrator is responsible for assuring .adequate team member coverage is in place to care for residents . Investigation revealed that a new management company took over the facility management on 5/1/2024 and the facility would no longer have a commercial laundry service to wash the residents' personal laundry. The facility was storing the residents' soiled laundry (in storage bins waiting to be laundered) in a storage building located behind the facility. The residents' personal laundry was stored with dried feces, urine, and was not separated. The facility implemented a new process where the former Housekeeping Supervisor or Housekeeper V was to take the residents' soiled personal laundry to a local laundromat 3 times a week. The items were not separated and were all washed together using a household detergent instead of the sanitizing agents that would ensure the personal items were properly sanitized against microbial contamination. Interviews revealed the water temperatures in the laundromat would only reach 140-142 Fahrenheit (F), and not the required 160 degrees F that would prevent or mitigate the potential spread of infection or communicable disease. During an observation of the laundry storage area (behind the facility) and interview on 8/16/2024 at 9:41 AM, the Administrator and Certified Nursing Assistant (CNA) T placed the residents' dirty clothes in plastic bags from a large green bin. The Administrator and CNA T were asked to remove the plastic bags from the 2 blue plastic containers which stored the residents' personal, for surveyor observation. The observation revealed 12 closed plastic bags with the residents' soiled laundry. The Administrator confirmed residents' personal laundry had not been contained or maintained in a sanitary condition. During a telephone interview on 8/16/2024 at 11:19 AM, the former Housekeeping Supervisor stated the facility had taken the residents' soiled laundry to the local laundromat for laundering but was unsure if the soiled clothing items were being sanitized or properly cleaned because the water was not hot enough to get the clothes clean and certain chemicals were not being used. The former Housekeeping Supervisor stated she had expressed her concerns (date unknown) to the Administrator with no solution to the concern. During an interview on 8/16/2024 at 11:51 AM, the Administrator stated, .we [the facility] did not know there was molded clothes [residents' soiled personal laundry] in the storage shed . During an interview on 8/20/2024 at 11:00 AM, the Administrator stated he was aware certain chemicals and water temperatures were to be used (to ensure proper sanitization) when washing resident's personal laundry and confirmed .I don't know what the temperatures [water] were at the laundromat . During an interview on 8/21/2024 at 12:00 PM, the Administrator stated he was informed on 4/28/2024 the facility would no longer have a commercial linen service to wash the residents' personal laundry, effective 4/30/2024. The facility had to .put something in place . It was decided the residents' personal laundry would be washed at the local laundromat starting 5/1/2024. The facility had a COVID-19 outbreak from 6/18/2024-8/7/2024. During the outbreak 22 residents (Resident #1, #2, #20, #33, #36, #42, #46, #53, #57, #71, #72, #78, #82, #340, #341, #3, #11, #27, #43, #12, #30, and #79) and 13 employees tested positive for COVID-19. The facility allowed 7 of the 13 COVID-19 positive employees to return to work before the required isolation time frame recommended by CDC guidance. The COVID-19 positive symptomatic and sick employees who worked had the potential to spread the COVID-19 infection to all residents in the facility. During an interview on 8/20/2024 at 12:36 PM, the DNS confirmed the dates Registered Nurse (RN) PP, Licensed Practical Nurse (LPN) BB, LPN CC, LPN DD, LPN FF, CNA G, and CNA W were allowed to return to work following testing positive for COVID-19. Each of the employees returned to work before the recommended quarantine time ended according to the CDC recommended guidelines for COVID-19 positive staff in a long-term care facility. The DNS revealed the facility had reviewed the COVID-19 Comprehensive Guide, dated 5/2023. The DNS stated employees were required to have a negative COVID-19 test (not 2 negative COVID-19 tests 48 hours apart per the CDC guidance) with no symptoms prior to returning to work. The DNS confirmed several COVID-19 positive employee were allowed to work. During a telephone interview on 8/22/2024 at 11:06 AM, the Infection Preventionist Regional Supervisor (IPRS) stated she was the facility's area reporting contact for COVID-19 infections/outbreaks and had been in contact with the facility's Infection Preventionist multiple times regarding the COVID-19 cases in the facility from 6/18/2024 to 8/7/2024. The IPRS stated the facility did not inquire about utilizing COVID-19 positive employees to work in the facility (with positive or negative) residents. Further interview revealed the IPRS was not aware of the facility's practice of utilizing COVID-19 positive employees to provide care to COVID-19 negative residents. The IPRS stated her recommendations to mitigate the COVID-19 spread and outbreak align with the CDC guidelines for quarantine for healthcare workers. The IPRS stated the current guidance did not permit COVID-19 positive healthcare workers to provide care to COVID-19 negative residents. The IPRS stated to her knowledge, there is not any recommendations related to healthcare workers in long-term care facilities that allow COVID-19 positive employees to provide care to COVID-19 negative residents. Refer to F880 The facility Administration failed to ensure there was sufficient staff to ensure 2 residents were provided transportation to scheduled outpatient appointments. Resident #9 missed 3 of 4 scheduled outpatient urology appointments on 6/11/2024, 7/22/2024, and 8/13/2024, and Resident #83 missed an outpatient doctor's appointment on 8/13/2024 due to insufficient staff to provide the residents' transportation needs. During an interview on 8/14/2024 at 10:51 AM, the DNS confirmed she was aware Resident #9 had missed the scheduled outpatient urology appointments on 6/11/2024, 7/22/2024, and 8/13/2024 due to having insufficient staffing to provide the resident's transportation needs. During an interview on 8/20/2024 at 8:41 AM, the Administrator stated Resident #83 had an outpatient doctor appointment scheduled on 8/13/2024, and confirmed the appointment had to be rescheduled related to insufficient staff available to transport or assist Resident #83 to the appointment. Refer to F658 The facility Administration failed to ensure there was sufficient staff to ensure 5 residents received their scheduled showers. Resident #33 missed 3 scheduled showers, Resident #39 missed 5 scheduled showers, Resident #49 missed 5 scheduled showers, Resident #77 missed 4 scheduled showers, and Resident #84 missed 1 scheduled shower during the time frame of 8/1/2024-8/16/2024. During an interview on 8/13/2024 at 6:30 PM, Licensed Practical Nurse (LPN) E stated she worked form 6:00 PM-6:00 AM and was typically assigned care for 50 residents on the hallway with 1 CNA and 2 nurses. LPN E stated showers were scheduled to be completed on both shifts and there were times when scheduled showers were not completed (unable to give exact dates) due to not enough staff. On Thursday 8/8/2024 there was 1 nurse and 1 CNA from 6:00 PM-6:00 AM on the hallway. LPN E further stated the Administrator had not asked if needs of the residents were being met or if the staff were able to complete the work assignments. During an interview on 8/13/2024 at 6:38 PM, LPN F stated she worked 6:00 PM-6:00 AM, worked the east hallway, there were typically 50 residents on the wing, and 2 nurses with 1 CNA to work the hallway. LPN F stated showers were scheduled to be completed on both shifts. There had been times when the scheduled showers were unable to be completed due to not enough staff (unable to give exact dates). The Administrator had not asked if needs of the residents were being met or if the staff were able to complete the work assignments. During an interview on 8/14/2024 at 1:13 PM, the DNS stated she received voiced concerns from CNAs and nurses regarding low staffing and scheduled showers not being completed. During an interview on 8/14/2024 at 3:00 PM, the Administrator stated he was aware the facility had some staffing concerns and stated, .I do know it [staffing concerns] exists . The Administrator confirmed he was aware some of the residents had not received scheduled showers at times. During an interview on 8/20/2024 at 6:31 PM, the DNS and the Administrator confirmed the facility failed to ensure the expected and sufficient level of staffing was available in the facility to meet all the resident care needs including the scheduled showers and transportation for scheduled outpatient physician appointments. Refer to F725 During an interview on 8/20/2024 at 7:35 PM, the Administrator stated the facility had some areas of improvement to address regarding infection prevention and control practices and sufficient staffing provisions. Validation of the Allegation of Compliance (AOC) Removal Plan to remove the immediacy of the Jeopardy (IJ) was conducted on 8/22/2024 through review of facility documentation, medical record reviews, and interviews. On 8/20/2024, the Administrator and DNS were educated on Infection Control Policies, COVID-19 Guidelines from the Infection Control Manual and CDC Recommendations, Transmission Based Precautions, Enhanced Barrier Precautions, QAPI, and Handling Soiled Linen by Regional [NAME] President, Regional Director of Clinical Operations, and Senior Director of Clinical Quality and Education. On 8/20/2024-8/21/2024, staff education was started by the DNS, or designee, with all staff on duty regarding isolation precautions for infection control including transmission- based precautions, hand hygiene, and enhanced barrier precautions, in-service on COVID-19 testing and guidelines related to safe care and prevention of COVID-19. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. On 08/20/24, (named commercial laundry service) agreed to a contract revision with the Administrator to provide personal laundry services twice per week (refer to exhibit 5). The personal laundry will be removed from the resident ' s area in bags and placed in labeled bin for (named commercial laundry service) pickup which is located in the laundry storage building. All personal laundry will be returned from (named commercial laundry service) in lined clean bin folded or layered flat and covered with protective sheeting on the south station administrative hall. Housekeeping services will sort, hang, and deliver to residents upon return. Administrator and DNS began educating staff on duty on 8/21/2024 regarding removal of personal laundry, placement in bin for transport to (named commercial laundry service) and return to residents upon return from (named commercial laundry service) on 8/21/24. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. Facility adopted a policy titled, Handling Soiled Linen, on 8/21/2024. The policy was reviewed and approved in an Ad Hoc QAPI (Quality Assurance and Performance Improvement) meeting held on 8/21/24. Review of the sign in sheet revealed the Administrator, Director of Nursing Services, Medical Director, and Regional Director of Clinical Operations Q were in attendance. Education was started on 8/21/2024, by DNS, or designee, with all staff on duty regarding policy on Handling Soiled Linen. Employees will not be allowed to work until they have received this training. The Administrator or designee will monitor the schedule to ensure no employee will work until their education has been completed. On 8/21/24, the Administrator and DNS conducted environmental rounds audit utilizing the environmental rounds tool and handling of soiled linens with no issues identified. Starting 8/21/2024 the following guidelines, recommended by cdc.gov titled Infection Control Guidelines: SARS-CoV-2 dated 6/24/2024, were initiated. The following steps will be: HCP who were asymptomatic throughout their infection and are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since the date of their first positive viral test if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7). HCP with mild to moderate illness who are not moderately to severely immunocompromised could return to work after the following criteria have been met: At least 7 days have passed since symptoms first appeared if a negative viral test is obtained within 48 hours prior to returning to work (or 10 days if testing is not performed or if a positive test at day 5-7), and, At least 24 hours have passed since last fever without the use of fever-reducing medications, and Symptoms (e.g., cough, shortness of breath) have improved. Current employees are required to test twice a week during COVID-19 outbreak and as needed with development of any signs or symptoms (e.g., those with runny nose, cough, sneezing, shortness of breath). If current employee tests positive while at work, employee will notify Administrator, DNS, and/or ADNS (Assistant Director of Nursing Services), and the employee will be sent home immediately and will remain off work according to current CDC guidelines. In the possibility of a staffing crisis, facility will initiate the following: Call all off duty staff including cross-trained staff Offer incentives Offer shift swaps or bonus day off Offer split shifts Call all licensed administrative staff that can come in and work under any capacity. If above points unsuccessful involve Corporate Regional Support Team for further guidance. An Ad Hoc QAPI meeting was conducted on 8/21/2024 with the Administrator, Director of Nursing Services, Director of Clinical Operations, Infection Preventionist, Minimum Data Set Coordinator, Director of Care Coordination and Medical Director to discuss, address, and review the deficient practice identified during the survey related to infection control practices and guidance to mitigate the spread of COVID-19 to staff and residents and infection control concerns identified with the handling of residents ' personal laundry. All corrective actions will continue until a Plan of Correction is developed. Refer to F835, F837, F867, and F880

Based on facility policy review, observation, and interview the facility failed to ensure a dietary aid wore a protective beard covering while working in the kitchen food preparation area which had the potential to affect 90 of 90 residents. The findings include: Review of the facility's policy titled, Team Member Sanitary Practices, dated 1/1/2017, revealed .center to promote guidelines for employee sanitary practices .wear hairnets or restraints .all hair including facial hair must be completely covered . During an observation in the food preparation area on 8/12/2024 at 10:48 AM, with the Dietary Manager (DM), revealed 1 dietary aid without the presence of a protective beard covering to ensure all the facial hair was covered and contained. During an interview on 8/12/2024 at 10:50 AM, the DM confirmed the dietary aid's beard was not fully covered in the food preparation area. The DM stated all hair, including facial hair, should be covered while working in the kitchen.

Based on facility assessment review, medical record review, facility ADL (Activities of Daily Living) documentation review, facility staffing schedule review, facility staffing time punch review, observations, and interviews, the facility failed to maintain adequate staffing levels to ensure 2 residents (Residents #9 and #83) were provided transportation to an outside physician appointment of 4 residents reviewed for transportation needs, and failed to meet the ADL needs (scheduled showers) for 5 residents (Residents #33, #39, #49, #77, and #84 ) of 24 residents reviewed for ADL care. The findings include: Review of the facility assessment dated [DATE] revealed .Staffing Plan .Based on the resident .population and their needs for care and support .there are sufficient team members to meet the needs of the residents .at any given time .The administrator is responsible for assuring .adequate team member coverage is in place to care for residents . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Difficulty Moving Spine, Chronic Obstructive Pulmonary Disease, Neurogenic Bladder, and Depression. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 was cognitively intact. During an observation and interview on 8/13/2034 at 10:35 AM, Resident #9 stated she had a urology appointment scheduled at 11:00 AM today and was waiting for the facility to provide transportation to the appointment. The resident stated if she was late to the appointment, the urologist would not see her. The resident stated she was unable to see the urologist in the past because of delayed transportation. During an interview on 8/14/2024 at 9:30 AM, Licensed Practical Nurse (LPN) H stated Resident #9 had missed 3 to 4 scheduled urology appointments due to transportation problems due to not enough staff to transport the resident. During an interview on 8/14/2024 at 10:51 AM, the Director of Nursing Services (DNS) confirmed she was aware Resident #9 had missed urology appointments on 6/11/2024, 7/22/2024, and 8/13/2024 related to insufficient staff to provide the transportation. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Chronic Pain, Liver Disease, Heart Burn, and Abdominal Swelling. Review of the admission MDS assessment dated [DATE], revealed Resident #83 had moderate cognitive impairment. During an interview on 8/19/2024 at 3:00 PM, Resident #83 stated he had missed an appointment with a stomach doctor sometime this month (unsure of the exact date) to get established with a new doctor. The resident stated a staff member had informed him the appointment was rescheduled and he was not informed why the appointment was rescheduled. During an interview on 8/20/2024 at 8:41 AM, the Administrator stated Resident #83 had an outpatient doctor appointment scheduled on 8/13/2024, and confirmed the appointment was rescheduled related to insufficient staff available to transport or assist Resident #83 to the appointment. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Diabetes Type 2, Autism, and Hypertension. Review of the quarterly MDS assessment dated [DATE], revealed Resident #33 was cognitively intact. The resident required supervision or touching assistance from staff for showers. Review of the facility ADL documentation for Resident #33 dated 5/1/2024-5/31/2024, revealed the resident was scheduled for a shower twice weekly. The documentation revealed the resident received 0 scheduled showers for the month of 5/2024. Review of the facility ADL documentation for Resident #33 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 2 showers for the month of 6/2024. Review of the facility ADL documentation for Resident #33 dated 7/1/2024-7/31/2024, revealed the resident was scheduled for a shower twice weekly. The resident received a partial bath on 7/9/2024 and 0 showers for the month of 7/2024. Review of the facility ADL documentation for Resident #33 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 2 showers from 8/1/2024-8/16/2024. During an interview on 8/14/2024 at 10:15 AM, Resident #33 stated he did not receive the scheduled showers routinely and wanted to be bathed twice weekly .it makes me feel better . During an interview on 8/14/2024 at 10:21 AM, LPN J stated she was the routine nurse for Resident #33 and the resident did not refuse showers. During an interview on 8/14/2024 at 8:20 PM, CNA C revealed Resident #33 did not typically refuse showers and she was not always able to complete the scheduled showers due to low staffing. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Confusion, Contractures of Left Hip, Left Knee, Right Ankle, Left Ankle, Anxiety, Dementia, Depression, Seizures, and Peripheral Vascular Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #39 was rarely or never understood and was dependent on staff for showers. Review of the facility ADL documentation for Resident #39 dated 5/1/2024-8/31/2024, revealed the resident was scheduled for a shower twice weekly. The resident received a bed bath on 5/6/2024 0 showers during the month of 5/2024. Review of the facility ADL documentation for Resident #39 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 2 bed baths and 0 showers during the month of 6/2024. Review of the facility ADL documentation for Resident #39 dated 7/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 0 showers for the month of 7/2024. Review of the facility ADL documentation for Resident #39 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 1 shower from 8/1/2024-8/16/2024. During an interview on 8/14/2024 at 3:49 PM, CNA B stated she had provided care for Resident #39. The resident required total assistance with bathing and did not refuse showers. The CNA stated she worked 4 (four) 12-hour shifts and on at least 2 of the days she was not able to complete the scheduled showers due to low staffing. Review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE] with diagnoses including Stroke, Anxiety, Dementia, and Need for Assistance with Personal Care. Review of the quarterly MDS assessment dated [DATE], revealed Resident #49 scored was cognitively intact and required partial to moderate assistance from staff for showers. Review of the facility ADL documentation for Resident #49 dated 5/1/2024-5/31/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 2 showers for the month of 5/2024. Review of the facility ADL documentation for Resident #49 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 1 shower for the month of 6/2024. Review of the facility ADL documentation for Resident #49 dated 7/1/2024-7/31/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 4 showers for the month of 7/2024. Review of the facility ADL documentation for Resident #49 dated 8/1/2024-8/16/2024, revealed the resident received 0 showers from 8/1/2024-8/16/2024. During an interview on 8/14/2024 at 3:49 PM, CNA B stated she had provided care for Resident #49 and the resident did not refuse showers or bed baths. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Brain Damage, Difficulty Walking, Weakness, Lack of Coordination, Bipolar, Drug Dependence, Restlessness, and Agitation. Review of the quarterly MDS assessment dated [DATE], revealed Resident #77 had moderate cognitive impairment and required substantial to maximal assistance from staff for showers. Review of the facility ADL documentation for Resident #77 dated 5/1/2024-5/31/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 3 showers and 1 bed bath for the month of 5/2024. Review of the facility ADL documentation for Resident #77 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 1 shower for the month of 6/2024. Review of the facility ADL documentation for Resident #77 dated 7/1/2024-7/30/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 1 bed bath, 1 partial bath, and 0 showers for the month of 7/2024. Review of the facility ADL documentation for Resident #77 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 1 shower from 8/1/2024-8/16/2024. Resident #84 was admitted to the facility on [DATE] with diagnoses including Hypothyroidism, Heartburn, Depression, and Acute Kidney Failure. Review of the quarterly MDS assessment dated [DATE], for Resident #84 revealed the resident was cognitively intact and required supervision or touching assistance from staff for showers. Review of the facility ADL documentation for Resident #84 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 3 showers and refused 1 shower for the month of 6/2024. Review of the facility ADL documentation for Resident #84 dated 7/1/2024-7/31/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 6 showers and refused 2 showers for the month of 7/2024. Review of the facility ADL documentation for Resident #84 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower twice weekly. The resident received 2 showers and refused 1 shower from 8/1/2024-8/16/2024. During an interview on 8/12/2024 at 1:43 PM, CNA K stated she worked the 6:00 AM-6:00 PM shift. The CNA typically cared for 20 residents and showers were scheduled for the 6:00 AM-6:00 PM and the 6:00 PM-6:00 AM shifts. CNA K also stated she was not always able to complete the scheduled showers due to low staffing. During an interview on 8/12/2024 at 2:25 PM, LPN A stated she worked the 6:00 AM-6:00 PM shift, there was typically 1 CNA and 1 Nurse on the west hallway with a current census of 24 residents. LPN A stated there had been times when residents had not received the scheduled showers (unable to give exact dates) due to low staffing. During an interview on 8/13/2024 at 6:05 PM, CNA C stated she worked the 6:00 PM-6:00 AM shift. The CNA typically worked the west hallway, there was currently 24 residents on the hallway, and there was 1 CNA and 1 nurse scheduled to care for the 24 residents. Both shifts at the facility were responsible to complete scheduled showers and there were times when she was not able to complete the scheduled showers (unable to give exact dates) due to low staffing. CNA C stated the west hallway needed 2 CNAs to ensure scheduled showers were completed and there was most always only 1 CNA assigned to the hallway. During an interview on 8/13/2024 at 6:21 PM, CNA D stated she worked the east hallway from 2:00 PM-10:00 PM and she started work at the facility approximately 1 month ago. She stated typically there were 2 CNA's and 2 nurses who worked the east hallway until 10:00 PM for a census 50 residents. After 10:00 PM the hallway usually worked with 1 CNA and 2 nurses. During an interview on 8/13/2024 at 6:30 PM, LPN E stated she worked the east hallway form 6:00 PM-6:00 AM. There were typically 50 residents on the hallway with 1 CNA and 2 nurses to care for the residents. Showers were scheduled to be completed on both shifts. LPN E stated there were times when scheduled showers were not completed (unable to give exact dates) due to not enough staff. On Thursday 8/8/2024 there was 1 nurse and 1 CNA from 6:00 PM-6:00 AM on the hallway. During an interview on 8/13/2024 at 6:38 PM, LPN F stated she worked 6:00 PM-6:00 AM, worked the east hallway with a usual resident census of 50 on the wing, and 2 nurses with 1 CNA to provide care for the 50 residents. LPN F stated showers were scheduled to be completed on both shifts and there were times the scheduled showers were not provided due to not enough staff (unable to give exact dates). During an interview on 8/13/2024 at 6:48 PM CNA G stated she worked 6:00 PM-6:00 AM on the east hallway. There was typically 1 CNA and 2 nurses scheduled to work the hallway with 50 residents. CNA E stated she was responsible to complete 4-6 showers on her shift and was .lucky to complete 1 . on her shift. During an interview on 8/14/2024 at 8:15 AM, LPN H stated she worked 6:00 AM-6:00 PM on the west hallway, the hallway currently had 24 residents, and there was typically 1 CNA and 1 nurse scheduled to work the hallway. LPN H stated there were times (unable to give exact dates) the scheduled showers were not able to be completed due to not enough staff. During an interview on 8/14/2024 at 8:40 AM, LPN I stated she worked 6:00 AM-6:00 PM on the east hallway and there were typically 2 nurses and 2 CNAs scheduled for 50 residents. LPN I stated there had been times the scheduled showers were not able to be provided due to low staffing. During an interview on 8/14/2024 at 8:53 AM, LPN J stated she worked 6:00 AM-6:00 PM on the east hallway, there were typically 50 residents on the hallway, and 2 Nurses and 2 CNAs scheduled on the hallway. LPN J stated scheduled showers were not always completed (unable to give exact dates) due to frequent low staffing. During an interview on 8/14/2024 at 10:21 AM, LPN J stated she was the routine nurse who provided care for Resident #33 and the resident did not refuse showers. During an interview on 8/14/2024 at 1:13 PM, the Director of Nursing Services (DNS) stated the facility overall average census was 85-90. The DNS has received voiced concerns from CNAs and nurses regarding CNA staffing and scheduled showers not being provided to the residents. The DNS stated the facility's expectation for staffing was as follows: 1.The overall staffing goal for the secure unit on the 6:00 AM-6:00 PM and 6:00 PM-6:00AM was 1 nurse and 2 CNAs. Currently the secure unit had 1 Nurse and 1 CNA scheduled .a lot of days . and the average daily census was 17-18 residents. 2.The overall staffing goal on the east hallway for the 6:00 AM-6:00 PM was 2 nurses and 3-4 CNAs. Currently the east hallway had 2 nurses and 2-3 CNAs scheduled on the 6:00 AM-6:00 PM shift. The overall staffing goal for the 6:00 PM-6:00 AM on the east hallway was 2 nurses and 3 CNAs.Currently the east hallway had 2 nurses and 2 CNAs scheduled and the average daily census was 45. 3.The overall staffing goal on the west hallway for the 6:00 AM-6:00 PM and the 6:00 PM-6:00 AM shift was 1 nurse and 2 CNAs.Currently the west hallway had 1 nurse and 1 CNA scheduled on the 6:00 AM-6:00 PM and 6:00 PM-6:00 AM shift and the average daily was census 24. During an interview and review of the facility assessment on 8/14/2024 at 3:00 PM, the Administrator stated he was aware the facility had some staffing concerns, but the staff had not complained to him regarding staffing .I do know it [staffing concerns] exist . The Administrator confirmed he was aware some of the residents had not received scheduled showers at times. The Administrator stated the facility expectation for staffing was as follows: 1.The overall staffing goal on the secure unit for the 6:00 AM-6:00 PM was 1 nurse and 1-2 CNAs scheduled. The overall staffing goal for the 6:00 PM-6:00 AM was 1 nurse and 1 CNA. The average daily census was 16-19. 2.The overall staffing goal on the east hallway for the 6:00 AM-6:00 PM was 2 nurses and 3-4 CNAs scheduled. The overall staffing goal for the 6:00 PM-6:00 AM on the east hallway was 2 nurses and 3 CNAs scheduled. The average daily census was 44. 3.The overall staffing goal for the west hallway for the 6:00 AM-6:00 PM and the 6:00 PM-6:00 AM shift was 1 nurse and 1-2 CNAs (depending on census). The average daily census was 18-22. Review of the facility assessment with the Administrator revealed the facility staffing would include .Total Number Needed or Average .Licensed nurses providing direct care .5 .Nurse aides .6-8 . The Administrator stated this staffing would be .for any given time in the facility .the 5th nurse would be the wound care nurse . During an interview on 8/14/2023 at 3:39 PM, CNA B stated staffing had been an issue, she worked 3 (three) 12 hour shifts a week and there were at least 2 days she was unable to complete the scheduled showers for the residents due to low staffing. During an interview on 8/14/2024 at 8:30 PM, CNA O stated she was not always able to complete scheduled showers for the residents in the facility due to low staffing. During a review of the staffing schedule compared to actual punch times revealed the following: Actual hours worked on Thursday 7/4/2024: 1.The secure unit 6:00 AM-6:00 PM shift had 1 nurse (5:50 AM-6:13PM) and 1 CNA (6:49 AM-6:48 PM). The 6:00 PM-6:00 AM shift had 1 nurse (6:00 PM-8:00 AM) and 1 CNA (8:04 PM-3:04 AM), which left no CNA from 3:04 AM-6:49 AM. 2.The east hallway 6:00 AM-6:00 PM shift had 2 nurses (1 from 6:20 AM-6:10 PM and 1 from 5:47 AM-6:14 PM) and 1 CNA (8:29 AM-4:08 PM) and 1 CNA (1:54 PM-6:00 PM), which left 1 CNA from 8:29 AM until 1:54 PM). The 6:00 PM-6:00 AM shift had 2 nurses (1 from 5:53 PM-6:20 AM and 1 from 6:00 PM to 6:12 AM) and 1 CNA (1 from 5:57 PM-6:12 AM and 1 CNA from 6:10 PM -1:58 AM, which left 1 CNA from 1:58 AM-6:12 AM. 3.The west hallway 6:00 AM-6:00 PM shift had 1 nurse (5:46 AM-6:13 PM) and 1 CNA (6:48 AM-5:59 PM). The 6:00 PM-6:00 AM had 1 nurse (6:12 PM-6:08 AM) and 1 CNA (5:53 PM-7:14 PM). Actual hours worked on Sunday 8/4/2024: 1.The secure unit 6:00 AM-6:00 PM shift had 1 nurse (6:00 AM-6:28 PM) and 1 CNA (6:35 AM-6:07 PM). The 6:00 PM-6:00 AM shift had 1 nurse (5:44 PM-6:38 AM) and 1 CNA (5:15 PM-6:30 AM). 2.The east hallway 6:00 AM-6:00 PM shift had 2 nurses (1 from 5:30 AM-6:00 PM and 1 from 5:45 AM-6:15 PM) and 1 CNA (6:23 AM-2:00 PM). The 6:00 PM-6:00 AM shift had 2 nurses (1 from 5:56 PM-10:00 PM and 1 nurse from 5:57 PM-6:33 AM). 1 CNA (5:51 PM-9:53 PM), 1 CNA (5:47 PM-2:00 AM), 1 CNA (9:46 PM-8:47 AM), which left 1 CNA on the hallway from 2:00 AM-PM-8:47 AM). 3.The west hallway 6:00 AM-6:00 PM shift had 1 nurse (5:59 AM-6:32 PM) and 1 CNA (6:05 AM-6:14 PM). The 6:00 PM-6:00 AM had 1 nurse (5:45 PM-6:29 AM) and 1 CNA (5:15 PM-6:30 AM). Actual hours worked on Thursday 8/8/2024: 1.The secure unit 6:00 AM-6:00 PM shift had 1 nurse (5:50 AM-6:16PM) and 1 CNA (6:48 AM-6:30 PM). The 6:00 PM-6:00 AM shift had 1 nurse (6:07 PM-6:04 AM) and 1 CNA (6:00 PM-3:04 AM) and 1 CNA (3:00 AM -6:08 AM). 2.The east hallway 6:00 AM-6:00 PM shift had 2 nurses (1 from 6:15AM-6:45 PM and 1 from 5:53 AM-6:55 PM) and 3 CNAs (1 CNA from 5:54 AM-6:17 PM, 1 CNA from 2:00PM-6:00 PM, 1 CNA from 6:00 PM-10:00 PM and 1 CNA from 5:18 PM-3:00 AM). The 6:00 PM-6:00 AM shift had 1 nurse for a full shift (from 5:59 PM-6:14 AM) and 1 nurse worked over to complete a medication administration pass only (clocked in at 5:53 AM and clocked out at 6:55 PM) and 1 CNA (6:11 PM-6:15 AM). 3.The west hallway 6:00 AM-6:00 PM shift had 1 nurse (5:30AM-6:09 PM) and 1 CNA (6:00 AM-2:00 PM). The 6:00 PM-6:00 AM shift had 1 nurse (5:41 PM-6:22 AM) and 1 CNA (6:16 PM-6:47 AM). The hallway was left without a CNA from 2:00 PM until 6:16 PM. Actual hours worked on Thursday 8/17/2024: 1.The secure unit 6:00 AM-6:00 PM shift had 1 nurse (6:00 AM-6:00 PM) and 1 CNA (6:47 AM-6:37 PM). The 6:00 PM-6:00 AM shift had 1 nurse (6:00 PM-6:00 AM) and 1 CNA (6:27 PM-10:05 PM) and 1CNA (10:00 PM-6:00 AM). 2.The east hallway 6:00 AM-6:00 PM shift had 1 nurse from (9:00 AM-6:30 PM), 1 nurse (worked over until 9:30 AM from the 6:00 AM shift), 1 nurse (6:00 AM- 6:00 PM), 1 CNA (5:21 AM-6:29 PM), 1 CNA (5:58 AM-6:29 PM), 1 CNA (8:10 AM-6:28 PM), and 1 CNA (1:45 PM-6:28 PM). The 6:00 PM-6:00 AM shift had 1 nurse (6:04 PM-6:00 AM), 1 nurse (6:07 PM-12:31 AM), 1 CNA (6:20 PM-6:00 AM), and 1 CNA (2:00 PM-10:00 PM). 3.The west hallway 6:00 AM-6:00 PM shift had 1 nurse (6:00 AM-10:00 AM), which left the hallway without a nurse from 10:00 AM-5:52 PM. 1 CNA (6:00 AM-7:00 PM). The 6:00 PM-6:00 AM shift had 1 nurse (5:52 PM-6:47 AM), and 1 CNA (6:04 PM-6:56 AM). During an interview on 8/20/2024 at 6:31 PM, The DNS and Administrator confirmed the facility failed to ensure the expected and appropriate level of staffing was scheduled and staff available in the facility to meet the resident care needs for showers and to provide transportation needs for outpatient physician appointments. Refer to F-584, F-677, and F-842

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure 4 of 10 residents (Residents #34, #10, #57, and #33) were treated with dignity during the lunch meal in the dining room on 8/12/2024 when residents at the same table were not served the meal at the same time. The findings include: Review of the facility policy titled, Resident's Rights and Quality of Life, dated 5/1/2012, revealed .It is the policy .all residents have the right to a dignified existence .with .access to .services inside .the facility . Review of the facility policy titled, Dining and Meal Service, dated 1/1/2017, revealed .The dining experience will be person-centered with the purpose of enhancing each individual resident's .quality of life .Individuals at the same table will be served and assisted at the same time . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypoglycemia, Major depressive Disorder, Type 2 Diabetes, and Hypertension. Review of the admission MDS assessment dated [DATE], revealed Resident #34 was unable to complete the BIMS assessment due to the resident was rarely/never understood. The resident required setup assistance from staff with eating. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Depression, Senile degeneration of Brain, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #10 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. The resident required setup assistance from staff with eating. Review of the medical record revealed Resident #57 was admitted to the facility on [DATE] with diagnoses including Dementia, Hyperglycemia, Depression, and Type 2 Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed Resident #57 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. The resident required setup assistance from staff with eating. Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Dementia, Type 2 Diabetes, Autistic Disorder, and Adult Failure to Thrive. Review of the quarterly MDS assessment dated [DATE], revealed Resident #33 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact and the resident was independent with eating. During a dining observation on 8/12/2024 at 1:00 PM, in the main dining room, a total of 10 residents were seated in the dining room for the lunch meal. The observations revealed the following: During an observation and interview on 8/12/2024 at 1:07 PM, Resident #57 was seated in a wheelchair rolling himself around the dining room. The resident stated to the surveyor he would like to have his lunch because he was hungry. Certified Nursing Assistant (CNA) N retrieved Resident #57's meal tray from a cart on the East hallway (not from the dining room cart). The resident seated himself at a table alone and was served the lunch meal at 1:20 PM, 13 minutes after the resident stated he was hungry and requested his meal. Resident #34 was seated at a table with Resident #55 who was served the lunch meal at 1:13 PM. Resident #34 received the lunch meal at 1:25 PM, 12 minutes after Resident #55 had been served. Resident #10 was seated at a table with Residents #8, #21, and #82 who received thier lunch meal at 1:17 PM. Resident #10 received the lunch meal at 1:34 PM, 17 minutes after Residents #21, #8, and #82 had been served. Resident #33 was seated by himself at a table and was served the lunch meal at 1:29 PM, 29 minutes after the dining meal started. During an observation and interview on 8/12/2024 at 1:33 PM, The Activity Director entered the dining room with Resident #10's meal tray and stated Resident #10's lunch meal was in the resident's room on the bedside table and stated she was unsure who had left the meal in Resident #10's room. The Activity Director confirmed Resident #10's meal tray was left in the resident's room and the resident was not served the meal in the dining room until 1:34 PM. During an interview on 8/12/2024 at 1:50 PM, the Regional [NAME] President stated residents in the dining room were to be served one table at a time and confirmed the residents were not served timely for the lunch meal.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide Activity of Daily Living (ADL) related to showers for 5 residents (Resident #33, #39, #49, #77, and #84) of 24 residents reviewed for ADL's. The findings include: Review of a facility policy titled, Resident's Right and Quality of Life, dated 5/1/2012, revealed .all residents have the right to a dignified existence, self-determination .services inside .the facility . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Diabetes Type 2, Autism, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. The resident required supervision or touching assistance from staff for showers. Review of the facility ADL documentation for Resident #33 dated 5/1/2024-5/31/2024, revealed the resident was scheduled for a shower on Monday and Thursday every week. The resident received 0 scheduled showers for the month of 5/2024. Review of the facility ADL documentation for Resident #33 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower on Monday and Thursday every week. The resident received a shower on 6/6/2024 (Thursday), and 6/14/2024 (Friday). The resident did not receive 6 scheduled showers for the month of 6/2024. Review of the facility ADL documentation for Resident #33 dated 7/1/2024-7/31/2024, revealed the resident was scheduled for a shower on Monday and Thursday of every week. The resident received a partial bath on 7/9/2024 (Tuesday) and did not receive 8 scheduled showers for the month of 7/2024. Review of the facility ADL documentation for Resident #33 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower on Monday and Thursday of every week. The resident received a shower 8/1/2024 (Thursday), 8/17/2024 (Saturday), and did not receive 3 scheduled showers from 8/1/2024-8/16/2024. Review of the facility ADL documentation for Resident #33 revealed the resident received 1 partial bed bath and a total of 4 showers for the time period of 5/1/2024-8/16/2024. During an interview and observation on 8/14/2024 at 10:15 AM, Resident #33 stated he did not receive scheduled showers routinely and wanted to be bathed twice weekly .it makes me feel better . Resident #33 was not unkempt and no odors noted. During an interview on 8/14/2024 at 10:21 AM, LPN J stated she was the routine nurse for Resident #33 and the resident did not refuse showers. LPN J further stated scheduled showers were not always completed (unable to give exact dates). During an interview on 8/14/2024 at 10:21 AM, LPN J stated she was the routine nurse for Resident #33 and the resident did not refuse showers. During an interview on 8/14/2024 at 8:20 PM, CNA C revealed Resident #33 did not typically refuse showers and was not always able to complete the scheduled showers. CNA C further stated there was typically 3 or 4 showers scheduled per shift. Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Confusion, Contractures of Left Hip, Left Knee, Right Ankle, Left Ankle, Anxiety, Dementia, Depression, Seizures, and Peripheral Vascular Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #39 did not have a BIMS assessment conducted due to the resident was rarely or never understood and was dependent on staff for showers. Review of the facility ADL documentation for Resident #39 dated 5/1/2024-5/31/2024, revealed the resident was scheduled for a shower on Monday and Thursday of every week. The resident received a bed bath on 5/6/2024 (Monday) and received 0 scheduled showers during the month of 5/2024. Review of the facility ADL documentation for Resident #39 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower on Monday and Thursday of every week. The resident received a bed bath on 6/20/2024 (Thursday), 6/27/2024 (Thursday) and did not receive 6 scheduled showers during the month of 6/2024. Review of the facility ADL documentation for Resident #39 dated 7/1/2024-7/31/2024, revealed the resident was scheduled for a shower on Monday and Thursday of every week.The resident received 0 scheduled showers for the month of 7/2024. Review of the facility ADL documentation for Resident #39 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower on Monday and Thursday of every week. The resident received a shower on 8/1/2024 (Thursday) and did not receive 5 of the scheduled showers from 8/1/2024-8/16/2024. Review of the facility ADL documentation for Resident #39 revealed the resident received a total of 1 bed bath and 2 showers for the time period of 5/1/2024-8/16/2024. During an observation on 8/13/2024 at 1:10 PM, Resident #39 was lying in bed in his room. The resident was not unkempt, and no odors were noted. During an interview on 8/14/2024 at 3:49 PM, CNA B stated she was familiar with Resident #39. The resident required total assistance with bathing and the resident did not refuse showers. The CNA stated she worked 4 (four) 12-hour shifts and at least 2 of the days she was not able to complete the scheduled showers.CNA B further stated there was typically 3 or 4 showers scheduled per shift. Review of the medical record for Resident #49 revealed the resident was admitted to the facility on [DATE] with diagnoses including Stroke, Anxiety, Dementia, and Need for Assistance with Personal Care. Review of the quarterly MDS assessment dated [DATE], revealed Resident #49 scored a 13 on the BIMS assessment which indicated the resident was cognitively intact and required partial to moderate assistance from staff for showers. Review of the facility ADL documentation for Resident #49 dated 5/1/2024-5/31/2024, revealed the resident was scheduled for a shower on Tuesday and Friday every week. The resident received a scheduled shower 5/3/2024 (Friday), and 5/24/2024 (Friday). The resident did not receive 7 scheduled showers for the month of 5/2024. Review of the facility ADL documentation for Resident #49 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower on Tuesday and Friday every week. The resident received a scheduled shower 6/4/2024 (Tuesday) and did not receive 7 scheduled showers for the month of 6/2024. Review of the facility ADL documentation for Resident #49 dated 7/1/2024-7/31/2024, revealed the resident was scheduled for a shower on Tuesday and Friday every week. The resident received a shower on 7/12/2024 (Friday), 7/16/2024 (Tuesday), 7/20/2024 (Saturday), and 7/30/2024 (Tuesday). The resident did not receive 5 scheduled showers for the month of 7/2024. Review of the facility ADL documentation for Resident #49 dated 8/1/2024-8/16/2024, revealed the resident received 0 of the 5 scheduled showers from 8/1/2024-8/16/2024. Review of the facility ADL documentation for Resident #49 revealed the resident received a total of 7 showers for the time period of 5/1/2024-8/16/2024 . During a telephone interview on 8/13/2024 at 5:30 PM, Resident #49's daughter stated she had never seen the resident unkempt or with odors. During an observation on 8/14/2024 at 3:40 PM, Resident #49 was observed in his room lying in bed. The Resident was not unkempt, and no odors were noted. During an interview on 8/14/2024 at 3:49 PM, CNA B stated she was familiar with Resident #49 and the resident did not refuse showers or bed baths. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Brain Damage, Difficulty Walking, Weakness, Lack of Coordination, Bipolar, Drug Dependence, Restlessness, and Agitation. Review of the quarterly MDS assessment dated [DATE], revealed Resident #77 scored a 7 on the BIMS assessment which indicated the resident had moderate cognitive impairment and required substantial to maximal assistance from staff for showers. Review of the facility ADL documentation for Resident #77 dated 5/1/2024-5/31/2024, revealed the resident was scheduled for a shower on Tuesday and Friday of every week. The resident received a shower 5/3/2024 (Friday), 5/10/2024 (Friday), 5/14/2024 (Tuesday), and received a bed bath on 5/28/2024 (Tuesday). The resident did not receive 4 scheduled showers for the month of 5/2024. Review of the facility ADL documentation for Resident #77 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower on Tuesday and Friday of every week. The resident received a shower 6/7/2024 (Friday) and the resident did not receive 7 scheduled showers for the month of 6/2024. Review of the facility ADL documentation for Resident #77 dated 7/1/2024-7/30/2024, revealed the resident was scheduled for a shower on Tuesday and Friday of every week. The resident received a bed bath 7/16/2024 (Tuesday), and a partial bath on 7/23/2024 (Tuesday). The resident did not receive 7 scheduled showers for the month of 7/2024. Review of the facility ADL documentation for Resident #77 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower on Tuesday and Friday of every week. The resident received a shower on 8/9/2024 (Friday) and did not receive 4 scheduled showers from 8/1/2024-8/16/2024. Review of the facility ADL documentation for Resident #77 revealed the resident received a total of 1 partial bed bath [ washing the face, hands, and genital/perineal area], 2 bed baths [washing the entire body], and 5 showers for the time period of 5/1/2024-8/16/2024. There was no documentation stating the resident refused showers. During an observation on 8/12/2024 at 1:40 PM, Resident #77 was in his room sitting on his bed. The resident was not unkempt, and no odors were noted. During an interview on 8/14/2024 at 3:49 PM, CNA B stated she was assigned to Resident #77 regularly; he required total assistance with ADLs, and she had seen him refuse showers but not often. Review of the medical record revealed Resident #84 was admitted to the facility on [DATE] with diagnoses including Hypothyroidism, Heartburn, Depression, and Acute Kidney Failure. Review of the quarterly MDS assessment dated [DATE], revealed Resident #84 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact and required supervision or touching assistance from staff for showers. Review of the facility ADL documentation for Resident #84 dated 6/1/2024-6/30/2024, revealed the resident was scheduled for a shower on Wednesday and Saturday every week. The resident received a shower on 6/12/2024 (Wednesday), 6/19/2024 (Wednesday), 6/29/2024 (Saturday), and the resident refused a shower on 6/5/2024 (Wednesday). The resident did not receive 5 scheduled showers for the month of 7/2024. Review of the facility ADL documentation for Resident #84 dated 7/1/2024-7/31/2024, revealed the resident was scheduled for a shower on Wednesday and Saturday every week. The resident received a shower on 7/3/2024 (Wednesday), 7/6/2024 (Saturday), 7/13/2024 (Saturday), 7/20/2024 (Saturday), 7/27/2024 (Saturday), and 7/31/2024 (Wednesday. The resident refused a shower on 7/10/2024 (Wednesday), and 7/24/2024 (Wednesday). The resident did not receive 1 scheduled shower for the month of 7/2024. Review of the facility ADL documentation for Resident #84 dated 8/1/2024-8/16/2024, revealed the resident was scheduled for a shower on Wednesday and Saturday every week. The resident received a shower 8/3/2024 (Saturday), 8/10/2024 (Saturday) and refused a shower on 8/7/2024 (Wednesday). The resident did not receive 1 scheduled shower from 8/1/2024-8/16/2024. Review of the facility ADL documentation for Resident #84 revealed the resident refused 4 showers and received a total of 11 showers for the time period of 6/1/2024-8/16/2024. During an observation on 8/12/2024 at 11:00 AM, Resident #84 was lying in bed in her room. The resident was not unkempt and no odors were noted. During an interview on 8/12/2024 at 1:43 PM, CNA K stated she worked the 6:00 AM-6:00 PM shift. The CNA typically cared for 20 residents and showers were scheduled for the 6:00 AM-6:00 PM and the 6:00 PM-6:00 AM shifts. CNA K also stated she was not always able to complete the scheduled showers. During an interview on 8/12/2024 at 2:25 PM, Licensed Practical Nurse (LPN) A stated she worked the 6:00 AM-6:00 PM shift, there was typically 1 Certified Nursing Assistant (CNA) and 1 Nurse on the west hallway, and the current census was 24. LPN A stated there had been times when residents had not received the scheduled showers (unable to give exact dates). During an interview on 8/13/2024 at 6:05 PM, CNA C stated she worked the 6:00 PM-6:00 AM shift. The CNA stated both shifts at the facility were responsible to complete scheduled showers and there were times when she was unable to complete the scheduled showers (unable to give exact dates). During an interview on 8/13/2024 at 6:30 PM, LPN E stated she worked the east hallway form 6:00 PM-6:00 AM. There were typically 50 residents on the hallway with 1 CNA and 2 nurses to care for the residents. Showers were scheduled to be completed on both shifts. LPN E stated there were times when scheduled showers were not completed (unable to give exact dates). During an interview on 8/13/2024 at 6:38 PM, LPN F stated she worked 6:00 PM-6:00 AM, worked the east hallway, there were typically 50 residents on the wing, and 2 nurses with 1 CNA to work the hallway. LPN F stated showers were scheduled to be completed on both shifts and there had been times when the scheduled showers were unable to be completed (unable to give exact dates). During an interview on 8/13/2024 at 6:48 PM CNA G stated she worked 6:00 PM-6:00 AM on the east hallway. CNA E stated she was responsible to complete 4-6 showers on her shift and .lucky to complete 1 . on her shift. During an interview on 8/14/2024 at 8:15 AM, LPN H stated she worked 6:00 AM-6:00 PM on the west hallway. LPN H stated there were times (unable to give exact dates) showers were completed. During an interview on 8/14/2024 at 8:40 AM, LPN I stated she worked 6:00 AM-6:00 PM on the east hallway and there had been times scheduled showers were not able to be completed. During an interview on 8/14/2024 at 8:53 AM, LPN J stated she worked 6:00 AM-6:00 PM on the east hallway and the scheduled showers were not always completed (unable to give exact dates). During an interview on 8/14/2024 at 1:13 PM, the Director of Nursing Services (DNS) stated the facility overall average census was 85-90. The DNS has received voiced concerns from CNAs and nurses regarding CNA staffing and scheduled showers not being completed. During an interview on 8/14/2024 at 3:00 PM, the Administrator stated he was aware the facility had some staffing concerns. The staff had not complained to the Administrator regarding staffing .I do know it [staffing concerns] exist . The Administrator confirmed he was aware some of the residents had not received scheduled showers at times. During an interview on 8/14/2023 at 3:39 PM, CNA B stated she worked 3 (three) 12 hour shifts a week and there were at least 2 days she was unable to complete the scheduled showers for the residents. During an interview on 8/14/2024 at 8:30 PM, CNA O stated CNA stated she was not always able to complete scheduled showers for the residents. During an interview on 8/20/2024 at 10:30 AM, the DNS confirmed baths were not being recorded as being completed or not. Residents were not care planned as refusing bathing or showers and she was not aware of residents being out of the facility and unavailable. DNS confirmed that Resident #33 had only received from May 2024 - August 2024 3 out of 32 showers scheduled for resident. Refer to F-725, F-835

Based on facility policy review, medical record review, and interviews the facility failed to ensure the medical record was accurate and complete for 4 residents (Resident #33, #39, #49, and #77) of 24 resident Activities of Daily Living (ADL) records reviewed. The findings include: Review of the facility's undated policy titled, Purpose of the Patient Record, revealed .records are maintained to provide complete .accurate .documentation . Review of the medical record revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Autistic Disorder, and Hypertension. Review of a comprehensive care plan for Resident #33 dated 6/25/2024, revealed .resident has an ADL self-care performance deficit .BATHING/SHOWERING .Setup and assist as needed . Review of a quarterly [NAME] Data Set (MDS) assessment dated [DATE], revealed Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #33 was cognitively intact and required supervision or touching assistance with bathing. Review of the facility ADL documentation for Resident #33 dated 5/1/2024-5/31/2024, revealed the resident received 0 of the 9 scheduled showers during the month of 5/2024. Continued review of the ADL documentation revealed several days which were left blank, documented as Resident Not Available (RNA), or Not Applicable (N/A). Review of the facility ADL documentation for Resident #33 dated 6/1/2024-6/30/2024, revealed the resident received a shower on 6/6/2024 and 6/14/2024 of 8 scheduled showers during the month of 6/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #33 dated 7/1/2024-7/31/2024, revealed the resident received a shower on 7/9/2024 of 9 scheduled showers during the month of 7/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #33 dated 8/1/2024-8/20/2024, revealed the resident received 0 of the 6 scheduled showers during the month of 8/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. During an interview on 8/14/2024 at 3:49 PM with Certified Nursing Assistant (CNA) B stated she works the resident's hall regularly. She stated the resident required minimum assistance with ADLs. She stated low staffing had been an issue and out of her 3 12-hour shifts there were at least 2 days she was not able to provide the scheduled showers or complete the documentation of care or showers provided. During an interview on 8/14/2024 at 8:20 PM, CNA C revealed Resident #33 usually did not refuse showers. CNA C stated she was not always able to complete the scheduled showers or document the care or showers provided. During an interview on 8/14/2024 at 8:30 PM, CNA O revealed Resident #33 refused showers at times. CNA O stated she provided Resident #33 a bath on Tuesday, 8/13/2024, but did not document the shower on the ADL record. CNA stated she was not always able to complete the scheduled showers or document the care or showers provided. 41291 Review of the medical record revealed Resident #39 was admitted to the facility on [DATE] with diagnoses including Wernicke's Encephalopathy, Contractures of Left Hip, Left Knee, Right Ankle, Left Ankle, Anxiety Disorder, Dementia, Major Depressive Disorder, Epilepsy, and Peripheral Vascular Disease. Review of a quarterly [NAME] Data Set (MDS) assessment dated [DATE], revealed a BIMS assessment score of 00, which indicated Resident #39 had severe cognitive impairment and was dependent with all ADLS. Review of a comprehensive care plan for Resident #39 dated 7/31/2024, revealed .requires total assistance with ADL self-care performance deficit . Review of the facility ADL documentation for Resident #39 dated 5/1/2024-5/31/2024, revealed the resident received 1 bed bath and 0 showers of 8 scheduled showers during the month of 5/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #39 dated 6/1/2024-6/30/2024, revealed the resident received a shower on 6/20/2024 of 9 scheduled showers during the month of 6/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #39 dated 7/1/2024-7/31/2024, revealed the resident received 0 of the 8 scheduled showers during the month of 7/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #39 dated 8/1/2024-8/20/2024, revealed the resident received a shower on 8/12/2024 of 6 scheduled showers during the month of 8/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. During an interview on 8/14/2024 at 3:49 PM, CNA B stated that she did not recall Resident #39 ever refusing baths or showers and stated the resident was available on the scheduled shower days. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Anxiety Disorder, Dementia, and Need for Assistance with Personal Care. Review of a comprehensive care plan for Resident #49 dated 5/15/2024, revealed .has an ADL self-care performance deficit . Review of a quarterly [NAME] Data Set (MDS) assessment dated [DATE], revealed Resident #49 scored a 13 on the BIMS which indicated Resident #49 was cognitively intact and required staff assistance with ADLS. Review of the facility ADL documentation for Resident #49 dated 5/1/2024-5/31/2024, revealed the resident received showers on 5/3/2024 and 5/24/2024 of 10 scheduled showers during the month of 5/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #49 dated 6/1/2024-6/30/2024, revealed the resident received showers on 6/4/2024 and 6/21/2024 of 9 scheduled showers during the month of 6/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #49 dated 7/1/2024-7/31/2024, revealed the resident received a shower on 7/12/2024, 7/16/2024, 7/19/2024, and 7/30/2024 of 9 scheduled showers during the month of 7/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #49 dated 8/1/2024-8/20/2024, revealed the resident received a shower on 8/9/2024 of 5 scheduled showers during the month of 8/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. During an interview on 8/14/2024 at 3:49 PM, CNA B did not recall Resident #49 ever refusing shower or baths. CNA B stated there were times showers/bed baths were not provided or documented as completed during the shift, .did not have time to do it . CNA B stated at times would stay over (work overtime) to catch up documentation up, but not always. 49786 Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Difficulty Walking, Weakness, Lack of Coordination, Bipolar Disorder, Stimulant Dependence, Restlessness, and Agitation. Review of a quarterly MDS assessment dated [DATE], revealed Resident #77 scored a 7 on the BIMS assessment which indicated the resident has a severe cognitive impairment. Review of a comprehensive care plan for Resident #77 dated 8/15/2024, revealed the resident had an ADL self-care deficit related to Weakness, Anoxic brain, functional quadriplegic, Malnutrition and required substantial/maximal assistance with bathing/showering. Review of the facility ADL documentation for Resident #77, dated 5/1/2024-5/31/2024, revealed the resident receive a shower on 5/7/2024, 5/14/2024, 5/21/2024, and 5/24/2024 of 8 scheduled showers during 5/2024. Review of the facility ADL documentation for Resident #77, dated 6/1/2024-6/30/2024, revealed the resident received a shower on 6/7/2024 of 8 scheduled showers during 6/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #77, dated 7/1/2024-6/31/2024, revealed the resident received a shower on 7/9/2024, 7/16/2024, and 7/23/2024 of 9 scheduled showers during 7/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. Review of the facility ADL documentation for Resident #77, dated 8/1/2024-8/19/2024, revealed the resident received a shower on 8/9/2024of 5 scheduled showers during 8/2024. Continued review of the ADL documentation revealed several days which were left blank or was documented as RNA or N/A. During an interview on 8/14/2024 at 3:39 PM CNA B stated she provided care for Resident #77, regularly. She stated the resident required total assistance with ADLs. CNA B stated she has seen him refuse showers but not often. She stated low staffing had been an issue and out of her 3 12-hour shifts there were at least 2 days she was unable to provide the scheduled showers. CNA B further stated there were times the showers were completed but she did not have time to document them on the ADL record. During an interview on 8/20/2024 at 10:18 AM, the DNS stated it was her expectation for residents to receive 2 scheduled showers per week. The DNS reviewed Resident #33, #39, #49, and #77's ADL bathing records and confirmed the residents had not received the scheduled showers. DNS stated that some baths had not been documented in the medical record and felt like some holes were failure to chart which resulted in inaccurate medical record.

Based on facility policy review, medical record review, observation, and interview, the facility failed to provide a clean, homelike environment for 1 resident (Resident #77) of 90 residents reviewed for a clean, homelike environment. Review of the facility's policy titled, Residents Rights and Quality of Life, dated 5/1/2012, revealed, .all residents have the right to a dignified existence .with access to services inside and outside the facility .to receive services in a facility environment that is safe, clean and comfortable . Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses including Difficulty Walking, Weakness, and Lack of Coordination. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #77 scored a 7 on the Brief Interview for Mental for Status (BIMS) assessment which indicated the resident had severe cognitive impairment. During observations in room [ROOM NUMBER] on 8/12/2024 at 11:00 AM; on 8/13/2024 at 2:45 PM; on 8/14/2024 at 1:35 PM; and on 8/20/2024 at 8:20 AM, revealed Resident #77's bathtub contained dead insects in the bottom of the bathtub with a brownish, black dirt-like substance around the drain. During an observation and interview in room [ROOM NUMBER] on 8/20/2024 at 8:20 AM, with the Administrator, revealed Resident #77's bathtub contained dead insects in the bottom of the bathtub with a brownish, black dirt-like substance around the drain. The Administrator confirmed Resident #77's bathtub had not been maintained in a sanitary manner and did not represent a clean, homelike environment for the resident.

Based on facility policy review, medical record review, facility investigation documentation review, observations, and interviews, the facility failed to protect the resident's right to be free from physical abuse from another resident for 2 residents (Resident #22 and #54) when Resident #45 punched Resident #22 in the face and when Resident #13 struck Resident #54 twice in the face of 90 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated 1/2019, revealed .Abuse .infliction of injury, unreasonable confinement, intimidation, or punishment .Willful .means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm .Physical Abuse: includes but is not limited to .hitting, slapping, punching .a resident to resident altercation will be reviewed as .a situation of abuse .resident to resident event include .physically aggressive behavior, such as hitting .residents with communication disorders . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Schizoaffective Disorder. Review of a quarterly Minimum Data Assessment (MDS) assessment dated [DATE], revealed Resident #22 scored a 2 of the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Review of a comprehensive care plan for Resident #22 revised 7/19/2024, revealed .impaired cognitive function .r/t [related to] Dementia .difficulty making decisions .at risk for abuse related to impaired cognition .staff to monitor [the] resident for any signs of emotional distress . Review of the facility's investigation documentation dated 7/19/2024 at 2:30 PM, revealed .alleged incident .abuse .resident involved .[Resident #22] .additional resident involved .[Resident #45] .witnesses .[Certified Nursing Assistant (CNA) M] .description of the allegation .[CNA M] .witnessed [Resident #22] walking in the dining room and was holding a sock. [Resident #45] stood up and punched him [Resident #22] in the side of the face .no injuries .incident was witnessed .investigation revealed it was a verified incident .actions taken post investigation .[Resident #45] moved to [a] non-secured area as we [the facility] believe he [Resident #45] will be better served around residents who can respond when he [Resident #45] is moving towards them in the hallway to avoid negative interactions with non-demented residents . Review of a witness statement by CNA M dated 7/19/2024, revealed .I was going into the dining room to assist another resident when I observed [Resident #22] standing beside the table that [Resident #45] was sitting .[Resident #22] was just standing there holding a sock, when all of a sudden [Resident #45] jumped up from his chair and hit [Resident #22] on the left side of his face. I immediately separated [Resident #45 and Resident #22] then yelled for the nurse . Review of a witness statement by Licensed Practical Nurse (LPN) L dated 7/19/2024, revealed .this nurse heard [CNA M] on [the] unit yell and responded immediately .nurse observed [CNA M] had separated [Resident #22 and Resident #45] .[CNA M] reported that [Resident #45] had punched [Resident #22] in the left side of [the] face .[CNA M] informed this nurse she observed [Resident #22] standing by the table holding a sock and [Resident #45] punched [Resident #22] in the left side of the face . Review of a Progress Note for Resident #22 dated 7/19/2024 at 4:00 PM, revealed .This nurse heard [the] CNA [certified nursing assistant] on [the] unit yell and immediately responded .[The] CNA on [the] unit reported that one resident [Resident #45] had punched another [Resident #22] in the left side of the face. This nurse too [took] one resident into another room and called the abuse coordinator. DNS [Director of Nursing Services] was notified and [police department] was called .[the] CNA informed this nurse that she was entering the dinning [dining] room to assist another resident when she observed .[Resident #22] .standing at the table holding a sock and .[Resident #45] .punched him in the left side of face .[Resident #22 and #45] still separated at this time. No s/s [signs and symptoms] of distress noted. No c/o [complaints of] pain at this time . Review of a Skin Assessment for Resident #22 dated 7/19/2024, revealed .no reddened areas .no bruises .no open areas . Review of a Progress Note for Resident #22 dated 7/19/2024 at 4:30 PM, revealed .DNS followed up with resident post event - resident states he is unaware of being hit in face - resident is sitting in chair eating dinner - resident currently smiling and laughing as this DNS was speaking with him - no signs of distress noted at this time - resident denies any needs or complaints . Review of a Progress Note for Resident #22 dated 7/20/2024, revealed .resident is currently lying in bed with eyes closed - resident was reported to have slept well last night without any distress noted - no current signs of distress noted at this time . Review of a Nurse Practitioner's (NP) Progress Note for Resident #22 dated 7/22/2024, revealed .I am following up with [Resident #22] today because he was punched on the left side of his face by .[Resident #45] .on July 19, 2024. The resident does not remember the incident. Upon examination, he has no physical injuries to his face . Review of a Psychiatric (Psych) NP Progress Note dated 7/26/2024, revealed .I am following up with [Resident #22] today because he was punched on the left side of his face by .[Resident #45] .on July 19, 2024. Resident has no memory of [the] altercation and no injury is noted on [the] face. Staff report that he [Resident #22] is generally calm and have never seen him [Resident #22] be aggressive .mood has been stable . Review of the medical record revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Auditory Hallucinations, and Impulsiveness. Review of an annual MDS assessment dated [DATE], revealed Resident #45 scored a 5 on the BIMS assessment, which indicated the resident had severe cognitive impairment. Review of the comprehensive care plan for Resident #45 initiated 4/19/2024, revealed .Resident has potential to be physically aggressive towards others . with interventions including .Administer medications as ordered .Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document .Modify environment .When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress .Provide positive feedback for good behavior . Review of a Progress Note for Resident #45 dated 7/19/2024 at 4:01 PM, revealed .This nurse heard [the] CNA on [the] unit yell and immediately responded .[The] CNA on [the] unit reported that one resident [Resident #45] had punched another [Resident #22] in the left side of the face. This nurse too [took] one resident into another room and called the abuse coordinator. DNS [Director of Nursing Services] was notified and [police department] was called .[The] CNA informed this nurse that she was entering the dinning [dining] room to assist another resident when she observed .[Resident #22] .standing at the table holding a sock and .[Resident #45] .punched him in the left side of face .[Resident #22 and #45] [are] still separated at this time. No s/s of distress noted. No c/o pain at this time . Review of a Skin Assessment for Resident #45 dated 7/19/2024, revealed .no reddened areas .no bruises .no open areas . Review of a Progress Note for Resident #45 dated 7/19/2024 at 4:40 PM, revealed .this DNS spoke with resident following earlier event - resident does not recall hitting another resident [Resident #22] .resident [Resident #45] denies feelings of anxiety or anger at this time .resident is currently sitting and eating dinner .resident denies any needs or complaints .no signs of distress or behaviors noted at this time . Review of a Progress Note for Resident #45 dated 7/20/2024 at 11:23 PM, revealed .Resident [was] in [a] good mood seems to have no memory of [the] altercation from [the] incident with [the] other resident [Resident #22] .no sign of injury or distress . Review of a NP Progress Note for Resident #45 dated 7/22/2024, revealed .I am following up on an incident .CNA had separated .[Resident #22 and Resident #45] .CNA on the unit reported [Resident #45] had punched .[Resident #22] .in the left side of the face .On examination today [Resident #45] has no injuries . Review of a Psychiatric NP Progress Note for Resident #45 dated 7/26/2024, revealed .Asked to see resident today due to resident having physical altercation with .[Resident #22] .this past week on [7/19/2024] and follow-up due to increasing [a mood stabilizing medication] on [the] day of [the] event .[Resident #45] went up to .[Resident #22] .and hit [Resident #22] while that resident [Resident #22] was standing holding a sock .[Resident #45] was unable to recall event .Staff unsure of what could have provoked him to hit [Resident #22] .Since [the] incident [resident to resident altercation] .[Resident #45] has been calm and had no verbal outbursts or physical aggression .[Resident #45] has been moved off of secured unit into general population .adjusting well . Review of a comprehensive care plan for Resident #45 revised 7/26/2024, revealed .Resident has potential to be physically aggressive towards others .administer medications as ordered .Psych NP to review medication list .psych NP increased mood stabilizer [7/19/2024] .impaired cognitive function .use of psychotropic medications .Trial resident off secure unit . During an interview on 8/12/2024 at 11:55 AM, LPN L stated she was working the afternoon the allegation occurred (7/19/2024). LPN L stated she heard yelling coming from the dining room area and headed in that direction. LPN L stated Resident #22 and Resident #45 were already separated by CNA M. LPN L stated she was met in the hallway by CNA M assisting Resident #22 back to his room. LPN L stated she assessed Resident #22 and Resident #45 for injuries from the altercation and there were not any redness or injuries observed to any part of the body. LPN L stated after the altercation, both the residents were separated and could not even recall the physical altercation moments after the event. LPN L stated there had not been any further resident to resident occurrences between Resident #22 and Resident #45 and felt like this was an isolated event. LPN L confirmed the altercation between Resident #22 and Resident #45 resulted in physical abuse when Resident #45 hit Resident #22 in the face. During a telephone interview on 8/12/2024 at 6:23 PM, CNA M stated she was working the afternoon (7/19/2024) of the altercation between Resident #22 and #45. CNA M stated she had exited the dining room to get the charting device and upon return to the dining room she observed [Resident #22] standing 2-3 feet away from Resident #45. CNA M stated Resident #22 was holding a pair of socks in his hands and was looking at Resident #45. CNA M stated before she could walk over to Resident #22 to redirect him away from Resident #45, Resident #45 quickly stood up from the chair and struck Resident #22's left jaw with a closed fist. CNA M stated she immediately separated the residents and alerted the nurse. CNA M stated the nurse assessed Resident #22 and Resident #45 for injuries and none were observed. CNA M stated there had not been any further occurrences between Resident #22 and Resident #45 and felt like this was an isolated event. During an observation on 8/13/2024 at 10:02 AM, Resident #22 was sitting on the side of the bed, watching television, and there were no behaviors present. During an observation on 8/13/2024 at 10:07 AM, Resident #45 was sitting up in the bed, watching television. Resident #45 did not exhibit any behaviors and was alert and oriented to person. During an interview on 8/14/2024 at 11:15 AM, the DNS stated she was notified of the altercation between Resident #22 and Resident #45 on 7/19/2024. The DNS stated Resident #22 and Resident #45 were assessed for injuries and none were observed. The DNS stated both residents were calm after the event and could not even recall the event. The DNS confirmed the altercation between Resident #22 and Resident #45 had occurred and resulted in Resident #22 being hit in the face by Resident #45. During an interview on 8/15/2024 at 9:20 AM, Psych NP stated she was notified of the altercation between Resident #22 and Resident #45 that occurred on 7/19/2024. The Psych NP stated immediate interventions were initiated and have been successful to prevent a reoccurrence. The Psych NP stated [Resident #45] could have been triggered by Resident #22 being too close to him, but it is unknown due to Resident #45's cognition and impulsiveness. The Psych NP stated Resident #22 and Resident #45 did not sustain any harm from this instance of resident-to-resident abuse. The Psych NP confirmed the resident-to-resident altercation between Resident #22 and Resident #45 resulted in physical abuse when Resident #45 hit Resident #22. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including Neurocognitive Disorder, Muscle Weakness, and Anxiety. Review of a quarterly MDS assessment dated [DATE], revealed Resident #54 scored a 10 of the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the facility's investigation documentation dated 8/12/2024 at 1:25 PM, revealed .alleged incident .abuse .who made the allegation .[Resident #338] .resident involved .[Resident #54] .additional resident involved .Resident #13 .description of the allegation .[Resident #13] approached [Resident #54] and hit him in the face twice .this was reported by [Resident #338] who is noted to be cognitively intact .no injuries .investigation summary .it was determined that [Resident #13] believes that [CNA N] is his girlfriend and that any time she gives care/attention to another resident is has the potential to rile him [Resident #13] up .actions taken post investigation .[Resident #13] moved from [the secure unit] to allow [Resident #13] to have better interactions with other staff and not trigger this behavior . Review of a witness statement for Resident #338 dated 8/12/2024, revealed .preparing to eat lunch .[Resident #54] in [the] wheelchair was sitting at the end of [the] table .[Resident #13] was pushing [the] chair towards [Resident #54] when .[Resident #13 and Resident #54] .exchanged a few words [unknown] then [Resident #13] hit [Resident #54] twice in [the] forehead .staff separated . Review of an untitled typed document provided by the facility (not dated, timed, or signed) revealed .Phone Interview with CNA N .On [8/12/2024] .I was in the dining room preparing the residents for lunch .I heard [LPN L] say something to [Resident #13] so I turned around quickly and saw [Resident #13] standing up close [to] and over [Resident #54] trying to hit him .I went over to assist [LPN L] to escort [Resident #13] out of [the] dining area .[Resident #13] was then redirected by [LPN L] to his room and I went back into [the] dining area to check on [Resident #54] which stated he was okay .[Resident #13] was taken his lunch to his room per resident request .[Resident #54] did not show any signs of distress after incident . Review of an untitled typed document provided by the facility (not dated, timed, or signed) revealed .Phone Interview with LPN L .On [8/12/2024] at approximately 1:24pm, this nurse and [CNA N] on duty were in dining area preparing lunch for residents when another resident [Resident #338] stated, Hey honey .[Resident #13] .just hit .[Resident #54] .in the face twice .This nurse turned around and observed [Resident #13] with his fist balled up and attempting to swing at [Resident #54]. This nurse intervened immediately and separated [Resident #13 and Resident #54]. [CNA N] assisted .and redirected [Resident #13] out of [the] dining area. I [LPN L] did perform full assessments on both residents to which no visible injuries or skin abnormalities were noted. [Resident #13] had been redirected to his room per his request .[LPN L] asked [Resident #13] what happened, [Resident #13] stated, 'he is trying to take my woman' .[Resident #54] . [was] interviewed and stated he was hit in the face .but stated he was okay and denied any feelings of distress at that time . Review of a Progress Note for Resident #54 dated 8/12/2024 at 5:04 PM, revealed .at approx [approximately] 1324 [1:24 PM] .[LPN L] . and .[CNA N] .on unit were in the dinning [dining] room preparing to serve lunch when .[Resident #338] .came up and told me [LPN L] that [Resident #13] had hit [Resident #54] in the face twice. This nurse turned around and observed [Resident #13] standing beside [Resident #54] with his fists balled. This nurse and CNA on [the] unit got between .[Resident #13 and #54] .as [Resident #13] swung [at Resident #54]. No contact was made. This nurse and CNA on unit took [Resident #13] into his room and CNA went back to [the] dinning [dining] room. This nurse asked [Resident #13] why he had hit [Resident #54]. He [Resident #13] stated 'Because I want to hit him' [Resident #54] .and began trying to go back out the door. This nurse stopped [Resident #13] and asked why he wanted to hit [Resident #54] for no reason and [Resident #13] stated 'I have my reasons, he's [Resident #54] trying to take my woman'. This nurse went back to check on [Resident #54] and asked what had happened. [Resident #54] stated 'nothing' .I [LPN L] then asked if someone had hit him, [Resident #54] stated 'yes' I [LPN L] asked where he had been hit. [Resident #54] stated .somewhere in the face . I asked if he was hurt and he stated 'No' .No obvious injury noted on either resident . Review of a Skin Assessment for Resident #54 dated 8/12/2024, revealed .no reddened areas .no bruises .no open areas . Review of a comprehensive care plan for Resident #54 revised 8/13/2024, revealed . At Risk for negative impact of trauma on physical and mental health R/T exposure to abuse, violent and other adverse experiences .Struck by another resident .room change . Review of a Progress Note for Resident #54 dated 8/13/2024 at 6:15 AM, revealed .Resident is in bed at present with eyes closed. O [no] distress or complaints noted. O [no] behaviors noted this shift . Review of a Physician's Progress Note for Resident #54 dated 8/13/2024, revealed .I am seeing him today after .[Resident #54] .was assaulted by .[Resident #13]. [Resident #54] does recall the episode [resident to resident altercation] vaguely. When asked [Resident #54] what happened .[Resident #54] states 'I remember getting punched in the face,' pointing to his left cheek. He remembers nothing about the circumstances of the incident or who punched him .Memory impaired but pleasant .[Resident #54] denies headache, facial pain, pain with chewing . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia with Psychotic Disturbance, Schizophrenia, and Muscle Weakness. Review of an annual MDS assessment dated [DATE], revealed Resident #13 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of a Skin Assessment for Resident #13 dated 8/12/2024, revealed .no reddened areas .no bruises .no open areas . Review of a Progress Note for Resident #13 dated 8/12/2024 at 4:56 PM, revealed .at approx [approximately] 1324 [1:24 PM] This nurse [LPN L] and CNA [CNA N] on unit were in the dinning [dining] room preparing to serve lunch when .[Resident #338] .came up and told me [LPN L] that [Resident #13] had hit [Resident #54] in the face twice. This nurse turned around and observed [Resident #13] standing beside [Resident #54] with his fists balled. This nurse and CNA on [the] unit got between the two residents [Resident #13 and #54] as [Resident #13] swung [at Resident #54] .nurse and CNA on unit took [Resident #13] into his room and CNA went back to [the] dinning [dining] room. This nurse asked [Resident #13] why he had hit [Resident #54]. He [Resident #13] stated 'Because I want to hit him [Resident #54]' and began trying to go back out the door. This nurse stopped [Resident #13] and asked why he wanted to hit [Resident #54] for no reason and [Resident #13] stated 'I have my reasons, he's [Resident #54] trying to take my woman'. This nurse went back to check on [Resident #54] and asked what had happened. [Resident #54] stated 'nothing' I [LPN L] then asked if someone had hit him, [Resident #54] stated 'yes' I [LPN L] asked where he had been hit. [Resident #54] stated ' .somewhere in the face .' I asked if he was hurt and he stated 'No' .No obvious injury noted on either resident . Review of a comprehensive care plan for Resident #13 revised 8/13/2024, revealed .Resident has potential to be physically aggressive r/t episode of balling up fist in threatening manner .Actual Resident had a physical altercation with another resident .resident struck other resident .provide physical and verbal cues to alleviate anxiety .give positive feedback .assist verbalization of source of agitation .assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated .modify environment . Review of a Progress Note for Resident #13 dated 8/13/2024 at 6:12 AM, revealed .Resident is in bed at present with eyes closed. O [no] behaviors noted this shift. O [no] distress or complaints at present . Review of a Physician's Progress Note for Resident #13 dated 8/13/2024, revealed .I would rate this patient's dementia is severe .severe memory impairment, diminished insight, judgment, and problem-solving .oriented times person only. Yesterday's [resident to resident altercation] appears to [have] been an isolated incident .unable to determine from available information whether there were hallucinations or the patient was simply impulsive and agitated. No evidence of physical injury on exam .ordered [anti-anxiety medication] PRN [as needed] [for] anxiety . Review of the medical record revealed Resident #338 was admitted to the facility on [DATE] with diagnoses including Fatigue, Muscle Weakness, and Dementia. Review of an admission MDS assessment dated [DATE], revealed Resident #338 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an interview on 8/13/2024 at 9:35 AM, Resident #338 stated she witnessed the resident-to-resident altercation on 8/12/2024 between Resident #13 and Resident #54. Resident #338 stated she was waiting on lunch in the dining room when she observed Resident #13 walk over to Resident #54 while he was sitting in the wheelchair at the dining room table and proceeded to hit Resident #54 in the forehead with a closed fist (unsure of specific hand). Resident #338 stated Resident #13 and Resident #54 was immediately separated by the staff and did not see any visible injuries to Resident #54. During an observation and interview on 8/13/2024 at 11:15 AM, Resident #54 was lying in the bed, listening to the radio. Further observation revealed Resident #54 did not exhibit any behaviors and was alert and oriented to person. Resident #54 could not recall being hit by Resident #13. During an observation and interview on 8/13/2024 at 11:20 AM, Resident #13 was sitting up in the bed, watching television. Further observation revealed Resident #13 did not exhibit any behaviors and was alert and oriented to person. Resident #13 could not recall hitting Resident #54. During an interview on 8/13/2024 at 11:45 AM, CNA N stated she was working the afternoon (8/12/2024) of the altercation between Resident #13 and #54. CNA N stated she was in the dining room, assisting the residents with hand hygiene, when she turned around and visualized Resident #13 standing over Resident #54 with his right fist balled up. CNA N stated she immediately went over to Resident #13 to redirect and intervene. CNA N stated Resident #13 and Resident #54 were immediately separated. CNA N stated LPN L assessed Resident #13 and Resident #54 for injuries and none were observed. CNA N stated she was not sure what caused the altercation between Resident #13 and Resident #54. CNA N stated there had no further occurrences between Resident #13 and Resident #54 and felt like this was an isolated event. During an interview on 8/14/2024 at 11:20 AM, the DNS stated she was notified on 7/19/2024 of the altercation between Resident #13 and Resident #54. The DNS stated Resident #13 and Resident #54 were assessed for injuries and none were observed. The DNS stated Resident #13 and Resident #54 were calm after the incident and could not recall the physical altercation. The DNS confirmed a resident-to-resident altercation occurred between Resident #13 and Resident #54 on 8/12/2024 which resulted in Resident #54 being hit in the face by Resident #13. During a telephone interview on 8/15/2024 at 8:55 AM, LPN L stated she was working the afternoon (8/12/2024) of the altercation between Resident #13 and #54. LPN L stated she was in the dining room, assisting the residents with hand hygiene, when she was alerted by Resident #338 that Resident #13 hit Resident #54 twice in the forehead. LPN L stated she saw Resident #13 standing over Resident #54 with his right fist balled up ready to swing and hit Resident #54. LPN L stated she immediately went over to Resident #13 to redirect and intervene. LPN L stated CNA N was present and assisted with redirecting Resident #13 away from Resident #54. LPN L stated she asked Resident #13 why he hit Resident #54 and Resident #13 told her it was because he wanted to and had his reasons. LPN L stated she asked Resident #54 if someone had hit him and Resident #54 told her .yes .somewhere on the face . LPN L stated Resident #13 and Resident #54 was assessed for injuries and none were observed. LPN L confirmed the resident-to-resident altercation between Resident #13 and Resident #54 resulted in physical abuse when Resident #13 hit Resident #54 in the forehead. During a telephone interview on 8/15/2024 at 9:25 AM, the Psych NP stated she was aware of the resident-to-resident altercation that occurred on 8/12/2024 between Resident #13 and #54. The Psych NP stated immediate interventions were initiated and have been successful to prevent reoccurrence. The Psych NP stated it is unknown if Resident #13 was triggered by Resident #54 due to the resident's cognition and considered this resident-to-resident altercation between Resident #13 and #54 an occurrence of physical abuse when Resident #13 hit Resident #54.

Based on facility policy review, medical record review, and interviews, the facility failed to ensure professional standards of practice were followed when transportation was not provided to outpatient scheduled appointments for 2 residents (Resident #9 and Resident #83) of 4 residents reviewed for transportation needs. The findings include: Review of the facility's policy titled, Resident's Rights and Quality of Life, dated 5/1/2012, revealed .all residents have the right to .services .outside the facility .or of a decision to be transferred . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Difficulty Moving Spine, Chronic Obstructive Pulmonary Disease, Neurogenic Bladder, Hypertension, Depression, and Heart Burn. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During an observation and interview on 8/13/2034 at 10:35 AM, Resident #9 was observed dressed, seated in a wheelchair with her purse in her hands, and stated she was scheduled to see the urologist today. The resident stated her appointment was at 11:00 AM and she was waiting for transportation to arrive to take her to the appointment. The resident stated the Administrator had told her the staff would transport her to her appointment today. The resident stated if she was late to the appointment, the urologist would not see her. The resident stated she was unable to see the urologist in the past because of delayed transportation getting her late to the appointment. During an interview on 8/14/2024 at 9:30 AM, Licensed Practical Nurse (LPN) H stated Resident #9 had missed 3 to 4 scheduled urology appointments due to transportation problems. LPN H also stated Resident #9 had been late for one urology appointment, and the urologist would not see the resident because of the resident's late arrival. During a telephone interview on 8/14/2024 at 9:44 AM, the Patient Care Associate at the Urologist Office stated Resident #9 had 3 missed appointments which were scheduled on 6/11/2024, 7/22/2024, and 8/13/2024. She also stated Resident #9 had an appointment on 6/25/2024, but the resident arrived too late for the appointment, and it had to be rescheduled. The appointment which was scheduled for 8/13/2024 was re-scheduled for 8/16/2024 after the resident missed her appointment again yesterday. During an interview on 8/14/2024 at 10:51 AM, the Director of Nursing Services (DNS) stated she was aware of Resident #9 had missed some urology appointments and stated the appointments were rescheduled related to insufficient staff to provide the transportation. The DNS confirmed Resident #9 had an appointment on 6/25/2024, arrived at the appointment late, and the Urology office rescheduled the appointment. The DNS confirmed Resident #9 missed scheduled Urology appointments on 6/11/2024, 7/22/2024, and 8/13/2024. The 8/13/2024 Urology appointment was rescheduled for 8/16/2024. During an interview on 8/15/2024 at 10:28 AM, the Medical Director (MD) stated Resident #9 had Chronic Urinary Retention and required an indwelling urinary catheter. The resident had a long history of recurrent Urinary Tract Infections (UTIs) and took Macrobid (antibiotic medication used to treat UTIs). The MD stated the facility Nurse Practitioner (NP) had evaluated the resident multiple times and had been able to treat Resident #9 at the facility with no complications. The MD further stated the missed Urology appointments did not cause the resident any harm. During an interview on 8/19/2024 at 9:52 AM, Resident #9 stated she was transported to the rescheduled urology appointment on 8/16/2024 by Medical Services and was evaluated by the urologist. 50480 Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Chronic Pain, Liver Disease, Heart Burn, and Abdominal Swelling. Medical record review of the admission MDS assessment dated [DATE], revealed Resident #83 scored an 11 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the Nurse Practitioner's (NP) note dated 7/22/2024, revealed the NP planned to discuss a stomach doctor consultation visit with the resident and resident's representative. The appointment was to establish the resident with a specialist. During an interview on 8/19/2024 at 3:00 PM, Resident #83 stated he had missed an appointment with a stomach doctor sometime this month (unsure of the exact date). The resident stated a staff member had informed him the appointment was rescheduled and he was not informed why the appointment had been rescheduled. The resident also stated the appointment was for him to become established with a different stomach doctor (due to a history of ascites from cirrhosis of the liver). During an interview on 8/20/2024 at 8:30 AM, the Resident Appointment Scheduler stated she was hired at the facility .a couple of weeks ago . Resident #83 had a .stomach doctor . appointment scheduled for 8/13/2024. The Resident Appointment Scheduler stated the day of Resident #83's appointment, she had rescheduled the appointment related to insufficient staff available to transport or assist Resident #83 to the appointment. During an interview on 8/20/2024 at 8:41 AM, the Administrator stated Resident #83 had a doctor appointment scheduled on 8/13/2024, and confirmed the appointment was rescheduled related to insufficient staff available to transport or assist Resident #83 to the appointment. During a telephone interview on 8/21/2024 at 10:19 AM, the Gastroenterology Associates office Appointment Scheduler stated Resident #83 had a consult appointment scheduled for 8/13/2024 and the resident was a .no show . for the appointment. The facility called the Gastroenterology office and rescheduled a new consult appointment for 11/8/2024 at 12:30 PM for Resident #83. During an interview on 8/22/2024 at 11:00 AM, NP W stated she was aware Resident #9 missed multiple urology visits and stated she was aware Resident #83 missed his stomach doctor appointment on 8/13/2024. NP W stated the rescheduled appointments were related to insufficient staff to provide the needed transportation or to assist the residents to their appointments. NP W also stated the missed appointments for Resident #9 and Resident #83 would not have caused harm or adverse effects to the residents.

Based on facility policy review, observation, and interviews the facility failed to ensure expired medications and medical supplies were not available for resident use in 1 of 2 medication rooms observed. The findings include: Review of the facility's policy titled, Medication Storage, revised 04/2022 revealed .the facility is responsible for maintaining proper storage .Expired .medications are immediately removed from stock and disposed . During an observation and interview on 8/19/2024 at 6:35 PM, in the East medication room with Licensed Practical Nurse (LPN) F revealed the following expired supplies: 5 - 3 milliliter (mL) 25 gauge (ga) x (by) 1 inch syringe (device used to deliver medication into the muscle) with an expiration date of 11/8/2023 2 - Heparin Lock Flush Solution 5mL syringe with 500 USP (United States Pharmacopeia) units in 0.9% (percent) Normal Saline (medication administered into intravenous lines to prevent blood clots in the line) with an expiration date of 3/2024 1 - 3 mL 22 ga x 1 in syringe with an expiration date of 4/30/2024 46 - 10 mg (milligram) Bisacodyl suppositories (medication given rectally to promote a bowel movement) with an expiration date of 4/30/2024 12 - 3 mL 21 ga x 1 in syringe with an expiration date of 4/30/2024 40 - 650 mg Acetaminophen suppositories (medication given rectally to relieve pain or reduce a fever) with an expiration date of 7/2024. LPN F confirmed a total of 18- 3 mL syringes, 86- suppositories, and 2- Heparin Lock Flushes were stored in the East medication room were expired and available for resident use. During an interview on 8/20/2024 at 10:55 AM, The Director of Nursing Services (DNS) stated the expired medications and supplies should have been removed from the East medication storage room, placed into the pharmacy return bin, and discarded by the pharmacy. The DNS also confirmed the total 18- 3 mL syringes, 86- suppositories, and 2- Heparin Lock Flushes were stored in the East medication room, were expired and available for resident use.

Based on facility policy review, observation, and interview, the facility failed to ensure garbage and refuse were properly contained in 3 of 3 dumpsters (dumpsters A, B, and C). The findings include: Review of the facility's policy titled, Waste Control, dated 1/1/2012, revealed .it is the policy of this facility to store garbage and trash in a sanitary manner .dumpster must be kept closed at all times . During an observation of the outside dumpster area on 8/12/2024 at 10:59 AM, with the Dietary Manager (DM), revealed 3 dumpsters for waste disposal. Further observation revealed dumpsters A, B, and C had no drain plugs intact to the bottom corner of all 3 dumpsters, which left a golf-ball sized opening. The missing dumpster plug to all three dumpsters left dumpster A, B, and C's contents open to the air, elements, and potential exposure to pests. During an interview on 8/12/2024 at 11:00 AM, the DM confirmed the drain plugs for dumpsters A, B, and C were not intact and all three dumpster's contents were not contained properly.

Based on facility documentation review and interview, the facility failed to complete the facility assessment to accurately reflect the needs and services provided by the facility, which had the potential to affect 90 of 90 residents. The findings include: Review of the Facility Assessment Tool dated 7/28/2024, revealed the facility did not include the staffing parameters for the secure unit and contingency staffing protocol in response to emergency and crisis situations. Further review revealed on 5/1/2024, the facility's laundry service had changed with new building modification plans to add an in-house laundry room which was not reflected in the facility's assessment. Continued review revealed no documentation in the facility assessment that the facility allowed input from the direct-care staff, residents, or resident families regarding the needs and services provided by the facility. During an interview on 8/20/2024 at 7:45 PM, the Administrator confirmed the secure unit staffing parameters, contingency staffing protocol in response emergency/crisis situations, building modification plans to add an in-house laundry room, change in the facility's laundry service, and documentation regarding the input from direct-care staff, residents, or resident families regarding the needs and services provided by the facility had not been reflected on the facility assessment dated [DATE].

Based on facility policy review, medical record review, facility investigations, and interviews, the facility failed to ensure allegations of abuse were reported to the state agency within 2 hours for 6 residents (Residents #1, #3, #4, #22, #11, and #12) of 21 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 2020, revealed .Reporting/Response. The facility will have written procedures that include .Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies ( . law enforcement when applicable) within specified time frames. Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or .Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury . Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Senile Degeneration of the Brain, Dementia, and Malignant Neoplasm of the Stomach and expired [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 scored a 9 on the Brief Interview Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the facility's investigation dated [DATE], revealed Resident #1 reported to Certified Nurse Assistant (CNA) E she was afraid of CNA D and did not want CNA D to provide care for her. Review of the Facility Reported Incident (FRI) for Resident #1 revealed the facility submitted an allegation of staff to resident verbal abuse on [DATE] at 12:55 PM, to the state agency. Further review revealed the allegation occurred on [DATE] at 4:30 AM. The facility failed to report to the state agency within the 2-hour timeframe, there was a delay of 8 hours and 25 minutes between the time of the incident identification and the time the facility reported the incident to the state agency. During a telephone interview on [DATE] at 6:30 PM, Licensed Practical Nurse (LPN) F confirmed she notified the Director of Nursing Services (DNS) of Resident #1's allegation on [DATE] and the DNS informed LPN F she would notify the Administrator. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Cerebral Infarction, Unspecified Dementia, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. During a telephone interview on [DATE] at 6:30 PM, LPN F confirmed she notified the Director of Nursing Services (DNS) of Resident #3's allegation of verbal abuse on [DATE] and the DNS informed LPN F she would notify the Administrator. Review of Resident #3's FRI revealed the facility submitted an allegation of staff to resident verbal abuse on [DATE] at 1:30 PM to the state agency. Further review revealed the incident occurred on [DATE] at 4:30 AM. The facility failed to report the incident to the state agency within the 2-hour timeframe, there was a delay of 9 hours between the time of the incident was identified and the time the facility reported the incident to the state agency. Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Alzheimer's Disease, Hallucinations, and Delirium. Review of a quarterly MDS assessment dated [DATE], revealed Resident #4's BIMS score showed moderate cognitive impairment. Medical record review revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Dementia, Other Behavioral Disturbance, Anxiety Disorder, and Encounter for Palliative Care. Review of an admission MDS assessment dated [DATE], revealed Resident #22 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment. Review of the facility investigation dated [DATE], showed the facility submitted a FRI as an allegation of physical abuse to the state agency. The documentation stated staff observed and intervened when Resident #22 had Resident #4's forearms in her hands on [DATE] at 10:32 AM. Further review revealed the date and time of reporting the allegation of physical abuse to the state agency was made on [DATE] at 2:00 PM. The facility failed to report the incident to the state agency within the 2-hour timeframe and there was a delay of 20 hours and 32 minutes between the time the incident was identified and the time the facility reported the incident to state agency. During an interview on [DATE] at 10:40 AM, the DNS confirmed the facility failed to report allegation of physical abuse for Resident 's #4 and #11 to the state agency timely and to the local police. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Mood Disorder, Anxiety Disorder, and Dementia. Review of an annual MDS assessment dated [DATE], revealed Resident #11 scored a 8 on a BIMS assessment, which indicated the resident had moderate cognitive impairment. Medical record review revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Heart Failure, and Atrial Fibrillation. Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 5 on a BIMS assessment which indicated the resident had severe cognitive impairment. Review of the FRI dated [DATE], revealed an alleged resident-to-resident altercation between Residents' #11 and #12 occurred on [DATE] at 8:15 PM. Continued review showed the facility reported the altercation to the state agency on [DATE] at 6:00 AM. Further review showed the facility failed to report the incident to the state agency within the 2-hour timeframe and there was a delay of 9 hours and 45 minutes between the time the incident was identified and the time the facility reported the incident to state agency. During an interview on [DATE] at 10:40 AM, the DNS confirmed the facility failed to report the allegation of resident-to-resident physical abuse on [DATE] between Resident #11 and Resident #12 to the state agency timely, within the mandatory 2-hour time frame. During an interview on [DATE] at 4:00 PM, the Administrator confirmed the facility failed to report employee to resident verbal abuse for Resident #1 and Resident #3 and the facility failed to report allegations of resident-to-resident physical abuse that occurred between Resident #4 and Resident #22 to the state agency within the mandatory 2-hour reporting period. During further interview the Administrator stated .I'm responsible . Refer to F600 and F610.

Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to ensure thorough investigations were conducted for 1 resident (Resident #13) of 3 residents reviewed for injuries of unknown origin and for 5 residents (Residents #11, #12, #1, #3, and #4 and #22) of 21 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Resident-to-Resident Altercations, dated ,d+[DATE], revealed .All altercations, including those that may represent resident-to-resident abuse, shall be investigated .Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercations .Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record . Review of the facility's policy titled, Abuse and Neglect - Clinical Protocol, dated ,d+[DATE], revealed .Assessment and Recognition .The nurse will assess the individual and document related findings. Assessment data will include .Injury assessment (bleeding, bruising deformity, swelling .pain assessment .Current behavior .Patients' age and sex .All current medications .Other platelet inhibitors .Vital signs .Behaviors over last 24 hours .history or tendency towards bruising .all active diagnosis .any recent labs . Review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, dated ,d+[DATE], revealed .All accidents or incidents involving residents .occurring on our premises shall be investigated .the following data shall be included .Report of Incident/Accident Form .The circumstances surrounding the accident or incident .name(s) of witnesses and their accounts of the accident or incident .Follow-up information . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia, Depression, and Seizures. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored an 8 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of a Nurse's note for Resident #13 dated [DATE], revealed the resident complained of chest/rib pain and a chest x-ray was order and completed on [DATE]. Review of Resident #13's Chest x-ray report (obtained through the mobile imaging company) dated [DATE], revealed the resident had sustained a left 9th rib fracture. Review of the facility's investigation for Resident #13 dated [DATE], revealed the facility was unable to determine how or where the resident's injury occurred. There were no noted changes in the resident's behavior related to his injury. The resident did state he had rib/chest pain on [DATE] and informed the nurse. Further review showed the facility had no documentation to indicate staff and resident interviews were conducted after Resident #13's injury of unknown origin was identified on [DATE]. During an interview on [DATE] at 9:25 AM, the Director of Nursing Services (DNS) stated the staff interviews for the injury of unknown origin could not be located and confirmed the injury of unknown origin investigation had not been completed for Resident #13. During an interview on [DATE] at 11:10 AM, the DNS confirmed it was her expectation the facility would conduct interviews with staff and residents, who had a BIMS of 12 or greater, after an identification of injury of unknown origin or any allegation of abuse. Continued interview confirmed there was no documentation of staff interviews in the facility's investigation. The DNS confirmed a thorough investigation was not conducted for Resident #13's injury of unknown origin. Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Depression, Mood Disorder, Insomnia, Anxiety Disorder, and Dementia. Review of an annual MDS assessment dated [DATE], revealed Resident #11 scored an 8 on a BIMS assessment which indicated the resident had moderate cognitive impairment. Medical record review revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Heart Failure, Atrial Fibrillation, and Insomnia. Review of a quarterly MDS assessment dated [DATE], revealed Resident #12 scored a 5 on a BIMS assessment which indicated the resident had severe cognitive impairment. Review of the facility investigation for Residents #11 and #12 dated [DATE], revealed a Certified Nursing Assistant (CNA) on [DATE], heard yelling in Resident #11's and #12's room (the residents were roommates) and entered the room. Further review revealed the nurse observed 3 vertical red areas, approximately 2 inches in length and ,d+[DATE] inch wide. Review revealed Resident #11 had no open areas noted on her skin. Resident #11 had a slight red area located on the right upper side of her face. Further review revealed no documentation of resident skin assessments, resident interviews or staff interviews were conducted by the facility and in the facility's investigation. During an interview on [DATE] at 11:10 AM, the DNS confirmed it was her expectation the facility would conduct interviews with staff and residents with a BIMS score of 12 or greater. The DNS confirmed it was her expectation skin assessments would be conducted on all residents with BIMS less than 12 following an allegation of abuse. The DNS confirmed the facility did not conduct a complete and through investigation into the resident-to-resident abuse incident which occurred on [DATE]. Medical record review revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Senile Degeneration of the Brain, Dementia, and Malignant Neoplasm of the Stomach. Resident #1 expired in the facility on [DATE]. Review of a quarterly MDS assessment dated [DATE], revealed Resident #1 scored a 9 on a BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the Nurse's progress notes for Resident #1 date [DATE], revealed no documentation to indicate the resident's physician and family were notified. Review of a facility investigation documentation dated [DATE], showed Resident #1 reported to Certified Nurse Assistant (CNA) E she was afraid of CNA D and did not want CNA D to provide care for her. Continued review showed no documentation of physician notification nor notification of family representative. Medical record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including Anemia, Unspecified Dementia, and Anxiety. Review of the quarterly MDS assessment dated [DATE], revealed Resident #3 scored 12 on a BIMS assessment which indicated the resident had moderate cognitive impairment. Review of the facility investigation summary of resident interviews conducted on [DATE], revealed Resident #3 reported CNA D was rude and talked down to him. Continued review showed no documentation of physician or family representative notification. During an interview on [DATE] at 11:10 AM, the DNS confirmed the expectation was to notify the residents' physician and family representative after any allegation of abuse. Continued interview confirmed there was no documentation of physician or family representative notification in the investigation documentation for Resident #1 and Resident #3. Medical record review revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Anxiety Disorder, Alzheimer's Disease, Hallucinations, and Delirium. Review of a quarterly MDS assessment dated [DATE], revealed Resident #4 had a BIMS score of 12 which indicated the resident had moderate cognitive impairment. Medical record review revealed Resident #22 was admitted to the facility on [DATE], with diagnoses including Dementia, Other Behavioral Disturbance, Anxiety Disorder, and Encounter for Palliative Care. Review of an admission MDS assessment dated [DATE], revealed Resident #22 scored a 6 on BIMS which indicated the resident had severe cognitive impairment. Review of the facility investigation dated [DATE], showed the facility failed to perform skin assessments, and complete staff and resident interviews after an allegation of Resident-to-Resident abuse between Resident #4 and #22. During an interview on [DATE] at 11:10 AM, the DNS confirmed the expectation was to conduct interviews with staff, and residents with a BIMS score of 12 or greater and to complete resident skin assessments after an allegation of abuse was identified. Continued interview confirmed there was no documentation of skin assessments or staff /resident interviews included in the facility investigation. The DNS confirmed a thorough investigation was not completed for the allegation of Resident-to-Resident abuse between Resident's #4 and #22. During an interview on [DATE] at 3:50 PM, the Administrator stated .We had issues with incomplete investigations . During an interview on [DATE] at 4:00 PM, the Administrator stated investigations for abuse and injuries of unknown origin were expected to include staff interviews, interviews with residents with BIMS of 13 or greater, and skin sweeps of residents. Further interview revealed .I'm responsible . 35460 40606

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent physical abuse for 1 resident (#3) of 8 residents reviewed for physical abuse. Resident #3 was the victim of a resident-to-resident altercation and sustained superficial lacerations and abrasions to both forearms, face, and a deep laceration behind the temple area of the scalp which required skin glue at the hospital emergency room , resulting in Harm for Resident #3. The findings include: Review of the facility policy Abuse & Neglect Policies & Procedures, undated, revealed Abuse is defined as wilful infliction of injury .Physical, verbal, mental . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was discharged to the hospital on 4/9/2022 for behavioral symptoms and return was not anticipated. Review of a baseline care plan dated 3/8/2022 showed Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's interventions for behaviors was to que and supervise the resident. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2 had a Brief Interview for Mental Status (BIMS) of 4, indicating severe cognitive impairment. The MDS showed no behavioral symptoms at the time of the assessment. Resident #2 was independent with bed mobility, transfer, and locomotion on and off unit. Review of a comprehensive care plan updated 4/9/2022 revealed Resident #2 was at risk for disruptive/inappropriate behaviors with interventions for behaviors of redirection, provide quiet, calm environment, and psych consult as needed. Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly MDS assessment dated [DATE] showed Resident #3 had a BIMS score of 6, indicating severe cognitive impairment. Review of a facility investigation dated 4/9/2022 revealed on 4/7/2022, at 8:00 PM, Resident #2 became agitated stating she wanted to go home. Resident #2 began exit seeking and hitting staff members when they attempted to redirect her. The investigation showed the physician was notified, ordered lab work, and a one time dose of [MEDICATION(S)] was ordered. Resident #2 went to bed shortly after and no further physical aggression was documented 4/7/2022 - 4/8/2022. Continued review revealed Resident #2 continued to wander the hallways but was easily redirected. On 4/9/2022, Resident #2 went into Resident #3's room and hit Resident #3 multiple times with a crucifix hanging on his wall. Resident #3 punched and kicked back to get Resident #2 off of him. Resident #3 was taken to the emergency room for superficial lacerations to his face and head and abrasions to his upper extremities. Resident #3 had one wound slightly gaping which was closed with skin glue at the hospital emergency room . Review of a skin assessment for Resident #3 on 4/9/2022 revealed the resident had a right ear superficial cut, a laceration above the left temporal area, right arm scratches, and the right side of the nose had a cut. Review of a nursing note for Resident #3 dated 4/9/2022 .transported via EMS [Emergency Medical Services] to hospital . Review of hospital emergency room records for Resident #3 dated 4/9/2022 revealed .Superficial lacerations and abrasions noted to the bilateral forearms, face, and the left parietal [behind temple area] scalp. Area on the left parietal scalp was slightly larger and deeper than the rest .Patient presents after a closed head injury due to an apparent assault .One wound was slightly gaping and was closed with skin glue Review of a witness statement on 4/9/2022, revealed Resident #3 stated .sleeping and I woke up to her over top of me hitting me with something . Review of a witness statement dated 4/9/2022, revealed Licensed Practical Nurse (LPN) #3 stated .Resident [Resident #3] rolled out of room in wheelchair with visible injuries .EMS, on-call Dr [doctor] was called . Review of a witness statement dated 4/9/2022, revealed Certified Nursing Assistant (CNA) #1 stated .I seen the resident [#3] coming out of their room, covered in blood . Review of a witness statement dated 4/9/2022, revealed CNA #2 stated .The resident [#3] was getting attack while in the Bed Sleep. He came out of the bed blooded and yelling . During observation and interview on 5/16/2022 at 10:00 AM, Resident #3 had no visual signs of scratches, bruising, or lacerations. Resident #3 stated he recalled an incident when Resident #2 came into his room while he was asleep in bed and began hitting him with something and they took her to jail. Resident #3 said he had no problems before or after that day with any residents in the facility. During telephone interview on 5/17/2022 at 2:30 PM, LPN #3 stated she was working on 4/9/2022 when Resident #2 and Resident #3 had an altercation. The LPN stated Resident #2 was in the hallway holding a crucifix. She stated Resident #3 came out of his room with visible injuries. The LPN stated both residents were transferred to the hospital. During an interview on 5/18/2022 at 8:29 AM, the Director of Nursing (DON) stated witnesses reported on 4/9/2022 Resident #2 was in the hallway holding a crucifix from Resident #3's room. Resident #3 came out of his room bleeding, stating Resident #2 had come in his room and assaulted him. The DON stated Resident #3 was sent to the emergency room for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 5/18/2022 at 9:15 AM, the Administrator stated the facility failed to protect Resident #3 from abuse. Interview confirmed on 4/9/2022, Resident #3 was harmed during a resident-to-resident altercation with Resident #2.

Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to ensure a resident was free from a significant medication error for one resident (Resident #1) of 6 residents reviewed for medication administration. Facility staff administered the incorrect medications to Resident #1 which resulted in admission to a hospital Intensive Care Unit on 6/17/2021. The findings include: Review of the facility policy titled, Administering Medications, revised 12/2012 showed .The Director of Nursing Services will supervise and direct all nursing personnel who administer medications and/or have related functions .Medications must be administered in accordance with the orders .The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include .Checking identification band .Checking photograph attached to medical record .verifying resident identification with other facility personnel .The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dose, right time and right method (route) of administration before giving the medication .Medications ordered for a particular resident may not be administered to another resident . Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician orders dated from 5/30/2021 through 6/28/2021 showed Resident #1 did not have a physician's order for oral or injectable diabetic medications. Review of Resident #1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility documentation titled, Medication Error Report, dated 6/16/2021 showed .Description of error .On 6/16/2021 at approximately 20:30 [8:30 PM] [Resident #1] received [roommate's name] bedtime PO [oral] medications by mistake. She [Resident #1] received .[MEDICATION(S)] [diabetic medication] 4 mg [milligram], [MEDICATION(S)] [diabetic medication] 1000 mg, [MEDICATION(S)] [pain medication] 5/325 mg, [MEDICATION(S)] [anti-convulsant medication] 100 mg, [MEDICATION(S)] [blood pressure medication] 5 mg, Carvediolol [blood pressure medication] 3.125 mg, [MEDICATION(S)] [cholesterol medication] 20 mg .Outcome to resident .Resident hypoglycemic throughout the night .sent to ER [emergency room ] .Corrective action taken .Nurse [Licensed Practical Nurse (LPN #3)] in-serviced on 5 rights - right time, dose, route, medication, patient .In-serviced to pull one resident medication at a time and to compare to MAR /a [before] administration .Measures taken to prevent recurrence .Nurse to administer medications to residents one at a time according to Five Rights of Medication Administration and to compare meds [medications] to MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's physician telephone order dated 6/17/2021 at 4:00 AM, showed .Give [MEDICATION(S)] [[MEDICATION(S)] gel medication to raise blood sugar] x [times] 2 orally . Review of Resident #1's second physician telephone order dated 6/17/2021 at 4:00 AM, showed .Give 2 injections of [MEDICATION(S)] [[MEDICATION(S)] fluid medication to raise blood sugar], snacks, and OJ [orange juice] /c [with] sugar packets . Review of Resident #1's interdisciplinary progress note dated 6/17/2021 at 6:52 AM, showed .BS [blood sugar] of 56, checked at 2:30 [am], given [MEDICATION(S)] gel .continue to monitor . Review of Resident #1's interdisciplinary progress note dated 6/17/2021 at 6:52 AM, showed LATE ENTRY FOR 6/17/2021 00:00 [12:00 AM] .BS 61 check at 00:00 [12:00 AM], given [MEDICATION(S)] gel . Review of Resident #1's interdisciplinary progress note dated 6/17/2021 at 6:54 AM, showed .BS 28 [critically low] checked at 4:30 [AM], clammy, hot to the touch, and confused .BS 55 .checked at 5:00 [AM] .continued to give [MEDICATION(S)] gel and [MEDICATION(S)] IM x 1 . Review of Resident #1's interdisciplinary progress note dated 6/17/2021 at 7:00 AM, showed .NP [Nurse Practitioner (NP #1)] called to advise care for resident multiple times starting approximately 20:45 [8:45] PM on 6/16/2021. Continued calling NP through shift 6p-6a [6:00 pm to 6:00 am] on 6/16-6/17/21. To advise further monitoring and Tx [treatment] for resident's [Resident #1] decreased BS . Review of Resident #1's nurses note (handwritten) dated 6/17/2021 untimed, showed blood sugars were checked every 2 hours and the lowest blood sugar documented was 89. Further review showed .1539 [3:39] PM, [Medical Director, MD] here doing rounds BS Lo [low] on glucometer [device used to check blood sugar] [MEDICATION(S)] 1 mg [milligram] IM [intramuscular] given. Order to send to ER .1550 [3:50 PM] BS 58 .[MEDICATION(S)] 1 mg IM given . Review of Resident #1's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] .[Resident #1] was given another resident's diabetes medications in error last night. Nurses have been monitoring her BS and making the [NP #1] aware. Nurses report she is doing well this am however, when I walk into the room, she is diaphoretic and unresponsive. 911 was called and [MEDICATION(S)] was given x 2. Vitals remained stable during the entire course of the event. [Resident #1] became responsive a [at] 15 minutes after first [MEDICATION(S)] injection .PE [physical exam] .evidence of distress .in acute distress unresponsive, regained consciousness 15 minutes after [MEDICATION(S)] injection, confused but talkative .Dx [diagnosis] .Drug-induced [CONDITION(S)] . Review of a physician telephone order dated 6/17/2021 at 3:39 PM, showed .Send to ER for Eval [evaluation] . Review of the comprehensive care plan showed an update on 6/17/2021 .Residents blood sugar decreasing due to wrong medications given .Goal .Resident will receive correct medications .Interventions .Resident monitored daily for physical and mental changes .Medications given using the 5 rights of medication administration . Review of facility documentation dated 6/17/2021 untimed, revealed the facility had completed an investigation and it was found that LPN #3 did not follow facility policy for medication administration. Review of discharge documentation from the hospital dated 6/19/2021 showed .Hospital Course .Presents to the ED [emergency department] with complaint of [CONDITION(S)] with altered mental status .she states she is not on any hyperglycemic agents [medications to lower blood sugar] .the patient was again noted to be hypoglycemic in the 30's .Patient was admitted with [CONDITION(S)] due to inadvertent .being given somebody else's medications including [MEDICATION(S)] at the nursing home .She was started on a D10 [10% [MEDICATION(S)] solution to increase blood sugar] drip. Also required some [MEDICATION(S)] [a medication used for overdose management of hypoglycemic medications] and was dialyzed .She had [CONDITION(S)] yesterday and will be dialyzed again today . Review of the Minimum Data Set significant change in status assessment dated [DATE], revealed Resident #1 had no cognitive impairment with a Brief Interview for Mental Status (BIMS) of 15. The resident required extensive assistance of 1-2 staff members to meet care needs. A wheelchair was documented for Resident #1's locomotion on unit. During an interview on 7/28/2021 at 8:40 AM with Resident #1, she confirmed she had to go to the hospital last month (unsure of date) for low blood sugar. Resident #1 stated she received her roommate's night dose of diabetic medications. She also stated she does not take any medication for diabetes and had bouts of low blood sugar and confusion after she received the medications. During an interview on 7/28/2021 at 1:30 PM, LPN #2 confirmed she received report LPN #3 had given Resident #1 medications that were prepared for her roommate, and Resident #1's blood sugars had been running low. LPN #2 stated it was conveyed in morning report that LPN #3 had notified NP #1 of Resident #1 receiving the wrong medication and received new orders from NP #1 for [MEDICATION(S)]. NP #1 felt Resident #1 could be treated in the facility. LPN #2 confirmed Resident #1 had altered mental status around 3:00 PM on 6/17/2021, and the MD was notified immediately. Resident #1's blood-sugar was checked and a reading of LOW (reading too low to give numerical value by equipment) was noted. During an interview on 7/29/2021 at 12:20 PM, the MD confirmed NP #1 had informed her of the medication error on the evening of 6/16/2021. The MD made rounds on 6/17/2021 and communicated with nursing staff before seeing Resident #1. The MD entered Resident #1's room and found her to be diaphoretic and not responding well. Resident #1's blood sugar was checked, and the result read from the glucometer was LOW. The MD ordered [MEDICATION(S)] injections which were given by nursing staff. An order was given to send Resident #1 to the ER. The MD confirmed she was aware Resident #1 was admitted to the Intensive Care Unit of the local hospital. The MD confirmed LPN #3 did not follow facility policy when administering medications to Resident #1 on 6/16/2021. Further interview confirmed Resident #1 had experienced harm from receiving the wrong medications, and stated .Harm enough to be sent out . During an interview on 7/29/2021 at 1:49 PM, LPN #3 confirmed she prepared Resident #1's medications and her roommate's medications at the same time. She then took the medications into the room in 1 hand and administered the roommate's medications to Resident #1. LPN #3 then went to administer medications to Resident #1's roommate and realized she had Resident #1's medication left in her hand. Resident #1 had taken the medications that LPN #3 had previously given her which was the wrong medications. LPN #3 stated she notified NP #1 of the medication error and orders were given to monitor the resident closely. LPN #3 confirmed Resident #1 had experienced low blood sugars throughout the night and had been confused. LPN #3 confirmed she had given [MEDICATION(S)] multiple times. LPN #3 stated Resident #1's blood sugar had stabilized and that was what she had reported to LPN #2 at change of shift (on 6/17/2021). LPN #3 confirmed she did not follow facility policy for medication administration. During an interview on 7/29/2021 at 3:19 PM, the Educator LPN #4 confirmed LPN #3 did not follow facility policy when administering medication to Resident #1 on 6/16/2021. Further interview confirmed the medication error was a significant high risk medication error and Resident #1 had to be hospitalized . During an interview on 7/29/2021 at 3:55 PM, the Interim Director of Nursing confirmed LPN #3 did not follow the medication administration policy. She stated .you don't fix up medications like that .2 [2 resident's medications] at a time and have them in 1 hand .that was careless . Continued interview confirmed .we gave her [Resident #1] the wrong meds . During an interview on 7/29/2021 at 5:05 PM, NP #1 stated she was informed of the medication error by LPN #3 and the NP discussed it with the MD. NP #1 confirmed she had multiple calls from nursing staff reporting Resident #1's condition on 6/16/2021 through 6/17/2021 in the AM. NP #1 had given orders for [MEDICATION(S)] to be administered, Resident #1's blood sugar stabilized (blood sugars from 6:00 AM - 2:00 PM ranged from 89 to 156), and the resident showed improvement. NP #1 stated the MD was to see the resident on 6/17/2021. NP #1 confirmed Resident #1 experienced harm due to receiving wrong medications.

Based on facility policy review, medical record review, review of facility's investigation, and interview, the facility failed to complete a fall risk assessment and failed to implement interventions to prevent falls for 1 resident (Resident #2) of 4 residents reviewed for accidents. The facility's failure to ensure interventions to prevent accidents were implemented resulted in Resident #2 receiving a [MEDICAL CONDITION] (Harm). The findings include: Review of the facility policy titled, Falls-Clinical Protocol, dated 3/2018 showed .The staff and practitioner will review each resident's risk factors for falling and document in the medical record.the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.the staff and physician will monitor and document the individual's response to the interventions intended to reduce falling.risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. Review of the facility policy, Fall Risk Assessment, dated 3/2018, showed .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident centered falls prevention plan based on relevant assessment information.upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission Evaluation and Interim Care Plan dated 12/6/2019 showed the section Screen for Fall Risk was left blank. Review of Resident #2's Fall Risk Assessment form dated 12/6/2019 showed it was left blank. Review of the admission Minimum Data Set ((MDS) dated [DATE] showed Resident #2 was moderately cognitively impaired, inattentive, required limited assistance of 1 staff member for activities of daily living (ADLs); except toileting, which required extensive assistance of 1 staff member and eating, which required supervision and set up. The resident's gait was unsteady, but the resident was able to stabilize without staff assistance during transitions and walking. The resident did not use mobility devices, had a urinary catheter, was frequently incontinent of bowels, and had a previous fall with minor injury. Review of a facility's fall investigation dated 12/29/2019 showed Resident #2 fell in another resident's room on 12/29/2019, resulting in a skin tear to the elbow. Interventions that were to be implemented after the fall included a physical therapy evaluation, bed in low position, and fall mats placed on both sides of the resident's bed. Review of Resident #2's Current Care Plan dated 12/29/2019 showed .Fall-Resident was found by another resident lying on the side of his bed. Resident notified staff that (Resident #2) had fallen.Interventions.Will receive total assistance with transfers to reduce the risk of falls.will receive total assistance with locomotion.will receive total assistance with walking to reduce the risk for falls.Provide safe, clutter free environment.Call light within reach, with prompt response to all requests.Resident's bed is low and locked; fall mats placed on both sides of bed; PT/OT (physical therapy/occupational therapy) to eval (evaluate) and treat.Mobility devices/equipment geri chair.Rehab to evaluation (evaluate) and follow up as ordered.Safety training and education as needed.Prompt to ask for assistance. Medical record review showed no PT/OT evaluation was completed after Resident #2 fell on [DATE]. Review of facility documentation dated 1/2/2020 at 9:30 PM showed .(Resident #2) Fall.fell into floor next to bed.bruising to R (right) leg and extreme pain.resident lying in floor on R side next to bed.Recommendations/Interventions to prevent recurrence: fall mats (an intervention that was to have been in place since the 12/29/2019 fall). Review of a Nurse's Progress note dated 1/2/2020 at 9:30 PM showed .CNA (Certified Nurse Assistant) informed this nurse that this resident (Resident #2) was in the floor at this time. This nurse observed resident lying in floor on right side next to bed. Head to toe assessment done at this time. Noted bruise to right hip and resident had right leg drawed (drawn) up. Resident moaning and groaning in pain at this time. Called (Nurse Practitioner) and orders for stat (immediate) x-ray to right hip and pelvis. Order for [MEDICATION NAME] (pain medication) 5/325 mg (milligrams) po (by mouth) x (times) 1 dose only for pain now. Neuro check done at this time and WNL (within normal limits). Awaiting mobile images at this time. Review of a Physician's Telephone Order (TO) dated 1/2/2020 showed .stat x-ray to R hip + (and) R pelvis.[MEDICATION NAME] 5/325 mg x 1 dose now for pain.fall.dementia.(decreased) mobility.TO per (named NP). Review of a Mobile Images Patient Report for Resident #2 dated 1/2/2020 showed Resident #2 had an Acute Right Femoral Neck fracture ([MEDICAL CONDITION]). Review of a Nurse's Progress note dated 1/2/2020 at 11:54 PM showed .(Resident #2) sent to ER (emergency room ) via E[CONDITION] (emergency medical services) at 11:45 PM as ordered by (named NP) on fall that happened on second shift. X-ray results confirms right head of femur fracture. V/S (vital signs) 108/[AGE] bp (blood pressure) [AGE].2 temp (temperature) 98 pulse 24 resp (respirations) 95 o2 (oxygen saturation) facial grimacing noted. Review of an Acute Care Hospital Emergency Department Physician's report dated [DATE] at 6:55 AM showed .Pt (patient) has right hip fx (fracture).CT (computed tomography) of pelvis showed minimally displaced.[MEDICAL CONDITION] femur with non-displaced femoral neck fracture. Review of a Hospital discharge summary dated 1/6/2020 showed Resident #2 had an Open Reduction Internal Fixation (open surgical repair of the hip) and Right Hip Pinning on [DATE] without complications. The resident was discharged back to the facility on [DATE]. Interview with Licensed Practical Nurse (LPN) #2 on 1/14/2020 at 2:51 PM confirmed .I arrived on shift.at 9:50 PM.got report from (LPN #1).(Resident #2) had fallen about 10 minutes before I came on shift.he (Resident #2) was laying on the ground.she (LPN #1) told me that the patient was ambulating to the bathroom and slipped and fell and he was on the floor and not to move him from doctor's orders for a suspected hip break.no fall mat (was beside the resident's bed). During interview on 1/14/2020 at 3:35 PM, CNA #1 confirmed the fall mats were not in place when Resident #2 was found on the floor. CNA #1 stated .was going to put (Resident #2) back into his bed but the nurse (LPN #1) said.looks like a fracture.(the resident) couldn't move it.appeared to be in severe pain.no pain except when moving him.NP wanted to get x-ray. During interview on 1/14/2020 at 3:46 PM, the Director of Nursing (DON) confirmed fall mats on both sides of the resident's bed was supposed to be implemented after Resident #2's fall on 12/29/2019. The DON stated she did not know if fall mats were in use when the resident fell on [DATE]. The DON confirmed Resident #2's admission fall risk assessment was not completed. During interview with the NP on 1/14/2020 at 4:52 PM, NP stated .a fall with pain I will typically order an x-ray and if there is a fracture, I will send them out.if there is a fall.may just be soft tissue injury.jarred from a fall, but not a fracture.I was told by the nurse.he was found in the floor.had pain in his leg.they said they don't know if there was an injury.they didn't give me a pain scale.didn't say how much leg pain.they were concerned enough they wanted an x-ray.there was a possible injury.So I gave an order for [REDACTED]. During telephone interview with CNA #2 on 1/21/2020 at 3:10 PM, CNA #2 stated .me and the other CNA walked in the room.he (Resident #2) was on the floor.no floor mats.(Resident #2) never had floor mats. During telephone interview with LPN #1 on 1/21/2020 at 4:05 PM, LPN #1 stated .(Resident #2) was in the floor next to his bed on his right side.no floor mats.when I was doing head to toe.he was favoring that right side.excruciating pain.at that time never saw them (fall mats).

Based on facility policy review, medical record review, review of the facility's falls investigation, and interview, the facility failed to implement the care plan for falls interventions for 1 resident (Resident #2) of 4 sampled residents. The facility's failure to implement care planned falls interventions resulted in Resident #2 falling and receiving a [MEDICAL CONDITION] (Harm). The findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, dated 12/2016, showed .care plan will.Describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.incorporate identified problem areas.aid in preventing or reducing decline in the resident's functional status and/or functional levels. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility fall's investigation dated 12/29/2019, showed Resident #2 fell in another resident's room and sustained a skin tear to the elbow. Review of Resident #2's Care Plan dated 12/29/2019 showed the fall risk interventions implemented after the fall included .PT/OT (physical therapy/occupational therapy) to eval (evaluate) and treat.fall mats placed on both sides of bed. Medical record review showed no documentation the resident was evaluated by PT/OT after the fall on 12/29/2019. Review of a facility fall's investigation dated 1/2/2020 at 9:30 PM showed .Fall.fell into floor next to bed.bruising to R (right) leg and extreme pain.resident lying in floor on R side next to bed.Recommendations/Interventions to prevent recurrence: fall mats (an intervention to have been implemented after the fall on 12/29/2019). During interview with the Director of Nursing (DON) on 1/14/2020 at 3:46 PM, the DON confirmed fall mats were to be implemented after the resident's fall on 12/29/2019. The DON was unsure if the fall mats were in place at the time of the resident's fall on 1/2/2020. Interview with the Rehab Manager on 1/17/2020 at 12:45 PM revealed Resident #2 had a fall on 12/29/2019 and a therapy did not complete an evaluation after that fall. The Rehab Manager stated a therapy evaluation was not completed until Resident #2 returned from the hospital after the fall on 1/2/2020. Telephone interview with Certified Nursing Assistant (CNA) #2 on 1/21/2020 at 3:10 PM revealed .me and the other CNA walked in the room.he (Resident #2) was on the floor.no floor mats (were in place). Telephone interview with Licensed Practical Nurse (LPN) #1 on 1/21/2020 at 4:05 PM confirmed she took care of Resident #2 on 1/2/2020 and .(Resident #2) was in the floor next to his bed on his right side.no floor mats (were in place). Refer to F-689

Based on medical record review, review of a facility's fall investigation, review of emergency services transport report, review of a hospital record, and interview, the facility failed to ensure nursing staff provided immediate and appropriate medical assessment and treatment after a fall for 1 resident (Resident #2) of 4 residents reviewed for accidents. The facility's failure to ensure emergency medical transport was called for transport of a resident after a fall resulted in Resident #2 lying on the floor in pain for 2 hours and 15 minutes after a fall (Harm). The findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE], showed Resident #2 was moderately cognitively impaired, inattentive, required limited assistance of 1 staff member for activities of daily living (ADLs); except toileting, which required extensive assistance of 1 staff member and eating which required supervision and set up. The resident's gait was unsteady, but the resident was able to stabilize without staff assistance during transitions and walking. The resident did not use mobility devices, had a urinary catheter, was frequently incontinent of bowels, and had a previous fall with minor injury. Review of the facility's fall investigation dated 1/2/2020 at 9:30 PM showed .Fall.fell into floor next to bed.bruising to R (right) leg and extreme pain.resident lying in floor on R side next to bed. Review of a Nurse's Progress Note dated 1/2/2020 at 9:30 PM showed .CNA (Certified Nurse Assistant) informed this nurse that (Resident #2) was in the floor at this time. This nurse observed resident lying in floor on right side next to bed. Head to toe assessment done at this time. Noted bruise to right hip and resident had right leg drawed (drawn) up. Resident moaning and groaning in pain at this time. Called NP (Nurse Practitioner) and orders for stat (immediate) x-ray to right hip and pelvis. Order for [MEDICATION NAME] (pain medication) 5/325 mg (milligrams) po (by mouth) x (times) 1 dose only for pain now. Neuro check done at this time and WNL (within normal limits). Awaiting mobile images at this time. Review of a Physician's Telephone Order (TO) dated 1/2/2020 showed .Stat x-ray to R hip + (and) R pelvis.[MEDICATION NAME] 5/325 mg x 1 dose now for pain.TO per (named NP). Review of a Nurse's Progress Note dated 1/2/2020 at 10:20 PM showed .received report from second shift (nurse) that patient (Resident #2) fell at 9:40 PM and mobile x-ray was in room. (2nd shift) Nurse reported that (named NP) ordered stat x-ray and not to move patient due to possible fracture of lower limb. Patient in floor with blanket and pillow no pain this time resting. 15 minute vital checks completed. Review of a Mobile Image Patient Report dated 1/2/2020 showed .Arrived 1000 (10:00) PM IN 10:07 PM OUT 10:17 PM.Acute right femoral neck fracture ([MEDICAL CONDITION]). Review of a Nurse's Progress Note dated 1/2/2020 at 11:30 PM showed .Received report from mobile x-ray of fracture to right head of femur. Report given to (named NP) new orders to send to ER (emergency room ). E[CONDITION] (emergency medical service) called and on there (their) way patient resting with eyes open no distress noted covered by blanket and head on pillow 15min (minute) vital sign checks continue. Review of a Nurse's Progress Note dated 1/2/2020 at 11:45 PM showed .E[CONDITION] arrived at facility patient covered with blanket and head on pillow transferred patient to stretcher pain noted on transfer to stretcher. Patient transferred to ER via ems. Review of a Nurse's Progress Note dated 1/2/2020 at 11:54 PM showed .patient sent to ER via ems at 11:45 PM as ordered by (named NP) on fall that happened on second shift. X-ray results confirms right head of femur fracture. V/S (vital signs) 108/[AGE] bp (blood pressure) [AGE].2 temp (temperature) 98 pulse 24 resp (respirations) 95 o2 (oxygen saturation) facial grimacing noted. Review of an E[CONDITION] Prehospital Care report dated 1/2/2020 showed .Nursing advised that the ptn (patient) had fallen at approximately 2130 (9:30 PM).The nurse that was on duty gave the ptn pain meds and contacted the nurse practitioner to get further instructions. He advised that the NP told nursing not to move the ptn until mobile imaging returned with the x-rays. Ptn was lying on the floor of his room with his right knee drawn into his body at approximately 90 degrees angle with his left leg straight. As E[CONDITION] entered the room, the ptn rolled onto his left side. E[CONDITION] got a draw sheet, rolled him onto his back onto the draw sheet, and two men lifted him onto the stretcher while supporting his right knee in a position of comfort. Ptn secured.At this point, E[CONDITION].asked nursing why they waited so long to call 911, and (nurse) advised that he wanted to call sooner, but that the NP told him to wait until the x-rays came back.Ptn made groaning noises when he was lifted, but was mostly unresponsive besides that.16 respirations per minute, BP 112/[AGE], heart rate 110, o2 saturation was 78% (normal range 92% - 100%) on room air. E[CONDITION] initiated o2 at 3L (liters) via nasal cannula and his saturation slowly climbed to [AGE]%. Review of an Acute Care Hospital Emergency Department Physician's report dated [DATE] at 6:55 AM showed .Chief Complaint.patient had witnessed fall.was in the floor for about 2 hours before E[CONDITION] was notified. Pt has right hip fx. (fracture) Patients RA (room air) sat (saturation) was 78%.found on floor.He apparently was left on the floor for 2 hr (hours) until portable x-ray was obtained. During interview on 1/14/2020 at 2:51 PM, Licensed Practical Nurse (LPN) #2 stated .I arrived on shift.at 9:50 pm.got report from the other nurse (LPN #1) on second shift.the resident had fallen about 10 mins (minutes) before I came on shift.(LPN #1) told me the doctor ordered a stat x-ray and not to move (Resident #2) because of a suspected hip break.I asked the nurse at this point.why not just send (the resident) to ER.she said the doctor wanted an x-ray first before he (Resident #2) was to be sent out.no pain at that point.he was laying on the ground.pillows.vital signs were normal.no rotations (of the resident's leg).no bruising at this time.looked at his hip and did not see bruising at the time.bruising came up about 30 minutes after that.(Resident #2 was in severe pain) because he couldn't move. When asked why the LPN did not call 911, LPN #2 stated .I didn't want to over-ride my doctor.did not question her (NP) order.was not aware I could.I did not get the order.I waited until x-ray came back.he wasn't able to move his broken leg.they (mobile x-ray) called me at 11:20 (PM).confirmed fracture.I immediately called (named NP) and (named NP) confirmed to send to ER.I reported to the NP.he was laying in the floor with a blanket on.comfortable.did VS (vital signs) every 15 minutes.he (Resident #2) did not report pain.(on the floor) for about 2 hours.she (LPN #1) told me that the patient was ambulating to the bathroom and slipped and fell and he was on the floor and not to move him from doctor's orders for a suspected hip break and.to wait until mobile x-ray result. During interview with the NP on 1/14/2020 at 4:52 PM, the NP stated .a fall with pain I will typically order an x-ray and if there is a fracture I will send them out.if there is a fall there may just be soft tissue injury.jarred from a fall but not a fracture.unnecessary transfer if no need.expected time frame is a couple of hours.I was told by the nurse.he was found in the floor.had pain in his leg.they said they don't know if there was an injury.they didn't give me a pain scale.didn't say how much leg pain.they were concerned enough they wanted an x-ray.there was a possible injury.they just said he was in pain.they said it appeared he was in pain.they didn't say severe.So I gave an order for [REDACTED]. NP stated .we do morning meeting.there wasn't any talk about him lying in the floor in severe pain.there was no talk about the [MEDICATION NAME] being ineffective.I wouldn't think there was a reason to not move resident unless suspected cervical injury.just his leg.I don't think it was necessary for him to lay on the floor. there was no report of bruising.rotation.open skin.they just said pain.there wasn't severe pain or notification of medication not being effective either. During interview with the Director of Nursing (DON) on 1/15/2020 at 9:52 AM, the DON said she was unaware the resident was lying on the floor for 2 hours until 1/14/2020. The DON stated LPN #1 called the NP and the NP gave an order for [REDACTED].(LPN #1) stayed with the resident.he (Resident #2) was in extreme amount of pain.I am just guessing that is why he was left there for that long.I would have called 911 and sent him (Resident #2) out right away. During telephone interview on 1/17/2020 at 8:25 PM, the Medical Director confirmed she was aware of Resident #2's fall on 1/2/2020, but she was not aware the resident was on the floor for 2 hours. The Medical Director stated .that is absolutely not acceptable.nurses should not allow that to happen.E[CONDITION] should have been called. During telephone interview on 1/21/2020 at 3:10 PM, Certified Nursing Assistant (CNA) #2 stated .we were told to leave him (Resident #2) on the floor by our nurse (LPN #1).because he had fallen.she asked me and the other CNA to not move him.if it (hip) was broke would've hurt him more.we helped mobile x-ray do the x-ray on the ground.we put a pillow.put blankets.I was under the impression if we moved him we'd hurt him worse. During telephone interview with LPN #1 on 1/21/2020 at 4:05 PM, LPN #1 confirmed she took care of the resident on 1/2/2020 .(Resident #2) was in the floor next to his bed on his right side.no floor mats.when I was doing head to toe.he was favoring that right side.excruciating pain.his leg was drawed (drawn) up.moaning, groaning, wincing.he was tense.could definitely tell he was in a lot of pain.I knew something was fractured I just didn't know how bad.I left him with an aide (CNA) to call the NP to let her know.told her he fell .and I wanted to send him to the ER.she told me no.she wanted a stat x-ray.told her I was very sure it was broken.she said we needed an x-ray.we need to verify that first.so I did what I was ordered to do.got an order for [REDACTED].(named NP) mentioned to just do an x-ray before we go any further.so I just took that as don't move him until the x-ray comes in.no order (was given to not move the resident). Refer to F-689

Based on facility policy review, medical record review, and interview, the facility failed to immediately notify the physician a resident, who was a full code (was to receive basic life support if found unresponsive or in [MEDICAL CONDITION]), was found unresponsive for 1 resident (#61) of 4 residents reviewed for death. The facility's failure to notify the physician Resident #61 was found unresponsive placed the resident in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) and resulted in death for Resident #61. The Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 12:15 PM. The Immediate Jeopardy was effective [DATE] - [DATE]. The findings include: Review of the facility policy Acute Condition Changes - Clinical Protocol dated ,[DATE] revealed .The nursing staff will contact the Physician based on the urgency of the situation. For emergencies, they will call or page the Physician and request a prompt response . Review of the facility policy Emergency Procedure - Cardiopulmonary Resuscitation, revised ,[DATE], revealed, .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Cardiopulmonary Resuscitation/Basic Life Support) shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are not obvious signs of irreversible death (e.g. rigor mortis) .If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR .If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911 .Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as 'C-A-B' (chest compressions, airway, breathing) .Continue with CPR/BLS until emergency medical personnel arrive . Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], after a hospitalization , with [DIAGNOSES REDACTED]. The resident expired in the facility on [DATE]. Medical record review of Resident #61's Plan of Care, with an effective date of [DATE], revealed .ADVANCE DIRECTIVES (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) -- FULL CODE (the resident was to receive basic life support, including cardiopulmonary resuscitation (CPR)) .Residents instructions will be followed . Medical record review of a Physician order for [REDACTED].Transfer to hospital if indicated . Medical record review of the Physicians Orders dated [DATE] - [DATE] revealed .Advance Directives .FULL CODE . Medical record review of a nurse's progress note dated [DATE] at 1:29 AM revealed .1030PM (10:30 PM on [DATE]) Entered room noted resident with no pulse or respirations. CPR started. DON (Director of Nursing) notified and here to pronounce resident. Poa (Power of Attorney) notified. Family at bedside . Medical record review revealed no documentation Emergency Medical Service (EMS) was called or the physician was notified that Resident #61 had been found unresponsive and CPR started. There was no documentation an order had been obtained from a physician to stop CPR. There was no documentation the physician had been notified of Resident #61's death or of discontinuation of CPR. Telephone interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 2:43 PM, revealed LPN #2 had arrived to work at 10:00 PM on [DATE] .about 10:15 (PM) I walked in and checked on him (Resident #61) and he wasn't breathing .we started CPR (the DON) came and pronounced him (pronounced death) .I called his family . LPN #3 and Certified Nursing Assistant (CNA) #1 had started CPR, and CPR had been provided for approximately ,[DATE] minutes. LPN #2 stated .I knew he was a full code . LPN #2 confirmed EMS and the physician had not been notified. Interview with LPN #3 on [DATE] at 3:01 PM, in the conference room, revealed LPN #3 had assisted with providing CPR to Resident #61. LPN #3 stated the physician and EMS had not been notified and an order had not been obtained from a physician to stop CPR. Interview with the DON on [DATE] at 3:40 PM, in the conference room, confirmed LPN #2 had called the DON at home and requested she come to the facility to pronounce Resident #61's death. Upon the DON's arrival to the facility, LPN #2 informed the DON Resident #61 was a full code, staff had not provided BLS/CPR, and EMS was not notified. The DON confirmed she had not notified the physician that Resident #61 was found unresponsive, BLS/CPR had been discontinued, and the resident died . Interview with the Nurse Practitioner (NP), Resident #61's healthcare provider, on [DATE] at 4:50 PM, in the conference room, revealed the facility had informed her of Resident #61's death the day after Resident #61 had died . It was the NP's expectation to have been notified when Resident #61 did not receive basic life support. Interview with the NP on [DATE] at 4:07 PM, in the conference room, confirmed the NP was first made aware Resident #61 did not receive basic life support on [DATE], during interview with the survey team. Interview with the NP on [DATE] at 4:41 PM, in the conference room, confirmed the NP expected the staff to notify her of all unexpected deaths at the time they occur. The NP confirmed Resident #61's death was unexpected. The NP confirmed she was on call the night of Resident #61's death. Telephone interview with the Medical Director (Resident #61's physician) on [DATE] at 4:08 PM, revealed the NP had notified the physician .sometime this week . that Resident #61 was found unresponsive, CPR had been discontinued without EMS being called, and the resident died . The Administrator had not made her aware until [DATE], .(the Administrator) called me today ([DATE]) . An acceptable removal plan, which removed the immediacy of the jeopardy, was received [DATE] at 12:20 PM. The corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of in-service training logs, review of facility policy, and staff interviews. Facility corrective actions included: On [DATE] - [DATE] the facility's leadership, consisting of the Administrator, the DON, and the Staff Education Coordinator, provided oversight and training to all on duty Nurses and CNAs. The oversight and training included: 1. Completion of Mock Code Blue drills on [DATE] at 5:35 AM and [DATE] at 3:16 PM. 2. Facility's policy and procedure Emergency Procedure - Cardiopulmonary Resuscitation included EMS notification and CPR to be maintained until EMS arrival. 3. Facility's newly implemented processes: Code Notebook, Code Blue forms, new Code Supervisor position and code team, and Code Blue procedures for all shifts beginning on [DATE]. On [DATE] at 5:35 AM and [DATE] at 3:16 PM, the facility's leadership conducted mock Code Blue drills which included a verbal in-service after the drill to review the steps of a Code Blue. Review of the mock code blue in-services conducted on [DATE] revealed 1 of 2 NPs, 2 of 4 RNs, including the DON, 4 of 13 LPNs, and 6 of 26 CNAs participated and were in-serviced by the Staff Education Coordinator. The surveyors review of the facility's removal plan, facility's training materials, interviews, and in-service logs dated [DATE] verified 16 CNAs and 9 Nurses, including all current Nurses and CNAs on duty, had completed the following training: 1. Facility's new process for Code Blue, including new Code Supervisor position, code team, CPR Oversite lead schedule, Code Notebook, and Code blue forms. 2. Facility's policy Emergency Procedure - Cardiopulmonary Resuscitation 3. Code Blue Quiz completed, including all code team members on duty on [DATE]. Review of CPR certification cards revealed 1 of 2 NPs, 4 of 4 Registered Nurses (RN), including the DON, 11 of 13 Licensed Practical Nurses (LPNs), and 7 of 26 CNAs had current CPR certifications. Review of Emergency Procedure - Cardiopulmonary Resuscitation policy in-service revealed 1 of 2 NPs, 8 of 13 LPNs, and 16 of 26 CNAs had been in-serviced as of [DATE], with Code Supervisors responsible to educate all oncoming staff who had not received the in-service training. Review of the CPR Oversite Lead Schedule dated [DATE] - [DATE] revealed an assigned Code supervisor for each shift. Staff interviews were completed with all on duty staff to include 3 LPNs and 7 CNAs. These interviews revealed they had received training on the facility's removal plan, which included identification of the current code team members, completion of the code blue quiz for the current code team members, and the Emergency Procedure - Cardiopulmonary Resuscitation policy and procedures. Review of the Code Blue Book on [DATE] at 1:40 PM revealed: 1. A list of Full Code status residents, a code supervisor job description, and code blue steps for the staff and the code lead. 2. A form entitled .TEAM Huddle Report . which included New Admissions, Discharges, Census, Staffing Schedule, Code Team, Reiterate Code Team Duties and Responsibilities, and the Code Events Performed. 3. The TEAM Huddle report included .REMINDERS .Code Status 1st - Delegate call to 911/EMS get Estimated Time of Arrival (ETA) - Always Notify the provider on call of any code blue scenario .TODAYS ACTIVITIES .Emergency Equip (Equipment) Cart & (and) AED (Automatic External Defibrillator) Checklist Complete . 4. A CPR Oversite Lead Schedule for dates of [DATE] - [DATE]. 5. A Code Blue Supervisor on call List with names of staff members and phone numbers. 6. Identification of staff members who had a current CPR certification. 7. A CPR Code Blue Record for scribing information during a code blue and a log to track when a Code Blue had occurred. Interview with the Staff Education Coordinator on [DATE] at 2:10 PM, in the conference room, revealed a BLS/CPR class had been scheduled for [DATE] at 6:00 AM and 2:00 PM and on [DATE] at 6:00 PM, for any staff needing current certification. Noncompliance at F-580 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance. Refer to F-678

Based on facility policy review, medical record review, and interview, the facility failed to honor wishes to receive basic life support services (BLS, medical care including cardiopulmonary resuscitation) for 1 resident (#61) of 4 residents reviewed for death. The facility's failure to provide basic life support for Resident #61 placed the resident in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) and resulted in death for Resident #61. The Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 12:15 PM. The facility was cited F-678 (J), which constitutes Substandard Quality of Care (SQC). The Immediate Jeopardy was effective [DATE] - [DATE]. The findings include: Review of the facility policy Emergency Procedure - Cardiopulmonary Resuscitation, revised ,[DATE], revealed, .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS (Cardiopulmonary Resuscitation/Basic Life Support) shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are not obvious signs of irreversible death (e.g. rigor mortis) .If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR .Select and identify a CPR Team for each shift in the case of an actual [MEDICAL CONDITION]. To the extent possible, designate a team leader on each shift who is responsible for coordinating the rescue effort and directing other team members during the rescue effort .If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [MEDICAL CONDITION] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911 .Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as 'C-A-B' (chest compressions, airway, breathing) .Continue with CPR/BLS until emergency medical personnel arrive . Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #61 expired in the facility on [DATE]. Medical record review of Resident #61's Plan of Care, effective date [DATE], revealed .ADVANCE DIRECTIVES (a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) -- FULL CODE (the resident was to receive cardiopulmonary resuscitation) .Residents instructions will be followed .Compliance with State and Federal guideline . Medical record review of a Physician order for [REDACTED].Transfer to hospital if indicated . Medical record review of the Physicians Orders dated [DATE] - [DATE] revealed .Advance Directives .FULL CODE . Medical record review of a nurse's progress note dated [DATE] at 1:29 AM revealed .1030PM (10:30 PM on [DATE]) Entered room noted resident (#61) with no pulse or respirations. CPR started. DON (Director of Nursing) notified and here to pronounce resident (pronounce death). Poa (Power of Attorney) notified. Family at bedside . Medical record review revealed no documentation emergency medical services (EMS) or a physician was called when Resident #61 was found unresponsive. Telephone interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 2:43 PM, revealed LPN #2 had arrived to work at 10:00 PM on [DATE] .about 10:15 (PM) I walked in and checked on him (Resident #61) and he wasn't breathing .we started CPR (the DON) came and pronounced him (pronounced death) .I called his family . LPN #2 stated LPN #3 and Certified Nursing Assistant (CNA) #1 had started CPR and CPR continued for approximately ,[DATE] minutes. LPN #2 stated .I knew he was a full code . LPN #2 confirmed EMS was not called when Resident #61 was found unresponsive. LPN #2 stated the DON had told her to stop CPR on Resident #61. Interview with LPN #3 on [DATE] at 3:01 PM, in the conference room, revealed LPN #3 had assisted with providing CPR for Resident #61 .I gave compressions (chest compressions during CPR). (CPR was provided) 2 to 3 minutes .we stopped .he was gone .I checked the pulse and there was no pulse LPN #3 confirmed EMS had not been called and an order had not been obtained from a physician to stop CPR. Interview with the DON on [DATE] at 3:40 PM, in the conference room, revealed .I had to come in and pronounce him (Resident #61's death) .called me at home .I didn't know what his code status was .when I got here (at the facility) they (LPN #2) told me he (Resident #61) was a full code . The DON arrived at the facility .A good 45 minutes to an hour . after receiving the phone call at home from LPN #2. The DON stated when she arrived at the facility, LPN #2 told her that CPR had not been initiated and EMS had not been called. It was the DON's expectation for a resident who was a full code to have CPR initiated, EMS to be notified, and for CPR to be continued until EMS arrived at the facility to take over care. The DON confirmed Resident #61 had not received basic life support per his wishes for full code status. Interview with the Nurse Practitioner (NP), who was Resident #61's healthcare provider, on [DATE] at 4:50 PM, in the conference room, revealed the facility had informed her of Resident #61's death the day after he died . The NP was not aware Resident #61 had not received basic life support as he requested. It was the NP's expectation for CPR to be initiated for a resident who was a full code, and for CPR to continue until EMS arrived. The NP stated .It wasn't handled appropriately from the start. We should know to initiate CPR and call 911 and when they get here they can take over . Telephone interview with Resident #61's family member on [DATE] at 8:59 AM, revealed Resident #61's wishes were to receive CPR. The family member had been notified on [DATE] Resident #61 had died . The family member stated the facility had informed him Resident #61 had received CPR, but he was unaware if EMS had been notified. Telephone interview with CNA #1 on [DATE] at 10:47 AM, revealed the CNA had assisted LPN #3 with providing CPR for Resident #61. The CNA was unsure of how long CPR had been performed. CNA #1 stated the DON had told them to stop CPR. Interview with LPN #2 on [DATE] at 6:27 AM, in the conference room, revealed on [DATE], upon arriving to work for the 10:00 PM shift, .he (Resident #61) was gone .I walked in the room .he had passed .no respirations no pulse . he looked yellowish .he was not cold yet . LPN #2 had checked Resident #61's code status on his chart and knew he was a full code. LPN #2 stated .I know to call the EMT's (Emergency Medical Technicians/EMS). But it's just crazy, because when they're dead, we have to call (the DON) . Telephone interview with CNA #3 on [DATE] at 7:24 AM, revealed on [DATE], LPN #2 had called the South Nurse's station and told LPN #3 Resident #61 had .passed away and was a full code . CNA #3 and LPN #3 had taken the crash cart (a cart carrying equipment used in emergency resuscitations) and went to assist LPN #2 with CPR. LPN #3 had started chest compressions and CNA #3 had told LPN #2 to call 911. LPN #2 came into Resident #61's room and told CNA #3 and LPN #3 the DON was coming to pronounce the resident, and LPN #3 stopped performing CPR. CNA #3 stated the code blue (emergency response system called over the intercom) had not been announced over the intercom to alert other staff in the building. Interview with CNA #6 on [DATE] at 9:12 AM, in the conference room, revealed CNA #6 worked the night of Resident #61's death. CNA #6 stated the code blue had not been announced over the intercom to alert other staff in the building to respond. Telephone interview with the Medical Director (who was also Resident #61's physician) on [DATE] at 4:08 PM, revealed it was her expectation for 911 to be called immediately, and CPR to be initiated and continued until EMS arrived, when a resident who was a full code was found unresponsive. The Medical Director confirmed Resident #61's wishes to receive basic life support had not been followed. In summary: Interviews during the investigation revealed differing statements as to how long Resident #61 had received CPR and differing reasons as to why CPR had been stopped without calling EMS or notifying the Physician to obtain an order to stop. An acceptable removal plan, which removed the immediacy of the jeopardy, was received [DATE] at 12:20 PM. The corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of in-service training logs, review of facility policy, and staff interviews. Facility corrective actions included: On [DATE] - [DATE] the facility's leadership, consisting of the Administrator, the DON, and the Staff Education Coordinator, provided oversight and training to all on duty Nurses and CNAs. The oversight and training included: 1. Completion of Mock Code Blue drills on [DATE] at 5:35 AM and [DATE] at 3:16 PM. 2. Facility's policy and procedure Emergency Procedure - Cardiopulmonary Resuscitation included EMS notification and CPR to be maintained until EMS arrival. 3. Facility's newly implemented processes: Code Notebook, Code Blue forms, new Code Supervisor position and code team, and Code Blue procedures for all shifts beginning on [DATE]. On [DATE] at 5:35 AM and [DATE] at 3:16 PM, the facility's leadership conducted mock Code Blue drills which included a verbal in-service after the drill to review the steps of a Code Blue. Review of the mock code blue in-services conducted on [DATE] revealed 1 of 2 NPs, 2 of 4 RNs, including the DON, 4 of 13 LPNs, and 6 of 26 CNAs participated and were in-serviced by the Staff Education Coordinator. The surveyors review of the facility's removal plan, facility's training materials, interviews, and in-service logs dated [DATE] verified 16 CNAs and 9 Nurses, including all current Nurses and CNAs on duty, had completed the following training: 1. Facility's new process for Code Blue, including new Code Supervisor position, code team, CPR Oversite lead schedule, Code Notebook, and Code blue forms. 2. Facility's policy Emergency Procedure - Cardiopulmonary Resuscitation 3. Code Blue Quiz completed, including all code team members on duty on [DATE]. Review of CPR certification cards revealed 1 of 2 NPs, 4 of 4 Registered Nurses (RN), including the DON, 11 of 13 Licensed Practical Nurses (LPNs), and 7 of 26 CNAs had current CPR certifications. Review of Emergency Procedure - Cardiopulmonary Resuscitation policy in-service revealed 1 of 2 NPs, 8 of 13 LPNs, and 16 of 26 CNAs had been in-serviced as of [DATE], with Code Supervisors responsible to educate all oncoming staff who had not received the in-service training. Review of the CPR Oversite Lead Schedule dated [DATE] - [DATE] revealed an assigned Code supervisor for each shift. Staff interviews were completed with all on duty staff to include 3 LPNs and 7 CNAs. These interviews revealed they had received training on the facility's removal plan, which included identification of the current code team members, completion of the code blue quiz for the current code team members, and the Emergency Procedure - Cardiopulmonary Resuscitation policy and procedures. Review of the Code Blue Book on [DATE] at 1:40 PM revealed: 1. A list of Full Code status residents, a code supervisor job description, and code blue steps for the staff and the code lead. 2. A form entitled .TEAM Huddle Report . which included New Admissions, Discharges, Census, Staffing Schedule, Code Team, Reiterate Code Team Duties and Responsibilities, and the Code Events Performed. 3. The TEAM Huddle report included .REMINDERS .Code Status 1st - Delegate call to 911/EMS get Estimated Time of Arrival (ETA) - Always Notify the provider on call of any code blue scenario .TODAYS ACTIVITIES .Emergency Equip (Equipment) Cart & (and) AED (Automatic External Defibrillator) Checklist Complete . 4. A CPR Oversite Lead Schedule for dates of [DATE] - [DATE]. 5. A Code Blue Supervisor on call List with names of staff members and phone numbers. 6. Identification of staff members who had a current CPR certification. 7. A CPR Code Blue Record for scribing information during a code blue and a log to track when a Code Blue had occurred. Interview with the Staff Education Coordinator on [DATE] at 2:10 PM, in the conference room, revealed a BLS/CPR class had been scheduled for [DATE] at 6:00 AM and 2:00 PM and on [DATE] at 6:00 PM, for any staff needing current certification. Noncompliance at F-678 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance.

Based on facility policy review, medical record review, interview, and review of personnel records, the facility failed to ensure staff had the knowledge and competencies for basic life support for 1 resident (#61) of 4 residents reviewed for death. The facility's failure to ensure the skills, knowledge, and competencies of staff in basic life support resulted in an Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) which resulted in death for Resident #61. The Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 12:15 PM. The Immediate Jeopardy was effective [DATE] - [DATE]. The findings include: Review of the facility policy Emergency Procedure - Cardiopulmonary Resuscitation, revised ,[DATE], revealed, .Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) .If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are not obvious signs of irreversible death (e.g. rigor mortis) .Preparation for Cardiopulmonary Resuscitation - 1. Obtain and/or maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel If sudden [MEDICAL CONDITION] is likely, begin CPR: a. Instruct a staff member to activate the emergency response system (code) and call 911 .Initiate the basic life support (BLS) sequence of events. 2. The BLS sequence of events is referred to as 'C-A-B' (chest compressions, airway, breathing) .Continue with CPR/BLS until emergency medical personnel arrive . Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed Resident #61 expired on [DATE]. Medical record review of the Physician's Order for Scope of Treatment (POST) form dated [DATE] revealed Resident #61 was to receive cardiopulmonary resuscitation (CPR). Medical record review of the Physicians orders dated [DATE] - [DATE] revealed Resident #61 was a Full Code (the resident was to receive cardiopulmonary resuscitation). Medical record review of a nurses progress note dated [DATE] at 1:29 AM revealed .1030PM ([DATE] at 10:30 PM) Entered room noted resident (Resident #61) with no pulse or respirations. CPR started. DON notified and here to pronounce resident (pronounce resident's death) . Telephone interview with Licensed Practical Nurse (LPN) #2 on [DATE] at 2:43 PM, revealed Resident #61 was observed on [DATE] at approximately 10:15 PM, in his room, and was not breathing. CPR was initiated by LPN #3 and CNA #1. LPN #2 confirmed Emergency Medical Service (EMS) was not called and CPR was stopped. The LPN stated .he was already gone .I knew he was a full code . Interview with LPN #3 on [DATE] at 3:01 PM, in the conference room, revealed on [DATE] at 10:15 PM CPR was initiated for Resident #61. LPN #3 initiated the chest compressions. LPN #3 stated .(CPR was stopped after) ,[DATE] minutes .we stopped .he was gone . LPN #3 stated no one had instructed or ordered the CPR to be stopped. LPN #3 stated .I'm not really sure what the policy is . LPN #3 confirmed she had not been trained on what to do during a code in the facility. LPN #3 confirmed staff had not obtained an order to stop CPR by a physician .just stopped because he had no pulse . Interview with the Director of Nursing (DON) on [DATE] at 3:40 PM, in the conference room, revealed when the DON arrived at the facility, LPN #2 stated Resident #61 was a full code. LPN #2 had told the DON CPR had not been initiated. The DON stated CPR was not being conducted upon the DON's arrival to the facility, and EMS had not been called. The DON confirmed it was the facility policy to initiate CPR and to continue CPR until EMS arrived. The DON confirmed she had pronounced Resident #61's death without EMS present and without notifying the physician. Telephone interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 10:47 AM, revealed CNA #1 had assisted with providing CPR for Resident #61. .we did CPR for a minute .a while CNA #1 was unable to establish how long CPR had been continued for Resident #61. CNA #1 was not aware of the last training or in-service she had received on BLS/CPR. Interview with Staff Development Coordinator (LPN #5) on [DATE] at 2:05 PM, at the Secured Unit nurses station, confirmed she had not been tracking the competencies or CPR certifications of staff members .I used to .I just haven't been .I've been working in other areas . Staff Development Coordinator LPN #5 had not tracked any CPR certifications in .about a year .or 6 months to a year . Interview with the Staff Education Coordinator on [DATE] at 5:32 PM, in the conference room, confirmed she had not tracked the certifications for BLS/CPR and did not have a current list of CPR certified staff members available. It was the Staff Education Coordinator's expectation for expired CPR certifications to be communicated to her by the staff members. The Staff Education Coordinator expected to be informed if there was need for a CPR/BLS class to be conducted. The Staff Education Coordinator confirmed the facility did not have a system in place for tracking staff competencies and CPR certifications. Interview with the DON on [DATE] at 7:05 AM, in the DON's office, confirmed CNA #1 had not provided proof of an updated CPR certification to the facility and was not aware if CNA #1 had a current up to date CPR certification. It was the DON's expectation for the Staff Development Coordinator and the Staff Education Coordinator to track the CPR competencies and certifications. In summary, LPN #2 and LPN #3 had not followed the facility policy or BLS training to call 911 after the initiation of CPR on a resident who was a full code. In addition, the staff had stopped CPR on Resident #61 without an order from a physician or arrival of EMS. CNA #1 had performed CPR on Resident #61 without the facility obtaining proof of current CPR certification. The facility failed to have a system in place to track and ensure staff had the required CPR certifications and competencies. An acceptable removal plan, which removed the immediacy of the jeopardy, was received [DATE] at 12:20 PM. The corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of in-service training logs, review of facility policy, and staff interviews. Facility corrective actions included: On [DATE] - [DATE] the facility's leadership, consisting of the Administrator, the DON, and the Staff Education Coordinator, provided oversight and training to all on duty Nurses and CNAs. The oversight and training included: 1. Completion of Mock Code Blue drills on [DATE] at 5:35 AM and [DATE] at 3:16 PM. 2. Facility's policy and procedure Emergency Procedure - Cardiopulmonary Resuscitation included EMS notification and CPR to be maintained until EMS arrival. 3. Facility's newly implemented processes: Code Notebook, Code Blue forms, new Code Supervisor position and code team, and Code Blue procedures for all shifts beginning on [DATE]. On [DATE] at 5:35 AM and [DATE] at 3:16 PM, the facility's leadership conducted mock Code Blue drills which included a verbal in-service after the drill to review the steps of a Code Blue. Review of the mock code blue in-services conducted on [DATE] revealed 1 of 2 NPs, 2 of 4 RNs, including the DON, 4 of 13 LPNs, and 6 of 26 CNAs participated and were in-serviced by the Staff Education Coordinator. The surveyors review of the facility's removal plan, facility's training materials, interviews, and in-service logs dated [DATE] verified 16 CNAs and 9 Nurses, including all current Nurses and CNAs on duty, had completed the following training: 1. Facility's new process for Code Blue, including new Code Supervisor position, code team, CPR Oversite lead schedule, Code Notebook, and Code blue forms. 2. Facility's policy Emergency Procedure - Cardiopulmonary Resuscitation 3. Code Blue Quiz completed, including all code team members on duty on [DATE]. Review of CPR certification cards revealed 1 of 2 NPs, 4 of 4 Registered Nurses (RN), including the DON, 11 of 13 Licensed Practical Nurses (LPNs), and 7 of 26 CNAs had current CPR certifications. Review of Emergency Procedure - Cardiopulmonary Resuscitation policy in-service revealed 1 of 2 NPs, 8 of 13 LPNs, and 16 of 26 CNAs had been in-serviced as of [DATE], with Code Supervisors responsible to educate all oncoming staff who had not received the in-service training. Review of the CPR Oversite Lead Schedule dated [DATE] - [DATE] revealed an assigned Code supervisor for each shift. Staff interviews were completed with all on duty staff to include 3 LPNs and 7 CNAs. These interviews revealed they had received training on the facility's removal plan, which included identification of the current code team members, completion of the code blue quiz for the current code team members, and the Emergency Procedure - Cardiopulmonary Resuscitation policy and procedures. Review of the Code Blue Book on [DATE] at 1:40 PM revealed: 1. A list of Full Code status residents, a code supervisor job description, and code blue steps for the staff and the code lead. 2. A form entitled .TEAM Huddle Report . which included New Admissions, Discharges, Census, Staffing Schedule, Code Team, Reiterate Code Team Duties and Responsibilities, and the Code Events Performed. 3. The TEAM Huddle report included .REMINDERS .Code Status 1st - Delegate call to 911/EMS get Estimated Time of Arrival (ETA) - Always Notify the provider on call of any code blue scenario .TODAYS ACTIVITIES .Emergency Equip (Equipment) Cart & (and) AED (Automatic External Defibrillator) Checklist Complete . 4. A CPR Oversite Lead Schedule for dates of [DATE] - [DATE]. 5. A Code Blue Supervisor on call List with names of staff members and phone numbers. 6. Identification of staff members who had a current CPR certification. 7. A CPR Code Blue Record for scribing information during a code blue and a log to track when a Code Blue had occurred. Interview with the Staff Education Coordinator on [DATE] at 2:10 PM, in the conference room, revealed a BLS/CPR class had been scheduled for [DATE] at 6:00 AM and 2:00 PM and on [DATE] at 6:00 PM, for any staff needing current certification. Noncompliance at F-726 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance. Refer to F-678

Based on review of the facility policy, medical record, and interview, the facility failed to follow Quality Assurance Performance Improvement (QAPI) policy to develop corrective actions for an adverse event when Resident #61, who was a full code (was to receive basic life support if found unresponsive or in [MEDICAL CONDITION]), was found unresponsive, staff did not call Emergency Medical Service (EMS), initiated cardiopulmonary resuscitation (CPR), then discontinued CPR without an order from a physician or EMS, and did not notify the physician the resident was found unresponsive and died , and did not ensure staff maintained CPR certifications and competencies. The facility's failure placed Resident #61 in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) and resulted in death for Resident #61. The Administrator was informed of the Immediate Jeopardy in the Administrator's office on [DATE] at 12:15 PM. The Immediate Jeopardy was effective [DATE] - [DATE]. The findings include: Review of facility policy Quality Assurance and Performance Improvement (QAPI) Program, revised ,[DATE], revealed, .The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents .Adverse events are tracked, monitored and investigated as they occur .Action plans are implemented to prevent recurrence of adverse events .Root Cause Analysis (RCA) is used to determine whether identified issues are exacerbated by the way care and services are organized or delivered, and if so, how .Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply 'do the right thing' . Medical record review revealed Resident #61 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review revealed the resident died in the facility on [DATE]. Medical record review revealed Resident #61 had indicated his wish to receive basic life support services in the event of cardiac or respiratory arrest (no heart beat or respirations). Resident #61 was found unresponsive in his room on [DATE] at approximately 10:30 PM. Staff in the facility did not call EMS or the resident's physician. Staff initiated CPR and then stopped CPR, without receiving an order from a physician to stop, and without EMS arriving to take over resuscitative efforts. Resident #61 expired. Interview with the Director of Nursing (DON) on [DATE] at 3:40 PM, in the conference room, confirmed the DON had considered the resident's death, and the staff actions after finding the resident unresponsive, to be a .serious event . but had not completed an investigation and did not follow the QAPI process to develop action plans for improvement. The DON confirmed the facility had not taken active measures to prevent a recurrence. Interview with the Staff Education Coordinator on [DATE] at 7:02 AM, in the conference room, confirmed she was not providing education on basic life support procedures or who needed to respond to a code blue (emergency situation when a resident is found unresponsive or in [MEDICAL CONDITION]). The Staff Education Coordinator confirmed there was no tracking system for CPR certifications or competencies for staff members. Interview with Administrator on [DATE] at 12:20 PM, in Administrator's office, revealed he did not know about the circumstances of Resident #61's death until [DATE], during the survey process .I was aware (Resident #61 died without basic life support being provided according to policy) this Wednesday ([DATE]), I should have been made aware .We can't have it all fixed in 24 hours .we identify our problems through discussion, but since we are in IJ (Immediate Jeopardy) we aren't doing it properly . The Administrator confirmed he should have been made aware of the adverse event, and the facility should have taken action and developed a plan for improvement. Telephone Interview with the Medical Director on [DATE] at 3:46 PM, confirmed .I was made aware of (the events regarding Resident #61's death) Tuesday or Wednesday ([DATE] or [DATE]) . The Medical Director confirmed Resident #61 not receiving basic life support was a .adverse event . that should have been taken to QAPI. The Medical Director stated, .I do not know why the event was not taken to QAPI . An acceptable removal plan, which removed the immediacy of the jeopardy, was received [DATE] at 12:20 PM. The corrective actions were validated on-site by the surveyors on [DATE] through review of documents, observations, review of in-service training logs, review of facility policy, and staff interviews. Facility corrective actions included: On [DATE] - [DATE] the facility's leadership, consisting of the Administrator, the DON, and the Staff Education Coordinator, provided oversight and training to all on duty Nurses and CNAs. The oversight and training included: 1. Completion of Mock Code Blue drills on [DATE] at 5:35 AM and [DATE] at 3:16 PM. 2. Facility's policy and procedure Emergency Procedure - Cardiopulmonary Resuscitation included EMS notification and CPR to be maintained until EMS arrival. 3. Facility's newly implemented processes: Code Notebook, Code Blue forms, new Code Supervisor position and code team, and Code Blue procedures for all shifts beginning on [DATE]. On [DATE] at 5:35 AM and [DATE] at 3:16 PM, the facility's leadership conducted mock Code Blue drills which included a verbal in-service after the drill to review the steps of a Code Blue. Review of the mock code blue in-services conducted on [DATE] revealed 1 of 2 NPs, 2 of 4 RNs, including the DON, 4 of 13 LPNs, and 6 of 26 CNAs participated and were in-serviced by the Staff Education Coordinator. The surveyors review of the facility's removal plan, facility's training materials, interviews, and in-service logs dated [DATE] verified 16 CNAs and 9 Nurses, including all current Nurses and CNAs on duty, had completed the following training: 1. Facility's new process for Code Blue, including new Code Supervisor position, code team, CPR Oversite lead schedule, Code Notebook, and Code blue forms. 2. Facility's policy Emergency Procedure - Cardiopulmonary Resuscitation 3. Code Blue Quiz completed, including all code team members on duty on [DATE]. Review of CPR certification cards revealed 1 of 2 NPs, 4 of 4 Registered Nurses (RN), including the DON, 11 of 13 Licensed Practical Nurses (LPNs), and 7 of 26 CNAs had current CPR certifications. Review of Emergency Procedure - Cardiopulmonary Resuscitation policy in-service revealed 1 of 2 NPs, 8 of 13 LPNs, and 16 of 26 CNAs had been in-serviced as of [DATE], with Code Supervisors responsible to educate all oncoming staff who had not received the in-service training. Review of the CPR Oversite Lead Schedule dated [DATE] - [DATE] revealed an assigned Code supervisor for each shift. Staff interviews were completed with all on duty staff to include 3 LPNs and 7 CNAs. These interviews revealed they had received training on the facility's removal plan, which included identification of the current code team members, completion of the code blue quiz for the current code team members, and the Emergency Procedure - Cardiopulmonary Resuscitation policy and procedures. Review of the Code Blue Book on [DATE] at 1:40 PM revealed: 1. A list of Full Code status residents, a code supervisor job description, and code blue steps for the staff and the code lead. 2. A form entitled .TEAM Huddle Report . which included New Admissions, Discharges, Census, Staffing Schedule, Code Team, Reiterate Code Team Duties and Responsibilities, and the Code Events Performed. 3. The TEAM Huddle report included .REMINDERS .Code Status 1st - Delegate call to 911/EMS get Estimated Time of Arrival (ETA) - Always Notify the provider on call of any code blue scenario .TODAYS ACTIVITIES .Emergency Equip (Equipment) Cart & (and) AED (Automatic External Defibrillator) Checklist Complete . 4. A CPR Oversite Lead Schedule for dates of [DATE] - [DATE]. 5. A Code Blue Supervisor on call List with names of staff members and phone numbers. 6. Identification of staff members who had a current CPR certification. 7. A CPR Code Blue Record for scribing information during a code blue and a log to track when a Code Blue had occurred. Interview with the Staff Education Coordinator on [DATE] at 2:10 PM, in the conference room, revealed a BLS/CPR class had been scheduled for [DATE] at 6:00 AM and 2:00 PM and on [DATE] at 6:00 PM, for any staff needing current certification. Noncompliance at F-867 continues at a scope and severity of D for monitoring of the effectiveness of corrective actions to ensure sustained compliance. Refer to F678 and F-726

Based on review of facility policy, review of medical records, review of facility investigation, observation, and interview, the facility failed to provide supervision to prevent accidents, and failed to complete a thorough investigation and implement appropriate interventions to prevent future falls after an unwitnessed injury for 1 resident (#29) of 3 residents reviewed for accidents. The facility's failure resulted in Resident #29 sustaining a pelvic fracture (harm). The findings include: Review of the facility policy Assessing Falls and Their Causes, dated 10/2010, revealed The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .Residents must be assessed in a timely manner for potential causes of falls .An incident report must be completed for resident falls .Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. Staff will evaluate chains of events or circumstances preceding a recent fall .The staff will continue to collect and evaluate information until they either identify the cause of falling or determine the cause cannot be found .If the cause is unknown but no additional evaluation is done, the physician or nursing staff should note why .When possible, the Attending Physician or nursing staff will document the basis for identifying specific factors as the cause . Medical record review revealed Resident #29 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. Review of medical records revealed no [DIAGNOSES REDACTED]. Medical record review of the Plan of Care - Current, dated 5/13/18, revealed, .At risk for falls r/t (related to) cognitive deficit and Hx (history) of falls .Interventions .Assist with ADLs (activities of daily living) to extent necessary. Encourage resident to ask for assistance when needed. Provide safe clutter free environment. Have call light within reach when in room. Answer promptly. Anticipate needs. Ensure resident wears appropriate foot wear. Rehab eval (rehabilitation evaluation) and follow up as needed. Provide mobility device as indicated .Staff assist with most adl's; transfer, mobility, locomotion, bathing and showering .Locomotion by WC (wheelchair) . Medical record review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 3, indicating severe cognitive impairment. Resident #29 had no functional limitation in range of motion, walking was not steady, but able to stabilize without staff assistance, and the resident required extensive assistance of 1 person for transfers, walking in room, walking in corridor, and locomotion on the unit. Review of the facility Incident Investigation and Review dated 4/13/19 at 12:00 PM, revealed .Resident (#29) noted to be having pain while sitting and standing. Resident stated when asked 'I fell ' then later stated 'I bumped it' while pointing at her waist/hip area. No episodes of falling reported by staff members or family. Resident assessed and no areas of redness, bruising, discoloration noted. No open areas noted. Staff reported that resident does ambulate in room, getting in and out of bed. Staff states that resident 'crawls into bed on hands and knees then flops down'. Staff states that resident could possible (possibly) had a fall and gotten self up. NP (Nurse Practitioner) was notified of complaints and an order obtained for x-rays. X-ray report positive for possible pelvic fracture. NP notified of results and orders obtained to send to ER (emergency room ) for further evaluation and treatment . Review of the Fall Investigation Worksheet revealed, .NOTE: This assessment must be completed by the licensed Nurse following each resident fall and submitted to the clinical supervisor . Review of the worksheet revealed it had an X marked across the entire page and there was no information documented on the form. Review of the form revealed the worksheet was supposed to be completed to document the location of the fall, position of the resident prior to the fall, the resident diagnosis/condition that may contribute, environmental factors, footwear/equipment at time of fall, medications that may be causative, assistive devices used by the resident, resident interview, signature and date of the staff completing the form, interventions initiated, and the Interdisciplinary Team's determination of what the fall was related to. Medical record review of Resident #29's Plan of Care revealed an entry on 4/13/19, Resident stated that she fell after having pain while sitting and standing. Resident later stated she bumped it while pointing at her waist/hip area. No redness or bruising noted. Resident does walk around in room and staff states she crawls into bed and crawls on hands and knees then flops down. NP notified and xray ordered. Xray showed possible pelvic fracture. NP notified of results and sent to ER for eval. (evaluation) and treatment. Review of the care plan revealed the section for Interventions was blank, with no interventions related to the incident documented. There was no documentation on the care plan of any interventions to prevent recurrence of accidents or injuries after the injury on 4/13/19. Review of the facility's Investigation of Bruises, Skin tears, Scratches, Etc, To determine etiology or origin of injury dated 4/14/19 at 12:00 PM, revealed, Describe injury including size, color, appearance, bleeding, etc: c/o (complaint of) pain to L (left) hip notified NP X-ray done pelvic fx fracture) noted sent to ER .Resident interview .Non-interviewable .Description of resident at time of discovery: laying in bed .Description of resident at last observation prior to injury: in bed asleep .Recommendations/Interventions to prevent recurrence: pad side rails on bed . The form had areas to be completed for date of injury, time of injury, how did fall occur, location that injury occurred, witness to injury, staff interview, DON signature and date, QA (Quality Assurance) review date, and Safety Committee review date, which were not completed. Review of Witness Statement Forms revealed there was only one witness statement and it was completed by Licensed Practical Nurse (LPN) #4, who had initiated the above investigation forms, on 4/14/19 at 12:00 PM. Review of the Witness Statement Form revealed .1. When was the Last time you saw the Resident: 11:30 am. 2. What were they doing? Laying in bed. 3. Did you witness the incident? No. 4. What were you doing at the time of the incident? @ (at) desk. 5. Did you notify your supervisor? Yes .6. Did you notify Administrative Staff? No .Summary of Event: Resident (#29) c/o pain to L hip area during ADLs. X-ray obtained dx (diagnosis) pelvic fx. Resident gets into bed on her knees, possible (possibly) hit side rail when trying to lay down. Ambulates ad lib (when desired) - in and out of bed - states fell . Medical record review of a mobile x-ray dated 4/14/19 at 4:42 PM, revealed .displaced left pubic fractures . Medical record review of the hospital ER history dated 4/14/19 at 7:27 PM, revealed .unwitnessed fall and was unable to get up on her own .mechanism of injury unknown . Medical record review of a hospital x-ray report dated 4/14/19 at 7:38 PM, revealed .displaced fractures involving the left superior and inferior pubic rami (bones comprised of a portion of the pelvic bones) . Observation on 10/7/19 at 3:25 PM, revealed Resident #29 was in a semi-private room with padded upper side rails on the bed and a call light on the bed. Observation on 10/7/19 at 3:30 PM, revealed Resident #29 was sitting in a wheelchair in the activity room and was pleasantly confused and not interviewable. Interview with Certified Nurse Assistant (CNA) #5 and CNA #7 on 10/8/19 at 11:32 AM, in the resident's room, revealed Resident #29 did not walk now, but before the injury resulting in the pelvic fracture, the resident would get up and walk in the room. Interview with CNA #9 on 10/8/19 at 2:36 PM, in the resident's room, revealed the CNA had not witnessed Resident #29 fall. The CNA stated, She was walking. Next thing I knew she was sent out (to the hospital). Telephone interview with LPN #4 on 10/8/19 at 3:45 PM, in the resident's room, revealed when the injury was discovered, 2 Certified Nursing Assistants (CNA) had completed personal care for Resident #29, prior to the resident getting out of bed, when the resident complained of pain. Prior to the injury, LPN #4 stated, .she could walk around, unsteady, but now can only transfer with 2 people . LPN #4 confirmed she had not witnessed a fall or been informed Resident #29 had a fall. Interview with the Director of Nursing (DON) on 10/9/19 at 8:00 AM, in the DON's office, confirmed a facility investigation for the pelvic injury was initiated as a fall investigation because the resident had a history of [REDACTED].one of the CNAs said she fell .can't remember who said that .but she had a history of [REDACTED].#4 did not witness a fall and the facility did not obtain any other witness statements. The DON stated .I don't know why she put the 'X' through the fall investigation worksheet .we didn't do a root cause analysis . The DON stated she determined the resident's injury to be the result of a fall due to an unsteady gait. Interview with CNA #4 on 10/9/19 at 8:52 AM, in the resident's room, revealed on 4/14/19, Resident #29 complained of pain during personal care and was unable to sit upright. CNA #4 confirmed she did not witness the resident fall and did not remember if she was asked about the injury by administration. Interview with CNA #8 on 10/9/19 8:59 AM, confirmed she was not asked by anyone for a witness statement and did not see Resident #29 fall. CNA #8 stated that Resident #29 .could walk by herself . prior to the injury. Interview with the Nurse Practitioner (NP) on 10/9/19 at 9:46 AM, in the conference room, confirmed she did not examine Resident #29 prior to her going to the ER. The NP examined the resident on 4/15/19, after returning to the facility, and the resident had no bruising or other signs of injury on her body. Interview with the DON and the MDS Coordinator on 10/9/19 at 11:05 AM, in the DON office, confirmed the DON could not identify a staff member who witnessed the resident fall, did not remember the name of the CNA who reported the resident fall, and confirmed the facility did not complete a thorough investigation to determine the cause of Resident #29's injury to implement appropriate interventions to prevent further accidents. In summary, Resident #29 was assessed on the MDS as requiring extensive assistance of one person for ambulating and she had an unsteady gait. Interviews with staff and review of the facility documentation confirmed staff was aware the resident was able to, and did walk independently in her room, and would get into and out of bed on her own. The resident was found to have a pelvic fracture by x-ray report on 4/14/19. The facility investigative documents had conflicting dates of 4/13/19 and 4/14/19 for the injury and the care plan dated the injury as 4/13/19. The facility did not follow their policy for fall investigations, did not complete a thorough investigation to determine the cause of the pelvic fracture, and failed to implement appropriate interventions to prevent further accidents.

Based on review of facility policy, medical record review, and interview, the facility failed to notify the physician immediately of the development of wounds for 3 residents (#2, #5, and #6) of 5 residents reviewed, resulting in harm to Resident #2. The findings included: Review of the facility policy, Prevention of Pressure Ulcers dated 3/2005, revealed .The facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review revealed the resident required extensive assistance for all levels of activities of daily living (ADLs) and was always incontinent of bowel and bladder. Medical record review of the weekly skin assessment dated [DATE], revealed .New Stage II ulcer on Coccyx .2 cm (centimeters) W (width) 1 cm L (length) . Review of the Medical Doctor/Nurse Practitioner (MD/NP) form, undated, revealed the staff left a note for the Nurse Practitioner (NP) regarding the new pressure wound to Resident #2's coccyx. Continued review revealed the document was initialed by the NP on 5/9/16 (2 days after discovery of the wound). Medical record review revealed Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated of 7/16/16 revealed Resident #5 had a BIMS score of 6 (severely impaired cognition), was total assist for transfers, required extensive assistance with dressing, eating, personal hygiene, and bathing, and was always incontinent of bowel and bladder. Medical record review of the weekly skin assessment dated [DATE] revealed .shearing prominent to left and right shoulders . Review of the MD/NP form, undated, revealed the staff left a note for the NP regarding the wound to Resident #5's scapulas. Continued review revealed the document was initialed by the NP on 7/20/16 (2 days after discovery of the wound). Medical record review revealed Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated of 4/3/16 revealed Resident #6 had a BIMS score of 8 (severely impaired cognition), required extensive assistance with transfers, limited assistance with dressing, eating, and personal hygiene, and was always incontinent of bowel and bladder. Medical record review of the weekly skin assessment dated [DATE] revealed .open area barrier cream applied (diagram indicated the location was on the buttocks) . Review of the MD/NP form, undated, revealed the staff left a note for the NP regarding the wound to Resident #6's buttocks. Continued review revealed the document was initialed by the NP on 8/01/16 (4 days after discovery of the wound). Interview with the treatment nurse on 10/3/16 at 12:00 PM, in the conference room, confirmed the staff nurse who discovered the wound was responsible for completion of the MD/NP form. Continued interview revealed the form was placed into a MD/NP communication book for review on the next provider visit. Further interview confirmed the facility did not have a process in place for immediate notification to the MD/NP between the time the wound was discovered and the time the provider was next in the facility. Interview with the Director of Nursing on 10/3/16 at 12:30PM, in the conference room, confirmed the facility failed to notify the Physician immediately of the wounds for Resident #2, #5, and #6. Refer to F-314

Based on review of facility policy, medical record review, and interviews, the facility failed to revise the care plan with interventions for the development of a pressure ulcer for 1 resident (#2), of 5 residents reviewed for pressure ulcers, resulting in harm to Resident #2. The findings included: Review of the facility policy Pressure Ulcers/Skin Breakdown - Clinical Protocol dated 4/2007, revealed .staff review and modify the care plan as appropriate, especially when .new wounds develop despite existing interventions . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review revealed the resident required extensive assistance for all activities of daily living and was always incontinent of bowel and bladder. Medical record review of the admission Braden Scale (assessment to determine the risk of the development of a pressure ulcer) dated 1/22/16 revealed the resident was at mild risk for the development of pressure ulcers. Medical record review of the interim care plan dated 1/23/16 revealed the facility had not care planned any actual or potential risk for alteration in skin integrity. Continued review of the care plan revealed, on 2/1/16, the facility implemented an intervention of moisture barrier to the resident's skin after bath and incontinence care. Further review revealed the resident required extensive assistance with bed mobility and to reposition every 2 hours. Medical record review of the quarterly Braden scale dated 4/23/16 revealed the resident remained at mild risk for the development of pressure ulcers. Medical record review of the weekly skin assessment dated [DATE], revealed .New Stage II ulcer on Coccyx .2 cm (centimeters) W (width) 1 cm L (length) . Medical record review of the Treatment Record revealed .5/19/16 (12 days after the wound was discovered) .Apply [MEDICATION NAME] (antibiotic) ointment to coccyx then apply Alginate Wound Dressing cover with Island Dressing Daily . Medical record review of the care plan revealed it was revised on 5/19/16 for the identification of a new stage II wound to Resident #2's coccyx. Continued review revealed the interventions implemented included a pressure reducing mattress, sheepskin in wheelchair due to constant scooting motion, and wound treatment as ordered. Interview with the Treatment Nurse on 10/3/16 at 12:00 PM, in the conference room, confirmed Resident #2's weekly skin assessment completed on 5/7/16 identified a new stage II pressure ulcer on Resident #2's coccyx. Continued interview confirmed the pressure ulcer increased in size from 2 cm by 1 cm on 5/7/16 to 2 cm by 2 cm on 5/29/16, and the facility had failed to implement treatment, initiate interventions, and update the care plan until 12 days after the wound was discovered. Interview with the Director of Nursing (DON) on 10/3/16 at 12:30 PM, in the conference room, confirmed the facility failed to initiate timely treatment, update the care plan for Resident #2's stage II pressure ulcer, and failed to follow facility policy, resulting in an increase in size from 2 cm by 1 cm on 5/7/16 to 2 cm by 2 cm on 5/29/16, which resulted in harm to Resident #2. Refer to F-314

Based on review of facility policy, medical record review, review of wound reports, and interviews, the facility failed to provide timely treatment and services to promote healing and prevent worsening of a pressure ulcer for 1 resident (#2), of 5 residents reviewed for pressure ulcers, resulting in harm to Resident #2. The findings included: Review of the facility policy Pressure Ulcer Treatment dated 3/2005, revealed .Stage II Protocol .Clean, shallow, minimal drainage: 1. Protect; 2. Manage drainage; 3. Promote moist wound healing; 4. Treatment: a. Cleanse with normal saline or other skin cleanser in accordance with physician orders and facility protocol; b. Apply barrier cream, hydrogel or hydrogel sheet (cut to fit); c. Cover with non-adhesive light gauze or transparent dressing; d. alternate dressing (use of thin [MEDICATION NAME]); and e. Change per physician order and manufacturer's directions . Medical record review revealed Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Continued review revealed the resident required extensive assistance for all activities of daily living and was always incontinent of bowel and bladder. Medical record review of the admission Braden Scale (assessment to determine the risk of the development of a pressure ulcer) dated 1/22/16 revealed the resident was at mild risk for the development of pressure ulcers. Medical record review of the interim care plan dated 1/23/16 revealed the facility had not care planned actual or potential risk for alteration in skin integrity. Continued review of the care plan revealed, on 2/1/16, the facility implemented an intervention of moisture barrier to the resident's skin after bath and incontinence care. Further review revealed the resident required extensive assistance with bed mobility and to reposition every 2 hours. Medical record review of the quarterly Braden scale dated 4/23/16 revealed the resident remained at mild risk for the development of pressure ulcers. Medical record review of the weekly skin assessment dated [DATE], revealed .New Stage II ulcer on Coccyx .2 cm (centimeters) W (width) 1 cm L (length) . Medical record review of the Treatment Record revealed .5/19/16 (12 days after the wound was discovered) .Apply [MEDICATION NAME] (antibiotic) ointment to coccyx then apply Alginate Wound Dressing cover with Island Dressing Daily . Medical record review of the care plan revealed it was revised on 5/19/16 with the identification of a new stage II wound and interventions implemented included a pressure reducing mattress, sheepskin in wheelchair due to constant scooting motion, and wound treatment as ordered. Review of the facility wound reports revealed Resident #2's coccyx wound was not added to the report until 5/29/16, when the coccyx wound had increased in size to 2 cm by 2 cm. Interview with the Treatment Nurse on 10/3/16 at 12:00 PM, in the conference room, confirmed Resident #2's weekly skin assessment completed on 5/7/16 identified a new stage II pressure ulcer on Resident #2's coccyx. Continued interview confirmed the pressure ulcer had increased in size from 2 cm by 1 cm on 5/7/16 to 2 cm by 2 cm on 5/29/16, the facility had failed to implement treatment, or initiate interventions, until 12 days after the wound was discovered, and the facility failed to add the wound to the facility wound report for tracking until 5/29/16 (22 days after discovery). Interview with the Director of Nursing (DON) on 10/3/16 at 12:30 PM, in the conference room, confirmed the facility failed to initiate timely treatment for [REDACTED].#2.

Based on medical record review, review of facility investigation, review of facility policy, review of window alarm monitoring documentation, observation, and interview, the facility failed to provide adequate supervision and/or security device to prevent elopement for one resident (#3) with identified elopement risk behaviors of seven sampled residents. The facility's failure to provide adequate supervision and/or security devices to prevent an elopement for Resident #3 resulted in Immediate Jeopardy (a situation that is likely to cause serious harm, injury, impairment, or death). The Immediate Jeopardy was effective June 17, 2012, through July 24, 2012. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m., in the Administrator's office. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated March 25, 2012, revealed, "...admitted by neurosurgery services for subarachnoid hemorrhage...underwent aneurysm clipping...resulting in waxing mental status changes, psychosis...discharged again in stable condition on 3-21-12...Daughter states...increased symptoms of agitation and mental status changes...picking at things and has been talking about hurting...self...asked for sharp objects and a knife and talked about cutting...wrist...Assessment and Plan:...concerns about suicidal ideations. Suicide precautions will be initiated..." Medical record review of a nurse's note dated April 14, 2012, at 2:05 p.m., revealed the resident was admitted to a room in the facility's secure unit and included, "...confused, ambulates with steady gait..." Medical record review of an undated Elopement Risk Form revealed a score of 10 and included, "...Total Score: 10 or Higher = (equals) At risk for elopement...Placed on Greenbriar (secure) unit for increased Elopement Risk..." Medical record review of a nurse's note dated April 14, 2012, at 11:00 p.m., revealed, "...Has episodes of exit-seeking. Will continue to monitor." Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was seven (moderate mental impairment), felt down, depressed, or hopeless nearly every day, and rejected care one to three days. Continued review revealed the resident ambulated with supervision, was steady at all times with transfers and ambulation, and required limited to extensive assistance with other activities of daily living. Medical record review of a nurse's note dated April 18, 2012, at 8:00 a.m., revealed, "...wanders continuously. Wants to go home..." Medical record review of a nurse's note dated April 23, 2012, at 8:00 p.m., revealed, "...continues to pace up and down...unit aimlessly..." Medical record review of the care plan dated April 23, 2012, revealed, "Problem...Special Care Unit Placement due to increasing confusion...diminished decision abilities r/t (related to) safety Goals Will know: family, staff faces, room location Interventions Special Care Unit ...Keep environment free of hazards...Assist in emergencies." Continued review revealed no intervention regarding staff supervision while in the resident's room and/or monitoring the window alarm..." Medical record review of a nurse's note dated May 3, 2012, at 9:00 p.m., revealed, "...shuts...self in room and slides chair against door..." Medical record review of a nurse's note dated May 5, 2012, at 3:00 p.m. revealed, "...Puts chair under door knob per night shift..." Medical record review of a physician's orders [REDACTED]." Medical record review of a nurse's note dated May 24, 2012, at 3:00 p.m., revealed, "Severely agitated - Focused on going home...will continue to monitor." Medical record review of a nurse's note dated May 29, 2012, at 9:00 a.m., revealed, "...wandering in hallway stating 'I want to leave here I don't belong here' exit seeking...continue to monitor." Medical record review of a nurse's note dated May 31, 2012, at 10:50 p.m., revealed, "...CNAs (Certified Nursing Assistants) said (resident) had been exit-seeking earlier. Will monitor." Medical record review of a nurse's note dated June 6, 2012, at 9:00 a.m., revealed, "...went out to patio and threatening to climb fence..." Medical record review of a nurse's note dated June 10, 2012, revealed, "(6A-6P) (6:00 a.m.-6:00 p.m.)...unable to concentrate any length of time on any one thing..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Medical record review of a physician's orders [REDACTED].@ (at) 2 pm." Medical record review revealed no documentation regarding a family intervention meeting. Medical record review of a Nurse Practitioner (NP) Progress note dated June 19, 2012, revealed, "...Nursing staff notified of increased agitation ...appears extremely agitated and has delusions, combative...Schizoaffective disorder ..." Medical record review of a physician's orders [REDACTED]." Medical record review of a nurse's note dated June 19, 2012, at 9:00 p.m., revealed, "...Trying to climb fence at patio. Unable to redirect..." Medical record review of an Elopement Risk assessment dated [DATE], revealed the resident had no history of elopement attempts in the last six months, a score of 9, and included,"Total Score: 10 or higher = (equals) at risk for elopement..." Medical record review of the care plan dated April 23, 2012, revealed no documentation regarding new interventions to address the resident's behavior and included, "...7-3-12...Comprehensive care plan reviewed and updated...with IDT (Interdisciplinary Team)..." Medical record review of a Psychotropic Medication Evaluation dated July 4, 2012, at 12:01 p.m., revealed, "...presents with severe insomnia...staff reported episodic mood swings...some inc (increased) delusions...Rationale for Recommendations...also may increase haldol 2 mg. 1/2 tab (tablet) afternoon in addition to bid dose prn (as needed)..." Continued review revealed the recommendations were approved by a nurse practitoner on July 20, 2012. Medical record review of a nurse's note dated July 6, 2012, at 8:00 a.m., revealed, "...wandering in hallway Asking repetively (repetitive) questions about going home...will monitor." Medical record review of a nurse's note dated July 11, 2012, at 2:00 p.m., revealed, "Resident with agitation exit seeking attempted to follow (name) off the floor...redirection unsuccessful...will cont to monitor." Medical record review of a Psychotropic Medication Management Progress Note dated July 13, 2012, at 12:45 p.m., revealed, "...appeared vigilant and paranoid. Staff reported...has been crazy...staff reported inc paranoia as dementia escalates. Current c/o (complaint) inc (include) physical aggression and irritability. Plan: inc haldol 2 mg tid (three times daily)...Indications for next visit: Acute Behavioral/Medical Problem...Delusions...Judgment Impaired...Ambulatory ...SI/HI (suicidal/homicidal ideation) Unable to assess due to patient's cognitive impairment..." Continued review revealed the Progress Note was not reviewed by a physician or a nurse practitioner until July 23, 2012, and included, "...Accept..." Medical record review of a nurse's note dated July 13, 2012, at 5:35 p.m., revealed, "Resident hollering that (resident) wanted to (go) home, that we have no right to keep...against (resident's) will...Going outside in enclosed area and attempting to climb fence...one on one monitoring in process..." Interview with the DON on July 30, 2012, at 12:15 p.m., in a conference room, revealed the DON was unaware of the initiation of one on one supervision on July 13, 2012, and unable to determine the duration of the one on one supervision. Medical record review of a nurse's note dated July 14, 2012, revealed, "@ (at) 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 9:00 a.m., revealed, "...continuously asking...when am I going home ...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio. Unable to redirect..." Medical record review of a nurse's note dated July 19, 2012, at 2:30 p.m., revealed, "...Res. (resident) crying today...wanted to go home. At one time ...yelled...and ran out back door...Will cont. to monitor behavior and attempt to redirect." Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "(CNA #2) came running over to South Station where I was on a med (medication) cart...said (resident) was out side, over at apartment complex...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Medical record review of a physician's orders [REDACTED].@ (at) noon." Medical record review of the Medication Administration Record dated July 2012 revealed the resident was administered Haldol 2 mg. at 8:00 a.m. and 8:00 p.m. from July 1, 2012, through July 23, 2012. Continued review revealed administration of Haldol 1 mg. at 12:00 p.m., was not initiated until July 24, 2012. Medical record review of nurse's notes dated between July 19, 2012 and July 30, 2012, revealed no documentation regarding additional elopement attempts. Review of facility policy Guidelines for Elopements dated 2008, revealed, "...Nursing personnel must investigate and report missing residents...It is the responsibility of all personnel to report any resident attempting to leave the premises...to the Charge Nurse a soon as practical...Attempt to prevent the departure...Upon return of the resident to the facility, the Charge Nurse should...Complete the incident report..." Review of a Notification of Unusual Occurrence Check List revealed, "...Date of Occurrence : 7/19/2012 Time: 8 p.m. Location: (the room the resident exited had a line drawn through it and the room the resident was moved to after the elopement was identified) ...Original care plan updated with NEW INTERVENTIONS: Yes...New Interventions one on one sitter...moved to room (another room on the other side of the hallway and where window opens to fenced courtyard)...Was the facility's policy implemented at all times? Yes...Supervisors Comments: Upon investigation it was found...resident pushed the window in (resident's) room open and screen out and went out window across the street to the apartments next door, about 50-75 yards...back within 10-15 mins (minutes)..." Review of a Post Fall Review Form dated July 19, 2012, revealed, "Date of Fall..." Continued review revealed the word "fall" had a line drawn through it, and included, "Location of fall Resident's room went out window ...Patient opens window in room and elopes from facility. Window alarm inaudible from hallway with door to room closed...Interdisciplinary Team Review/Recommendations...Ensure Alarm on Window Working...Resident was out of facility approximately 10- 15 mins (minutes) (estimate) ...Approximate Distance 50 - 75 ft (feet)." Continued review revealed the form was not dated or signed. Review of a "Monthly Window Alarm Test for Greenbriar" (secure unit) dated 2012 revealed the alarm in the resident's window was tested in June and included, "OK." Continued review revealed no documentation for testing window alarms of the secure unit in July 2012 as of July 27, 2012. Review of the facility investigation and a witness statement dated July 19, 2012, revealed, "I...(RN #1) was working the med (medication) cart on South Station, about 8 pm (p.m.)...CNA came running...told me (resident) was out side over at apartment complex...I ran over to Greenbriar (secure unit) to see if it was really (resident), when I went into Greenbriar...(Licensed Practical Nurse (LPN ) #1) was doing...med cart, (LPN #1) did not know that (resident) was gone. I went to dinning (dining) room no (resident) , I ran down the hall to (resident's) room, the door was shut, I could not hear the alarm, I opened the door and I could hear the alarm but it was not very loud, the window was open...(resident) was gone. I ran to the apartment complex next door the police was bring (bringing) (resident) back to the nursing home in (police) car..." Review of the facility investigation and a statement by (LPN #1) dated July 19, 2012, revealed, "...at approximately 0740 pm- 800 pm (7:40 p.m.-8:00 p.m.) I was in the process of self-orienting myself to e-charting and the e-mar (electronic charting and electronic Medication Administration Record)...at the desk...(RN #1) enters the unit and says...has been told a resident has eloped from the unit. I...was unaware of this...and we both proceeded rapidly to (resident's) room...An alarm, which was inaudible standing immediately outside the closed door, was sounding...(resident) was returned to the unit by a law enforcement officer..." Review of the facility investigation and a statement by CNA #1 dated July 19, 2012, revealed, "While I was out on my lunch break I noticed (resident) running around in the yards over at the fairgrounds (an apartment complex). I asked if I could give...a ride back ...hit me 3 times. That's when I realized it was going to take more than me to get...back...(CNA #2) was at the front door...to let some family members out...The family members followed us over and asked what (resident) looked like...They told me to get in with them and they would drive me around to see if I could find (resident). I happened to see a man across the street pointing towards an apartment...the woman that was with us said I'm a nurse let me take care of this. She knocked on the door and said she was calling the law. Her husband called 911. The cops showed up and (RN #1) and (Maintenance Director) was walking over...the cop took (resident) over to the nursing home..." Review of the facility investigation dated July 25, 2012, revealed, "...Date of Alleged Event: 07/19/2012...was in own room, opened the window, and crawled out of window (resident)...running down the road...Resident had just left the facility when seen by the CNA in the fair grounds (apartment complex) no more than 15 minutes...The LPN and the CNAs did not hear the alarm going off in the room due to the door was shut..." Review of the facility investigation revealed no documentation regarding when and by whom the resident was last seen prior to the observation by CNA #1 of the resident outside the facility on July 19, 2012. Observation on July 26, 2012, at 10:15 a.m., revealed the door to the resident's room was closed. Observation on July 26, 2012, revealed a security camera on the nurse's station displayed views of the two exit doors from the unit and the day/activity room. Observation on July 26, 2012, at 2:07 p.m., revealed the resident asleep in bed, the room was the first room from the exit door to the courtyard and furthest from the nurse's station, and a fenced courtyard was visible through the resident's window. Continued observation revealed an alarm sounded when the exit door was opened. Observation on July 26, 2012, at 3:02 p.m., revealed the resident independently walked with a steady gait to the nurse's station and stated, "I wanna (want to) go home. I love you. Can I go home with you?" Observation on July 27, 2012, at 10:25 a.m., revealed the resident asleep on the bed and the door to the room was open. Observation on July 27, 2012, at 11:27 a.m., revealed the resident seated at a table in the dining room. Interview with the Maintenance Director on July 27, 2012, at 11:57 a.m., in a conference room, revealed alarms had been placed on every window of the secure unit for at least two years. Continued interview revealed operation of the alarms was tested monthly and the alarm was tested the evening the resident eloped (after the elopement). The Maintenance Director stated, "...If you were at the desk (you) could not hear it. You'd have to be close to it. (There is) no way to adjust the volume." Interview with the Maintenance Director on July 27, 2012, at 12:17 p.m., in a conference room, revealed the Maintenace Direcotor was unaware the resident had attempted to elope through the window of the resident's room prior to the elopement on July 19, 2012. Observation with the Maintenance Director on July 27, 2012, at 12:55 p.m., revealed the distance from the bottom of the resident's window to the ground of the parking lot was thirty-four inches. Continued observation revealed the time required to walk from outside the resident's window to the apartment from which the resident was returned to the facility was less than three minutes. Continued observation revealed the area outside the resident's window included the facility's parking lot adjoining a wooded area, a drainage ditch, and intersection of two public streets. Observation on July 30, 2012, at approximately 9:30 a.m., revealed an industrial park, a water treatment plant, and a bridge over a creek less than a minute from the facility driving at twenty miles per hour (the posted speed limit). Interview with the DON on July 27, 2012, at 1:37 p.m., in a conference room, revealed LPN #1, CNA #3, and CNA #4 were assigned to the secure unit at the time the resident eloped on July 19, 2012. Continued interview revealed the facility's investigation did not include statements from CNA #3 or CNA #4. Interview with CNA #1 on July 27, 2012, at 1:45 p.m., in a conference room, revealed CNA #1 had left the facility for lunch at approximately 7:00 p.m. and on returning from lunch observed the resident out of the facility. Continued interview revealed the resident was on the far side of the second street from the facility, and CNA #1 stated, "...I noticed (resident) right there on the side of the road straight across the street from (the) apartment where (resident) was at...hit me two to three times right up the side of the head...decided I needed more help...I got to the road to turn in here, looked back and saw (resident) running toward that apartment. Saw (resident) go up the steps...That shocked me that (resident) was that far and nobody noticed..." Medical record review of the resident's care plan dated April 23, 2012, and interview with MDS Coordinator #1 on July 27, 2012, at 2:05 p.m., in a conference room, revealed the care plan was the resident's current care plan. Continued interview confirmed the resident's care plan had not been revised to address the resident's recurrent attempts and history of elopement. Interview with the Director of Nursing and the Administrator on July 27, 2012, at 2:20 p.m., revealed the DON had no additional investigations regarding elopment attempts by the resident. Continued interview revealed the twenty-four hour communication book had no documentation regarding the resident's previous elopement attempts. Continued interview confirmed the facility had failed to provide adequate supervision and/or safety device to ensure the resident with recurrent elopement attempts did not elope from the facility. The DON stated, "...have spoken to all RN managers. All say they were unaware of (resident's) previous attempts to elope. The only knowledge (DON's) of resident's behavior was the elopement..." In summary, the facility failed to provide adequate supervision for Resident #3 following elopement attempts on June 17, 2012, and July 14, 2012, and the resident successfully eloped from the facility on July 19, 2012. Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, revision of policies and procedures regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect and staff education. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring corrective actions through the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a plan of correction. Refer to F157-J. Refer to F224-J, Substandard Quality of Care. Refer to F225-J, Substandard Quality of Care. Refer to F250-J, Substandard Quality of Care. Refer to F272-J. Refer to F280-J. Refer to F309-J, Substandard Quality of Care. C/O: #

Based on review of facility policy, medical record review, and interview, the facility failed to notify the physician of recurrent elopement attempts for one resident (#3) with identified elopement risk behaviors of seven sampled residents. The facility's failure to notify the physician of recurrent elopement attempts by Resident #3 resulted in an actual elopement and Immediate Jeopardy (a situation that is likely to cause serious injury, harm, impairment, or death). The Immedidate Jeopardy was effective on June 17, 2012, through July 24, 2012. The Administrator and Director of Nursing were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m. in the Administrator's office. The findings included: Review of facility policy, Guidelines for Assessing a Change in a Resident's Condition Status, dated June 2008 revealed, "...Our facility shall promptly notify the...Attending Physician...of changes in the resident's medical/mental condition and/or status...The Nurse supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: a. An accident or incident involving the resident...Instructions to notify the physician of changes in the resident's condition..." Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated March 25, 2012, revealed, "...admitted by neurosurgery services for subarachnoid hemorrhage...underwent aneurysm clipping...resulting in waxing mental status changes, [MEDICAL CONDITION] again in stable condition on 3-21-12...Daughter states...increased symptoms of agitation and mental status changes...picking at things and has been talking about hurting...self...asked for sharp objects and a knife and talked about cutting...wrist...Assessment and Plan:...concerns about [MEDICAL CONDITION]. Suicide precautions will be initiated..." Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was seven (moderate mental impairment), felt down, depressed, or hopeless nearly every day, and rejected care one to three days. Continued review revealed the resident ambulated with supervision, was steady at all times with transfers and ambulation, and required limited to extensive assistance with other activities of daily living. Medical record review of a care plan dated April 23, 2012, revealed, "...Notify MD (Medical Doctor) if behavior interferes with functioning..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., revealed, "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review revealed no documentation regarding notification of the physician. Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA (Certified Nursing Assistant) calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Medical record review revealed no documentation regarding notification of the physician. Medical record review of a physician's orders [REDACTED]." Medical record review of a nurse's note dated July 14, 2012, revealed, "@ (at) 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Medical record review revealed no documentation regarding notification of the physician. Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio (a courtyard enclosed by a six foot fence). Unable to redirect..." Medical record review revealed no documentation regarding notification of the physician. Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "...CNA (#2) came running over to South Station where I was on a med (medication) cart...said (resident) was out side, over at apartment complex...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Telephone interview with the resident's physician (Medical Doctor) (M.D. #1) on July 30, 2012, at 12:20 p.m., in the administrator's office and in the presence of the Director of Nursing (DON) and the Administrator, revealed M.D. #1 was unaware of the resident's attempts to elope from the facility on June 17, 2012, and July 14, 2012, and confirmed the facility had failed to notify M.D. #1 regarding the resident's recurrent elopement attempts. In summary, the facility failed to notify M.D. #1 following elopement attempts by Resident #3 on June 17, 2012, and July 14, 2012, resulting in the resident's actual elopement from the facility on July 19, 2012. Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, and revision of policies and procedures regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect, and education of nursing staff regarding notification regarding unsafe behaviors. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a Plan of Correction. C/O: #

Based on review of facility policy, medical record review, review of facility investigation, review of window alarm monitoring documentation, observation, and interview, the facility failed to prevent neglect for one resident (#3) with identified elopement risk behaviors of seven sampled residents. The facility's failure to prevent neglect for Resident #3 with repeated elopement attempts and actual elopement resulted in Immediate Jeopardy (a situation in which the provider's non-compliance with one or more requirements of participation has caused, or is likely to cause serious harm, injury, impairment, or death). The Administrator and Director of Nursing were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m., in the Administrator's office. The Immediate Jeopardy was effective on June 17, 2012, through July 24, 2012. The findings included: Review of facility policy, Preventing Resident Abuse, dated August 2008 revealed, "Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures...to assist in preventing abuse...Our abuse prevention/intervention program includes, but is not necessarily limited to...Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect; Assessing residents with signs and symptoms of behavior problems and developing and implementing care plans to address behavioral issues...Involving qualified psychiatrists and other mental health professionals to help the staff manage difficult or aggressive residents...Identifying areas within the facility that may make abuse and/or neglect more likely to occur...and monitoring these areas regularly...Striving to maintain adequate staffing on all shifts to ensure that the needs of each resident are met...Encouraging all personnel...to report any signs or suspected incidents of abuse to facility management immediately...To help with recognition of incidents of abuse, the following definitions of abuse are provided...Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated March 25, 2012, revealed, "...admitted by neurosurgery services for subarachnoid hemorrhage...underwent aneurysm clipping...resulting in waxing mental status changes, [MEDICAL CONDITION] again in stable condition on 3-21-12...Daughter states...increased symptoms of agitation and mental status changes...picking at things and has been talking about hurting...self...asked for sharp objects and a knife and talked about cutting...wrist...Assessment and Plan:...concerns about [MEDICAL CONDITION]. Suicide precautions will be initiated..." Medical record review of a nurse's note dated April 14, 2012, at 2:05 p.m., revealed the resident was admitted to a room in the facility's secure unit and included, "...confused, ambulates with steady gait..." Medical record review of an undated Elopement Risk Form revealed a score of 10 and included, "...Total Score: 10 or Higher = (equals) At risk for elopement...Placed on Greenbriar (secure) unit for increased Elopement Risk..." Medical record review of a nurse's note dated April 14, 2012, at 11:00 p.m., revealed, "...Has episodes of exit-seeking. Will continue to monitor." Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was seven (moderate mental impairment), felt down, depressed, or hopeless nearly every day, and rejected care one to three days. Continued review revealed the resident ambulated with supervision, was steady at all times with transfers and ambulation, and required limited to extensive assistance with other activities of daily living. Medical record review of a nurse's note dated April 18, 2012, at 8:00 a.m., revealed, "...wanders continuously. Wants to go home..." Medical record review of a nurse's note dated April 23, 2012, at 8:00 p.m., revealed, "...continues to pace up and down...unit aimlessly..." Medical record review of the care plan dated April 23, 2012, revealed, "Problem...Special Care Unit Placement due to increasing confusion...diminished decision abilities r/t (related to) safety Goals Will know: family, staff faces, room location Interventions Special Care Unit...Keep environment free of hazards...Assist in emergencies." Continued review revealed no intervention regarding staff supervision while in the resident's room and/or monitoring the window alarm. Medical record review of a nurse's note dated May 3, 2012, at 9:00 p.m., revealed, "...shuts...self in room and slides chair against door..." Medical record review of a nurse's note dated May 5, 2012, at 3:00 p.m., revealed, "...Puts chair under door knob per night shift..." Medical record review of a physician's orders [REDACTED]." Medical record review of a nurse's note dated May 24, 2012, at 3:00 p.m., revealed, "Severely agitated - Focused on going home...will continue to monitor." Medical record review of a nurse's note dated May 29, 2012, at 9:00 a.m., revealed, "...wandering in hallway stating 'I want to leave here I don't belong here' exit seeking...continue to monitor." Medical record review of a nurse's note dated May 31, 2012, at 10:50 p.m., revealed, "...CNAs (Certified Nursing Assistants) said (resident) had been exit-seeking earlier. Will monitor." Medical record review of a nurse's note dated June 6, 2012, at 9:00 a.m., revealed, "...went out to patio and threatening to climb fence..." Medical record review of a nurse's note dated June 10, 2012, revealed, "(6A-6P) (6:00 a.m.-6:00 p.m.)...unable to concentrate any length of time on any one thing..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Medical record review of a physician's orders [REDACTED].@ (at) 2 pm." Medical record review revealed no documentation regarding a family intervention meeting. Medical record review of a Nurse Practitioner Progress note dated June 19, 2012, revealed, "...Nursing staff notified of increased agitation...appears extremely agitated and has [MEDICAL CONDITIONS] disorder..." Medical record review of a physician's orders [REDACTED]." Medical record review of a nurse's note dated June 19, 2012, at 9:00 p.m., revealed, "...Trying to climb fence at patio (enclosed courtyard). Unable to redirect..." Medical record review of an Elopement Risk assessment dated [DATE], revealed the resident had no history of elopement attempts in the past six months, a score of 9, and included,"Total Score: 10 or higher = (equals) at risk for elopement..." Medical record review of the care plan revealed, "...Plan of Care Comments...7-3-12...Comprehensive care plan reviewed and updated...with IDT (Interdisciplinary Team) for quarterly CP (care plan) meeting." Continued review revealed no revision of the care plan regarding the resident's recurrent elopement attempts. Medical record review of a [MEDICAL CONDITION] Medication Evaluation dated July 4, 2012, at 12:01 p.m., revealed, "...presents with severe [MEDICAL CONDITION] reported episodic mood swings...some inc (increased) [MEDICAL CONDITION] for Recommendations...also may inc (increase) [MEDICATION NAME] 2 mg 1/2 tab (tablet) afternoon in addition to bid dose prn (as needed)..." Continued review revealed the recommendations were approved by a nurse practitoner on July 20, 2012. Medical record review of a nurse's note dated July 6, 2012, at 8:00 a.m., revealed, "...wandering in hallway Asking repetively (repetitive) questions about going home...will monitor." Medical record review of a nurse's note dated July 11, 2012, at 2:00 p.m., revealed, "Resident with agitation exit seeking atempted to follow (name) off the floor...redirection unsuccessful...will cont (continue) to monitor." Medical record review of a [MEDICAL CONDITION] Medication Management Progress Note dated July 13, 2012, at 12:45 p.m., revealed, "...appeared vigilant and paranoid. Staff reported '...has been crazy'...staff reported increased paranoia as dementia escalates. Current c/o (complaint) inc (include) physical aggression and irritability. Plan: increase [MEDICATION NAME] 2 mg tid (three times daily)...Indications for next visit: Acute Behavioral/Medical [MEDICAL CONDITION] Impaired...Ambulatory ...SI/HI (suicidal/homicidal ideation) Unable to assess due to patient's cognitive impairment..." Continued review revealed the Progress Note was not reviewed by a Physician or a Nurse Practitioner until July 23, 2012, (ten days later) and included, "...Accept..." Medical record review of a physician's orders [REDACTED].@ noon." Medical record review of a nurse's note dated July 13, 2012, at 5:35 p.m., revealed, "Resident hollering that (resident) wanted to (go) home, that we have no right to keep...against (resident's) will...Going outside in enclosed area and attempting to climb fence...one on one monitoring in process..." Interview with the Director of Nursing (DON) on July 30, 2012, at 12:15 p.m., in a conference room, revealed the DON was unaware of the initiation of one on one supervision and unable to determine the duration of the one on one supervision documented in the nurse's note on July 13, 2012. Medical record review of a nurse's note dated July 14, 2012, revealed, "@ 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 9:00 a.m., revealed, "...continuously asking...when am I going home...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio. Unable to redirect..." Medical record review of a nurse's note dated July 19, 2012, at 2:30 p.m., revealed, "...Res. (resident) crying today...wanted to go home. At one time...yelled...and ran out back door...Will cont. to monitor behavior and attempt to redirect." Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "(name CNA) (#2) came running over to South Station where I was on a med (medication) cart...said (resident) was out side, over at apartment complex...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Continued review revealed administration of [MEDICATION NAME] 1 mg at 12:00 p.m., was initiated July 24, 2012, twenty days following the first recommendation (of July 4, 2012) to increase the resident's medication, ten days after the resident's third elopement attempt (on July 14, 2012), and five days after the resident's elopement (on July 19, 2012). Review of a facility investigation for a Notification of Unusual Occurrence Check List revealed, "...Date of Occurrence: 7/19/2012 Time: 8 p.m. Location: (the room the resident exited had a line drawn through it and the room the resident was moved to after the elopement was identified)...Original care plan updated with NEW INTERVENTIONS: Yes...New Interventions one on one sitter...moved to room (another room on opposite side of hallway and where window exits to courtyard)...Was the facility's policy implemented at all times? Yes...Supervisors Comments: Upon investigation it was found...resident pushed the window in (resident's) room open and screen out and went out window across the street to the apartments next door, about 50-75 yards...back within 10-15 mins (minutes)..." Review of a Post Fall Review Form dated July 19, 2012, revealed, "Date of Fall..." Continued review revealed the word "fall" had a line drawn through it and included, "Location of fall Resident's room went out window...Patient opens window in room and elopes from facility. Window alarm inaudible from hallway with door to room closed...Interdisciplinary Team Review/Recommendations...Ensure Alarm on Window Working...Resident was out of facility approximately 10-15 mins (estimate)...Approximate Distance 50-75 ft (feet)." Continued review revealed the form was not dated or signed. Review of a "Monthly Window Alarm Test for Greenbriar" (secure unit) dated 2012 revealed the alarm in the resident's window was tested in June and included, "OK." Continued review revealed no documentation for testing window alarms on the secure unit in July 2012 as of July 27, 2012. Review of a facility investigation and a witness statement dated July 19, 2012, revealed, "I...(RN #1) was working the med cart on South Station, about 8 pm (p.m.)...CNA came running...told me (resident) was out side over at apartment complex...I ran over to Greenbriar (secure unit) to see if it was really (resident), when I went into Greenbriar...(Licensed Practical Nurse) (LPN) #1 was doing...med cart, LPN #1 did not know that (resident) was gone. I went to dinning (dining) room no (resident), I ran down the hall to (resident's) room, the door was shut, I could not hear the alarm, I opened the door and I could hear the alarm but it was not very loud, the window was open...(resident) was gone. I ran to the apartment complex next door the police was bring (bringing) (resident) back to the nursing home in (police) car..." Review of a facility investigation and LPN #1's statement dated July 19, 2012, revealed, "...at approximately 0740 pm- 800 pm (7:40 p.m.-8:00 p.m.) I was in the process of self-orienting myself to e-charting and the e-mar (electronic charting and electronic Medication Administration Record)...at the desk...(RN #1) enters the unit and says...has been told a resident has eloped from the unit. I...was unaware of this...and we both proceeded rapidly to (resident's) room...An alarm, which was inaudible standing immediately outside the closed door, was sounding...(resident) was returned to the unit by a law enforcement officer..." Review of the facility investigation and a statement by CNA #1 dated July 19, 2012, revealed, "While I was out on my lunch break I noticed (resident) running around in the yards over at the fairgrounds (an apartment complex). I asked if I could give...a ride back (resident) hit me 3 times. That's when I realized it was going to take more than me to get (resident) back...(CNA #2) was at the front door...to let some family members out...The family members followed us over and asked what (resident) looked like...They told me to get in with them and they would drive me around to see if I could find (resident). I happened to see a man across the street pointing towards an apartment...the woman that was with us said I'm a nurse let me take care of this. She knocked on the door and said she was calling the law. Her husband called 911. The cops showed up and (RN #1) and (Maintenance Director) was walking over...the cop took (resident) over to the nursing home..." Review of the facility investigation dated July 25, 2012, revealed, "...Date of Alleged Event: 07/19/2012...was in own room, opened the window, and crawled out of window (resident)...running down the road...Resident had just left the facility when seen by the CNA...no more than 15 minutes...The LPN and the CNAs did not hear the alarm going off in the room due to the door was shut..." Observation on July 26, 2012, at 10:15 a.m., revealed the door to the resident's room was closed. Observation on July 26, 2012, at 2:07 p.m., revealed the resident asleep in bed. Continued observation revealed the resident's current room was the first room from the exit door to the courtyard and furthest from the nurse's station, and a fenced courtyard was visible through the resident's window. Observation on July 26, 2012, at 3:02 p.m., revealed the resident independently walked with a steady gait to the nurse's station and stated, "I wanna (want to) go home. I love you. Can I go home with you?" Observation on July 27, 2012, at 10:25 a.m., revealed the resident asleep on the bed and the door to the room was open. Interview with the Maintenance Director on July 27, 2012, at 11:57 a.m., in a conference room, revealed alarms had been placed on every window of the secure unit for at least two years. Continued interview revealed operation of the alarms was tested monthly, the alarm had been checked the evening the resident eloped (after the elopement) and he stated, "...If you were at the desk (you) could not hear it. You'd have to be close to it. (There is) no way to adjust the volume." Interview with the Maintenance Director on July 27, 2012, at 12:17 p.m., in a conference room, revealed the Maintenance Director was unaware the resident had attempted to elope through the window of the resident's room prior to the elopement on July 19, 2012. Interview with CNA #1 on July 27, 2012, at 1:45 p.m., in a conference room, revealed CNA #1 had left the facility for lunch at approximately 7:00 p.m. and on returning from lunch observed the resident out of the facility. Continued interview revealed the resident was on the far side of the second street from the facility, and CNA #1 stated, "...I noticed (resident) right there on the side of the road straight across the street from (the) apartment where (resident) was at...hit me two to three times right up the side of the head...decided I needed more help...I got to the road to turn in here, looked back and saw (resident) running toward that apartment. Saw (resident) go up the steps...That shocked me that (resident) was that far and nobody noticed..." Medical record review of the resident's care plan and interview with MDS Coordinator #1 on July 27, 2012, at 2:05 p.m., in a conference room, revealed the care plan was the resident's current care plan. Continued interview confirmed the resident's care plan had not been revised to address the resident's recurrent attempts and history of elopement. Interview with the DON and the Administrator on July 27, 2012, at 2:20 p.m., revealed the DON had no additional investigations regarding elopement attempts by the resident. Continued interview revealed the twenty-four hour communication book had no documentation regarding the resident's previous elopement attempts on June 17, 2012, at 2:00 p.m. and 9:30 p.m. Continued interview confirmed the facility had failed to provide adequate supervision and/or safety device to ensure the resident with recurrent elopement attempts did not elope from the facility. The DON stated, "...have spoken to all RN managers. All say they were unaware of (resident's) previous attempts to elope. The only knowledge (DON's) of resident's behavior was the elopement. Staff did not report barring the door with a chair or previous attempts to get out the window." Interview with NP #1 and the DON on July 30, 2012, at 12:00 p.m., in a conference room, (DON) revealed the evaluations and/or recommendations of the mental health provider were difficult to comprehend related to conflicting recommendations documented on the form, but in different sections of the form, completed by the mental health provider . Continued interview confirmed the facility failed to contact the mental health providers for clarrification of the recommendations on the form completed by the mental health providers. Telephone interview with the resident's physician (M.D. #1) on July 30, 2012, at 12:20 p.m., in the Administrator's office and in the presence of the DON and the Administrator, revealed he was unaware of the resident's attempts to elope from the facility on June 17, 2012, and July 14, 2012, and confirmed the facility had failed to notify M.D. #1 regarding the resident's recurrent elopement attempts. Continued interview with M.D. #1 revealed M.D. #1 was the facility's Medical Director, and confirmed the recommendations for changes in the resident's antipsychotic medication was not communicated or acted on timely. Continued interview revealed timely administration of the increased dose of antipsychotic medication may have improved the resident's behavior and prevented the resident's elopement on July 19, 2012. Telephone interview with a Psychiatric Nurse Practitioner (PNP) on July 30, 2012, at 4:05 p.m., and in the presence of the DON, revealed the PNP provides assessments of residents and stated, "...I take my assessments back to (mental health provider) and (mental health provider) follows up on communicating to facility what (my) recommendations are." Interview with the DON on July 30, 2012, at approximately 4:15 p.m., in the DON's office, confirmed the facility neglected to provide the care required by Resident #3. The DON stated, "...We missed every opportunity..." Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other residents at risk, and revision of policies and procedures and staff education regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring corrective actions through the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a plan of correction. Refer to F157 J. C/O: #

Based on medical record review, observation, and interview, the facility failed to provide required social services to prevent elopement for one resident (#3) with identified elopement risk behaviors of seven sampled residents. The facility's failure to provide required Social Services to prevent elopement for Resident #3 resulted in Immediate Jeopardy (a situation that is likely to cause serious harm, injury, impairment, or death). The Immediate Jeopardy was effective June 17, 2012, through July 24, 2012. The Adminstrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m., in the Administrator's office. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated March 25, 2012, revealed, "...admitted by neurosurgery services for subarachnoid hemorrhage...underwent aneurysm clipping...resulting in waxing mental status changes, psychosis...discharged again in stable condition on 3-21-12 ...Daughter states...increased symptoms of agitation and mental status changes...picking at things and has been talking about hurting...self...asked for sharp objects and a knife and talked about cutting...wrist...Assessment and Plan:...concerns about suicidal ideations. Suicide precautions will be initiated..." Medical record review of a nurse's note dated April 14, 2012, at 2:05 p.m., revealed the resident was admitted to a room in the facility's secure (locked) unit. Medical record review of a nurse's note dated April 14, 2012, at 11:00 p.m., revealed, "...Has episodes of exit-seeking. Will continue to monitor." Medical record review of a nurse's note dated April 18, 2012, at 8:00 a.m., revealed, "...wanders continuously. Wants to go home. States '...let me go home...these people are driving me crazy.' Will notify Social Services..." Medical record review of a nurse's note dated April 18, 2012, at 6:40 p.m., revealed, "...Resident expressed desire to be moved off of this unit...'These people back here are driving me crazy & (and) I am afraid of them.' Will leave information with (Social Service Director) for further intervention..." Medical record review of a nurse's note dated April 22, 2012, at 3:00 p.m., revealed, "...wanting to stay with staff - stating 'they will hurt me.'..." Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was seven (moderate mental impairment), felt down, depressed, or hopeless nearly every day, and rejected care one to three days. Medical record review of the care plan dated April 23, 2012, revealed, "Problem...Mood pleasant - No behaviors noted, refused skin assessment...Notify nursing of any change in mood/behavior...Disciplines... SS (social service) Visit one: one (one staff to one resident) with resident weekly...Discipline SS..." Continued review revealed the care plan was revised by the Interdisciplinary team, no documentation regarding new interventions to address the resident's behavior and included, "7-3-12...Comprehensive care plan reviewed and updated...with IDT (Interdisciplinary Team)." Medical record review of a nurse's note dated May 5, 2012, at 2:00 p.m. revealed, "...doesn't like to be alone in (resident's) room..." Medical record review of a physician's orders [REDACTED]." Medical record review of a nurse's note dated May 24, 2012, at 3:00 p.m., revealed, "Severely agitated - Focused on going home...will continue to monitor." Medical record review of a nurse's note dated May 27, 2012, at (first shift) revealed, "...at times becomes verbally threatening to other resd (residents)..." Medical record review of a nurse's note dated May 29, 2012, at 9:00 a.m., revealed, "...I want to leave here I don't belong here...exit seeking ...continue to monitor." Medical record review of a nurse's note dated June 6, 2012, at 9:00 a.m., revealed, "...went out to patio and threatening to climb fence..." Medical record review of a nurse's note dated June 10, 2012, revealed, "(6A-6P) (6:00 a.m.-6:00 p.m.)...unable to concentrate any length of time on any one thing..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA (Certified Nursing Assistant) calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Medical record review of a physician's orders [REDACTED].@ (at) 2 pm." Medical record review revealed no documentation regarding a family intervention meeting. Medical record review of a Nurse Practitioner Progress note dated June 19, 2012, revealed, "...Nursing staff notified of increased agitation...appears extremely agitated and has delusions, combative...Schizoaffective disorder ..." Medical record review of a Psychotropic Medication Evaluation dated July 4, 2012, at 12:01 p.m., revealed, "...Mood/Affect...Dysphoric Severity 6...Flat Severity 7 (1 = Least Severe, 10 = (equals) Most Severe)..." Continued review revealed, "...presents with severe insomnia...staff reported episodic mood swings...some inc (increased) delusions...Rationale for Recommendations...also may increase haldol 2 mg 1/2 tab (tablet) afternoon in addition to bid dose prn (as needed)..." Continued review revealed the recommendations were approved by a nurse practitoner on July 20, 2012. Medical record review of a nurse's note dated July 6, 2012, at 8:00 a.m., revealed, "...wandering in hallway Asking repetively (repetitive) questions about going home...will monitor." Medical record review of a nurse's note dated July 11, 2012, at 2:00 p.m., revealed, "Resident with agitation exit seeking attempted to follow (name) off the floor...redirection unsuccessful...will cont to monitor." Medical record review of a Psychotropic Medication Management Progress Note dated July 13, 2012, at 12:45 p.m., revealed, "...appeared vigilant and paranoid. Staff reported...has been crazy...staff reported inc (increased) paranoia as dementia escalates. Current c/o (complaint) inc (include) physical aggression and irritability. Plan: increase haldol 2 mg. tid (three times daily)...Indications for next visit: Acute Behavioral/Medical Problem...Delusions...Judgment Impaired...Ambulatory ...SI/HI (suicidal/homicidal ideation) Unable to assess due to patient's cognitive impairment...Behavior interventions not indicated in patient record." Continued review revealed the Progress Note was not reviewed by a physician or a nurse practitioner until July 23, 2012 (ten days later) and included, "...Accept..." Medical record review of a physician's orders [REDACTED].@ noon." Medical record review of a nurse's note dated July 13, 2012, at 5:35 p.m., revealed, "Resident hollering that (resident) wanted to (go) home, that we have no right to keep...against (resident's) will...Going outside in enclosed area and attempting to climb fence..." Medical record review of a nurse's note dated July 14, 2012, revealed, "@ 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 9:00 a.m., revealed, "...continuously asking...when am I going home...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio. Unable to redirect..." Medical record review of a nurse's note dated July 19, 2012, at 2:30 p.m., revealed, "...Res. (resident) crying today...wanted to go home. At one time ...yelled...and ran out back door...Will cont. to monitor behavior and attempt to redirect." Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "(CNA #2) came running over to South Station where I was on a med (medication) cart...said (resident) was out side, over at apartment complex ...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Medical record review of the Medication Administration Record dated July 2012 revealed the resident was administered Haldol 2 mg. at 8:00 a.m. and 8:00 p.m. from July 1, 2012, through July 23, 2012. Continued review revealed administration of Haldol 1 mg. at 12:00 p.m., was not initiated until July 24, 2012 (twenty days following the first recommendation of July 4, 2012). Observation on July 26, 2012, at 3:02 p.m., revealed the resident ambulated to the nurse's station and stated, "I wanna (want to) go home. I love you. Can I go home with you?" Interview with the Social Service Director (SSD) on July 27, 2012, at 3:17 p.m., in a conference room, revealed the physician ordered a family meeting scheduled for June 18, 2012, the meeting did not occur, and the SSD stated, "...don't know the purpose of the meeting..." Interview with the SSD on July 30, 2012, at 11:00 a.m., in a conference room, revealed the resident's risk for elopement was discussed in a care plan meeting on July 3, 2012, and the resident's recurrent attempts to elope were not discussed. Continued interview revealed in response to inquiry regarding a behavior plan for the resident, the SSD stated, "Certain things we expect from a resident who's on (secure unit). Have a minister that we can call in if we want...(Resident) doesn't like anyone to come to (resident's) door...Couldn't figure out why (resident) was afraid of a particular resident. (I) visit every unit weekly...no behavior plan for (resident)..." Continued interview revealed the SSD provided more frequent one on one visits with the resident and diversional activies after the resident eloped. Continued interview revealed the SSD was uncertain if the resident was currently treated by a mental health provider and confirmed the facility failed to provide social services to attain the highest practicable mental and psychosocial well-being for Resident #3, resulting in elopement and placing Resident #3 in Immediate Jeopardy. Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, revision of policies and procedures, and staff education regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect, increased frequency of routine one on one visits by the SSD and on request of secure unit staff. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring corrective actions through the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a plan of correction. Refer to F157-J. Refer to F224-J, Substandard Quality of Care. Refer to F225-J, Substandard Quality of Care. C/O: #

Based on medical record review and interview, the facility failed to re-assess one resident with recurrent unsafe behaviors (#3) of seven sampled residents. The facility's failure to re-assess the recurrent unsafe behaviors of Resident #3 resulted in an actual elopement and Immediate Jeopardy (a situation that is likely to cause serious harm, injury, impairment, or death). The Immediate Jeopardy was effective June 17, 2012, through July 24, 2012. The Adminstrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m., in the Administrator's office. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated March 25, 2012, revealed, "...admitted by neurosurgery services for subarachnoid hemorrhage...underwent aneurysm clipping...resulting in waxing mental status changes, [MEDICAL CONDITION] again in stable condition on 3-21-12...Daughter states...increased symptoms of agitation and mental status changes...picking at things and has been talking about hurting...self...asked for sharp objects and a knife and talked about cutting...wrist...Assessment and Plan:...concerns about [MEDICAL CONDITION]. Suicide precautions will be initiated..." Medical record review of an undated Elopement Risk Form revealed a score of 10 and included, "...Total Score: 10 or Higher = (equals) At risk for elopement ...Placed on Greenbriar (secure) unit for increased Elopement Risk..." Medical record review of a nurse's note dated April 14, 2012, at 2:05 p.m., revealed the resident was admitted to a room in the facility's secure unit and included, "...confused, ambulates with steady gait..." Medical record review of a nurse's note dated April 14, 2012, at 11:00 p.m., revealed, "...Has episodes of exit-seeking. Will continue to monitor." Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was seven (moderate mental impairment), felt down, depressed, or hopeless nearly every day, and rejected care one to three days. Continued review revealed the resident ambulated with supervision, was steady at all times with transfers and ambulation, and required limited to extensive assistance with other activities of daily living. Medical record review of a nurse's note dated April 18, 2012, at 8:00 a.m., revealed, "...wanders continuously. Wants to go home..." Medical record review of a nurse's note dated April 23, 2012, at 8:00 p.m., revealed, "...continues to pace up and down...unit aimlessly..." Medical record review of a nurse's note dated May 3, 2012, at 9:00 p.m., revealed, "...shuts...self in room and slides chair against door..." Medical record review of a nurse's note dated May 5, 2012, at 3:00 p.m. revealed, "...Puts chair under door knob per night shift..." Medical record review of a nurse's note dated May 24, 2012, at 3:00 p.m., revealed, "Severely agitated - Focused on going home...will continue to monitor." Medical record review of a nurse's note dated May 29, 2012, at 9:00 a.m., revealed, "...wandering in hallway stating 'I want to leave here I don't belong here' exit seeking ...continue to monitor." Medical record review of a nurse's note dated May 31, 2012, at 10:50 p.m., revealed, "...CNAs (Certified Nursing Assistants) said (resident) had been exit-seeking earlier. Will monitor." Medical record review of a nurse's note dated June 6, 2012, at 9:00 a.m., revealed, "...went out to patio and threatening to climb fence..." Medical record review of a nurse's note dated June 10, 2012, revealed, "(6A-6P) (6:00 a.m.-6:00 p.m.)...unable to concentrate any length of time on any one thing..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Medical record review of a Nurse Practitioner's (NP) Progress note dated June 19, 2012, revealed, "...Nursing staff notified of increased agitation...appears extremely agitated and has [MEDICAL CONDITIONS] disorder..." Medical record review of a nurse's note dated June 19, 2012, at 9:00 p.m., revealed, "...Trying to climb fence at patio. Unable to redirect..." Medical record review of an Elopement Risk assessment dated [DATE], revealed the resident had gone more than 120 days without an elopement attempt, a score of 9, and included,"Total Score: 10 or higher = (equals) at risk for elopement..." Medical record review of a nurse's note dated July 6, 2012, at 8:00 a.m., revealed, "...wandering in hallway Asking repetively (repetitive) questions about going home...will monitor." Medical record review of a nurse's note dated July 11, 2012, at 2:00 p.m., revealed, "Resident with agitation exit seeking attempted to follow (name) off the floor...redirection unsuccessful...will cont to monitor." Medical record review of a [MEDICAL CONDITION] Medication Evaluation dated July 4, 2012, at 12:01 p.m., revealed, "...presents with severe [MEDICAL CONDITION] reported episodic mood swings...some inc (increased) [MEDICAL CONDITION]" Medical record review of a [MEDICAL CONDITION] Medication Management Progress Note dated July 13, 2012, at 12:45 p.m., revealed, "...appeared vigilant and paranoid. Staff reported...has been crazy...staff reported inc paranoia as dementia escalates. Current c/o (complaint) inc (include) physical aggression and irritability...." Medical record review of a nurse's note dated July 14, 2012, revealed, "@ (at) 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 9:00 a.m., revealed, "...continuously asking...when am I going home...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio. Unable to redirect..." Medical record review of a nurse's note dated July 19, 2012, at 2:30 p.m., revealed, "...Res. (resident) crying today...wanted to go home. At one time ...yelled...and ran out back door...Will cont. to monitor behavior and attempt to redirect." Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "(CNA #2) came running over to South Station where I was on a med (medication) cart...said (resident) was out side, over at apartment complex ...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Medical record review of an Elopement Risk Form dated July 19, 2012, completed by the Licensed Practical Nurse on duty at the time of the resident's elopement, revealed a score of twelve and included, "...2 or more attempts...Total Score: 10 or Higher = (equals) At risk for elopement..." Interview with MDS Coordinator #3 on July 27, 2012, revealed MDS Coordinator #3 was unaware the resident had attempted elopement prior to the elopement on July 19, 2012. Interview with the Social Service Director (SSD) on July 30, 2012, at 11:00 a.m., revealed the interdisciplinary team reviewed the resident's risk for elopement on July 3, 2012. The SSD stated, "...We talked about (resident) wanting to go home, the risk for elopement was discussed but not elopement attempts..." Interview with NP #2 on July 30, 2012, at 12:00 p.m., in a conference room, revealed NP #2 had reviewed the resident's mental health assessment documentation, did not understand it, and failed to clarify the assessment data. Interview with Registered Nurse (RN) #2 on July 30, 2012, at approximately 4:00 p.m., revealed RN #2 completed the elopement risk assessment dated [DATE]. RN #2 stated related to the incorrect assessment that documented the resident had not eloped in the last 120 days, "The assessment is incorrect. I did it. It's solely my responsibility." Interview with the DON on July 30, 2012, at approximately 4:15 p.m., in the DON's office, confirmed the facility failed to reassess Resident #3. The DON stated, "...missed every opportunity..." Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, revision of policies and procedures regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect and staff education. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring corrective actions through the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a plan of correction. Refer to F157-J. Refer to F224-J, Substandard Quality of Care. Refer to F225-J, Substandard Quality of Care. Refer to F250-J, Substandard Quality of Care. C/O: #

Based on medical record review, review of facility investigation, observation, and interview, the facility failed to revise the care plan to address recurrent unsafe behaviors for one resident (#3) of seven sampled residents. The facility's failure to revise the care plan to address recurrent recurrent unsafe behaviors of Resident #3 resulted in an actual elopment and Immediate Jeopardy (a situation that is likely to cause serious harm, injury, impairment, or death). The Immedidate Jeopardy was effective on June 17, 2012, through July 24, 2012. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m. in the Administrator's office. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated March 25, 2012, revealed, "...admitted by neurosurgery services for subarachnoid hemorrhage...underwent aneurysm clipping...resulting in waxing mental status changes, [MEDICAL CONDITION] again in stable condition on 3-21-12 ...Daughter states...increased symptoms of agitation and mental status changes...picking at things and has been talking about hurting...self...asked for sharp objects and a knife and talked about cutting...wrist...Assessment and Plan:...concerns about [MEDICAL CONDITION]. Suicide precautions will be initiated..." Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was seven (moderate mental impairment), felt down, depressed, or hopeless nearly every day, and rejected care one to three days. Medical record review of a nurse's note dated April 14, 2012, at 11:00 p.m., revealed, "...Has episodes of exit-seeking. Will continue to monitor." Medical record review of a nurse's note dated April 18, 2012, at 8:00 a.m., revealed, "...wanders continuously. Wants to go home..." Medical record review of the care plan dated April 23, 2012, revealed, "Problem...Special Care Unit Placement due to increasing confusion...diminished decision abilities r/t (related to) safety Goals Will know: family, staff faces, room location Interventions Special Care Unit ...Keep environment free of hazards...Assist in emergencies..." Medical record review of a nurse's note dated April 23, 2012, at 8:00 p.m., revealed, "...continues to pace up and down...unit aimlessly..." Medical record review of a nurse's note dated May 3, 2012, at 9:00 p.m., revealed, "...shuts...self in room and slides chair against door..." Medical record review of a nurse's note dated May 5, 2012, at 3:00 p.m. revealed, "...Puts chair under door knob per night shift..." Medical record review of a nurse's note dated May 24, 2012, at 3:00 p.m., revealed, "Severely agitated - Focused on going home...will continue to monitor." Medical record review of a nurse's note dated May 29, 2012, at 9:00 a.m., revealed, "...wandering in hallway stating 'I want to leave here I don't belong here' exit seeking ...continue to monitor." Medical record review of a nurse's note dated May 31, 2012, at 10:50 p.m., revealed, "...CNAs (Certified Nursing Assistants) said (resident) had been exit-seeking earlier. Will monitor." Medical record review of a nurse's note dated June 6, 2012, at 9:00 a.m., revealed, "...went out to patio and threatening to climb fence..." Medical record review of a nurse's note dated June 10, 2012, revealed, "(6A-6P) (6:00 a.m.-6:00 p.m.)...unable to concentrate any length of time on any one thing..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Medical record review of a nurse's note dated July 11, 2012, at 2:00 p.m., revealed, "Resident with agitation exit seeking attempted to follow (name) off the floor...redirection unsuccessful...will cont to monitor." Medical record review of a nurse's note dated July 13, 2012, at 5:35 p.m., revealed, "Resident hollering that (resident) wanted to (go) home, that we have no right to keep...against (resident's) will...Going outside in enclosed area and attempting to climb fence..." Medical record review of a nurse's note dated July 14, 2012, revealed, "@ (at) 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window ...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 9:00 a.m., revealed, "...continuously asking...when am I going home ...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio. Unable to redirect..." Medical record review of a nurse's note dated July 19, 2012, at 2:30 p.m., revealed, "...Res. (resident) crying today...wanted to go home. At one time ...yelled...and ran out back door...Will cont. to monitor behavior and attempt to redirect." Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "(CNA #2) came running over to South Station where I was on a med (medication) cart...said (resident) was out side, over at apartment complex...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Review of a Notification of Unusual Occurrence Check List revealed, "...Date of Occurrence : 7/19/2012 Time: 8 p.m. Location: (the room the resident exited had a line drawn through it and the room the resident was moved to after the elopement was identified) ...Original care plan updated with NEW INTERVENTIONS: Yes..." Review of the original care plan revealed it had been updated but had not been updated with interventions related to attempts to elope and/or actual elopements. Observation on July 26, 2012, at 3:02 p.m., revealed the resident ambulated to the nurse's station and stated, "I wanna (want to) go home. I love you. Can I go home with you?" Medical record review of the resident's care plan and interview with MDS Coordinator #1 on July 27, 2012, at 2:05 p.m., in a conference room, revealed the care plan was the resident's current care plan. Continued interview confirmed the facility failed to revise the resident's care plan to address the resident's recurrent attempts to elope and/or actual elopement. Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, revision of policies and procedures regarding identification, investigation, and notification of unusual occurrences and/or neglect and staff education. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring corrective actions through the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a plan of correction. Refer to F157-J. Refer to F224-J, Substandard Quality of Care. Refer to F225-J, Substandard Quality of Care. Refer to F250-J, Substandard Quality of Care. Refer to F272-J. C/O: #

Based on medical record review and interview, the facility failed to timely communicate recommendations for a change in an antipsychotic medication for one resident (#3) with recurrent unsafe behaviors of seven sampled residents. The facility's failure to ensure a change in an antipsychotic medication for recurrent unsafe behaviors was started timely for Resident #3 resulted in Immediate Jeopardy (a situation that is likely to cause serious harm, injury, impairment, or death). The Immedidate Jeopardy was effective on June 17, 2012, through July 24, 2012. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m., in the Administrator's office. The findings included: Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a physician's orders [REDACTED]." Medical record review of a physician's orders [REDACTED]. po (by mouth) bid." Medical record review of a nurse's note dated June 6, 2012, at 9:00 a.m., revealed, "...went out to patio and threatening to climb fence..." Medical record review of a nurse's note dated June 10, 2012, revealed, "(6A-6P) (6:00 a.m.-6:00 p.m.)...unable to concentrate any length of time on any one thing..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA (Certified Nursing Assistant) calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Medical record review of a [MEDICAL CONDITION] Medication Evaluation dated July 4, 2012, at 12:01 p.m., revealed, "...presents with severe [MEDICAL CONDITION] reported episodic mood swings...some inc (increased) [MEDICAL CONDITION] for Recommendations...also may increase [MEDICATION NAME] 2 mg 1/2 tab (tablet) afternoon in addition to bid dose prn (as needed)..." Continued review revealed the recommendations were approved by a nurse practitoner on July 20, 2012. Medical record review of a [MEDICAL CONDITION] Medication Management Progress Note dated July 13, 2012, at 12:45 p.m., revealed, "...appeared vigilant and paranoid. Staff reported '...has been crazy...staff reported inc paranoia as dementia escalates. Current c/o (complaint) inc (include) physical aggression and irritability. Plan: inc [MEDICATION NAME] 2 mg tid (three times daily)...Indications for next visit: Acute Behavioral/Medical [MEDICAL CONDITION] Impaired...Ambulatory ...SI/HI (suicidal/homicidal ideation) Unable to assess due to patient's cognitive impairment..." Continued review revealed the Progress Note was not reviewed by a physician or a nurse practitioner until July 23, 2012, and included, "...Accept..." Medical record review of a physician's orders [REDACTED].@ (at) noon." Medical record review of a nurse's note dated July 13, 2012, at 5:35 p.m., revealed, "Resident hollering that (resident) wanted to (go) home, that we have no right to keep...against (resident's) will...Going outside in enclosed area and attempting to climb fence..." Medical record review of a nurse's note dated July 14, 2012, revealed, "@ (at) 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 9:00 a.m., revealed, "...continuously asking...when am I going home ...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio. Unable to redirect..." Medical record review of a nurse's note dated July 19, 2012, at 2:30 p.m., revealed, "...Res. (resident) crying today...wanted to go home. At one time ...yelled...and ran out back door...Will cont. to monitor behavior and attempt to redirect." Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "(CNA (#2) came running over to South Station where I was on a med (medication) cart ...said (resident) was out side, over at apartment complex ...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Medical record review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. at 8:00 a.m. and 8:00 p.m. from July 1, 2012, through July 23, 2012. Continued review revealed administration of [MEDICATION NAME] 1 mg. at 12:00 p.m., was not initiated until July 24, 2012, at 12:00 p.m., twenty days following the first recommendation (of July 4, 2012) to increase the resident's medication, ten days after the resident's third elopement attempt (on July 14, 2012), and five days after the resident's elopement (of July 19, 2012). Interview with Nurse Practitioner (NP) #1 and the Director of Nursing (DON) on July 30, 2012, at 12:00 p.m., in a conference room, revealed the evaluations and/or recommendations of the mental health provider were difficult to understand. Continued interview confirmed the facility failed to clarify the mental health provider's recommendations. Telephone interview with the resident's physician (Medical Doctor, MD #1) on July 30, 2012, at 12:20 p.m., in the Administrator's office and in the presence of the Director of Nursing and the Administrator, revealed M.D. #1 was the facility's Medical Director. Continued interview with MD #1 confirmed the recommendations for changes in the resident's antipsychotic medication were not communicated or acted on in an effective, timely manner. Continued interview revealed MD #1 was aware of communication difficulties with the mental health provider and timely administration of the increased dose of antipsychotic medication may have improved the resident's behavior and prevented the resident's elopement on July 19, 2012. Telephone interview with a Psychiatric Nurse Practitioner (PNP) on July 30, 2012, at 4:05 p.m. and in the presence of the DON, revealed the PNP assessed the residents and she stated, "...I take my assessments back to (mental health provider) and (mental health provider) follows up on communicating to facility what (my) recommendations are." Interview with the DON on July 30, 2012, at approximately 4:10 p.m., in the DON's office, revealed the mental health provider had been informed regarding conflicting data in the mental health documentation. Continued interview confirmed the facility failed to timely communicate recommendations for an increase in the resident's antipsychotic medication, resulting in a delay in treatment and placing Resident #3 in Immediate Jeopardy. Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, and revision of policies and procedures and staff education regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect, and collaboration with the mental health provider on the revision and clarrification of the mental health assessment forms. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring corrective actions through the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a plan of correction. Refer to F157-J. Refer to F224-J, Substandard Quality of Care. Refer to F225-J, Substandard Quality of Care. Refer to F250-J, Substandard Quality of Care. Refer to F272-J. Refer to F280-J. C/O: #

Based on medical record review, facility policy review, review of facility investigations, review of window alarm monitoring documentation, observations and interviews, the facility failed to administer care in a manner to assess and notify the physician of recurrent unsafe behaviors, failed to prevent neglect, failed to thoroughly investigate recurrent elopement attempts and/or an elopement, failed to provide required social services, failed to revise the care plan to address recurrent unsafe behavior, failed to timely communicate recommendations for an increase in an antipsychotic medication, failed to provide adequate supervision and/or security device to prevent elopement for one resident (Resident #3) of seven sampled residents. The Administrator failed to ensure processes were in place to notify the physician, prevent neglect, investigate, provide social services, revise the care plan, communicate medication recommendations, and provide adequate supervision and/or security devices for repeated attempts to elope and the successful elopement by Resident #3 resulted in Immediate Jeopardy (a situation that is likely to cause serious injury, harm, impairment, or death). The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m., in the Administrator's office. The Immediate Jeopardy was effective June 17, 2012, through July 24, 2012. The findings included: Resident #3 removed a window screen and attempted to elope from the facility on June 17, 2012, at 2:00 p.m., attempted to elope through a window on June 17, 2012, at 9:30 p.m., and attempted to elope through a window on July 14, 2012, at 1:00 p.m. Interview with Minimum Data Set Coordinator (MDS Coordinator) #1 on July 27, 2012, at 2:05 p.m., in a conference room, confirmed the facility failed to revise the resident's care plan to address recurrent attempts to elope and/or actual elopement. Interview with the DON and the Administrator on July 27, 2012, at 2:20 p.m., in the DON's office, revealed no knowledge regarding the resident's attempts to elope two times on June 17, 2012. Continued interview revealed the DON had reviewed the twenty-four hour communication book and spoken with nursing managers. The DON stated, "...all say they were unaware of previous attempts to elope..." Continued interview revealed no reports of elopement attempts had been made and the facility had no investigations into the resident's attempts to elope prior to July 19, 2012. Interview with the DON on July 30, 2012, at 12:15 p.m., in a conference room, revealed the DON was unaware of the initiation of one on one supervision for Resident #3 on July 13, 2012, and unable to determine the duration of the one on one supervision. Telephone interview with the resident's physician (Medical Doctor) (M.D. #1) on July 30, 2012, at 12:20 p.m., in the administrator's office and in the presence of the Director of Nursing (DON) and the Administrator, revealed M. D. #1 was unaware of the resident's attempts to elope from the facility on June 17, 2012, and July 14, 2012. Continued interview confirmed the recommendations for changes in the resident's antipsychotic medication were not communicated or acted on in an effective, timely manner and timely administration of the increased dose of antipsychotic medication may have improved the resident's behavior and prevented the resident's elopement on July 19, 2012. Interview with the Social Service Director (SSD) on July 30, 2012, at 11:00 a.m., in a conference room, revealed the resident's risk for elopement was discussed in a care plan meeting on July 3, 2012, and the resident's recurrent attempts to elope were not discussed. Continued interview revealed the SSD was uncertain if the resident was currently treated by a mental health provider. Interview with Registered Nurse (RN) #2 on July 30, 2012, at approximately 4:00 p.m., revealed RN #2 completed the elopement risk assessment dated [DATE]. RN #2 stated, "The assessment is incorrect. I did it. It's solely my responsibility." Interview with the DON on July 30, 2012, at approximately 4:15 p.m., in the DON's office, confirmed the facility neglected to provide the care required by Resident #3. The DON stated, "...We missed every opportunity..." The facility neglected to act to address the resident's repeated attempts to elope and Resident #3 successfully eloped from the facility through a window on July 19, 2012. Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, and revision of policies and procedures and staff education regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring of corrective actions. The facility is required to submit a plan of correction. Refer to F157 J. Refer to F224 J, Substandard Quality of Care. Refer to F225 J, Substandard Quality of Care. Refer to F250 J, Substandard Quality of Care. Refer to F272 J. Refer to F280 J. Refer to F309 J, Substandard Quality of Care. Refer to F323 J, Substandard Quality of Care.

Based on review of facility policy, medical record review, review of facility investigation, and interview, the facility failed to thoroughly investigate recurrent elopement attempts and/or an elopement for one resident (#3) with identified elopement risk behaviors of seven sampled residents. The facility's failure to investigate recurrent elopement attempts by Resident #3 resulted in an acutal elopement and Immediate Jeopardy (a situation that is likely to cause serious harm, injury, impairment, or death). The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on July 30, 2012, at 12:38 p.m. in the Administrator's office. The Immediate Jeopardy was effective on June 17, 2012, through July 24, 2012. The findings included: Review of facility policy, Guidelines for Abuse Investigations, dated August 2007 revealed, "All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management...individual conducting the investigation will, as a minimum...Review the completed 'Occurrence Report'...Review the resident's medical record...Interview the resident's Attending Physician as needed to determine the resident's current level of cognitive function and medical condition...Interview staff members...who have had contact with the resident during the period of the alleged incident...Review all events leading up to the alleged incident..." Review of facility policy Guidelines for Elopements dated 2008 revealed, "...It is the responsibility of all personnel to report any resident attempting to leave the premises...the Charge Nurse should...Complete the incident report..." Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of a hospital History and Physical dated March 25, 2012, revealed, "...admitted by neurosurgery services for subarachnoid hemorrhage...underwent aneurysm clipping...resulting in waxing mental status changes, [MEDICAL CONDITION] again in stable condition on 3-21-12 ...Daughter states...increased symptoms of agitation and mental status changes...picking at things and has been talking about hurting...self...asked for sharp objects and a knife and talked about cutting...wrist...Assessment and Plan:...concerns about [MEDICAL CONDITION]. Suicide precautions will be initiated..." Medical record review of a nurse's note dated April 14, 2012, at 2:05 p.m., revealed the resident was admitted to a room in the facility's secure unit and included, "...confused, ambulates with steady gait..." Medical record review of an undated Elopement Risk Form revealed a score of 10 and included, "...Total Score: 10 or Higher = (equals) At risk for elopement ...Placed on Greenbriar (secure) unit for increased Elopement Risk..." Medical record review of a nurse's note dated April 14, 2012, at 11:00 p.m., revealed, "...Has episodes of exit-seeking. Will continue to monitor." Medical record review of an admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was seven (moderate mental impairment), felt down, depressed, or hopeless nearly every day, and rejected care one to three days. Continued review revealed the resident ambulated with supervision, was steady at all times with transfers and ambulation, and required limited to extensive assistance with other activities of daily living. Medical record review of a nurse's note dated April 18, 2012, at 8:00 a.m., revealed, "...wanders continuously. Wants to go home..." Medical record review of a nurse's note dated April 23, 2012, at 8:00 p.m., revealed, "...continues to pace up and down...unit aimlessly..." Medical record review of the care plan dated April 23, 2012, revealed, "Problem...Special Care Unit Placement due to increasing confusion...diminished decision abilities r/t (related to) safety Goals Will know: family, staff faces, room location Interventions Special Care Unit...Keep environment free of hazards...Assist in emergencies." Continued review revealed no intervention regarding staff supervision while in the resident's room and/or monitoring the window alarm. Medical record review of a nurse's note dated May 3, 2012, at 9:00 p.m., revealed, "...shuts...self in room and slides chair against door..." Medical record review of a nurse's note dated May 5, 2012, at 3:00 p.m. revealed, "...Puts chair under door knob per night shift..." Medical record review of a nurse's note dated May 24, 2012, at 3:00 p.m., revealed, "Severely agitated - Focused on going home...will continue to monitor." Medical record review of a nurse's note dated May 29, 2012, at 9:00 a.m., revealed, "...wandering in hallway stating 'I want to leave here I don't belong here' exit seeking...continue to monitor." Medical record review of a nurse's note dated May 31, 2012, at 10:50 p.m., revealed, "...CNAs (Certified Nursing Assistants) said (resident) had been exit-seeking earlier. Will monitor." Medical record review of a nurse's note dated June 6, 2012, at 9:00 a.m., revealed, "...went out to patio and threatening to climb fence (fence enclosed courtyard)..." Medical record review of a nurse's note dated June 10, 2012, revealed, "(6A-6P) (6:00 a.m.-6:00 p.m.)...unable to concentrate any length of time on any one thing..." Medical record review of a nurse's note dated June 17, 2012, at 2:00 p.m., "called to resident's room screen removed from window and resident attempting to climb out redirected while staff was attempting to fix window but resident continues to attempt to leave...will cont (continue) to monitor." Medical record review of a nurse's note dated June 17, 2012, at 9:30 p.m., revealed, "Responded to CNA calling out. Went to resident's room to see CNA holding resident to keep (resident) from falling out of open window onto the ground. Resident had pushed screen out and attempted to climb out of window. This nurse was told the resident had made the same attempt earlier today...Will monitor." Interview with the DON and Administrator on July 27, 2012, at 2:20 p.m., in the DON's office, revealed the resident's attempts to elope on June 17, 2012, had not been reported. Continued interview with the DON and Administrator confirmed the facility had not investigated the attempted elopements. Medical record review of an Elopement Risk assessment dated [DATE], revealed the resident had no elopement attempts in the past six months, a score of 9, and included,"Total Score: 10 or higher = (equals) at risk for elopement..." Medical record review of the care plan dated April 23, 2012, revealed, "Plan of Care Comments..7-3-12...Comprehensive care plan reviewed and updated...with IDT (Interdisciplinary Team) for...quarterly CP (care plan) meeting..." Continued review revealed no revision of the care plan regarding the resident's recurrent elopement attempts. Medical record review of a nurse's note dated July 6, 2012, at 8:00 a.m., revealed, "...wandering in hallway Asking repetively (repetitive) questions about going home...will monitor." Medical record review of a nurse's note dated July 11, 2012, at 2:00 p.m., revealed, "Resident with agitation exit seeking attempted to follow (name) off the floor...redirection unsuccessful...will cont to monitor." Medical record review of a nurse's note dated July 13, 2012, at 5:35 p.m., revealed, "Resident hollering that (resident) wanted to (go) home, that we have no right to keep...against (resident's) will...Going outside in enclosed area and attempting to climb fence...one on one monitoring in process..." Interview with the Director of Nursing (DON) on July 30, 2012, at 12:15 p.m., in a conference room, revealed the DON was unaware of the initiation of one on one supervision on July 13, 2012, and unable to determine the duration of the one on one supervision. Medical record review of a nurse's note dated July 14, 2012, revealed, "@ (at) 1 pm (1:00 p.m.) window alarm sounding resident with one leg out window redirected back in window...Helped resident to bed covered with blanket and exited room." Medical record review of a nurse's note dated July 14, 2012, at 1:30 p.m., revealed, "resident continuing to attempt to climb out window...RN (Registered Nurse) notified of situation...will continue to monitor." Interview with the DON and Administrator on July 27, 2012, at 2:20 p.m., in the DON's office, confirmed the attempted elopement had not been reported or investigated. Medical record review of a nurse's note dated July 16, 2012, at 9:00 a.m., revealed, "...wandering...exit seeking shaking door to leave...will cont to monitor." Medical record review of a nurse's note dated July 17, 2012, at 9:00 a.m., revealed, "...continuously asking...when am I going home...will cont (continue) to monitor." Medical record review of a nurse's note dated July 17, 2012, at 6:15 p.m., revealed, "...Exit seeking, trying to remove screen in window and climb over fence on patio. Unable to redirect..." Medical record review of a nurse's note dated July 19, 2012, at 2:30 p.m., revealed, "...Res. (resident) crying today...wanted to go home. At one time ...yelled...and ran out back door...Will cont. to monitor behavior and attempt to redirect." Medical record review of a nurse's note dated July 19, 2012, at 7:40 p.m., revealed, "(name CNA) (#2) came running over to South Station where I was on a med (medication) cart...said (resident) was out side, over at apartment complex...(CNA #1) was on lunch and came driving back to nursing home and seen (resident) running up the road to apartment complex...saw (resident) go into apartment #124...the police came and helped get (resident) back to (secure unit)..." Review of a Notification of Unusual Occurrence Check List revealed, "...Date of Occurrence : 7/19/2012 Time: 8 p.m. Location: (the room the resident exited had a line drawn through it and the room the resident was moved to after the elopement was identified)...Original care plan updated with NEW INTERVENTIONS: Yes...New Interventions one on one sitter...moved to room (another room on opposte hallway and where window exits to enclosed courtyard)...Was the facility's policy implemented at all times? Yes...Supervisors Comments: Upon investigation it was found...resident pushed the window in (resident's) room open and screen out and went out window across the street to the apartments next door, about 50-75 yards...back within 10-15 mins (minutes)..." Review of a Post Fall Review Form dated July 19, 2012, revealed, "Date of Fall..." Continued review revealed the word "fall" had a line drawn through it, and included, "Location of fall Resident's room went out window...Patient opens window in room and elopes from facility. Window alarm inaudible from hallway with door to room closed...Interdisciplinary Team Review/Recommendations...Ensure Alarm on Window Working...Resident was out of facility approximately 10-15 mins (estimate) ...Approximate Distance 50-75 ft (feet)." Continued review revealed the form was not dated or signed. Review of the facility investigation and a statement by Registered Nurse (RN #1) dated July 19, 2012, revealed, "I...was working the med cart on South Station, about 8 pm (p.m.)...CNA came running...told me (resident) was out side over at apartment complex...I ran over to Greenbriar (secure unit) to see if it was really (resident), when I went into Greenbriar...(Licensed Practical Nurse) (LPN ) #1 was doing...med cart, (LPN #1) did not know that (resident) was gone. I went to dinning (dining) room no (resident) , I ran down the hall to (resident's) room, the door was shut, I could not hear the alarm, I opened the door and I could hear the alarm but it was not very loud, the window was open...(resident) was gone. I ran to the apartment complex next door the police was bring (bringing) (resident) back to the nursing home in (police) car..." Review of the facility investigation and a statement by LPN #1 dated July 19, 2012, revealed, "...at approximately 0740 pm-800 pm (7:40 p.m.-8:00 p.m.) I was in the process of self-orienting myself to e-charting and the e-mar (electronic charting and electronic Medication Administration Record)...at the desk...(RN #1) enters the unit and says...has been told a resident has eloped from the unit. I...was unaware of this...and we both proceeded rapidly to (resident's) room...An alarm, which was inaudible standing immediately outside the closed door, was sounding...(resident) was returned to the unit by a law enforcement officer..." Review of the facility investigation and a statement by Certified Nursing Assistant (CNA #1) dated July 19, 2012, revealed, "While I was out on my lunch break I noticed (resident) running around in the yards over at the fairgrounds (an apartment complex). I asked if I could give...a ride back (resident) hit me 3 times. That's when I realized it was going to take more than me to get (resident) back...(CNA #2) was at the front door...to let some family members out...The family members followed us over and asked what (resident) looked like...They told me to get in with them and they would drive me around to see if I could find (resident). I happened to see a man across the street pointing towards an apartment...the woman that was with us said I'm a nurse let me take care of this. She knocked on the door and said she was calling the law. Her husband called 911. The cops showed up and (RN #1) and (Maintenance Director) was walking over...the cop took (resident) over to the nursing home..." Review of the facility investigation dated July 25, 2012, revealed, "...Date of Alleged Event: 07/19/2012...was in own room, opened the window, and crawled out of window (resident)...running down the road ...Resident had just left the facility when seen by the CNA in the fair grounds (apartment complex) no more than 15 minutes...The LPN and the CNAs did not hear the alarm going off in the room due to the door was shut..." Interview with CNA #1 on July 27, 2012, at 1:45 p.m., in a conference room, revealed CNA #1 had left the facility for lunch at approximately 7:00 p.m. and on returning from lunch observed the resident out of the facility. Continued interview revealed the resident was on the far side of the second street from the facility (not the location identified in the facility's investigation), and CNA #1 stated, "...I noticed (resident) right there on the side of the road straight across the street from (the) apartment where (resident) was at...hit me two to three times right up the side of the head...decided I needed more help...I got to the road to turn in here, looked back and saw (resident) running toward that apartment. Saw (resident) go up the steps...That shocked me that (resident) was that far and nobody noticed..." Telephone interview with local Law Enforcement Officer #1 on July 30, 2012, at 9:45 a.m., revealed an officer responded to a complaint call on July 19, 2012, at 7:37 p.m. regarding a facility resident. Continued interview confirmed an officer returned the resident to the facility and the complaint call was completed at 8:13 p.m. Interview with the DON and the Administrator on July 27, 2012, at 2:20 p.m., in the DON's office, revealed no knowledge regarding the resident's attempts to elope two times on June 17, 2012. Continued interview revealed the DON had reviewed the twenty-four hour communication book and spoken with nursing managers. The DON stated, "...all say they were unaware of previous attempts to elope..." Continued interview revealed no reports of elopement attempts had been made and the facility had no investigations into the resident's attempts to elope prior to July 19, 2012. Continued interview confirmed the facility failed to investigate recurrent elopement attempts for Resident #3, placing Resident #3 in Immediate Jeopardy. Corrective actions which removed the immediacy of the jeopardy, included one on one supervision of the resident while installation of additional alarms to the windows on the secure unit was completed, assessment and care plan revision for the resident and other resident's at risk, and revision of policies and procedures and staff education regarding identification, investigation, and notification of unusual occurrences including abuse and/or neglect. The surveyor verified the corrective actions on July 30, 2012, by observation, medical record review, policy review, and interview. Non-compliance continues at a "D" level for monitoring corrective actions through the facility's Quality Assurance/Performance Improvement Program. The facility is required to submit a plan of correction. Refer to F157 J. Refer to F224-J-Substandard Quality of Care. C/O: #

Based on medical record review, review of hospital records, review of the facility investigation, review of facility policy, observation and interview the facility failed to assess the impact of a fall for one resident (#5) resulting in a delay in treatment and a delay in the administration of pain medication and failed to ensure physician's orders were followed for the administration of narcotic pain medication ([MEDICATION NAME]) for one (#2) of six residents reviewed. The facility's failure resulted in harm for residents #5 and #2. Resident #5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the Minimum Data Set (MDS) dated [DATE], revealed the resident had no difficulty focusing attention and no disorganized thinking; required extensive assistance with activities of daily living including transfers and ambulation and had no limitation in range of motion. Medical record review of the MDS dated [DATE], revealed the resident had difficulty focusing attention and disorganized thinking; was not ambulatory; had impairment in functional range of motion in the lower extremity; and had a fall with major injury since the most recent MDS dated [DATE]. Medical record review of the restorative plan of treatment dated June 1-30, 2011, and July 1-31, 2011, revealed the restorative staff ambulated the resident fifteen feet three times a week. Medical record review of a pain assessment dated [DATE], revealed the resident denied having pain. Medical record review of the physician's recapitulation orders dated July 1-31, 2011, and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Medical record review of a day shift (6:00 a.m.-6:00 p.m.) nurse's note by Licensed Practical Nurse (LPN) #9 dated July 31, 2011, revealed, "...found in floor in seated position. Alarm sounding...dressed in gown. No shoes or socks on...full range of motion all extremities. No s/s (signs or symptoms) discomfort appreciated...Unable to do orthopedic for resident (secondary) to res (resident) inability to stand. Will monitor closely..." Medical record review of nurses' notes dated July 31-August 2, 2011, revealed no documentation the resident's condition, vital signs or pain was assessed on night shift (6:00 p.m.-6:00 a.m.) July 31-August 1, 2011 or on August 3, 2011. Medical record review of a nurse's note dated August 5, 2011, revealed the Nurse Practitioner (NP) was asked to check the resident's right hip, leg, knee and foot. Medical record review of the (NP) note dated August 5, 2011, revealed, "...Nurses noted that patient's right leg seems to be rotated inward since a recent fall. They also said that she seems to have pain when the right leg is moved. She was found a few days ago on the floor beside her bed; nobody witnessed the fall...made a face and complained when the right hip and right knee were palpated...sits with the right leg rotated inward...has an area of ecchymosis with some [MEDICAL CONDITION] on the plantar surface of the right foot...also complained when this area was palpated..." Review of a facility x-ray report dated August 5, 2011, revealed, "...acute femoral neck fracture...moderate [MEDICAL CONDITION]" Medical record review of a nurse's note dated August 5, 2011, at 10:15 p.m., revealed the resident was transported to the hospital. Review of a hospital history and physical dated August 6, 2011, revealed, "...Apparently, the patient fell Sunday (July 31, 2011)...Right [MEDICAL CONDITION] status [REDACTED]. Review of a hospital x-ray report dated August 6, 2011, revealed, "...complete fracture through the right femoral neck in the subcapital region...cephalad (anterior) displacement of the distal fracture fragment. Valgus (outward) angulation at the fracture site..." Review of a hospital operative report dated August 6, 2011, revealed, "...Right total hip arthroplasty..XXX[AGE] year-old...with Dementia who fell at the nursing home onto...right hip...had persistent pain and reluctance to bear weight on the leg...was eventually brought to the emergency department, where x-rays demonstrated the presence of a subacute displaced femoral neck fracture..." Medical record review of a nurse's note revealed the resident returned to the facility on [DATE]. Medical record review of the MAR indicated [REDACTED]. 2011. Review of the facility policy (guidelines) for managing falls revealed, "...If a fall occurs, the licensed staff assesses for injury and then investigates the cause using a Post Fall Assessment/Investigation Report Form...Post fall documentation will include vital signs and assessment every shift for 72 hours..." Interview on April 2, 2012, at 1:10 p.m., in the conference room, with the Director of Nursing (DON) revealed LPN #9 was terminated after the fall on July 31, 2011, because LPN #9 failed to assess the resident for any signs of injury after the fall; failed to complete an Incident Report; failed to notify the oncoming shift of the fall; and failed to include the fall on the 24 hour nursing report. Continued interview with the DON confirmed the resident "suffered harm from the fall," and LPN #9 failed to document appropriately and failed to make proper notifications after the fall. Continued interview confirmed the resident had no falls between July 31, 2011, and August 5, 2011, when the resident was assessed with [REDACTED]. Review of the hospital x-ray report dated August 6, 2011, and interview on April 3, 2012, at 9:00 a.m., in the conference room with the NP confirmed the resident would have been in "extreme pain" with turning, repositioning and transfers after the fall on July 31, 2011, which resulted in the [MEDICAL CONDITION]. Continued interview confirmed if the resident was unable to verbally communicate pain due to Dementia, the resident would have had nonverbal signs of pain including grimacing. Continued interview with the NP confirmed the resident would have had an "immediate anteversion (internal rotation) of the hip" following the fracture. Interview on April 3, 2012, at 10:20 a.m., in the conference room with Registered Nurse (RN) Supervisor #3 and RN Supervisor #4 confirmed residents who fell were assessed every shift for pain or signs of injury for seventy-two hours after the fall. Medical record review and interview on April 3, 2012, at 10:50 a.m., in the conference room with the DON confirmed the resident was not assessed for pain or signs of injury for seventy-two hours after the fall on July 31, 2011, as required by facility policy. Continued interview confirmed LPN #9 "could not have assessed" the resident accurately after the fall on July 31, 2011, and "That's why (LPN #9) was terminated." Resident #2 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the MDS dated [DATE], revealed the resident was cognitively intact, experienced pain occasionally and pain was rated a five when ask, on a zero to ten scale with zero being no pain and ten as the worst pain one could imagine. Medical record review of the physician's recapitulation orders dated September 1-30, 2011, revealed "[MEDICATION NAME] (pain) 25 mcg (microgram) apply 1 patch topically w/ (with) 12 mcg=37 mcg change every 72 hours check placement each shift..." Medical record review of a physician's telephone order dated September 26, 2011, revealed "...D/C (discontinue) [MEDICATION NAME] 12 mcg and 25 [MEDICATION NAME] ER (Extended Release) 60 mg (milligram) bid (twice daily)..." Medical record review of a nurse's note dated September 27, 2011, at 9:20 p.m., revealed, "...Held [MEDICATION NAME] on 8 pm med pass...very lethargic...could not sit up. Administered all other 8 pm meds...had to be reinforced x (tmes) 5 to open mouth and sip water...slurred speech...very disoriented...observed to be jerking on (right) side of body. Attempted to obtain pulse rate...could not obtain for pt. (patient) jerking arms..." Medical record review of a nurse's note dated September 27, 2011, at 9:35 p.m., revealed, "placed call to NP & (and) notified of vs (vital signs)...B/P (blood pressure) 96/46...NP wanted [MEDICATION NAME] (reverses effects of [MEDICATION NAME]) 0.4 ml (milliliter) given..." Medical record review of a nurse's note dated September 27, 2011, at 9:45 p.m., revealed "0.4 ml [MEDICATION NAME] administered IM (Intramuscular)...no response to [MEDICATION NAME] NP back and informed of...response. NP then advised to go ahead and proceed w/ (with) sending pt to ER (emergency room )..." Review of a facility medication error investigation dated September 28, 2011, revealed on September 26, 2011, LPN #5 administered [MEDICATION NAME] ER 60 mg and failed to remove the [MEDICATION NAME]es. Continued review revealed the resident was "...slow to respond, slurred speech"...and was transported to the hospital for evaluation. Review of a hospital discharge summary dated October 3, 2011, revealed, "...transferred to our facility because of [MEDICAL CONDITION] and [MEDICAL CONDITION] started on [MEDICATION NAME] was thought possibly to have an overdose..given [MEDICATION NAME] at the nursing home and her vital signs improved...came to our ER and initially blood pressure was 140/59...however, after some time in the ER, her heart rate blood pressure bottomed out again. Her heart rate went down to the 30s and blood pressure ws in the 60s or 70s...given another dose of [MEDICATION NAME] again and once again about 2-3 hours later...vital signs dropped again...started on a [MEDICATION NAME] drip at that time...spoke with the nursing home and apparently health wise the patients have been taken off the [MEDICATION NAME]es for safety reasons...did respond to the [MEDICATION NAME] drip and over the next 24 hours was able to be taken off of the drip..." Medical record review of a nurse's note dated October 3, 2011, at 8:00 p.m., revealed the resident returned to the facility by way of ambulance. Interview with the DON on April 3, 2012, at 1:05 p.m., in the conference room, confirmed the [MEDICATION NAME] was not removed as ordered by the physician on September 26, 2011, prior to the administration of [MEDICATION NAME]; the resident was transferred to the hospital and the facility's policy for pain medication was not followed. C/O #