Every finding on record at Sandy Springs Center for Nursing and Healing LLC

Based on observations, staff interviews, and policy review, the facility failed to ensure the kitchen was clean, staff washed hands and wore gloves appropriately between task changes, staff wore a beard cover when wearing a beard, and temperatures were recorded for the refrigerator and freezer. These failures had the potential to affect 144 residents who consumed food prepared by the kitchen.Findings include:Review of the facility policy titled, Preventing Foodborne Illness- Employee Hygiene and Sanitary Practice with an issue date of April 2024, Policy: Nutrition Services staff shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Gloves are single use items and must be discarded after completing the task for which they were used. The use of disposable gloves does not substitute for proper handwashing. Hairnets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.Review of the facility policy titled, Refrigerator and Freezer with an issue date of April 2024 revealed, Policy: This facility will ensure safe refrigerator and freezer maintenance, temperature, and sanitation and will observe food expiration guidelines. Guidelines: 1. Acceptable temperatures should be 41degrees Fahrenheit or lower for refrigerators and freezers should keep frozen foods solid. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures.1. Observation of the kitchen on 04/16/2026 at 12:17 PM, Dietary Aide (DA)2 entered the kitchen and went to the box of gloves and put them on without washing hands. DA3 was standing near the serving table and was not wearing a beard cover. Observations on 04/16/2026 at 1:06 PM, DA2 and DA3 were observed to enter back into the kitchen and both went to the box of gloves and picked out gloves. DA2 and DA3 were observed to pick up wrapped utensils and place them on trays. DA2 also started wiping the bottom of the cart with paper towels. DA2 was observed to take off the gloves and reach into another box, retrieve some gloves, and put them on without washing hands. During an interview on 04/16/2026 at 1:31 PM, DA2 and DA3 were both asked about washing their hands when entering the kitchen. They both stated they should have washed their hands when they came in. DA2 was asked about changing his gloves after wiping the bottom of the cart. DA2 stated he should have washed his hands before getting the new gloves.2. During observations on 04/16/2025 at 1:35 PM, review of the logs hanging on the wall next to the refrigerator and freezer revealed no temperatures documented on the evening of 04/14/2026, no temperatures recorded for 04/15/2026 and no temperature recorded for the morning of 04/16/26. During an interview on 04/16/2026 at 1:35 PM, the Registered Dietician (RD) was asked if there should be temperatures recorded for the missing times on the days of 4/14/2026, 4/15/2026 and 4/16/2026. The RD stated, yes, there should be temperatures recorded.During an interview on 04/16/2026 at 145 PM, the Dietary Manager (DM) was asked about the temperatures. The DM stated, yes, there should be temperatures. The DM was also asked about DA2 and DA3 should have washed their hands each time they returned to the kitchen. The DM said yes. The DM was asked if it was appropriate for the staff to wipe something and then just change gloves. The DM stated no they should wash hands when changing gloves.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure appropriate infection control practices were implemented with the onset of a COVID outbreak. The facility failed to ensure the dental hygienist used infection control interventions to ensure the dental cart moving from room to room was cleaned and a Certified Nursing Assistant (CNA) using the same box of wipes room to room, not following infection control practice. As a result of this deficient practice, all facility residents had the potential for illness from a COVID exposure since the facility was already in outbreak on the [NAME] unit. The facility census was 144 residents.Findings include: Review of the undated facility policy titled, Linen Operations and Management, revealed, .Clean linen should be transported on carts designated for clean linen only. The policy did not address how clean linen should be transported once it is removed from the cart to take it to a resident room. Review of the facility policy titled, Infection Prevention and Control Program, dated April 2025 revealed, . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 10. Equipment Protocol (a) All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment.(c) Reusable items potentially contaminated with infectious materials shall be placed in an impervious clear plastic bag. Label bag as Contaminated and place in the soiled utility room for pickup and processing. Review of the facility policy titled COVID Prevention, Response, and Reporting, reviewed August 2025, revealed It is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-I9 infections. The Infection Preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection in the community and illnesses present in the facility. The facility will provide guidance about recommended actions for residents and visitors. Source control is recommended more broadly in the following circumstances: By residing or working on a unit or area of the facility experiencing a SARS-CoV-2 or other outbreak of respiratory infection; universal use of source control could be discontinued as a mitigation measure once the outbreak is over. Responding to a newly identified SARS-CoV-2 infected HCP (health care professional) or resident: . A single new case of SARS-CoV-2 infection in any HCP or resident should be evaluated to determine if others in the facility could have been exposed . The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based approach- (e.g. unit 'floor' or other specific area(s) of the facility approach is preferred if all potential contact cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. 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. The Infection Preventionist, or designee, will monitor and track COVID-19 related information to include, but not limited to: a. The number of residents and staff who exhibit signs and symptoms of COVID-19. b. The number of residents and staff who have suspected or confirmed COVID-I9 and date of confirmation. c. Staff and resident vaccination status. d. Employee compliance with hand hygiene. e. Employee compliance with standard and transmission-based precautions. f. Employee compliance with cleaning and disinfection policies and procedures. 1. Observation upon entrance into the building on 04/13/2026 at 8:30 AM, the check-in desk posted a sign indicating COVID outbreak and no hand sanitizer at the front desk where visitors signed in. During an interview on 04/13/2026 at 8:40 AM, prior to the entrance conference, the Assistant Administrator confirmed COVID was in the building with two new positive cases and uncertain about wearing N95 masks or surgical masks, saying N95 masks were in the process of being provided to the staff currently due to two new positive cases. During an interview on 04/13/2026 at 8:48 AM, the Director of Nursing (DON) did not know the policy for masking during a COVID outbreak. During the entrance interview on 04/13/2026 at 8:55 AM, the Assistant Administrator explained the Infection Control Preventionist (IP) was off work for the week with a family emergency and the DON would be covering for the IP in her absence. The DON explained there were three positive COVID and eight new cases just identified 04/12/2026. During an interview on 04/13/2026 at 2:33 PM, the DON provided a list of positive residents, when tested, and the results. The first resident tested positive 03/30/2026 and on 04/07/2026, four more residents tested positive and another one on 04/09/2026. The next test was done on 04/12/2026 which resulted in five more, for a total of 11 positive, 10 currently in the facility in isolation. During an interview on 04/14/2026 at 8:45 AM, the Administrator provided documentation of the line testing for the positive residents for the affected [NAME] unit. Testing results for all residents on the [NAME] unit were not provided and only the day nursing staff tested for the [NAME] unit were provided. No testing information was provided for housekeeping staff or physical therapy staff who regularly enter resident rooms on [NAME] unit. An observation on 04/14/2026 at 11:40 AM, Registered Nurse (RN)1 was sitting at the nursing station in the [NAME] unit hallway, mask dangling off one ear and Licensed Practical Nurse (LPN) 4 was standing at the medication cart in the [NAME] unit hallway, near the nursing station, with no mask. During the interview on 04/14/2026 at 11:40 AM, RN1 confirmed that LPN4 did not need to wear a mask in the hallway, only when entering an isolation room with airborne precautions. During an interview on 04/16/2026 at 9:42 AM, LPN5, Unit Manager, explained staff were to take a COVID test if they had any symptoms. A list of staff members was provided to document if a staff member did self-test for COVID, then the results were to be marked on the sheet. During the outbreak for COVID, staff were to wear masks in the hallway. During an interview on 04/16/2026 at 1:00 PM, the DON (acting IP) confirmed the COVID outbreak was not clearly documented when COVID testing was done, results of the frequent testing, tracking all involved staff during the outbreak and information about who and where to wear masks in the facility was not well communicated to the staff or staff monitored for compliance. During an interview on 04/14/2026 at 4:33 PM, the Assistant Administrator confirmed there should be consistent and aligned direction from management and the IP for the personal protective equipment (PPE) to be worn by staff in the facility during a COVID outbreak. There should be accurate documentation of the testing for COVID done for both residents and staff to ensure anyone with a possible positive COVID test, no symptoms, was not exposed to other staff and residents in the facility. 2. During an observation on 04/13/2026 at 9:45 AM, Certified Nursing Assistant (CNA) 1 took a package of wipes out of room [ROOM NUMBER] to room [ROOM NUMBER] on the East wing. During an observation on 04/13/2026 at 9:50 AM, CNA1 was observed carrying clean unbagged linen to room [ROOM NUMBER] while holding it against her uniform. During an observation on 04/13/2026 at 10:13 AM, CNA1 took the same package of wipes from room [ROOM NUMBER] to room [ROOM NUMBER] on the East wing. During an interview on 04/13/2026 at 10:13 AM, CNA1 stated she should not take wipes from one room to another, but she only had one package of wipes for the unit. She stated she did not know how she was supposed to transport clean linen. She stated she was not taught to transport it in a bag and or not hold it up against her clothing. During an observation on 04/13/2026 at 10:25 AM, the Dental Hygienist (DH) took her entire dental cart into room [ROOM NUMBER]. During an observation on 04/13/2026 at 10:29 AM, the DH took her entire dental cart with all supplies into room [ROOM NUMBER]. It contained a bottle of mouth wash, individually wrapped toothbrushes, Cavi wipes, toothpaste, cleaning tools in plastic bins, paper dental drapes, and hand sanitizer. During an interview on 04/13/2026 at 10:31 AM, the DH stated she took her cart into every room including isolation rooms. She stated she could not leave it unattended due to having cleaning tools in her plastic bins. She stated most of the items were single use items. During an interview on 04/13/2026 at 11:59 AM, the Administrator stated the facility had plenty of wipes and staff should not take one package from room to room. He also stated clean linens should be transported in a bag and not held against an employee's clothing. The Administrator stated the dental cart should not be taken into all rooms with all supplies. He stated at the very least it could be covered, or the hygienist could only take in the supplies she needed for each resident. The Administrator stated the entire cart should not go into any resident room and especially not into an isolation room.

Based on resident and staff interviews, record review, and facility policy review, the facility failed to ensure a baseline care plan was completed/ shared with the resident for one of one resident (Resident (R) 95) reviewed for baseline care plan. As a result of this deficient practice the residents may not have received care and services needed.Findings include:Review of the facility's policy titled, Baseline Care Plan reviewed/revised October 2025, revealed The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the residents that meet professional standards of quality care. The baseline care plan will: . Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including but not limited to . Initial goals based on admission orders.Review of R95's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 03/31/2026 with medical diagnoses that included spinal stenosis, lumbar region with neurogenic claudication and Post surgical care.Review of R95's comprehensive Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 04/08/2026, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R95 was cognitively intact.Review of R95's Assessments tab in the EMR the assessment titled Baseline Care Plan was incomplete, the first section titled general information was begun and the following four sections not completed, including Functional Status, Health Conditions, Dietary-Therapy-Social Services, and Care plan summary-signatures.During an interview on 04/14/2026 at 11:30 AM, R95 verbalized she did not know what the plan of care was to be, what care to expect and no one had spoken to her about what to expect.During an interview on 04/16/2026 at 9:31 AM, the Licensed Practical Nurse, (LPN) 5 Unit Manager, confirmed each new resident was to have a baseline care plan completed within 48 hours of admission. A written form was to be printed out and given to the resident. LPN5 reviewed R95 EMR and confirmed the baseline care plan was not completed within 48 hours.During an interview on 04/16/2026 at 4:33 PM, the Assistant Administrator confirmed the expectation was for the staff to complete the baseline care plan within 48 hours of admission and to share the plan with the residents.

Based on staff interviews, record review, and review of facility policy, the facility failed to ensure the physician's orders were followed by failing to do a urinary analysis with culture and sensitivity (UA, C&S), a two part test to diagnose a urinary tract infection, for one of one (Resident (R)26) resident reviewed for laboratory orders. This deficient practice had the potential to allow residents to go with undiagnosed ailments when tests were not completed as ordered.Findings include:A facility policy titled Documentation in Medical Record revised November 2023 revealed, Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation.Review of R26's undated admission Record located under the Profile tab in the electronic medical record (EMR) revealed an admission date of 03/03/2026 with diagnosis of traumatic subdural hemorrhage with loss of consciousness, malignant neoplasm of prostate, and diabetes mellitus.Review of R26's admission Minimum Data Set (MDS) assessment located under the MDS tab in the EMR with a Assessment Reference Date (ARD) of 03/06/2026 that revealed a brief interview for mental status (BIMS) with a unmeasured score indicating severe cognitive capabilities, with impairment of lower extremities on both sides and incontinent of both bladder and bowel. Review of R26's 03/13/2026, Care Plan located under the Care Plan tab in the EMR revealed the resident was totally dependent on staff for toileting and required two staff with a mechanical lift for transfers.Review of R26's Progress Notes located under Progress Notes tab in the EMR revealed on 03/23/2026 the Certified Nurse Practitioner (CNP) wrote the Certified Nursing Assistant reports a .urine has a strong odor.Review of R26's physician orders located under the Orders tab located in the EMR revealed an order, dated 03/24/2026, for a UA, C&S (may straight cath [catheter]. Review of R26's lab results located under the Results tab in the EMR revealed no results for the UA, C&S.During an interview on 04/16/2026 at 9:02 AM, the Director of Regulatory Compliance (DRC) was asked if he could locate the results of the UA, C&S. The DRC stated that the Director of Nursing (DON) and another nurse went to try and do the UA, C&S and do a straight catheter to get the sample. The wife would not let the nurses get the sample. The DON offered to place a Foley instead, but the wife would not allow the sample to be drawn. There was no documentation and communication to the CNP and the order was not discontinued.During an interview on 04/16/2026 at 9:46 AM, the CNP was asked about the UA order. The CNP stated the results were looked for every day after the order was written. The CNP stated there should have been some communication from the staff so something else could be done. Intravenous fluid was given so there was additional hydration.During an interview on 04/16/2026 at 10:45 AM, the Director of Nursing (DON) was asked about the order and results. The DON stated the wife would not allow the sample to be obtained. The DON stated that Registered Nurse (RN)2 was asked to try and get the sample, but the wife said no. The DON stated documentation should have been put in the chart and communicated with the CNP.During an interview on 04/16/2026 at 11:38 AM, RN1 stated the family did not want a straight cath done to do the UA, C&S. RN1 stated that he assumed the UA, C&S would be done at another time.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure the March 2026 recommendations from the pharmacist were communicated to the resident's physician and results of the communication documented in the resident's medical record for one of five residents (Resident (R)1) reviewed for unnecessary medications. This deficient practice had the potential for the recommendations needing action by the physician were not addressed affecting needed resident care.Findings include:Review of the facility's policy titled, Medication Regimen Review, reviewed August 2023, revealed The pharmacist shall communicate any irregularities to the facility in the following ways: Verbal communication to the attending physician, Director of Nursing, and/or staff of any urgent needs. Written communication to the attending physician, the facility's Medical Director, and the Director of Nursing.Review of R1's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 04/25/2024 and a readmission date of 02/10/2026 with medical diagnoses that included anxiety disorder and bipolar disorder. Review of R1's comprehensive Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/25/2026, revealed a Brief Interview for Mental Status (BIMS) score unable to be determined due to severe cognitive impairment.Review of the pharmacy recommendations for March 2026 revealed recommendations from the pharmacist review included Discharge summary recommends metformin 500 milligrams (mg) twice daily but this medication is not active on the Medication Administration Record (MAR), discharge summary recommends metoprolol tartrate 25mg twice daily but this medication is not active on the MAR, discharge summary recommends prasugrel 10mg daily but this medication is not active on the MAR. The recommendations were emailed to the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) and were not followed up.During an interview on 04/16/2026 at 3:56 PM, the Director of Regulatory Compliance (DRC) confirmed the pharmacy recommendations for R1 for March 2026 were not communicated to the physician. During an interview on 04/16/2026 at 4:33 PM, the Assistant Administrator confirmed the expectation was the pharmacy recommendations were to be communicated to the physician for a response to the recommendations.

Based on resident family and staff interviews, record review, and facility policy review, the facility failed to ensure the risks, benefits and alternatives involved in the use of psychotropic medications were communicated to the resident/resident representative for one of five residents (Resident (R)1) reviewed for unnecessary medications. This deficient practice had the potential for the resident/resident representative not being informed of treatments being administered by the facility.Findings include:Review of the facility's policy titled, Use of Psychotropic Medication, reviewed March 2025, revealed, Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.Review of R1's admission Record located in the electronic medical record (EMR) under the Profile tab, revealed an admission date of 04/25/2024 and a readmission date of 02/10/2026 with medical diagnoses that included anxiety disorder and bipolar disorder. Review of R1's comprehensive Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/25/2026, revealed a Brief Interview for Mental Status (BIMS) score unable to be determined due to severely cognitive impairment.Review of R1's Orders tab in the EMR, documented physician orders for aripiprazole, Oral Tablet 10 MG (milligram) Give 1 tablet via G-Tube (gastrostomy tube) in the morning for Manic Behavior, buspirone HCl Oral Tablet 5 MG Give 1 tablet via G-Tube two times a day for Anxiety, and Paxil Oral Tablet 10 MG Give 1 tablet via PEG-Tube (percutaneous endoscopic gastrostomy tube) in the morning.Review of R1's Misc tab in the EMR lacked documentation of information about the benefits, risks, and alternatives for the prescribed medications aripiprazole-an antipsychotic, buspirone-antianxiety, and paroxetine-antianxiety psychotropic medications communicated to the resident/resident representative.During a phone interview on 04/16/2026 at 3:50 PM, Family Member (FM)1 confirmed not being informed by the facility or physician about the change in medications since readmission.During an interview on 04/16/2026 at 12:35 PM, the Quality Coordinator confirmed the facility did not inform the family about the benefits vs risk or alternatives for the psychotropic medications and should have provided the information to the resident representative.During an interview on 04/16/2026 at 4:33 PM, the Assistant Administrator confirmed the expectation that residents receiving psychotropic medications need to be informed about the benefits, risks, and possible alternative interventions prior to being administered the psychotropic medications.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure written information regarding the right to formulate and advanced directive, change an advanced directive, or the right to accept and/or refuse medical and surgical treatment was provided to one of two residents (Resident (R) 10) or their resident representative (RR) for advanced directives out of a total sample of 33 residents. This failure had the potential for resident wishes regarding care not to be honored. Findings include:Review of the facility policy titled, . Advanced Directives-Residents' Rights Regarding Treatment, dated October 2025, revealed, It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical and surgical treatment and to formulate an advanced directive. (2.) The facility will provide the resident or resident representative [with] information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and to formulate an advanced directive.Review of R10's admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R10 admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, unspecified dementia, unspecified protein calorie malnutrition, and major depressive disorder. Review of R10's quarterly Minimum Data Set (MDS), with and assessment reference date (ARD) of 04/02/2026 and located under the MDS tab of the EMR, revealed R10 had a Brief Interview for Mental Status (BIMS) score of three out of 15, indicating she had severely impaired cognition. During an interview and record review on 04/15/2026 at 9:38 AM, the Social Service Director (SSD) confirmed R10's EMR did not contain evidence that written information was provided to the resident and or the RR regarding advanced directives and the right to accept and/or refuse medical and surgical treatment. The SSD verified an admission packet, which contained information regarding advanced directives, was not in R10's EMR. During an interview and record review on 04/15/2026 at 11:30 AM, the Admissions Coordinator confirmed R10's EMR did not reveal the resident and/or the RR received written information regarding the right to formulate an advanced directive or the right to accept or refuse medical and surgical treatment. She stated she would contact the RR to have a new admission packet completed that would include the written information regarding advanced directives. The Admissions Coordinator verified R10's EMR did not contain an admission packet with the required information regarding advanced directives.

Based on observations, record review, resident and staff interviews, and facility policy review, the facility failed to provide written documentation of a hospital transfer to four of five residents (Resident (R) 27, R5, R12 and R4), and to their representative reviewed out of a total sample of 33 residents. The facility also failed to create a recapitulation (summary) of the resident's stay at the facility, a final summary of the resident's status, and reconciliation of all pre- and post-discharge medications and notification of the Ombudsman of the resident's discharge for one of five residents reviewed (R)158. This failure placed the resident and/or the resident's representative at risk for lack of awareness of rights, including the right to appeal the transfer.Findings include: Review of the facility policy titled, Bed Hold Prior to Transfer, dated March 2025 revealed, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. Review of the facility policy titled, Transfer and Discharge (including AMA) [against medical advice], dated March 2025 revealed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided (a) the specific reason and basis for transfer or discharge. (b) the effective date of transfer or discharge. (c) The specific location (such as name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged . (d) An explanation of the right to appeal the transfer or discharge to the state. (e) The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests. (f) Information on how to obtain an appeal form. (g) Information on obtaining assistance in completing and submitting the appeal hearing requests. (h) The name, address (mailing and email), and telephone number of the representative of the Office of the State Long-Term Care Ombudsman. (i) For nursing facility residents with intellectual and developmental disabilities (or related disabilities), or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations.Emergency Transfers to Acute Care. (g)Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated. 1. Review of R27's admission Record, located under the Profile tab in the electronic medical record (EMR), revealed R27 originally admitted on [DATE] with diagnoses including atherosclerotic heart disease, unsteadiness on feet, retention of urine, manic episode, anemia, and pulmonary embolism without acute cor pulmonale. Review of R27's discharge return anticipated Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/08/2026 and located under the MDS tab of the EMR, revealed R27 had a Brief Interview for Mental Status (BIMS) score of nine out of 15, indicating moderately impaired cognition. Review of R27's Progress Note, dated 02/16/2026 at 4:28 PM and located under the Progress Notes tab of the EMR, revealed R27 was sent to the hospital for severe toe pain and a concern for osteomyelitis. Review of R27's EMR under the MISC, tab did not reveal evidence that the resident or his representative received written information regarding the transfer/discharge or a bed hold notice. 2. Review of R5's admission Record, located under the Profile tab in the EMR, revealed R5 admitted on [DATE] with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction, chronic obstructive pulmonary disease (COPD), and chronic systolic (congestive) heart failure. Review of R5's quarterly MDS, with an ARD of 02/08/2026 and located under the MDS tab of the EMR, revealed R5 had a BIMS score of 10 out of 15, indicating moderately impaired cognition. Review of R5's Progress Note, dated 03/19/2026 at 11:10 PM and located under the Progress Notes tab in the EMR, revealed R5 called 911 and stated he was hurting and wanted to go to the hospital. Review of R5's MISC, tab of the EMR did not reveal evidence of the resident or the representative receiving a written transfer/discharge notice or bed hold notice. 3. Review of the admission Record, located under the Profile tab in the EMR revealed R12 admitted to the facility on [DATE] with diagnoses including. Review of R12's quarterly MDS, assessment with an ARD of 01/08/2026 and located under the MDS tab of the EMR revealed a BIMS score of 14 out of 15, indicating intact cognition. Review of R12's Progress Note, dated 02/19/2026 at 10:12 AM and located under the Progress Notes tab of the EMR, revealed R12 was sent to the hospital for respiratory distress. Review of R12's MISC, tab of the EMR did not reveal evidence of the resident or the representative receiving a written transfer/discharge notice or bed hold notice. During an interview on 04/15/2026 at 9:22 AM, R12 stated she had not received a bed hold notice or transfer/discharge notice. 4. Review of R4's admission Record, located under the Profile tab in the EMR revealed R4 was admitted on [DATE] with diagnoses including history of falling, chronic (systolic) congestive heart failure, personal history of pulmonary embolism, anxiety disorder, depression, and mood disorder due to known physiological condition. Review of R4's quarterly MDS, with an ARD of 01/30/2026 and located under the MDS tab in the EMR, revealed R4 had a BIMS score of 15 of 15, indicating he was cognitively intact. Review of the Progress Note, dated 04/09/2026 at 7:46 PM and located under the Progress Note tab of the EMR, revealed R4 was sent to the hospital for right side abdominal pain. Review of R4's MISC, tab of the EMR did not reveal evidence of the resident or the representative receiving a written transfer/discharge notice or bed hold notice. During an interview and record review on 04/14/2026 at 3:57 PM, the Director of Nursing (DON) stated the facility had not been providing bed hold notifications or transfer/discharge notices with the residents or providing one to the resident representative when a resident was sent to the hospital. He stated the facility sent an einteract (electronic version) transfer summary with the resident to the hospital. 5. Review the EMR under the Census tab, revealed R158 was admitted on [DATE]. Under the Diagnoses tab, the EMR documented R158 diagnoses including congestive heart failure, panic disorder, and kidney failure. In the EMR, under the Progress notes tab, the clinical note indicated R158 was discharged from the facility on 02/12/2026 against medical advice (AMA). R156 was not available for interview. Review of the EMR, under the Progress Notes tab, and dated 02/12/2026, revealed R156 departed the facility with their belongings, but lacked information regarding the disposition of R156's medications. An interview with the facility's Corporate Compliance Officer on 04/16/2026 at 11:00 AM revealed it was the facility policy to discharge residents with their medications or document the medications destruction if the medications were not taken by the resident upon discharge.

Based on observations, staff and resident representative interviews, record reviews and review of the facility's policy titled, Housekeeping Guidelines, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, clean, comfortable and homelike environment for residents. Findings include: During review of the facility's policy document titled, Housekeeping Guidelines, Daily Resident/Patient Room Cleaning, undated, revealed, The room cleaning tasks should be performed in the following order: 1. Straighten up the residence room. 2. Dust all flat surfaces with a cloth and disinfectant, clean the air vent covers, and spot clean all necessary areas. 3. Dust mop the floor and sweep all trash and debris to the door and pick it with the dustbin. 4. Empty and clean the trash cans and put in a new liner if necessary. 5. Wet mop the room using disinfectant, ensuring A caution floor sign is in use. During the initial observations of the facility on 12/15/2025 at 11:15 am, all units toured had a lingering foul odor noted. The flooring on the East and [NAME] units revealed stains and spills with trash on the floors. Residents' rooms were observed with large stains and spills. The Terrace unit, some rooms were observed with stains on the flooring and furniture, food particles and spills on the floors. During an observation/interview on 12/16/2025 at 9:00 am with the EVS Director revealed stains and food particles on the floors in the halls and in some residents' rooms. The EVS Director revealed that the floors had not been mopped in days and stated, this isn't just from one day. The EVS Director revealed he noted foul odors in the facility stating, it smells like urine, and someone sprayed something to mask the smell. The EVS Director went on to reveal that she had ordered parts for the repair of broken cleaning equipment. She admitted to not being able to have the floors stripped and waxed. During an interview on 12/16/2025 at 12:00 pm with R9's daughter she stated, three times a week I come here and there's stuff all over the floor and not just on my mom's side but on the neighbor's side as well. Now her roommate can walk and move around so I don't know if they just expect her to clean it up, but she'll spill like coffee all over the floor and it's just sticky and they'll just leave it there and I don't think she could mop it up. During an observation on 12/17/2025 at 12:00 pm of the facility revealed continued stains on the floors in the hallway on the East and [NAME] unit. Resident's rooms continue to require sweeping and mopping. Furniture on the Terrace unit remained stained and the walls on the Terrace unit revealed red-colored stains on the wall. During an interview on 12/18/2025 at 9:59 am with the Director of Nursing (DON) revealed that he was aware that there were a number of sanitary issues that needed addressing and they were currently working on those issues.

Based on observations, staff interviews, and record review, the facility failed to ensure one of two facility ice machines located in the service hallway of the East Wing Unit was free from visible dirt and debris. This deficient practice had the potential to affect all residents who received ice from this ice machine.Findings include:On 12/16/2025 at 2:38 pm, during an inspection of the ice machine on the East Wing of the Facility, visible brown/black residue was present along the interior chute. Slime-like buildup was observed on the underside of the ice shield. Loose particulate debris was present in the ice collection bin. The ice machine was actively producing ice at the time of observation.During an observation/ interview of the ice machine on 12/16/2025 at 2:38 pm on the East unit revealed black substance inside the lid with dust particles around the front of the machine on the inside. The Director of Maintenance (DM) confirmed that the machine needed to be cleaned and confirmed the observation. The DM denied the Dietary Department being responsible for the cleaning and maintenance of the ice machine.During an interview on 12/16/2025 at 2:38 pm with the DM, it was revealed that cleaning the ice machine was the responsibility of the Housekeeping Department and that he was unaware of the cleaning schedule of the ice machine. The DM revealed that the machine was down for a few weeks and that he replaced the water filtration system. The DM admitted that it needed cleaning when he replaced the part and stated that he had to empty the machine while it was down for repair.During an interview with the Housekeeping Supervisor on 12/16/2025 at 2:59 pm, it was revealed that her department was not responsible for the cleaning of the ice machine. The Housekeeping Supervisor stated that the DM was responsible for cleaning the ice machine. The Housekeeping Supervisor also stated that she and others did some research after the meeting and was able to confirm that it was the DM's responsibility to clean the ice machines. Additionally, the Housekeeping Supervisor stated that the DM had been made aware that it was the Maintenance Department's responsibility to clean the ice machines. The Housekeeping Supervisor confirmed that neither the Housekeeping Department nor the Facility Maintenance Department had been cleaning the ice machines due to each one thinking that it was the other one's responsibility for the task.Review of the Ice Machine Cleaning Log for the past 90 days showed no documented cleaning. Per the Corporate Risk Manager, there was no formal policy that spoke to whose responsibility it was to clean the ice machines.

Based on observations, interviews, and record review, the facility failed to ensure medications were secured, one of three medication carts on the East wing was left unlocked and unattended. The deficient practice had the potential to cause harm to residents located on the East Wing Unit by allowing unauthorized access to medications.Findings include:Per the Facility's Medication Storage Policy, dated October 1, 2025, all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, and medication rooms). Only authorized personnel will have access to the keys to locked compartments. During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.Observation on 12/18/2025 at 8:38 am, during a tour of the East Wing Unit, a medication cart (Middle Cart) positioned to the left of the East Wing Nursing Station was left unlocked. There were no licensed nurses or other authorized staff present in the hallway. The cart contained multiple medications (i.e. oral medications in blister packs, PRN (as needed medications), topical treatments and controlled (locked) substances. This cart remained unattended for approximately 15 minutes before staff returned.On 12/18/2025 at 8:53 am, the Assistant Director of Nursing observed and confirmed that the medication cart ( Middle Cart) positioned to the left of the East Wing Nursing Station was unlocked and unattended.On 12/18/2025 at 8:55 am, the Unit Manager observed that the medication cart (Middle Cart) positioned to the left of the East Wing Nursing Station was unlocked and unattended.On 12/18/2025 at 9:15 am, the Director of Nursing (DON) confirmed that leaving the medication cart unlocked and unattended was deficient practice. The DON stated that the expectation was that medication carts remain locked at all times when not in the direct possession of a licensed nurse.

Based on observations, policy reviews and staff interviews, the facility failed to ensure that the kitchen was maintained in a sanitary manner. Specifically, the facility failed to maintain hot food items on the steam table above 135 degrees to prevent food borne illness, failed to ensure staff entering the kitchen wore a hairnet properly, and failed to ensure the dish machine had a final rinse temperature at or above 180 degrees for proper sanitization. The deficient practices had the potential to adversely affect 146 of 146 residents receiving an oral diet. Findings include: During the initial tour of the kitchen on 3/10/2025 at 9:49 am, it was observed that the kitchen did not have a foot-pedal trash can. During a subsequent visit on 3/27/2025 at 9:48 am the kitchen did not have a foot-pedal trash can. When staff washed and dried their hands with paper towels, staff was observed adjusting the lid of the trash container to place paper in the trash can. During an interview on 3/27/2025 at 10:21 am with Dietary Aide (DA) WW who stated that the staff in the kitchen did not have access to a trash can with a foot pedal. During an observation on 3/27/2025 at 10:15 am of the high temp dishwasher showed that the gauges on the dishwasher were not moving and stayed stationary. The wash showed 152 degrees Fahrenheit (F) and the rinse was 160 degrees F. The gauges were observed for approximately seven minutes. During a subsequent observation on 3/27/2025 at 10:49 am showed that the manufacture's suggestion was if the water was not reaching the minimum temperature for the wash of 140 degrees F and rinse cycle to be a minimum of 120 degrees F, then a sanitation agent for the wash cycle should be used. During an observation on 3/31/2025 at 11:15 am, an observation was made in the kitchen during tray preparation and temperatures were as follows: Pork Tenderloin -158 degrees F Greens -189 degrees F Beans-186 degrees F Chopped Turkey-157 degrees F Pureed [NAME] Beans-131 degrees F Pureed Beans-145 degrees F Regional Consultant had the staff remove the pureed green beans to place in preheated oven to get temperature up. During an observation on 3/31/2025 at 11:15 am, the Regional Consultant was observed to not have all of her hair placed under her hairnet. Also, the Dietary Manager (DM) was observed to have acrylic nails approximately two inches in link with navy blue polish with silver glitter. During an observation on 4/8/2025 at 2:52 pm, the DM was observed with acrylic nails approximately two inches in link with navy blue polish with silver glitter. A review of the undated policy entitled, Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices showed that in reference to hair nets, hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. Further review of the policy stated that in reference to fingernails, fingernails shall be kept clean and trimmed. No fake nails, nail polish. A review of the manufacture's suggestion for the high-temperature dishwasher wash cycle is to wash at a minimum of 159 degrees F and the rinse cycle to be a minimum of 180 degrees F; using with chemical sanitation solution to be a minimum for wash, 140 degrees F and rinse to be a minimum of 120 degrees F. The thermometer used by maintenance staff showed 141 degrees F. When this was pointed out to the Maintenance Director, he stated that he would have to investigate it. During an interview on 4/8/2025 at 10:20 am, DA EE, stated that she works as a Cook/Aid and she has washed the dishes in the kitchen. It's a little gauge up there and we look at the wash cycle and the rinse cycle. The maintenance man came in after you and fixed it. They had an issue before this survey. We only use it with the three- compartment sink with the stripping. We go get the maintenance when we do not know if the washer is reaching the temperature. DA EE stated that in reference to food temperatures, you take the temp when you put it at the line and before serving. The holding temp is 155. If it's not at the minimum temperature we put it back in the oven. DA EE further stated that in reference to hair nets and nails, you have to make sure your hair is secure in the hair net, and policy states no fake nails or artificial nail, no long nails - they must be cut. During an interview on 4/8/2025 at 2:52 pm, the DM stated that she was working in the role of a cook that day. DM also stated that she did not know what the policy stated in reference to wearing acrylic nails and would have to get back with writer. During an interview on 4/9/2025 at 3:17 pm, Consultant Registered Dietician (CRD) stated that in reference to the dishwasher gauges and sanitation level not registering where it needed to, she had not received a report that the dishwasher was not working correctly, except the gauge to the one against the wall. CRD stated that she would expect the staff to report that there was an issue and get the machine repaired as soon as possible, even if that meant that the dietary staff had to hand wash and dry the dishes until the dishwasher was repaired. CRD stated that in reference to the cold food, CRD stated that it was her expectation that staff would take the temperature of the food as it is taken out of the oven and temp the food again before it is served. CRD stated that in reference to DM wearing acrylic nails and Regional Consultant, if the cook or dietary aids are preparing or setting up the food, they should not have those nails. The staff should always wear their hair net covering their hair completely.

Based on observations, interviews, and record review, the facility failed to ensure Personal Protective Equipment (PPE) was available for three residents (R) R47, R104, and R399 on Enhanced Barrier Precautions (EBP), failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were functioning, and failed to maintain infection control during peri care for Resident (R) 4, of eight residents reviewed for infection control precautions. Findings include: A facility policy titled, Infection Surveillance revised 5/2023 indicated, A system of infection surveillance serves as a core activity of the facilities infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. 1. Record review of the Admission Record revealed that R47 was admitted to the facility on [DATE] with diagnoses of, but not limited to, dementia, bladder cancer, iron deficiency, hypertension, depression, neuropathy. Observation and interview on 3/11/2025 at 10:24 am of R47 revealed posting outside of room instructing EBP required for close contact with resident. There was no PPE visibly available for resident care. ABHR dispenser not working in resident's room. R47 was unaware of where to find PPE in his room. He stated, You will have to ask the nurse. 2. Record review of the Admission Record revealed that R104 was admitted to the facility on [DATE] with diagnoses of, but not limited to, displaced open fracture type II of greater trochanter of left femur, bone necrosis, immunodeficiency, subarachnoid hemorrhage, diabetes type 2, Alzheimer's disease, dementia, atrial fibrillation, chronic kidney disease, hyperlipidemia, osteoarthritis of hip. Observation and interview on 3/11/2025 at 10:24 am of R104 revealed posting outside of room instructing EBP required for close contact with resident. There was no PPE visibly available for resident care. ABHR dispenser not working in resident's room. Resident bed bound and nonverbal. 3. Record review of the Admission Record revealed that R399 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Alzheimer's disease, dementia, contracture of right and left knees, adult failure to thrive, muscle weakness, gastrostomy (PEG-tube), PICC-line, surgically closed wound infection of front left trochanter (left hip). Observation and interview on 3/10/2025 at 10:30 am of R399 revealed a posting outside of room instructing EBP required for close contact with resident. There was no PPE visibly available for resident care. During observation and interview on 3/13/2025 at 4:58 am, CNA VV stated she was unaware that R104 and R47 required Enhanced Barrier Precautions. The surveyor pointed to the EBP signs posted on the wall by the residents' door. The CNA stated she did not don PPE when giving care to the two residents overnight. She stated the nurse only has access to the storeroom where the PPE station is stored. During observation and interview on 3/13/2025 at 5:03 AM, LPN UU stated she was just the night nurse. She was unaware that R104 and R47 required Enhanced Barrier Precautions. Admitting she had not donned PPE while caring for the two residents overnight. We have PPE in the storeroom. She went to the storeroom and put the PPE station in the hall between the resident's rooms. In a tour and interview with the facility Director of Nursing (DON) on 3/13/2025 at 6:47 am, she stated PPE was located in residents' wardrobe or closets mixed with residents clothing. DON was informed that staff were rendering care to R104, R47, and R399, no gowns were donned by the nurses or CNA and ABHR dispensers in above rooms were not functioning. 4. In a tour and interview on 3/27/2025 at 1:11 pm with facility contracted Regional Housekeeping/Laundry Director XX replaced ABHR in rooms 304, 307, 309, and 323 due to improperly functioning dispensers. He stated he ordered new foam action dispensers for facility to replace current dispensers. In an interview on 3/31/2025 at 12:35 pm with the facility Assistant Director of Nursing/Infection Preventionist (ADON/IPC) she stated that housekeeping is responsible for managing ABHR dispensers and the staff should have donned gowns when providing care with residents with EBP protocols. 49479 5. R4 was admitted into the facility on [DATE] with diagnoses of, but not limited to immunodeficiency conditions, end stage renal disease, dementia, and unilateral primary osteoarthritis of right knee. Review of R4's care plan revealed R4 was incontinent of bowel and bladder and required extensive to total assistance with Activities of Daily Living (ADLs). The care plan also stated R4 would receive peri-care with each incontinent episode. R4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, moderate cognitive impairment. The MDS also revealed R4 required extensive to total assistance with ADLs. Observation of incontinent care on 4/8/2025 at 11:45 am for R4 performed by Certified Nursing Assistants (CNAs) JJ and assisted by CNA BB revealed the infection control protocol for incontinent care had not been followed. CNA JJ used a disposable wipe and cleansed the R4's perineal area from back to front four times. CNA JJ also used a one clean washcloth and cleansed the R4's buttock from back to front three times. An interview on 4/9/2025 at 3:43 pm with the Director of Nursing (DON) revealed when peri-care was performed the nursing staff should always cleanse from front to back.

Based on record review and staff interviews, the facility failed to complete Preadmission Screening/Resident Review Assessment I and II (PASARR) for two of three sampled residents; Resident (R) 74 and R31 for serious mental disorders or intellectual disabilities and related conditions. Findings include: A facility policy titled, Resident Assessment - Coordination with PASARR Program date reviewed/revised 12/2022, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level I - initial pre-screening that is completed prior to admission . ii. Positive Level I Screen - necessitates a PASARR Level II evaluation prior to admission. 1. Review of the Admission Record (AR) revealed that R74 was admitted to the facility on [DATE] with diagnoses of, but not limited to, dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, psychosis, and anxiety disorder. Review of Quarterly Minimum Data Set (MDS) dated [DATE] revealed R74 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with most activities of daily living (ADLs). Review of R74's PASARR I dated 3/10/2021 negative diagnosis for Alzheimer's disease, Parkinson's disease, bipolar disorder, schizophrenia, or dementia. All fields were blank on the form. Review of R74's DMA-6 revealed it was certified by doctor on 3/3/2021 with a diagnosis of failure to thrive requiring nursing facility care. Review of R74's psychotropic medication administration disclosure dated 5/13/2024 received verbal consent from Resident Representative (RP). Interview on 3/18/2025 at 12:28 PM with Social Services Director (SSD) he stated he would check with medical records to see if they facility has a properly completed PASARR on file for R74. Interview on 3/18/2025 at 4:25 PM with the SSD stated the facility did not complete a PASARR on R74 when she was admitted in 2021. The SDD reported that he sent the home office a PASARR request, but the system rejected the request because of its' age. They will have to complete a new PASARR to correct R74's chart. The SSD stated he will audit the system for other residents PASARR that may have been missed. They are planning on hiring a new Medical Records staff member. Review of R74's initial PASARR I dated 3/18/2025 with diagnosis for dementia, Alzheimer's disease, somatoform disorder, and anxiety disorder. 49472 2. Resident 31 was admitted to the facility on [DATE] and was noted as having diagnoses of major depressive disorder, social phobia, anxiety disorder, unspecified, unspecified psychosis not due to a substance or known physiological condition, adjustment disorder with mixed disturbance of emotions and conduct, obsessive-compulsive disorder, unspecified, bipolar disorder, unspecified, paranoid personality disorder. Review of the medical diagnoses of R31 showed that resident had a diagnosis of bipolar disorder and paranoid personality disorder with an onset date of 10/24/2022 for both diagnoses. Review of the facility records showed a PASARR I for R31. A request was made for PASARR level II, but none was provided. During an interview on 4/10/2025 at 12:01 pm with the Social Service Director (SSD) who stated that after reviewing R31 PASSAR, he noted that there were some diagnoses that were not included at the time of admission. SSD stated that he put in a request for an evaluation for R31. Also, SSD stated that he had the physician to complete a new Disability and Medical Assessment (DMA)-6.

Based on staff interviews, record review, and a review of the facility policy titled Weight Monitoring, the facility failed to perform weekly weights after significant weight loss and failed to implement a dietician recommendation for one resident (R) 20 of four residents reviewed for nutrition. Findings include: Review of the facility's policy titled, Weight Monitoring, it was revealed that 5. Weight monitoring schedule will be developed upon admission for all residents: . b. newly admitted residents- monitor weight weekly for four weeks C. Resident with weight loss- monitor weight weekly d. if clinically indicated- monitor weight daily e. All others- monitor weight monthly. Review of R20's Electronic Medical Record (EMR) revealed an original admitted [DATE] and a discharge date of [DATE]. R20 was admitted with multiple diagnosis of but not limited to periprosthetic fracture around other internal prosthetic joint, personal history of other mental and behavioral disorders, sequela, dementia, psychotic disturbance, mood disturbance, cognitive communication deficit, depression and anemia. R20 has a Brief Interview for Mental Status (BIMS) of 01; indicating that R20 was severely cognitively impaired. Review of R20's Quarterly Minimum Data Set (MDS); Section K Swallowing/Nutritional Status, dated 3/21/2025, revealed R20 was coded for weight loss of 5% or more in the last month. Review of R20's EMR revealed the following documented weights: 12/20/2024 at 9:50 am =138.0 pounds 12/20/2024 at 1:06 pm = 141.4 pounds 1/1/2025 at 8:15 am = 142.0 pounds 1/3/2025 at 9:11 am = 144.7 pounds 1/17/2025 at 10:41 am = 137.2 pounds 2/6/2025 at 8:34 am =139.1 pounds 3/10/2025 15:03 =127.3 pounds There are no other recorded weight entries for R20. The significant weight loss of occurred between the following dates: 1/3/2025 to 1/17/2025 at a 5.2% weight loss in less than a month and between 2/6/2025 to 3/10/2025 at an 8.48 % weight loss in one month. Review of R20's Nutritional assessment dated [DATE] revealed that R20's food consumption was 26-100% and resident is eating independently or with some supervision. Current weight is 127.3# this is a decrease MDS: -5.0% change over 30 day(s). It was also revealed in the Nutritional Assessment that R20 will be recommended to receive 2.0 supplement TID to address weight management. Have already implemented some supplemental foods with meal trays. Review of R20's Medication Administration Record for January 2025 and February 2025, it was revealed that a Physician's for 2.0 Supplement 120 milliliters at bedtime for weight loss with a start date of 1/29/2025 and an end date of 2/15/2025. A physician's order for the '2.0 supplement TID to address weight management' per the Nutritional Assessment was not found. During an interview on 4/01/2025 at 12:08 PM, the Restorative Aide (RA) JJ revealed that new residents, they get weighed the for 3 consecutive days in a row to get a baseline weight and then weekly for the first 4 weeks. If the resident stays longer than a month, they get weight monthly. The RA JJ continued that she prints out the resident census and goes around the facility to take the residents weights, records it on the list dates it and gives it to the recorder. The RA JJ stated the data is entered by the previous Staff Development Coordinator (SDC) but now the data is entered by the Assistant Director of Nursing (ADON). The RA JJ stated the new admissions have a different list, so she knows to take them weekly that way. The RA JJ continues that if a resident loses weight, then that resident is put on a supplement and weighs them once a week. During an interview on 4/1/2025 at 3:45 pm, the Consultant Registered Dietician (CRD) confirmed that residents that have significant weight loss should be weighed weekly. The CRD also stated that ideally the weight will be completed by Wednesdays to discuss weights in the weekly risk meeting or quality of life meetings. The CRD continued that they would pull the weight report that day and go through and mark everybody the CRD have concerns about and try to mark them before it's a significant weight loss. The CRD also stated that getting weight timely had been a pain point that had been discussed in the past. During an interview on 4/1/2025 at 3:55 pm, the Consultant Registered Dietician (CRD) confirmed that R20s had significant weight loss. The CRD also confirmed recommending 2.0 supplement TID in addition to supplemental meals like additional protein like eggs during breakfast. When asked about the TID supplement for the weight loss that R20 had after the 3/10/2025 weight, the CRD stated an order wasn't put in place because it was an oversight on her part to inform the physician about R20's weight loss. Interview on 4/8/2025 at 11:47 am, the ADON revealed that she noticed that weekly weights are not being done after a resident had weight loss but also it seemed infrequent for the first four weeks for newly admitted residents.

Based on record review and staff interviews, the facility failed to ensure Vancomycin (antibiotic medication) was administered as ordered for one of six sampled residents. Resident (R) 399 missed three daily doses of intervenous (IV) Vancomycin prescribed for surgically closed wound infection of front left trochanter (left hip). Findings include: Review of the Admission Record revealed R399 was admitted to the facility on [DATE] with diagnoses of, but not limited to, Alzheimer's disease, dementia, contracture of right and left knees, adult failure to thrive, muscle weakness, gastrostomy (PEG-tube), PICC-line, surgically closed wound infection of front left trochanter (left hip). Review of Quarterly Minimum Data Set (MDS) dated [DATE], revealed R399 had a brief interview for mental status (BIMS) score of 00, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with most activities of daily living (ADLs). Review of Physician Order revealed, Start Date: 3/6/2025: Administration time: 6:00 am: Order Summary: Vancomycin HCl Intravenous Solution 1000 milligrams (mg) /200 milliliters (ml) (Vancomycin HCl) Use 1 gram intravenously in the morning for closed wound infection. Review of medication administration record (MAR) revealed R399 had missed doses on 3/10/2025, 3/14/2025 (No documentation), and 3/17/2025. No note that the physician was notified or labs drawn. In an interview on 4/9/2025 at 3:57 pm with the facility Director of Nursing (DON) she stated her expectation for a medication that is not given would be that there is an explanation for why it was not given in the MAR/Nursing Progress Notes and notification for the provider. In an interview with LPN KK on 4/10/2025 at 11:37 am regarding medication administration expectations and documentation she stated, Give medications at the right time and chart and monitor the residents. Usually, when I give an injection, and I would document as soon as I can. I would document right away; I would not wait until the end of the shift to document medication administration. If I didn't have an IV medication, I would call the pharmacy to see where it was, and phone the physician when it came and asked if the medication could be given at that time. If the medication came late, I would put in a one-time order and document it and give the medication.

Based on record review and interviews, the facility failed to provide Activities of Daily Living (ADL) care for two of 17 sampled residents (R) (R4 and R A). Findings include: 1. R4 was admitted into the facility on [DATE] with diagnoses of, but not limited to immunodeficiency conditions, end stage renal disease, dementia, and unilateral primary osteoarthritis of right knee. Record review of R4's care plan revealed R4 was incontinent of bowel and bladder and required extensive to total assistance with Activities of Daily Living (ADLs). The care plan also stated R4 would receive peri-care with each incontinent episode. R4's Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. The MDS also revealed R4 required extensive to total assistance with ADLs. A record review of R4's Point of Care (POC) which was completed by the Certified Nursing Assistants (CNAs) revealed: R4's POC documentation for January 2025 revealed on 1/1/2025, 1/4/2025, 1/5/2025, 1/6/2025, 1/9/2025, 1/10/2025, 1/19/2025, 1/20/2025, 1/23/2025, 1/24/2025, 1/25/2025, 1/27/2025, and 1/31/2025 for January 2025 were left blank. R4's POC documentation for February 2025 revealed on 2/1/2025, 2/2/2025, 2/9/2025, 2/11/2025, 2/12/2025, 2/18/2025, 2/22/2025, and 2/28/2025 for February 2025 were left blank. R4's POC documentation for March 2025 revealed on 3/1/2025, 3/6/2025, 3/12/2025, 3/14/2025, 3/17/2025, 3/18/2025, 3/21/2025, 3/22/2025, and 3/23/2025 for March 2025 were left blank. Review of the Grievance Reports dated 6/6/2023, 6/23/2023, 9/16/2023, 2/13/2024, and 5/13/2024 complained of R4 not receiving showers and being urine soaked on those dates. A telephone interview on 3/26/2025 at 9:27 am with the Family of R4 revealed there had been numerous times when R4 was found soaked in urine. They stated the main concern had been the inconsistent daily care of R4. They stated sometimes R4 would be cleaned and other times R4 would be soaked in urine. R4's clothing was washed by the family and on numerous occasions the clothing had been soaked in urine. Interview on 3/31/2025 at 12:35 pm with the Assistant Director of Nursing (ADON) revealed no knowledge of why blanks in the POC and no documentation had been entered. ADON stated there should not have been any blanks in the POC documentation because it meant the only assumption was that it was not done. 49687 2. Review of R A's Electronic Medical Record (EMR) revealed an original admitted [DATE] and a discharge date of [DATE]. R A was admitted with multiple diagnosis of but not limited to periprosthetic fracture around other internal prosthetic joint, personal history of other mental and behavioral disorders, sequela, dementia, psychotic disturbance, mood disturbance, cognitive communication deficit, depression and anemia. R A has a BIMS score of 01; indicating that R A was severely cognitively impaired. Interview on 3/24/2025 at 9:05 am, a Resident Sitter SS stated the R A was completely wet that morning upon arrival. Resident Sitter RR urged the team to come to the facility at night because that is when the staff leaves resident wet and soiled for hours. Reviewed R A POC documentation regarding peri-care for January 2025 through March 2025 revealed the following The POC documentation for January 2025 revealed that R A did not receive peri care on the following dates and shift: 1/21/2025--day shift 1/27/2025--day shift 1/31/2025--night shift The POC documentation for February 2025 revealed that R A did not receive peri care on the following dates and shift: 2/7/2025--night shift 2/8/2025--evening shift 2/13/2025--day shift 2/14/2025--day shift 2/16/2025--night shift 2/18/2025--day shift 2/19/20250--day and night shifts 2/22/2025--day shift 2/28/2025--night shift The POC documentation for March 2025 revealed that R A did not receive peri care on the following dates and shift: 3/1/2025--night shift 3/2/2025--night shift 3/4/2025--day shift 3/6/2025--night shift 3/19/2025--night shift Interview on 4/9/2025 at 3:43 pm, the Director of Nursing (DON) revealed if peri-care was not given, it should have been marked Not Applicable (N/A). The DON continued that there were various reasons why the POC would be left blank, but all were unacceptable. During an interview on 4/10/2025 at 10:05 am, Certified Nursing Assistant (CNA) BB revealed that staff cannot go home without charting. CNA BB continued they won't let you out of the door until charting is complete. CNA BB also revealed that as soon as I give incontinent care, I try to put it in the POC or at least before I go home.

Based on interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to administer scheduled medications within 60 minutes before or after the scheduled medication time for one Resident (R) 151 of nine sampled residents reviewed for medication administration. Findings include: Review of the facility's policy titled Medication Administration date reviewed/revised January 2023 revealed, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The facility's policy explanation and guidelines revealed .17. Sign MAR (Medication Administration Record) after administered . Review of the Electronic Medical Record (EMR) revealed R151 was admitted into the facility with multiple diagnoses that included but not limited to sepsis cystitis without hematuria, urinary tract infection, systemic inflammatory response of non-infectious origin, depression, cognitive communication, and dysphagia. Review of R151's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed, Section C (Cognitive Pattern) a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. The MDS also indicated R151 was frequently incontinent of bowel and bladder and was dependent on nursing staff for personal hygiene. Review of 151's Physician's Orders revealed: 1. Aspirin Enteric Coated Delayed Release 81 milligram (mg): give one tablet at 8:00 pm every day. 2. Atorvastatin Calcium 30 mg: give one tablet at 8:00 pm every Monday, Wednesday, and Friday. 3. Ropinirole Hydrogen Chloride (HCl) 0.25 mg: give two tablets at 9:00 pm every day. 4. Zinc-Magnesium Aspart-Vit-B6 10-150-3.83 mg: give two tablets at 8:00 pm every day. 5. Osteo Bi-Flex Triple Strength oral tablet: give one tablet twice a day at 8:00 am and 8:00 pm every day. 6. Metamucil Fiber chewable tablets: give three times a day at 9:00 am, 1:00 pm, and 9:00 pm every day. Review of 151's Medication Administration Audit Report documented the following: Scheduled date - 2/16/2024; 8:00 pm-9:00 pm - administration time 1:41 am. Scheduled date - 2/17/2024; 8:00 pm-9:00 pm - administration time 12:03 am. Scheduled date - 2/20/2024; 8:00 pm -9:00 pm - administration time 2:03 am. Scheduled date - 2/22/2024; 8:00 pm-9:00 pm - administration time 1:02 am. Scheduled date - 3/11/2024; 8:00 pm-9:00 pm - administration time 3:54 am. Scheduled date - 3/12/2024; 8:00 pm-9:00 pm - administration time 5:17 am. Scheduled date - 3/15/2024; 8:00 pm-9:00 pm - administration time 1:32 am. Scheduled date - 3/17/2024; 8:00 pm-9:00 pm - administration time 3:43 am. Scheduled date - 3/19/2024; 8:00 pm-9:00 pm - administration time 12:22 am. Scheduled date - 4/8/2024; 8:00 pm-9:00 pm - administration time 1:23 am. Scheduled date - 4/12/2024; 8:00 pm-9:00 pm - administration time 2:29 am. During an interview on 4/9/2025 at 3:43 pm the Director of Nursing (DON) was unable to provide an explanation of why the medications were administered late. A record review of the facility's Grievance Log revealed several complaints of residents who had received their medications late.

Based on staff interview, record review, a review of the facility policy titled Comprehensive Care Plans, the facility identifies weight loss for two residents (R) (R20 and R59) of four residents reviewed for nutrition out of 36 sampled residents. Findings include: In a review of the facility's policy titled, Comprehensive Care Plans, revised on 9/12/2022, revealed that, 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preference in developing goals of care. The policy also stated that All care assessment areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will be address in the plan of care. 1. In a review of R20's Electronic Medical Record (EMR) revealed an original admitted [DATE], with multiple diagnosis of but not limited to periprosthetic fracture around other internal prosthetic joint, personal history of other mental and behavioral disorders, sequela, dementia, psychotic disturbance, mood disturbance, cognitive communication deficit, depression and anemia. R20 has a Brief Interview for Mental Status (BIMS) of 01; indicating that R20 was severely cognitively impaired. R20's Dietary Progress note dated 1/29/2025 at 1:15 PM revealed R20's food consumption was 51-100% and resident is eating independently or with limited assistance. Current weight is 1347.2 # Ht is 68 and BMI is 20.9 nl range and IBW 64 kg or141# Will recommend 120 ml 2.0 Supplement and supplemental foods with each meal tray for snacks. Review of R20's nutritional assessment dated [DATE] revealed that R20's food consumption was 26-100% and resident is eating independently or with some supervision. Current weight is 127.3# this is a decrease MDS: -5.0% change over 30 day(s) [ Comparison Weight 2/6/2025, 139 Lbs, -8.6% , -12 Lbs ]; -7.5% change [ Comparison Weight 12/20/2024, 138.0 Lbs, -7.8% , -10.7 Lbs ]; Ht. 68: BMI is 19.4. IBW is 140 # or 64 KG. Will recommend 2.0 supplement TID to address weight management. Have already implemented some supplemental foods with meal trays. Review of R20's quarterly Minimum Data Set (MDS); Section K Swallowing/Nutritional Status, dated 3/21/2025 revealed R20 was coded for weight loss of 5% or more in the last month. In a review of R20's care plan, last revised on 3/22/2025 did not include R20's weight loss. During an interview on 4/7/2025 at 12:23 pm, MDS Director revealed that the facility would notify family for the weight loss and then the care plan should be updated which is usually done by the Registered Dietician (RD). The MDS Director confirmed R20's weight loss was coded in the MDS; however, it did not get care planned. 2. In a review of R59s 's Electronic Medical Record (EMR) revealed an original admitted [DATE], with multiple diagnosis of but not limited to Malignant neoplasm of unspecified part of unspecified bronchus or lung, Anemia, Hypotension, Muscle weakness and chronic kidney disease, stage V. R59 has a Brief Interview for Mental Status (BIMS) of 13; indicating that R59 was cognitively intact. In a review of R59's five day Minimum Data Set (MDS); Section K Swallowing/Nutritional Status, dated 2/2/2025 revealed R59 was coded for weight loss of 5% or more in the last month. In a review of R59's care plan, last revised on 2/14/2025 did not include R59's refusal to eat meals or R59's being at risk for weight loss. Review of R59's progress note dated 3/7/2025 at 9:24 am revealed R59 frequently refuses to eat and will refuse medications. Resident has been educated on multiple occasions regarding importance of her medication regimen In an interview on 4/8/25 at 1:32 PM, the MDS Director, Yes you are correct, I see it coded in the five-day MDS for weight loss but it's not in the care plan, so it is a care plan issue. The MDS Director also stated Is it a dual effort with the IDT to ensure it get to the care plan.

Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure certified nursing assistants (CNAs) demonstrated competency in skills and techniques necessary to care for residents' needs related to transfers using a mechanical lift for two of 15 CNA competency documents that were provided. During observations of a transfer of R#12 by way of a mechanical lift, the resident voiced discomfort and concern of falling during the transfer. Observations revealed the resident was not appropriately positioned in the mechanical lift sling and as a result, after the resident was transferred to the wheelchair, R#12 slid from the wheelchair into the floor because the resident could not be appropriately positioned in the chair. A review of training records revealed the competency evaluations for the CNAs that performed the transfer (CNA RR and CNA TT) indicated they had not met all the requirements to demonstrate competence and there was no evidence that the CNAs were retrained to ensure competence. On 5/4/23, determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 5/4/23 at 6:10 p.m. The noncompliance related to the IJ was identified to have existed on 5/3/23. An Acceptable Removal Plan was received on 5/6/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 5/6/23. Findings included: The facility's undated policy, titled, Safe Resident Handling/Transfers, indicated, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy also revealed, 11. Staff will be educated on the use of safe handling/transfer practices to include use of mechanical lift devices upon hire, annually and as the need arises in changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. A review of R#12's Admission Record revealed the facility admitted the resident on 1/30/23 with diagnoses that included metabolic encephalopathy, peripheral vascular disease, acquired absence of right lower leg below the knee, hemiplegia and hemiparesis following a cerebrovascular disease affecting left dominant side, muscle weakness, and vascular dementia with behavioral disturbance. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/23 revealed R#12 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderately impaired cognition. The MDS further indicated R#12 required the extensive assistance of one person for activities of daily living including dressing, eating, and personal hygiene. The MDS indicated for transferring, the activity only occurred once or twice, and no setup or physical help was required from staff. A review of R#12's Care Plan, last reviewed on 2/6/23, indicated the resident had an activity of daily living (ADL) self-care deficit related to dementia, generalized muscle weakness, cardiovascular accident with left sided weakness, and a right below the knee amputation. The care plan interventions, initiated on 2/6/23, directed staff to encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use the call bell to call for assistance, and for physical therapy and occupational therapy to evaluate and treat the resident as ordered by the physician. The care plan did not include interventions that directed staff how to provide assistance to the resident for transfers or equipment that was needed for transfers. Observations on 5/3/23 from 10:13 a.m. to 10:27 a.m. revealed Certified Nursing Assistant (CNA) RR and CNA TT transferred R#12 from the bed to a wheelchair using a mechanical lift. The CNAs did not ensure the sling for the lift was appropriately placed to support the resident during the transfer and the resident's buttocks were unsupported during the transfer. Observations revealed the staff continued to transfer the resident despite the resident voicing concerns that they were falling and were having pain during the transfer while in the lift sling. After the resident was placed in the wheelchair, the resident could not be repositioned in the wheelchair because the sling was not positioned correctly and as a result the resident slid from the wheelchair onto the floor. The resident did not sustain any injuries as a result of the fall. A review of an Employee Education/In-service sheet, dated 3/27/23, revealed 32 employees attended lift and transfer training provided by the Staff Development Coordinator (SDC), 16 of which were certified nursing assistants (CNAs). During an interview with CNA RR on 5/3/23 at 1:14 p.m., she stated she was an internal agency CNA who had worked frequently at the facility for the past two years. She stated the last mechanical lift training she received was about three weeks ago, and the training, which was an in-service and demonstration, covered how to get the residents ready for a lift and the procedure for a safe mechanical transfer. A review of a Total Mechanical Lift Competency Checklist for CNA RR dated 3/28/23, revealed the SDC observed the CNA's competency and checked No for five of the 17 steps. The steps the CNA did not meet were: Demonstrates ability to lower resident after lift has failed, Locate emergency stop button and its purpose, Verbally prepares resident for safe transfer, Gently raises resident minimally from surface. Unweight resident from bed. Performs a safety check, and Removes sling from under resident. Only leaves sling on resident if Care Planned. The SDC did not provide documentation that education was provided to ensure CNA RR was competent in all aspects of how to transfer a resident by way of a mechanical lift. During an interview with CNA TT on 5/3/23 at 10:38 a.m., she stated she had worked at the facility for a little over a month. Per CNA TT, she completed the mechanical lift training and demonstration during orientation. A review of CNA TT's Total Mechanical Lift Competency Checklist dated 3/29/23 revealed the CNA did not meet the criteria for one of the 17 steps, Adjust bed to height that promotes good body mechanics. During an interview with the Staff Development Coordinator (SDC) on 5/4/23 at 12:24 p.m., she stated she provided in-service training to all nursing staff on safe mechanical lift transfers and sling placement. She stated the training included how to operate the mechanical lifts, safe sling placement for a transfer, and a satisfactorily completed demonstration with the nursing staff before she approved the staff's competency to perform a mechanical lift transfer on the Total Mechanical Lift Competency Checklist. She stated mechanical lift transfer training was completed upon hire, annually, and if the need was identified for one-to-one training. The SDC stated if the skills check off was done correctly during floor observations, it was outlined on the comprehensive check-off sheet. She stated if the CNA forgot a step during the demonstration, the CNA was immediately provided one-to-one education privately, away from the earshot of the residents. She stated if retraining was needed, the CNAs would demonstrate a lift on the facility manikin to ensure safety during a mechanical lift transfer. She stated a competency checklist that had four or five No responses indicated the staff was not competent in the skills to perform a safe mechanical lift transfer. She stated retraining would be provided until the CNA completed a demonstration with all Yes indications, which demonstrated the competency needed for a safe mechanical lift transfer. She stated education would be provided until the deficit in training was identified and corrected with the CNA. The SDC stated CNA RR had completed the mechanical lift transfer training and completed the skills demonstration during a mechanical transfer of a resident. She stated she oversaw the training and skills demonstration with CNA RR. She stated she re-educated CNA RR after the five No indications were revealed on the comprehensive skills check-off sheet. She stated that aside from the documentation on the check-off sheet that specified education provided, there was no other documentation to indicate how re-education was provided to ensure CNA RR was competent to perform a mechanical lift transfer. She stated that since CNA RR was an internal agency CNA, the facility training was only provided because an issue was identified. During an interview with the Administrator on 5/5/23 at 4:33 p.m., he stated he expected the CNA competencies to be accompanied by satisfactory demonstration skills check off. He stated the SDC completed the CNA competency skills check off, and if the CNAs could not demonstrate a safe mechanical lift transfer, retraining and another demonstration should be conducted with the CNA before another mechanical lift transfer was performed for a resident. During an interview with the DON on 5/6/23 at 1:02 p.m., she stated she expected the CNAs to be trained and demonstrate competency of safe mechanical lift procedures. She stated all CNAs were provided mechanical lift training and completed a demonstration with the SDC during new hire orientation. She stated if any issues arose on the floor around mechanical lift transfers, the CNA would be pulled aside and provided one-to-one re-education. She stated mechanical lift transfers were also a part of the annual training provided to all nursing staff. She stated if a CNA had four or five No answers that indicated they were not competent to perform a mechanical lift transfer, it would be deemed an unsafe transfer and re-education would be provided immediately using the facility manikin. She stated a follow-up check should be completed a few days after re-education to make sure the staff member retained the training. The facility implemented the following actions to remove the IJ: 1. Ad hoc meeting held on 5/4/23 at 7:00 p.m. with Medical Director, center Nurse Practitioner, Administrator, Director of Nursing, Assistant Director of Nursing, center Educator (SDC), Director of Operations for Georgia, Regional Director of Clinical Operations, and other center management team members to address concerns identified during the survey process related to accidents and incidents, staff competency, and comprehensive care plans to review the findings for IJs and plan for removal of IJs issues. 2. On 5/3/23, R#12 was assessed by the NP and determined to be without injuries or adverse effects. The resident was assessed for pain by a licensed nurse and the resident did not complain of pain above her usual pain level. In addition, she stated she was not hurt. 3. On 5/4/23, the Regional Director of Clinical Operations educated the Director of Nursing, ADON, and Staff Development Coordinator on the facility's Safe-Resident-Handling Transfer (Mechanical lift) process for residents requiring the use of a mechanical lift to ensure licensed nurses and certified nursing assistants can demonstrate competencies through return demonstration as evidenced by both visual and skilled competency checklist for safe transfer.? 4. On 5/4/23, the Staff Development Coordinator provided education with return demonstration competency to certified nursing assistants (both facility hired and contracted CNAs) on safe transfers of residents requiring the use of a mechanical lift. Education included: Ensuring the resident's care plan included the type of transfer the resident needed for a safe transfer to include the use of a mechanical lift, use and communication of the appropriate sling size, care planning the number of staff needed for a transfer, documenting the sling size on the Kardex, assessing/determining if the sling has been placed on the resident correctly before using the mechanical lift, and communicating with the nurse if the resident is in pain. 5. As of 5/5/23, Currently there are 27 certified nursing assistants, 22 Licensed Practical Nurses, and 10 Registered Nurses of which currently 100% of current RNs, 100% of current LPNs, and 88% of current CNAs have been re-educated by the Staff Development Coordinator (SDC) on importance of using the proper sling sizes when transferring residents using a mechanical lift; assessing the resident on admission, annually, and quarterly for lift assessment; using the manufacturer's guidelines to measure for appropriate sling size when needed (manufacturer's guidelines will be kept at the nurses' station); ensuring that the slings placement has been checked/assessed before using the mechanical lift; and the ongoing importance safe transfer education along with competency validation Four LPNs and Four RNs were educated over the phone and will complete education in person at next scheduled shift. 6. The Director of Nursing and nursing management team (consisting of Unit Managers, ADON, MDS, and SDC) using a tool labeled Mechanical Lift Observation will conduct a 10% random observation audit daily (Monday through Friday) for two weeks of residents' transfers of those requiring the use of a mechanical lift and then weekly times four weeks and monthly times two months to ensure ongoing and sustained competency related to ensure ongoing and sustained compliance with mechanical lift usage, appropriate sling size, documentation of sling size on the Kardex, appropriate placement of the sling for the resident use. 7. Newly hired CNAs (contracted and or agency) as well as newly hired will receive education upon hire will receive ongoing education as needed on Transfer assessments, safe transfer, mechanical lift use, and appropriate sling size and use. CNAs will be required to perform return demonstrations on mechanical lift use upon hire, annually, and as needed. Those current CNAs who did not attend the re-education on the importance of Safe-Resident-Handling Transfer (Mechanical lift) process received the re-education via telephone conference. Currently, there are no staff members on FLMA or LOA. Any clinical staff who were not re-educated due to Vacation, PRN Status, etc., will be re-educated prior to resuming their duties on their designated shift by the Nurse Manager, Shift Supervisor or Charge Nurse. Newly hired stakeholders, Agency or PRNs will be re-educated during orientation or prior to assuming the responsibilities of their designated shift by the Staff Development Coordinator (SDC) or Director of Nursing. 8. The Center administrator will review results from the Mechanical Lift Observation audits in the Quality Assurance Performance Improvement Committee meeting for four weeks then monthly times two months to ensure compliance is achieved and sustained. QAPI team will continue to monitor and the SDC will conduct 1:1 reeducation as areas identified as non-compliance and report results to QAPI committee. The administrator will sign and communicate the results of the audit review with the Medical Director and the members of the committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Action verified through interview with the DON, SDC, and the Medical Director and review of the Ad Hoc QAPI minutes dated 5/4/23 on 5/6/23 and with the Administrator on 5/7/23 who was unavailable on 5/6/23. 2. Action verified through interview with the Medical Director and DON and review of facility fall investigation on 5/6/23. 3. Action verified through interview with the DON, ADON, and SDC and a review of training records and demonstration competencies on 5/6/23. 4. Action verification completed through staff interviews and a review of training records and demonstration competencies on 5/6/23. Interviews with 12 CNAs, five LPNs, one RN, and the Director of Rehabilitation present in the facility on 5/6/23 revealed the re-education regarding mechanical lifts and sling sizes had been provided by the SDC and DON. Telephone interviews with 19 CNAs, 10 LPNs, and four RNs across day, evening, and night shifts revealed the re-education regarding mechanical lifts and sling size had been provided by the SDC and DON. 5. Action verification completed through staff interviews and a review of training records and demonstration competencies on 5/6/23. Interviews with 12 CNAs, five LPNs, one RN, and the Director of Rehabilitation present in the facility on 5/6/23 revealed the re-education regarding mechanical lifts and sling sizes had been provided by the SDC and DON. Telephone interviews with 19 CNAs, 10 LPNs, and four RNs across day, evening, and night shifts revealed the re-education regarding mechanical lifts and sling size had been provided by the SDC and DON. 6. Action verified through interview with the DON, a review of the Mechanical Lift Observation tool, and a demonstration of its use on 5/6/23. 7. Action verified through interview with the DON and SDC on 5/6/23. 8. Actions verified through interview with the Administrator on 5/7/23, as he was not available on 5/6/23. Action also verified through interview with the DON on 5/6/23, a review of the Mechanical Lift Observation tool, and a demonstration of its use on 5/6/23.

48313 Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure two of four sampled residents (R) (R#12 and R#69) for accidents received adequate supervision to prevent accidents. Observations of a mechanical lift transfer of R#12 on 5/3/23 revealed the resident voiced discomfort and concern that they were falling during the transfer and the observation revealed the mechanical lift sling was not positioned properly to support the resident during the transfer. The Certified Nursing Assistants (CNAs), CNA RR and CNA TT, who were performing the transfer failed to appropriately supervise the transfer and intervene to properly position the resident in the sling when the resident verbalized discomfort. As a result, once the resident was moved to the wheelchair, the staff were unable to effectively position the resident in the chair, and the resident slid from the wheelchair onto the floor. In addition, interviews with nursing staff revealed CNAs who lacked the minimum training and oversight to ensure correct sling sizes and safe practices were utilized during mechanical lift transfers. Additionally, R#69 had a syncopal episode and staff left the resident sitting in a wheelchair unattended. The resident fell and sustained a laceration to the forehead and rib fractures. On 5/4/23, determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 5/4/23 at 6:10 p.m. The noncompliance related to the IJ was identified to have existed on 5/3/23. An Acceptable Removal Plan was received on 5/6/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 5/6/23. Findings included: 1. A review of an undated facility policy titled, Safe Resident Handling/Transfers, revealed, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. The policy also revealed, 8. The facility will ensure that there are appropriate amounts of varying sizes of slings to accommodate residents and that residents will be measured correctly as per manufacturer's instructions on proper sling sizing. The policy also indicated, 11. Staff will be educated on the use of safe handling/transfer practices, to include use of mechanical lift devices upon hire, annually and as the need arises or changes in equipment occur. 12. The staff must demonstrate competency in the use of mechanical lifts prior to use and annually with documentation of that competency placed in their education file. 13. Staff members are expected to maintain compliance with safe handling/transfer practices. A review of R#12's Admission Record revealed the facility admitted the resident on 1/30/23 with diagnoses that included metabolic encephalopathy (abnormalities of water, electrolytes, vitamins, and other chemicals that adversely affect brain function), peripheral vascular disease (a disorder of the circulatory system outside the brain and heart), acquired absence of right lower leg below the knee, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease affecting the left dominant side, vascular dementia with behavioral disturbance, anxiety disorder, and depression. A review of a five-day Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/23/23, revealed R#12 had a Brief Interview for Mental Status (BIMS) score of seven, which indicated severe cognitive impairment. The MDS indicated the resident was totally dependent on two or more people for transfer. The MDS indicated the resident used a wheelchair and weighed 186 pounds. A review of R#12's Care Plan, revised on 2/27/23, indicated R#12 had an activity of daily living (ADL) self-care performance deficit related to dementia, generalized muscle weakness, and a stroke. The interventions directed staff to encourage the resident to participate to the fullest extent possible with each interaction. The care plan did not address the resident's need for assistance with transfers or the use of a mechanical lift for transfers. A review of a Lift Transfer Reposition assessment, dated 2/20/23, revealed R#12 was unable to transfer independently or with supervision without using a device, was able to bear 50% of their weight on one or both legs, was unable to perform a stand-pivot transfer with limited assistance, and a gait/transfer belt was not required. The assessment indicated the resident did not require a total lift but required two-staff assistance with repositioning in bed. The area of the assessment regarding care planning was not checked 'yes' or 'no' to indicate whether the care plan for repositioning/transferring was completed or updated. Observations on 5/3/23 from 10:13 a.m. to 10:27 a.m. revealed CNA RR and CNA TT performing a mechanical lift transfer of R#12. Both CNAs communicated to the resident that they were going to transfer the resident from the bed to the wheelchair. The resident acknowledged the CNAs and was already lying on a mechanical lift sling in their bed. The sling appeared very large underneath the resident. CNA RR positioned the lift for transfer of the resident, attached the sling loops to the corresponding hooks, and pulled on them, checking for secure placement. CNA RR confirmed the hooks were securely attached and asked if CNA TT was ready. CNA TT nodded and prepared to spot the resident's head and shoulders. CNA RR was operating the lift and spotting the resident's feet and buttocks during the transfer. CNA RR then communicated with the resident before she began to lift the resident from the bed. As the resident was being lifted from the bed, the resident's buttocks were observed to be hanging off the edge of the sling, unsupported. The resident asked twice for the CNAs to reposition them in the sling due to their leg hurting. CNA RR acknowledged the resident's discomfort and reassured the resident of their safety but continued to transfer the resident and lowered the resident into the seat of the wheelchair. After the resident was lowered into the wheelchair, CNA TT attempted to reposition the resident from behind by pulling on the sling, but verbalized the sling was not underneath the resident. R#12 began complaining of pain and, as CNA RR placed the resident's foot in the foot support, the resident complained of sliding from the seat cushion in their wheelchair and voiced a fear of falling. CNA TT and CNA RR continued their attempts to reposition the resident using the sling. CNA RR stopped the attempted repositioning and stated the wheelchair was too small for the resident and that the CNAs needed to put the resident back into bed. CNA RR quickly stripped the bed linens and left to retrieve clean ones. CNA TT stayed with the resident. R#12 was slumped down in the wheelchair with their chin tucked against their chest and continued to voice that they were sliding in the wheelchair and felt like they were choking and needed to be pulled up. CNA RR returned with clean sheets and quickly made the bed before assisting CNA TT. CNA TT stated CNA RR should go get a third staff member to assist them with the resident, due to how badly the resident was positioned in the wheelchair. The resident still complained they were slipping and afraid of falling. CNA RR continued to attempt the repositioning of the resident, and when CNA RR leaned the resident forward to attempt to get the sling back underneath the resident, R#12 slid from the wheelchair onto the floor, landing with their left leg folded underneath them. CNA RR went out into the hallway to retrieve a third staff member. CNA RR returned moments later with a male staff member. CNA RR, CNA TT, and the male staff member attempted to lift R#12 from the floor using the sling, which had become stuck on the wheelchair, inhibiting the manual lift. CNA SS entered the room and asked what had happened. CNA RR stated the sling had been improperly placed underneath the resident during transfer. CNA SS instructed the staff to lay the resident down flat to reposition them correctly on the sling for transfer from the floor to their bed and provided the resident with a pillow. The sling was positioned correctly underneath the resident, who was then safely transferred back into bed for a nursing assessment. During an observation with the Central Supply Manager on 5/4/23 at 12:49 p.m., the sling in R#12's room was observed to be an extra-large. The Central Supply Manager stated the extra-large sling was too big and not the correct size for R#12. She stated the large sling, color-coded yellow, was the most secure fit for R#12. She stated if the CNAs had questions about the sling size required for R#12, they should have come to ask her about the appropriate size. During a follow-up interview with the Central Supply Manager on 5/5/23 at 3:19 p.m., she stated she used the sling sizing guide and confirmed R#12 needed a size large for a weight range between 154-264 pounds. She stated the resident's weight had not fluctuated since admission, so the resident did not require evaluation for a different size sling. During an interview with CNA SS on 5/3/23 at 10:31 a.m., she stated she was an internal agency CNA who had been working at the facility for three months. She stated the sling should be positioned to cover the resident's bottom and be lined up with the resident's shoulders. She stated the resident's shoulders should also line up with the safety hooks of the lift. She stated the bottom straps should be underneath the resident's legs to support the resident and keep them from hanging in the lift. She stated the resident's bottom should not be hanging out, and the sling the resident required should cover the resident's entire backside, buttocks to shoulders, for support. CNA SS stated she had received mechanical lift training a couple of months ago and completed the in-service training and demonstration. She stated the Staff Development Coordinator (SDC) led the training and covered how to position the sling and operate the mechanical lift for a safe transfer. During an interview with CNA TT on 5/3/23 at 10:38 a.m., she stated she had been working at the facility for a little over a month. She stated as the spotting CNA for a transfer with a mechanical lift, she would make sure the resident's head was supported by the sling and not slumping back. She stated she completed the mechanical lift training and demonstration during orientation. She stated the sling should be positioned under the resident's buttocks and around the resident's shoulders, and she would watch the resident's head and limbs for safety during transfer. She stated if the resident was not securely in the sling, the resident could slide out during transfer. She stated the sling had been positioned underneath Resident #12 and crossed in between their legs, with their arms crossed over their chest during the lift. She stated she did not notice any issues with the sling placement until the resident was in the wheelchair, at which point it was too high up on the resident. She stated that due to the improper placement of the sling underneath the resident, the CNAs could not correctly reposition the resident to prevent the slide from the wheelchair. During an interview with CNA RR on 5/3/23 at 1:14 p.m., she stated she was an internal agency CNA who had worked frequently at the facility for the past two years. She stated the last mechanical lift training she received was about three weeks ago, and it covered how to get the residents ready for a lift and the procedure for a safe transfer using a mechanical lift. She stated she completed the in-service and accompanying demonstration. She stated the sling should be placed below the resident's buttocks and even with their shoulders so the lift could hold them. She stated she had positioned the resident on the sling appropriately on the bed before the lift, so it should have supported their buttocks throughout the lift. She stated she did not notice if the resident's buttocks were supported during the transfer and only noticed an issue when the resident was in the wheelchair. She stated when the resident was in the wheelchair, she noticed the sling had come up too high above the resident's shoulders, making it difficult to reposition the resident. She stated R#12 had requested to get out of bed to relieve the pain in their leg. She stated R#12 stayed in bed most of the time but had insisted on getting up this morning. She stated she informed the unit manager, who confirmed the resident could get out of bed. At the time of the survey, there were 27 CNAs employed by the facility, according to the facility's Removal Plan. A review of the facility's training information revealed a document titled, Employee Education/In-service dated 3/27/23, that indicated 32 employees attended a training that covered lifts and transfers, 15 of whom were CNAs. The lift training was provided and overseen by the SDC. Further review of the training documents revealed CNA RR completed a Total Mechanical Lift Competency Checklist on 3/28/23, and No was indicated next to five of the 17 steps including: demonstrates ability to lower resident after lift has failed, locate emergency stop button and its purpose, verbally prepares resident for transfer, gently raises resident minimally from surface, unweight resident from bed, performs a safety check,, and removes sling from under resident, only leaves sling on resident if Care Planned. Handwritten entries next to the five No responses indicated, education provided; however, there was no documentation of the specific re-education that was provided, nor was there a competency checklist that indicated CNA RR had successfully completed a return demonstration. Further review of the training information revealed CNA TT completed a Total Mechanical Lift Competency Checklist on 3/29/23, and No was indicated by one of the 17 steps, adjust bed to height that promotes good body mechanics. There was no evidence that CNA TT was retrained in the area that was checked No. During an interview with Licensed Practical Nurse (LPN) ZZZ on 5/3/23 at 2:18 p.m., she stated she had worked at the facility for two weeks. She stated she assessed R#12 after the incident and found no visible injury and had notified the medical director and family member. She stated the resident reported no pain following the incident. During an interview with LPN YYY on 5/3/23 at 3:34 p.m., she stated mechanical lift transfers were always done with two staff members. She stated the sling should be above the shoulders and below the buttocks, before being crisscrossed in between the resident's legs, and securely attached to the lift. She stated if the CNAs saw any safety concerns during a transfer, they were to stop transferring the resident and return them to bed, reposition the sling, and attempt the transfer again. She stated Resident #12 had no complaints of pain or injury after the incident that morning. She stated the CNAs reported to her the resident was sliding from the wheelchair during repositioning but did not mention anything to her about the sling position not being safe during the transfer. She stated the resident had no previous slides out of the wheelchair or falls. During an interview with the SDC on 5/4/22 at 12:24 p.m., she stated she had worked at the facility since 2/1/23. She stated she provided in-service training to all nursing staff regarding safe mechanical lift transfers and sling placement. She stated the training included how to operate the mechanical lifts, safe sling placement for a transfer, and a satisfactorily completed demonstration with the nursing staff before approving their competencies to perform a mechanical lift transfer on the Total Mechanical Lift Competency Checklist. She stated mechanical lift transfer training was completed upon hire, annually, and if the need was identified for one-to-one training. The SDC stated if the skills check off was done correctly during floor observations, it was outlined on the comprehensive check-off sheet. She stated if the CNA forgot a step during the demonstration, the CNA was immediately provided one-to-one education privately. She stated if retraining was needed, the CNAs would demonstrate a lift on the facility manikin to ensure safety during a mechanical lift transfer. She stated a CNA competency checklist that had four or five No indications did not meet the requirements for a satisfactory skills demonstration. She stated retraining would be provided until the CNA completed a demonstration with all Yes indications, demonstrating the comprehension needed for a safe mechanical lift transfer. The SDC stated CNA RR had completed the mechanical lift transfer training and completed the skills demonstration during a mechanical lift transfer of a resident. She stated she oversaw the training and skills demonstration with CNA RR. She stated she re-educated CNA RR after the five No indications were revealed on the comprehensive skills check-off sheet. She stated that aside from the documentation of education provided on the original skills check-off sheet, she had no further documentation of CNA RR's re-education or successful return demonstration of a safe mechanical lift transfer. The SDC stated during a transfer, if the resident's buttocks were unsupported by the sling, the CNAs should lay the resident back down and reposition the sling for a safe transfer. She stated sling safety and correct positioning should be checked after the resident had been slightly lifted from the surface upon which they had been resting, before continuing the transfer. She stated if the resident was hanging out of the sling, it was an unsafe transfer. She stated if the resident was complaining of pain, discomfort, or fear of falling, the CNAs should stop the transfer and re-evaluate the sling placement and transfer technique. During an interview with R#12 on 5/4/23 at 12:49 p.m., the resident stated they were fine, in no pain, and sustained no injury from the incident the previous day. During an interview with CNA II on 5/4/23 at 1:47 p.m., she stated she was an agency CNA who had worked at the facility off and on for two years. She stated the green slings did not indicate a size and she would just eyeball them, and if the sling was too big or too small, it should not be used for the resident. She stated she received training about how to operate, clean, and raise and lower residents in the mechanical lift. She stated the residents' buttocks should not be hanging out of the sling. She stated the resident's arms should be in the sling and the resident should be comfortable. She stated that before beginning the transfer, the resident should be slightly lifted from the bed to make sure the sling was placed correctly. She stated she had to search for the slings she needed for mechanical lifts, and if she could not find one, a transfer using the mechanical lift was not provided. During an interview with CNA MM on 5/4/23 at 1:47 p.m., she stated she had received training for mechanical lift transfers from the facility. She stated the sling size a resident required was determined by weight and was color coded on the sling. She stated the sizing chart for the sling was located on the lift and indicated the size correlation to color on the sling. She stated this chart was not always what was used when retrieving a sling for a resident. She stated that at times, she could not find a sling, and when this occurred, she would let the Assistant Director of Nursing (ADON) know. During an interview with CNA JJ on 5/4/23 at 1:51 p.m., she stated she had been a CNA at the facility for three years. She stated the sling size was determined by weight. She stated the facility did not have enough slings for everyone that required a mechanical lift. She stated CNAs had to check the slings for holes or tears and inspect the lift before providing a mechanical lift transfer to make sure everything was safe for use. She stated all mechanical lift transfers required two staff for assistance. She stated the SDC provided the mechanical lift training about two weeks ago and made sure everyone could do it. During an interview with CNA PP on 5/4/23 at 1:52 p.m., she stated she had never received mechanical lift training from the facility or been told how to find the sling size required for a resident. During an interview with CNA QQ on 5/4/23 at 2:01 p.m., she stated she had never received mechanical lift training from the facility. She stated she received mechanical lift training from the agency she worked for and knew how to do it from her [AGE] years of experience as a CNA. During an interview with the Assistant Director of Nursing (ADON) on 5/5/23 at 11:40 a.m., she explained the color sizing guide on the mechanical lift used for R#12's transfer. She stated the color chart on the lift indicated the size of sling the resident required for a safe transfer. She stated the color corresponded to size, but the weight guidelines were not included on the lift itself. She stated the CNAs could find the appropriate color by checking the sling size documented on the KARDEX Care Cards (a summary or overview of residents' care needs). On 5/5/23 at 11:45 a.m., the ADON retrieved the KARDEX Care Card for R#12, and it indicated R#12 utilized an extra-large sling and was transferred via mechanical lift with the assistance of two staff. A copy of R#12's KARDEX Care Card was requested from the facility but was not received. During an interview with the Administrator on 5/5/23 at 4:33 p.m., he stated he had been the Administrator of the facility since 2/1/12 and the CNA Kardex and the electronic health record (EHR) should communicate the transfer requirements of the residents to the nursing staff. He stated he did not believe the resident's mechanical lift transfer needs or the sling size needed for transfers should be included on the residents' care plans. The Administrator stated he expected nursing staff to provide safe mechanical lift transfers to residents per the procedures of the facility. The Administrator stated he expected the CNA competencies to be accompanied by a satisfactory demonstration skills check-off. He stated the SDC completed the CNA competency skills check-off, and if the CNAs could not demonstrate a safe mechanical transfer, retraining and another demonstration should be conducted with the CNA before the staff performed another mechanical lift transfer for a resident. The Administrator stated that as far as he knew, the facility had enough lift slings so that each resident had the appropriate size. The Administrator stated that after a resident sustained a fall, an investigation would be initiated, and the resident assessed for injury and safety. During an interview with the DON on 5/6/23 at 1:02 p.m., she stated she had worked for the facility since 2017, taking over as the DON in the spring of 2020. She stated she expected the CNAs to be trained and demonstrate competency with safe mechanical lift procedures and expected nursing staff to be aware of residents' transfer needs, know where mechanical lift and sling requirements were documented on the KARDEX and care plan, and know how to determine the size of sling required by each resident for a mechanical lift transfer. She stated all CNAs were provided mechanical lift training and completed a demonstration with the SDC during new hire orientation. She stated if any issues arose regarding mechanical lift transfers, the CNA would be pulled aside and provided one-to-one re-education. She stated mechanical lift transfers were also a part of the annual training provided to all nursing staff. She stated if a CNA had four or five No indications during the demonstration of a mechanical lift transfer, it would be deemed an unsafe transfer and re-education would be provided immediately with the facility manikin. She stated a follow-up should be completed a few days after re-education to make sure the staff person retained the information. The DON stated she expected the sling to be positioned safely underneath the resident, supporting their coccyx. She stated the sling placement and hooks should be checked for secure placement as a part of the visual safety inspection before the lift was initiated. She stated all mechanical lift transfers should be completed after the resident was slightly lifted from the surface. She stated if the CNAs had any doubts about safety or the resident voiced discomfort or fear during a mechanical lift transfer, the transfer should be stopped, the resident returned to the original surface, and the nurse consulted. She stated she expected the CNAs to watch the resident constantly during the lift procedure to ensure the sling was positioned safely. She stated she expected any concerns with the mechanical lifts or availability of sling sizes to be reported to management and if needed, the lift would be removed from service. She stated all equipment was inspected before use. She stated the resident's weight determined the sling size to use for a mechanical lift transfer. She stated the CNAs should compare the KARDEX to the documented weight and color of the sling (which indicated the size of the sling) to ensure the correct sling was used before a transfer. 2. A review of a facility policy titled, Fall Prevention Program, implemented October 2022, revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The policy also indicated, Monitor for changes in resident's condition, gait, ability to rise/sit, and balance. Additionally, the policy indicated, The risk assessment categorizes residents according to low, moderate, or high risk, and defined specific protocols for low/moderate risk and high risk. A review of R#69's Admission Record revealed the facility admitted R#69 on 10/31/22 with diagnoses that included unspecified abnormalities of gait and mobility, lack of coordination, repeated falls, unsteadiness on feet, laceration without foreign body, hypertension, and fracture of one rib on the left side sequela. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 3/22/23, revealed R#69 had a Brief Interview for Mental Status (BIMS) score of three, indicating the resident was severely cognitively impaired. The MDS also indicated R#69 did not experience falls since the prior assessment and required extensive assistance with bed mobility, transfers, and locomotion on the unit. A review of R#69's Fall Risk Assessment, dated 10/31/22, revealed the resident had a score of 12. The assessment revealed a score greater than 10 indicated the resident was considered at risk for falls. The Fall Risk Assessment did not indicate if R#69's score was considered low, moderate, or high risk. A review of R#69's Care Plan revealed a focus area initiated on 11/1/22 that indicated the resident had fall, gait, and balance problems, including a fall on 11/1/22. The resident was at risk for falls and had syncope. A planned intervention directed staff to follow the facility's fall protocol (initiated 11/2/22). The Care Plan did not specify whether staff should follow the fall protocols for low/moderate fall risk or high fall risk. A review of R#69's Order Summary Report, which included active orders as of 5/4/23, revealed no orders addressing fall prevention or fall protocols. A review of R#69's Progress Notes, dated 12/10/22 at 3:05 p.m., revealed R#69 was found sitting in their wheelchair unresponsive but breathing and had a pulse rate of 90 beats per minute. Within a minute of Licensed Practical Nurse (LPN) XXX continuously calling the resident's name and performing sternal rubs, the resident became alert but was trembling. LPN XXX contacted R#69's physician and obtained orders to send the resident to the hospital. While calling 911, LPN XXX heard a loud noise, and R#69 was found lying face down on the floor, with a visible laceration to the top right eyebrow. R#69 was lifted off the floor back into the wheelchair and sent to the hospital. A review of R#69's Change in Condition Follow Up, dated 12/10/22, revealed R#69 fell out of their wheelchair due to a syncopal (fainting) episode. R#69 suffered a laceration above their right eye. The plan was to send the resident to the emergency room (ER) for evaluation and treatment. A review of R#69's Full QA [Quality Assurance] Report, with an incident date of 12/10/22, revealed the date and time of the incident involving R#69 was 12/10/22 at 10:31 a.m. The resident was found unresponsive and slumped over in their wheelchair. The resident's physician was notified and gave orders to send the resident to the hospital. While calling 911, a loud sound was heard, and the resident was found face down in front of the nurse's station with a visible laceration to the top right eyebrow. According to the form, the Director of Nursing (DON) and the Administrator were both notified of the incident in person on 12/10/22 at 10:31 a.m. The Administrator electronically signed the form on 12/29/22 at 9:47 a.m. A review of R#69's hospital record, dated 12/10/22, revealed R#69 had a syncopal episode and an unwitnessed fall. R#69 had a laceration to the right side of the forehead above the eyebrow. Additionally, the After Visit Summary indicated X-rays and a computed tomography (CT) scan revealed a non-displaced rib fracture on the right side. A review of R#69's medical record revealed no evidence the resident's fall was evaluated for causative factors. In an interview on 5/3/23 at 11:31 a.m., R#69 stated they fell out of their wheelchair and bumped their head. During an interview on 5/4/23 at 11:14 a.m., the DON stated when a fall occurs, a licensed nurse should assess the resident for injury/pain and, if safe to do so, transfer the resident to a safe position. She stated staff would need to complete fall documentation and notifications to the physician and family. She indicated if it was not safe to transfer a resident then they should call emergency medical services (EMS). She stated that after a fall, the facility needed to find out the cause of the fall to mitigate the risk of future falls and injury. She indicated that after the cause was determined, the staff should implement interventions, communicate the interventions during their huddles, and the resident's care plan should be updated by the nurses to include the interventions as soon as possible. The DON indicated the facility reviewed falls Monday through Friday as an interdisciplinary team (IDT). She revealed the supervisors were expected to call her if a fall occurred and she would direct them to interview staff to find out the cause. She indicated that while interviews were conducted following R#69's fall, they may not have made it into the record. She stated her understanding was that R#69 had a syncopal episode, the nurse left them in the wheelchair, and the resident fell out. She stated LPN III, the weekend supervisor, interviewed LPN XXX, who was an agency nurse and no longer worked at the facility. She indicated she did not know if LPN XXX was provided education on ensuring the resident was safe before leaving the resident's side to notify the physician. During an interview on 5/4/23 at 1:37 p.m., LPN III said that after a fall, the nurse should assess the resident for injury and ensure the resident's safety before getting the resident up from the floor. If it was not safe to move the resident, the nurse should call 911, notify the physician and family, and document any injuries.[TRUNCATED]

45555 Based on observations, interviews, record review, document review, and facility policy review, the facility failed to develop a comprehensive care plan for two of 57 sampled residents (R#12 and R#120). A review of the care plan for R#12 revealed a care plan was not developed to address the resident's needs related to transferring and the use of a mechanical lift to include the sling size that was needed. During observations of a transfer of R#12 utilizing a mechanical lift on 5/3/24, the resident voiced discomfort and concern that the resident was going to fall during the transfer using the lift. Further observations revealed the resident was not properly placed in the sling and the resident was not properly supported by the sling during the transfer. As a result, the resident was placed in a wheelchair and could not be properly positioned in the wheelchair and the resident slid from the wheelchair onto the floor sustaining no injuries. Also, the facility failed to include care plan objectives and interventions for indwelling urinary catheter care for R#120. On 5/4/23, determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 5/4/23 at 6:10 p.m. The noncompliance related to the IJ was identified to have existed on 5/3/23. An Acceptable Removal Plan was received on 5/6/23. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 5/6/23. Findings included: A review of the facility's policy titled, Comprehensive Care Plans, revised 9/12/22, indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy also revealed, The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. A review of R#12's Admission Record revealed the resident's original admitted was 1/30/23 with a readmission on 2/20/23. R#12's diagnoses included metabolic encephalopathy, peripheral vascular disease, acquired absence of the right lower leg below the knee, hemiplegia and hemiparesis following a cerebrovascular accident affecting the left dominant side, and vascular dementia with behavioral disturbance. A review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/2/23 revealed R#12 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderately impaired cognition. The MDS further indicated R#12 required the extensive assistance of one person for activities of daily living including dressing, eating, and personal hygiene. The MDS indicated for transferring, the activity only occurred once or twice, and no setup or physical help was required from staff. A review of the five-day MDS with an ARD of 2/23/23 revealed R#12 was totally dependent on physical assistance from two-persons for transfers. The MDS further indicated the resident used a wheelchair. The use of a mechanical lift was not checked as used for R#12. A review of R#12's Care Plan, last reviewed on 2/6/23, indicated the resident had an activity of daily living (ADL) self-care deficit related to dementia, generalized muscle weakness, cardiovascular accident with left sided weakness, and a right below the knee amputation. The care plan interventions, initiated on 2/6/23, directed staff to encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use the call bell to call for assistance, and for physical therapy and occupational therapy to evaluate and treat the resident as ordered by the physician. The care plan did not include interventions that directed staff how to provide assistance to the resident for transfers or equipment that was needed for transfers. Observations on 5/3/23 from 10:13 a.m. to 10:27 a.m. revealed Certified Nursing Assistant (CNA) RR and CNA TT transferred R#12 from the bed to a wheelchair using a mechanical lift. The CNAs did not ensure the sling for the lift was appropriately placed to support the resident during the transfer and the resident's buttocks were unsupported during the transfer. Observations revealed the staff continued to transfer the resident despite the resident voicing concerns that they were falling and were having pain during the transfer while in the lift sling. After the resident was placed in the wheelchair, the resident could not be repositioned in the wheelchair because the sling was not positioned correctly and as a result the resident slid from the wheelchair onto the floor. The resident did not sustain any injuries as a result of the fall. During an interview with CNA UU on 5/4/23 at 11:13 a.m., she stated she had worked at the facility for two weeks. She stated she had been a CNA for [AGE] years, and her mechanical lift knowledge came from her experience. CNA UU stated the care plans should be at the nurse's station and available for CNAs to review. She stated the care plans told the nursing staff what to do regarding care requirements, behaviors, and diet orders. She stated a resident's transfer needs and requirements should be included in the care plan as well. She stated she was not sure of the size of sling R#12 needed for transfers using the mechanical lift, but would go ask the nurse before providing transfer assistance. During an interview with Licensed Practical Nurse (LPN) ZZZ on 5/4/23 at 10:23 a.m., she stated she had worked at the facility for two weeks. LPN ZZZ stated she would expect to see mechanical lift transfer needs on the care plan so nursing staff would know what to do for a resident. She stated she had access to the care plans, and it should include how many staff were required for a safe transfer, the type of lift needed for the transfer, fall interventions, diet orders, and any other risks to the resident. She stated she was working with R#12 that day and upon review of the care plan, could not find the resident's transfer needs to include if a mechanical lift was needed or the size sling the resident needed documented on the care plan. During an interview with the Director of Rehabilitation (DOR) on 5/4/23 at 10:43 a.m., she stated she had been the DOR for one year. She stated the mechanical lift transfer status of a resident was based on evaluation. She stated if the resident was totally dependent and maximum assistance for transfers was required, the therapy department recommended the mechanical lift transfers for resident safety. She stated the therapy department completed the mechanical lift evaluations and communicated their recommendations to the nursing staff. The DOR stated she did not update the resident care plans. She stated the care plans should include fall risk, behaviors, transfer needs, and other care needs. She stated any recommendations from the therapy department were discussed in the interdisciplinary team (IDT) meetings and forwarded to the nursing department. During an interview with MDS Coordinator EEE on 5/5/23 at 12:43 p.m., she stated she had been the MDS Coordinator for nine years at the facility. She stated she completed the comprehensive care plans and updated them during the resident's quarterly review. She stated the purpose of the resident's care plan was to help relay care needs to nursing staff. She stated the care plan should include fall risk and transfer assistance requirements under the ADL objectives. She stated mechanical lift transfer status and therapy recommendations were discussed in the IDT meetings. She stated if she was made aware of the resident's use of a mechanical lift for transfers, she would include it in the comprehensive care plan, but she did not include the specific transfer needs on the comprehensive care plan. MDS Coordinator EEE stated she did not know how to include bed mobility and transfer needs on the residents' care plans. She stated the resident's transfer information should be on the KARDEX Care Cards (a file used for overviews of residents' care in a facility) available to the CNAs at the nurse's station and that was where the CNAs should be referring for resident care needs. The MDS Coordinator stated Resident #12 had been discussed during IDT meetings related to behaviors and discharge planning but never about transfer requirements. During an interview with the Administrator on 5/5/23 at 4:33 p.m., he stated he had been the Administrator at the facility since 2/1/12. He stated the resident care plans should be updated by the department that monitored them. He stated nurses would update the nursing tasks, and activities would update the activity tasks. He stated the CNA Kardex and the electronic health record (EHR) should communicate the transfer status of the residents to the nursing staff. He stated he did not believe the resident's mechanical lift transfer needs or required sling size needed to be included on the resident's care plans. The Administrator stated the purpose of a care plan was to inform the staff of resident care needs, and acknowledged, in hindsight, that mechanical lift transfer requirements and sling size were a care need and should be included in the care plan so nursing staff had access to the information. During an interview with the Director of Nursing (DON) on 5/6/23 at 1:02 p.m., she stated she had worked for the facility since 2017, taking over as DON in the spring of 2020. She stated she expected nursing staff to be aware of resident transfer needs, where mechanical lift and sling requirements were documented on the KARDEX, and on the care plan. The DON stated the resident care plans were updated during IDT meetings and were initially compiled by MDS Coordinator EEE, noting all nurses could make updates to the care plan. She stated interventions should be added timely, especially for safety concerns. She stated the IDT met daily to review events and put things in place for the residents. 2. A review of an Admission Record indicated the facility admitted Resident #120 on 02/24/2023 with diagnoses that included hydronephrosis with renal and ureteral calculous obstruction (excess urine accumulation in the kidneys as a result of an obstruction to urine flow). An admission MDS, with an ARD date of 2/27/23, revealed Resident #120 had a BIMS score of 15, which indicated the resident was cognitively intact. The resident required extensive assistance with their ADLs, including toilet use and personal hygiene. The MDS indicated the resident had an indwelling catheter. A review of a Nursing Comprehensive Assessment, dated 2/25/23, indicated R#120 had an indwelling urinary catheter. A review of an Order Summary Report for active orders as of 5/5/23 indicated R#120 had an order, dated 4/6/23, for staff to perform catheter care every day and evening shift and as needed. Additional orders were added on 5/3/23 to specify the size of the catheter and indicate bedside straight drainage for a diagnosis of bilateral hydronephrosis, to change the catheter when occluded or leaking as needed, and to replace the drainage system if disconnection or leakage occurred every 30 days and as needed. A review of R#120's Care Plan revealed a focus area addressing the indwelling catheter, initiated on 5/3/23. This was during the survey and after the surveyor requested information regarding the resident's use of the catheter. Prior to this, R#120's Care Plan did not address the use of an indwelling catheter or interventions for the care of the catheter. During an interview on 5/4/23 at 10:58 a.m., Unit Manager (UM) LLL stated the use of a catheter should be care planned. She stated the Care Plan should include fall and skin risks and medications based on the assessment. She stated the Care Plan was updated by the interdisciplinary team (IDT) when needed, such as after falls and with medication changes, and the nurse should update the Care Plan with any changes. During an interview on 5/4/23 at 2:03 p.m., Registered Nurse (RN) NNN stated the use of a catheter should be care planned. During an interview on 5/4/23 at 2:20 p.m., Licensed Practical Nurse (LPN) OOO stated the use of a catheter should be care planned. During an interview on 5/5/23 at 4:32 p.m., the Administrator stated he thought the use of a catheter should be care planned. He stated the Care Plan should include items from the nursing assessment including medication reviews. He stated updating the comprehensive Care Plan was done by the nursing department, if nursing related, or according to the proper discipline. During an interview on 5/6/23 at 12:24 p.m., the DON acknowledged R#120's Care Plan did not address the resident's use and care of the indwelling urinary catheter. The DON stated the use of a catheter should be care planned, and R#120 now had a Care Plan in place for the use of their catheter. The DON stated the Baseline Care Plan should include everything the staff needed to know to care for a resident. Per the DON, any items on the Baseline Care Plan should be included on the comprehensive Care Plan unless there was an area that needed to be changed because it was determined to not be appropriate. She stated the Care Plan was initiated by the MDS staff and any nurse or IDT member could update the Care Plan. The facility implemented the following actions to remove the IJ: 1. Ad hoc meeting held on 5/4/23 at 7:00 pm with Medical Director, center Nurse Practitioner, Administrator, Director of Nursing, Assistant Director of Nursing, center Educator (SDC), Director of Operations for Georgia, Regional Director of Clinical Operations, and other center management team members to address concerns identified during the survey process related to accidents and incidents, staff competency, and comprehensive care plans to review the findings for IJs and plan for removal of IJs issues. 2. A care plan was developed for RI R#12 and the resident was further assessed by the NP on 5/3/23 in which no injuries or adverse effects were identified. The resident was assessed for pain by a licensed nurse and the resident did not complain of pain above [the resident's] usual pain level. In addition, [R#12] stated [R#12] was not hurt. 3. On 5/4/23 the Center Administrator, Director of Operations, Director of Nursing, and Regional Director of Clinical Operations reviewed the center policy on Comprehensive Care Plan. No process changes or recommendations were made because of this review. 4. On 5/4/23, to identify other residents that may be affected by this practice, 100% of residents of the total census (census 136-136 residents out of 136) received a current transfer assessment which included the 37 residents who required the use of a mechanical lift were reassessed by a licensed nurse to ensure the appropriate transfer techniques and appropriate sling sizing would be used to successfully transfer residents. The licensed nurse did not note any injuries or harm to any resident. 5. On 5/4/23, the Staff Development Coordinator began to re-educate licensed nurses and CNAs on the importance of ensuring that the type of transfer techniques needed for the resident to safely transfer to the use of a mechanical lift and the number of staff needed to safely transfer a resident, documenting the sling size on the Kardex to ensure communication are care planned. Currently there are 27 certified nursing assistants, 22 Licensed Practical Nurses, and 10 Registered Nurses of which currently 100% of current RNs, 100% of current LPNs, and 88% of current CNAs have been re-educated. Four LPNs and Four RNs were educated over the phone and will complete education in person at next scheduled shift. 6. Those clinical staff members who did not attend the re-education on the importance of the development and on following the comprehensive care plan received the re-education via telephone conference. Currently, there are no staff members on FLMA [sic; FMLA; Family and Medical Leave Act] or LOA [leave of absence]. Any clinical staff members who were not re-educated due to Vacation, PRN [pro ne nata; as needed] Status, etc., will be re-educated prior to resuming their duties on their designated shift by the Unit Nurse Manager, Shift Supervisor or Charge Nurse. Newly hired clinical staff such as Agency or PRNs will be re-educated during orientation or prior to assuming the responsibilities of their designated shift by the Staff Development Coordinator (SDC) or Nurse Manager. 7. On 5/4/23 the Registered Nurse MDS Coordinator conducted a 100% review of care plans for residents' transfer needs to ensure those requiring the use of a mechanical lift care plans were updated to reflect their need for a mechanical lift for transfers and to ensure the number of staff needed to ensure a safe transfer. Revision of care plans was completed on 5/4/23. 8. The Regional Director of Clinical Services re-educated the center Staff Development Coordinator, DON, ADON, and MDS team on Person-Centered Care Plan to include development, implementation, and revision of care plans related to mechanical lift use and risk reduction related to accidents and injuries on 5/4/23. 9. ADL care plans will be reviewed by the MDS Coordinator(s) (licensed nurses) to ensure mechanical lift use, the number of staff members needed to safely transfer a resident, and appropriate sling size is documented on the Kardex to ensure a safe transfer related to residents requiring the use of a mechanical lift are reflective on the resident plan of care weekly for four weeks; then monthly for two months. 10. The Director of Nursing, or Assistant Director of Nursing, will complete random audits of 20% of mechanical transfers care plans weekly for four consecutive weeks: then monthly for two months. The Regional Director of Clinical Services will conduct random care plan audits to ensure that comprehensive care plans are developed and updated for residents requiring the use of a mechanical lift for a safe transfer monthly for the next two months. 11. On 5/4/23, 37 of 37 residents' Kardex (which is an extension of the care plan) were reviewed and revised to specifically include the appropriate sling size for each resident requiring the use of a mechanical lift. Any Kardex found to be without documentation of the appropriate sling size was updated and communicated with the Center's CNAs, licensed nurses, and physical therapy department. 12. The administrator [Administrator] reviewed the results of the audits and shared the findings with the Ad Hoc Quality Assurance Performance Improvement Committee on 5/5/23. The administrator will share the findings of audits related to care plans and mechanical lifts with the QAPI Committee weekly for four weeks then monthly for two months to ensure compliance is achieved and sustained with care planning mechanical lifts, sling size, and number of people needed to support a safe transfer. The administrator will sign and communicate the results of the audit review with the Medical Director and the members of the QAPI committee. Subsequent plans of corrections will be implemented as necessary. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Action verified on 5/6/23 through review of the Ad Hoc QAPI minutes dated 5/4/23 and 5/6/23 and interview with the DON, SDC, and Medical Director on 5/6/23 and interview with the Administrator on 5/7/23 as the Administrator was not available for interview on 5/6/23. 2. Action verified 5/6/223 through review of the record for R#12 and review of the care plan. 3. Action verified through interviews with the Administrator on 5/7/23 who was unavailable on 5/6/23. 4. Action verified through interview with the DON, and Administrator (on 5/7/23) and review of the 37 residents' charts requiring mechanical lifts on 5/6/23. 5. Action verification completed on5/6/223. Interviews with 12 CNAs, five LPNs, one RN, and the Director of Rehabilitation present in the facility on 5/6/23 revealed the re-education of updating care plan interventions had been provided by the SDC and DON. Telephone interviews with 19 CNAs, 10 LPNs, and four RNs across day, evening, and night shifts revealed the re-education revealed the re-education of updating care plan interventions had been provided by the SDC and DON. 6. Action verified through interview with the DON and SDC on 5/6/23. 7. Action verified through interviews with the DON and review of the records of the 37 residents who required a transfer with a mechanical lift and review of the Kardex Care Cards on 5/6/23. 8. Action verified through training record document review and interviews with the SDC, ADON, and DON on 5/6/23. 9. Action verified through review of care plans and interview with the MDS Coordinator, SDC, and DON on 5/6/23. 10. Action verified via interview with DON on 5/6/23. 11. Action verified on 5/6/23 through review of the Kardex for the residents on each unit. 12. Action verified through interview with the DON on 5/6/23 and the Administrator on 5/7/23.

Based on observation, interview and record review, the facility failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two residents (R28 and R29) residents that had tracheotomies (trachs) and required multiple medical apparatus including ventilator (machine to aid and/or deliver respirations). Review of the CMS Form 672, signed and dated by the Director of Nursing on 11/1/16, revealed no evidence of trachs, and 5 receiving respiratory treatments. The sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/12/16 at 3:36 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) situation. The facility's failure to ensure all necessary respiratory related medical equipment for two residents (R28 and R29) with tracheotomies were readily available; and that a safe and appropriate power source was available for their medical equipment, placed residents at risk of serious harm or death effective on 6/25/16 Those failures left residents vulnerable to respiratory distress, and/or death. This failure increased the likelihood for serious harm to two (2) of 2 residents (R28 and R29) with tracheotomies, who: Required back-up replacement inner cannulas in the event their cannulas became dislodged and required emergency replacement. The facility did not ensure the necessary equipment for potential respiratory distress (Ambu bags -manual resuscitators- for both residents, and correctly sized replacement inner cannulas for their tracheotomies) was available, and; Required more electrical outlets to ensure effective delivery of care via medical apparatus than was available. The facility used power strips to provide the extra power that did not meet safety standards. It was not acceptable to obtain power for medical equipment other than directly from the wall. R28 and R29 required multiple medical apparatus (requiring a safe and reliable power source). Since some of their required equipment (oxygen, suction and nebulizers) were directly related to their compromised breathing status, that failure also rose to the level of immediate jeopardy (IJ). The residents were roommates and both required more electrical outlets (seven for R28 and six for R29) than the room provided (4 were available per resident). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F328 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Review of the CMS Form 671 signed and dated on 11/1/16 by the DON revealed there are no residents with trachs, and four (4) residents receiving respiratory treatments. Findings include: 1. On 8/12/16, at approximately 12:30 p.m., a family member (F1) of R28, came to the survey team and expressed his concern over the facility being able to provide the needed care for his family member. R28 was admitted to the facility on [DATE] from an acute hospital, out of state, without an onsite assessment. He had [DIAGNOSES REDACTED]. According to his admission Minimum Data Set (MDS) assessment, completed 7/6/16, his [DIAGNOSES REDACTED]. R28 was totally dependent on staff for all Activities of Daily Living (ADLs). Review of the care plan for R28 revealed the presence of the [MEDICAL CONDITION], but it did not list the type or size of the inner cannula. There was evidence to include having a back-up inner cannula or Ambu bag available for respiratory emergencies, or what to do if the inner cannula became dislodged. There was no evidence of a pressure relieving air mattress, although it was ordered by the physician. On 8/12/16, at approximately 12:30 p.m., F1 of R28 stated that he wanted to find out who he needed to call to address some concerns he had regarding care of R28. He stated the facility staff had, almost killed R28 three (3) times, if I had not been here then R28 would not still be here. He stated he was going to talk to the doctor and requested the complaint line number. On 8/12/16, at approximately 12:45 p.m., F1 stated that awhile back, maybe around mid-July, he entered the room of R28 to find him in bed. He appeared to be choking. When F1 asked R28 if he was choking, F1 stated R28 nodded yes. F1 ran to get the nursing staff for assistance. He stated they were not able to clear the airway with suctioning and the staff had called 911. F1 stated that someone from the facility had also called the respiratory therapist (RT) who stated she was close by and would come to the building. F1 also stated the RT was able to clear a mucus plug (an accumulation of mucus in the airway that occurs because a patient can't cough to clear their own airway) and his father was not transported to the emergency room per his request as he was no longer at risk. F1 described a second occasion where he had entered the room if R28 to find the water bottle (humidifier) on the tubing empty and he found a hole in the humidifier bag that hangs in between the tubing, he observed R28 was having difficulty breathing. F1 called the nurses and the West unit manager (UM) and another nurse did not know how to use the Ambu bag (a manual resuscitator, used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) to assist his father with breathing. The son stated he had to show the nurses how to use it. F1 stated those were just two (2) examples of how the staff were not taking care of R28. The son went on to state the facility did not have enough electrical sockets to plug in all of the equipment need for R28. He stated he had asked every day for two (2) weeks to get a power strip as staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in. He stated the air mattress was needed for R28 as he had two severe pressure ulcers. F1 stated he finally complained to the NHA and requested the power strip. F1 explained the NHA had stated he was unaware that this was an issue and he would find a power strip as soon as possible. The son reported it took a few more days after speaking to the NHA to get the power strip. Observation on 8/12/16, at approximately 12:45 p.m., when returning to observe R28 and do a cursory review of the room to ensure all necessary equipment for a patient with a [MEDICAL CONDITION] was available, he was observed lying slightly turned to his left side facing the window. He was lying on what appeared to be an air mattress with the head of the bed elevated at approximately a 30-degree angle. R28 had a [MEDICAL CONDITION] and received oxygen via a Tran'[MEDICAL CONDITION] set up which was on the right side of the bed when standing at the end of the bed facing R28. There was a humidifier bottle attached at the top of the tubing which was about one-quarter full. Further down the tubing, there was an air pouch which appeared to be a plastic bag humidifier attached that contained moisture. The two residents shared a room and both had tracheotomies. They were required to have replacement inner cannulas for the residents, in the event their [MEDICAL CONDITION] cannulas became dislodged and needed to be replaced to ensure adequate breathing. A facility Licensed Practical Nurse (LPN117) was providing wound care for R28, with the assistance of a Certified Nursing Assistant. When asked where the extra cannulas were stored, LPN117 indicated the top of a dresser, located on side of the room nearest R28. There were various supplies (dressings, tubing, etc.) jumbled together in a disorderly fashion. What was found by the surveyors were inner cannulas size 8 and size 6. R28 required a size 8 and R29 required a size 4. The room was crowded with equipment and supplies and a power strip was observed taped to the floor with multiple cords plugged into it. The suction machine was on the left side of the bed and back, there was other equipment in front of the suction machine. On 8/12/16, at approximately 1:00 p.m., the DON was interviewed and informed they did not have the proper sized inner cannulas in the room. She immediately went to the room with the same staff nurse (LPN117) observed during wound care, and returned with a size 4 cannula that she said was found in a drawer. That observation was not confirmed and the equipment needed to be readily accessible (as in taped above the bed of each [MEDICAL CONDITION] patient) was not available when surveyors observed the room. Nor was LPN117 able to verbalize where that cannula was when asked by the surveyor during the initial observation of the wound care for R28. The DON confirmed the following pieces of equipment were needed for R28: Oxygen concentrator to deliver oxygen [MEDICAL CONDITION]; A suction machine/aspirator (used to clear the airway of blood, saliva, mucus, vomit or other secretions); A pressure relieving air mattress (used to prevent pressure ulcers by dispersing pressure away from the affected areas and bony prominences); A nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs, or in the case of R28, used to deliver medication via his [MEDICAL CONDITION]); An intravenous (IV) administration set up (to infuse liquid substances directly in to a vein, for R28 it was used to administer antibiotics) - though not in use during the survey; A Negative-pressure wound therapy (NPWT) machine (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second and third degree burns); and An electric hospital bed (which allowed for raising and lowering of the bed itself, as well as the ability to raise and lower both the head and foot of the bed). On 8/12/16 at 1:45 p.m., staff physician 165 (primary care physician for R28) stated R28 was a very sick man when he was admitted due to having a Stage 4 and a Stage 2 pressure ulcer, as well as history of acute [MEDICAL CONDITION] and that he was a quadriplegic. Physician 165 stated he had suggested, on more than one occasion, that the son move R28 to a more prominent facility that was staffed with more skilled staff to [MEDICAL CONDITION] wound care, but the son refused to move his father. Physician 165 stated he also wanted the resident transferred to a higher acuity level of care as the wounds were not improving as much as he had wanted them to. He stated he was not consulted regarding whether or not to accept R28 into the facility. Physician 165 stated that he had many discussions with the son and had advised the family R28 would benefit from a facility that provides a higher level of care such as a hospital or long-term acute care (LTAC). He also stated that on 8/6/16 he had requested the resident go to the hospital to be evaluated by an infection disease doctor as he suspected R28 had a colonized infection in his trach. He explained the son requested they wait until the following Monday as he wanted to consult some others and decide if he wanted his father sent to the hospital. Physician 165 stated he did not receive a call back from the son, so he ordered a consult from an infectious disease physician to take place at the nursing home. He stated R28 was stable but he continued to believe the resident would benefit from a higher level of care, but family would not allow, so his best course of action was to request the consult 2. R29 was most recently admitted to the facility on [DATE] (he had resided there previously) with [DIAGNOSES REDACTED]. R29 was a readmit from an acute hospital stay. According to a progress note dated 5/23/16, and as documented on the care plan, R29 pulled his [MEDICAL CONDITION] out and was sent to hospital, where they replaced it and sent him back to the facility. Documentation showed the resident was not in respiratory distress and yet the facility still did not attempt to [MEDICAL CONDITION]. R29 was care planned for history of self extubation (removing his own trachea tubing and cannula) as a behavior, the facility did not have the appropriate size inner cannula ready at his bedside. As evidenced by documentation of having to be hospitalized for [REDACTED]. His Admission Minimum Data Set (MDS), competed on 5/20/16, showed R29 was extensively to totally dependent on staff for all ADLs. He was also fed via a gastrostomy feeding tube. Observation on 8/12/16, at approximately 12:45 p.m., R29 (roommate of R28) also had a [MEDICAL CONDITION]. Their supplies were co-mingled together on a dresser on the side of the room of R28. There was only one (1) Ambu bag present, and there should have been one (1) for each resident. They also needed to have back up inner cannulas readily accessible in the event [MEDICAL CONDITION] dislodged and needed to be replaced to ensure breathing. There were two (2) different sizes in the room - a size 8 and a size 6. R28 required a size 8 and R29 required a size 4. LPN117 (who was the facility wound care nurse) was asked where the needed cannulas might be, and stated they should be in the pile of supplies. She could not state the required size for each resident, so in the event of an emergency the correct sized inner cannula would not be used. Interview on 8/12/16, at approximately 3:36 p.m., the NHA stated that they did not have enough outlets for either resident (R28 or R29) to accommodate their medically necessary, physician ordered, equipment. He stated that when R28 (on 6/26/16) was admitted they realized they did not have enough outlets and directed the Maintenance Director to take and install a power strip in the room. The NHA stated that both R28 and R29 had more medical equipment than they had outlets for and the decision was made to unplug the air mattress for R28. He stated the air mattress was uninflated for a couple of days. (cross refer to F314). Therefore, R28 was admitted on [DATE], indicating a total of over thirteen (13) weeks, the facility had known that the R28 and R29 did not have enough electrical power outlets to support the ventilator equipment, other needed equipment including pressure prevention mattress for residents with pressure sores, and suctioning equipment. The NHA stated he had checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He indicated he was not aware that a power strip could not be used in lieu of proper connectivity to the facility power source (the wall outlets). On 8/12/16, at approximately 1:00 p.m., the Director of Nursing (DON) was interviewed and confirmed the following pieces of equipment were needed for R29: Oxygen concentrator to deliver oxygen [MEDICAL CONDITION]; A suction machine/aspirator (used to clear the airway of blood, saliva, mucus, vomit or other secretions); A nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs; An electric hospital bed (which allowed for raising and lowering of the bed itself, as well as the ability to raise and lower both the head and foot of the bed), and: A feeding tube administration set up (to infuse liquid nourishment directly into his stomach via a gastrostomy tube). The DON had just started work at the facility approximately one week prior to the survey start date and had no direct observation of the specifics of the allegations made by F1 for R28, but was aware of the issues via record review and her nursing staff. She also stated she had heard there was a problem with having enough outlets for all needed medical equipment and they had power strips in place to meet their needs. She stated she was not aware that a power strip was contraindicated for use with medical equipment. On 8/13/16, at approximately 10:30 a.m., the Maintenance Director was interviewed with the NHA. He confirmed he had been directed to install a power strip in the room of R28. He stated when he went to deliver the power strip, the staff were providing cares to R28, so he left the power strip at the West Wing Nurses station and the nursing staff was supposed to hook up the power strip. A few days went by before it was discovered the power strip had not been installed. The NHA also stated a few days went by before he was made aware of the fact the power strip had still not been installed. As soon as he was aware, he took immediate action to have it put in place. ***The facility implemented the following actions to remove the Immediate Jeopardy: II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by August 13, 2016. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. ***The State survey agency validated the corrective action taken by the facility as follows: Review of physician orders [REDACTED]. Observation on 8/18/16 at 9:00 a.m. verified that both R28 and R29 were not in the facility. Interview on 8/18/16 at 9:05 a.m. with Admissions Coordinator verified that the facility had not admitted any future residents with higher acuity of tracheotomies until additional specialized training is completed for licensed nurses. Observation on 08/18/16 at 9:10 a.m. with DON, revealed that the Admission Grid was updated to include rooms that could be used to admit any future high risk respiratory tracheotomies (trach) residents to facility. The DON confirmed that the facility will not admit residents [MEDICAL CONDITION] trained Respiratory Therapist being on staff and all licensed nurses have completed specialized training. Review of a skills check list related to the treatment of [REDACTED]. Interview on 8/18/16 at 9:15 a.m. with DON and Admission Coordinator provided education to all licensed staff to ensure all high acuity residents with tracheotomies will not be admitted to the facility without trained Respiratory Therapist being on staff and all licensed nurses completed specialized training. Review of employee training education signature sheets verified the facility implemented new protocol on [MEDICAL CONDITION] for [MEDICAL CONDITION]. Interview on 8/18/16 at 9:25 a.m. the Nursing Home Administrator (NHA) confirmed he is actively recruiting respiratory therapist. Review of the Northeast Atlanta Health and Rehabilitation Center Electrical Safety/Non-Use of Power Strips for Medical Equipment log training log verified that two (2) of two maintenance staff received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16. In addition, it was verified that ninety-six (96) of a total of one-hundred ninety-one (191) facility employees received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16 and 8/13/16. Interview on 8/19/16 at 11:04 a.m. with the facility NHA confirmed a 100% room audit was completed for appropriate electrical outlets and all power strips were removed from resident rooms on/or before 8/13/16. Observation on 8/19/16 beginning at 11:04 a.m. with the facility NHA and Maintenance Director confirmed there were no power strips in any resident rooms on the East, West and Terrace Units of the facility therefore validating there were no rooms with power strips; the Admission Board, in the Admissions Office to have blue dots identifying a total of eight (8) rooms with red emergency electrical boxes capable of safely providing power to suctioning and similar equipment related to tracheotomy care. Review of the Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting signature sheet revealed all disciplines signatures were present. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director acknowledged becoming aware of the ventilator issues during the survey. He continued to state it is never ok to use a power strip for medical equipment, and the residents were immediately they were transferred. The facility presently will not admit any residents with trachs until sufficient training and the availability of a Respiratory Therapist for consultation. The Medical Director revealed that the QA Committee discussed Respiratory during the meetings held on 8/24/16, 9/21/16 and 10/12/16. Interview on 11/8/16 at 2:20 p.m. With the NHA and the DON revealed that they were not aware of the problems with the ventilator residents until the survey in August 2016. Per DON she immediately located the correct cannula; re-organized the room and sorted their supplies and reported to the family and the physician.

Based on observation, interview, and record review, the facility was not administered in an effective manner, utilizing all its resources, [MEDICAL CONDITION] care, insulin and blood sugar monitoring, pressure sore management, completion of medical record, supervision to prevent accidents, privacy/dignity, indwelling urinary catheter management, contracture management, medication administration timely, development/revision and implementation of care planning, for twenty-four (24) residents (R4, R5, R6, R9, R10, R14, R15, R18, R19, R22, R10, R18, R19, R20, R22, R23, R24, R25, R27, R28, R29, R32, R183 and R231), and dietary management to prevent food borne pathogens. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on 6/9/16 (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of pressure ulcers to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. Findings include: 1. The NHA failed to ensure that a family was notified of an allegation of abuse (R6), development of pressure sores, and blood sugar monitoring results below seventy (70) for five (5) residents (R6, R22, R10, R19, R24). Cross refer to F157 for details Review of the facility's Diabetic Management Policy most recently revised in June 2008 Notify the physician of abnormal blood glucose test results and symptoms exhibited; Notify the physician of abnormal blood glucose test results, symptoms exhibited and interventions implemented. Cross refer to F157 Review of a facility policy, dated 7/16/16, received, from the Corporate Nurse as current, indicated; Each Resident has the right to be free from mistreatment, neglect, abuse. Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. 2. The NHA failed to ensure that one resident (R6) on 6/9/16 from verbal, emotional and physical abuse by staff. The facility was aware of the alleged abuse on 6/9/16, the perpetrator continued to work. Interview on 11/8/16 at 2:20 p.m. with the NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Cross refer to F223 for details The NHA failed to report to the State Survey Agency (SSA) a substantiated allegation of verbal and physical abuse, which occurred on 6/9/16. The facility incident report was not sent to the SSA until 6/17/16, which was eight (8) days after the incident. The final investigation report was not sent to the SSA until 6/22/16, which was thirteen (13) days after the incident. Cross refer to F225 for details The NHA failed to report, failed to protect residents from the increased likelihood of abusive behavior by a Certified Nursing Assistant (CNA) who verbally, emotionally and physically abused (R6), failed to investigate the allegation of the abuse timely, failed to adhere to the facility's policy related to abuse and failed to report to the SSA as required. Review of a facility policy, dated 7/16/16, received, from the Corporate Nurse as current, indicated; Each Resident has the right to be free from mistreatment, neglect, abuse. Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the NHA and/or Director of Nursing. Interview on 11/8/16 at 2:20 p.m. with the NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Cross refer to F226 for details In addition, this is a repeat deficiency which was cited on 1/21/16, related to abuse, once the NHA was made aware of the alleged neglect/abuse the perpetrators continued to work at the facility. Additionally, once becoming aware of the allegations, the administrator failed to notify the SSA, there was no documented evidence the NHA suspended the alleged perpetrators, investigated the incident and reported the incident to the appropriate SSA. It is noted that the NHA was not present at the time of the incident, however the NHA was the NHA at the facility when the allegation was made, and is responsible for the lack of action and compliance with the Federal Guidelines. 3. The NHA failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two residents (R28, R29) that had tracheostomies and required multiple medical apparatus. Interview on 8/12/16, at approximately 12:45 p.m., with the son went on to state the facility did not have enough electrical sockets to plug in all of the equipment need for R28. The son explained the NHA had stated he was unaware that this was an issue and he would find a power strip as soon as possible. The son reported it took a few more days after speaking to the NHA to get the power strip. Cross refer to F281, F328, and F 517 for details The NHA failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for six residents (R18, R20, R22, R23, R25 and R28). The NHA was interviewed on 8/12/16 at approximately 3:36 p.m. and said there were not enough outlets for R28 or his roommate (R29), the NHA said both R28 and his roommate (R29) had more medical equipment than they had outlets in the room, so the decision was made to unplug R28's air mattress. He stated the air mattress for R28 was uninflated for a couple of days. The DON and NHA were interviewed on 8/11/16 at 12:55 p.m. The DON said she started on 7/25/16 and she identified immediately the holes in TARs. Interview on 8/11/16 at 3:17 p.m., the NHA did not have an answer for why he did not have a plan in place prior other than, he was trying to determine the root cause. He stated, he feels that the holes in the MAR and BS issues were first noticed in July 2016 but, he did not have the minutes in front of him. The failed to ensure residents without pressure ulcers did not develop pressure ulcers, failed to ensure residents with pressure ulcers did not worsen, and failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for six residents (R18, R20, R22, R23, R25 and R28); failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two (R28, R29) residents that had tracheostomies and required multiple medical apparatus. Cross refer to F 282, F314 for details 4. The NHA failed to ensure that residents who receive insulin and blood glucose monitoring were completed according to facility policy for eleven residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27). Interview on 8/11/16 at 3:17 p.m., the NHA did not have an answer for why he did not have a plan in place prior other than, he was trying to determine the root cause. He stated, he feels that the holes in the MAR and BS issues were first noticed in July 2016 but, he did not have the minutes in front of him. Cross refer to F281, F309, and F514 5. The NHA failed to ensure that privacy was provided for R30 and R10 during activities of daily living (ADL's) during personal care, and failed to respect the privacy for R4 with an uncovered indwelling catheter bag being exposed while up in the common areas. Cross refer to F164 6. The NHA failed to ensure that a Care Plan (CP) was initiated and/or revise related to use of a right arm sling for R183 and failed to ensure that a CP was developed and/or revise Care Plan related to behaviors for R39. Cross refer to F279 and F318 7. The NHA failed to ensure there was a physician's orders [REDACTED]. 8. The NHA failed to ensure adequate supervision to prevent accidents/falls, and failed to ensure the Fall Management policy was implemented including investigation of falls for R15 suffered actual harm when she fell again contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise. 9. The NHA failed to ensure cold foods were stored, served at appropriate temperatures and failed to ensure food holding temperatures were measured and recorded per the facility policy, therefore a total of one-hundred-three (103) residents are at risk to food borne pathogens. 10. The NHA failed to ensure the Quality Assurance Committee developed and implemented plans of action to correct identified quality deficiencies. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by August 13, 2016. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. III. A facility wide skin sweep was conducted for residents at risk for pressure sores (PS) on 8/12/16, 8/13/16 and 8/14/16. Current dressings were observed for placement and appropriate dates by facility staff on 8/13/16. Unit managers will observe a minimum of five (5) dressings per week for appropriate placement and dates. Audits of current PS were completed 8/16/16 to assure treatments are in place for each wound and are written appropriately. PS will be reviewed by the interdisciplinary team weekly at the scheduled AT RISK meetings. The facility Medical Director will be notified for any needed changes. An audit was conducted by the District Director of Clinical Services on 8/13/16 for wounds assessed by the wound physician to determine if there was any deterioration of existing wounds since his visit on 8/5/16. The District Director of Clinical Services (DDCS) and/or designee will attend at least one at Risk meeting per month to determine if further audits are needed. The following education began on 8/12/16 and will be completed by 9/2/16 for the licensed nurses by the DON/Nursing Administration including: Assessment, measurements, staging and documentation of wounds upon admission; Obtaining/entering treatment orders into the computer upon admission/identification of new pressure areas, and; Documentation of treatments provided. Licensed staff not scheduled to work on 8/12/16, will receive education prior to the start of their next shift. Training and education regarding the Skin System has been integrated into the orientation process of new licensed nursing staff and agency nurses. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting was held 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee meeting for review and further recommendations. ***The State survey agency validated the corrective action taken by the facility as follows: I. Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ, observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report II. Review of physician orders [REDACTED]. Observation on 8/18/16 at 9:00 a.m. verified that both R28 and R29 were not in the facility. Interview on 8/18/16 at 9:05 a.m. with Admissions Coordinator verified that the facility had not admitted any future residents with higher acuity of tracheotomies until additional specialized training is completed for licensed nurses. Observation on 08/18/16 at 9:10 a.m. with DON, revealed that the Admission Grid was updated to include rooms that could be used to admit any future high risk respiratory tracheotomies (trach) residents to facility. The DON confirmed that the facility will not admit residents [MEDICAL CONDITION] trained Respiratory Therapist being on staff and all licensed nurses have completed specialized training. Review of a skills check list related to the treatment of [REDACTED]. III. Review of the PS education re-training in-service sign in sheet revealed any employee that has not received the education will not work until the education is completed with competence exam check off signatures. Interview on 8/16/16 at 10:14 a.m. with the DON, NHA verified the facility implemented the updated policy on dressing changing and proper dressing placement for all licensed nursing staff members. Interview on 8/18/16 at 10:00 a.m. the NHA verified the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting. Review of the signature sheet revealed all disciplines signatures were present on 8/12/16, and that the Medical Director was in attendance. The NHA stated that if a serious situation occurred he notified the Medical Director. Interview on 8/19/2016 at 11:04 a.m. with the Administrator revealed there has not been another QAPI committee meetings since the meeting on 8/12/16 to evaluate reports, audits and monitoring tools, and this will be reviewed in the next monthly QAPI meeting. Review of the sign in sheets revealed that thirty nine (39) out of sixty-five (65) Licensed Nurses (LNs) received education on Wound Care Prevention and Treatment on 08/12/16, including that all current and newly admitted residents would be provided wound care treatments as ordered by Physician and weekly skin documentation will be completed, including; Assessment, measurements, staging and documentation of wounds upon admission; Obtaining/entering treatment orders into the computer upon admission/identification of new pressure areas, and; Documentation of treatments provided. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed he was made aware during survey in August 2016 of the concerns related to the PS. The PS were discussed in the QA meeting and a plan was made to do a skin sweep. The Medical Director stated he was satisfied with the skin sweep, and they changed their wound care physician. The Medical Director stated that everyone should be notified immediately as soon as a PS is found, including the family. The Medical Director stated that he is receiving the PS report every week and was seeing great improvement overall. He revealed that he was involved with the plan to complete a skin sweep and over saw the project. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON was conducted. NHA stated the problem with PS had been identified in July 2016, however it was decided to wait until the current DON (started employment on 7/26/16) was present to implement any plans of improvement. When notified, a skin sweep of entire facility residents occurred, during the skin sweep, the physician and families were notified. An Ad Hoc 8/1/2016 QA meeting was conducted and plan of action and/or Allegation of Compliance (AoC) was developed, approved and implemented. The NHA and DON confirmed that the Quality Improvement Organization (QIO) was contacted immediately following the August 2016 survey. Interview on 8/18/16 at 9:15 a.m. with DON and Admission Coordinator provided education to all licensed staff to ensure all high acuity residents with tracheotomies will not be admitted to the facility without trained Respiratory Therapist being on staff and all licensed nurses completed specialized training. Review of employee training education signature sheets verified the facility implemented new protocol on [MEDICAL CONDITION] for [MEDICAL CONDITION]. Interview on 8/18/16 at 9:25 a.m. the Nursing Home Administrator (NHA) confirmed he is actively recruiting respiratory therapist. Review of the Northeast Atlanta Health and Rehabilitation Center Electrical Safety/Non-Use of Power Strips for Medical Equipment log training log verified that two (2) of two maintenance staff received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16. In addition, it was verified that ninety-six (96) of a total of one-hundred ninety-one (191) facility employees received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16 and 8/13/16. Interview on 8/19/16 at 11:04 a.m. with the facility NHA confirmed a 100% room audit was completed for appropriate electrical outlets and all power strips were removed from resident rooms on/or before 8/13/16. Observation on 8/19/16 beginning at 11:04 a.m. with the facility NHA and Maintenance Director confirmed there were no power strips in any resident rooms on the East, West and Terrace Units of the facility therefore validating there were no rooms with power strips; the Admission Board, in the Admissions Office to have blue dots identifying a total of eight (8) rooms with red emergency electrical boxes capable of safely providing power to suctioning and similar equipment related to tracheotomy care. Review of the Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting signature sheet revealed all disciplines signatures were present. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director acknowledged becoming aware of the ventilator issues during the survey. He continued to state it is never ok to use a power strip for medical equipment, and the residents were immediately they were transferred. The facility prese

Based on the findings of deficient practices identified during the Complaint Survey, from 8/8/16 through 11/9/16, demonstrated that the facility failed to ensure the Quality Assurance Committee developed and implemented appropriate plans of action to correct identified quality deficiencies to attain the residents' highest practicable physical, mental, and psychosocial well-being. The facility also failed to identify additional quality deficiencies which had the potential to affect all residents. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on 6/9/16 (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of pressure ulcers to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. Findings include: Non-compliance was determined to constitute substandard quality of care and Immediate Jeopardy to resident health and safety for the following requirements: F223, failure to protect residents from abuse; F225, failure to investigate and report substantiated abuse in a timely manner; F226 Abuse, failure to implement the facility policy for abuse to protect all residents during the investigation of an allegation of abuse; F314 Pressure Ulcers, failure to prevent development of pressure ulcers,failure to prevent worsening of pressure ulcers, and failure to provide treatments as ordered; and F328 Respiratory/Tracheostomies, failure to ensure respiratory equipment needed was available. Additional deficient practices cited that had the potential to affect all 149 residents included: F495, Nurse Aide Competency, failure to provide new Certified Nurse Aides (CNAs) with 16 hours of training prior to direct contact with residents and failure to ensure CNAs were proficient in performing the [MEDICATION NAME] Maneuver; and Findings include: 1. The QaPI committee failed to ensure that residents were free of abuse. On 6/9/16, R6 was verbally, emotionally and physically abused by facility staff. In addition, this is a repeat deficiency which was cited on 1/21/16, related to abuse, which was cited at IJ, and the facility achieved compliance on 3/10/16, this was discussed in QaPI, including an action plan, and QaPI reporting for 3 months, at which time QaPI would determine any additional recommendations. Once the NHA was made aware of the alleged neglect/abuse the perpetrators continued to work at the facility. Additionally, once becoming aware of the allegations, the administrator failed to notify the SSA, there was no documented evidence the NHA suspended the alleged perpetrators, investigated the incident and reported the incident to the appropriate SSA. It is noted that the NHA was not present at the time of the incident, however the NHA was the NHA at the facility when the allegation was made, and is responsible for the lack of action and compliance with the Federal Guidelines. Cross refer F 157, F223, F225 and F226 for details 2. Resident Rights/Notification of Changes: The facility failed to notify the family and physician in a timely manner of an allegation of abuse for 1 (R6) cross refer to F223, 225, F226; failed to notify responsible parties of a residents with a pressure ulcer cross refer to F314; and failed to notify the physician as ordered related to insulin and when blood sugar assessment (cross refer to F309. Quality Assurance Performance Improvement (QAPI) Review of the QAPI meeting minute's summary, dated 6/22/16 revealed the facility had identified a system issue in regards to Medication Management/[MEDICAL CONDITION] Management during this meeting. The comments/documentation section revealed the following findings in pertinent part; Identified issue with blood sugar and insulin; Plan to Discuss B/S policy and potential issues; Discuss changes in practice and process with Medical Director. Initiate follow up BS process auditing for August 2016 (Standing Order Process with expectations of delivery) Revisit and Reeducate on sliding scale protocol. Education to clinical team on process/policy. Implementing a random audit to review BS's weekly or monthly as identified to assure clinical compliance. Create Performance Improvement Project when interim DON starts. Adding clinical team audit of glucose/glucometer review. Review of the QAPI Performance Improvement Project (PIP), with an initiated date of 7/26/16, with, Medication Administration Part 2, identified under the heading, Opportunity for Improvement. The PIP team members identified were the interdisciplinary team, DON, Unit Managers and the Pharmacy. The status identified that it was in process with an anticipated completion date of 8/30/16. The Plan identified the following 5 headings; SMART Goal (Objective for Improvement) Diabetes Management; Baseline Measure: Holes in the Medication Administration Record (MAR), Inconsistent documentation of interventions initiated for high BS and Low BS and Medical Doctor (MD) notification of any new orders, Inconsistent documentation of follow up. All BS over 250 at HS require MD notification; Root Cause: Inconsistent staffing-Unit managers working the floor at times. Multiple medications per resident, multiple interruptions during med pass. Nurses not documenting and following up; Obstacles: Agency nurses used. Inconsistent staffing, and knowledge deficits; Projected Outcome: Diabetes management requires both preventative measures and treatment of [REDACTED]. The PIP identified the following 4 action items: Additional training specific to diabetes management, to include appropriate assessment of hypo/hyperglycemic episodes; Agency nurses to have minimum of 2 hours of orientation prior to working the floor; Ensure accuchecks are being done consistently and timely, through daily audits and weekly thereafter; Daily monitoring of nurse ' s progress notes, and holes in the MAR and weekly thereafter. A document titled, Ad Hoc QAPI Meeting Agenda/Summary with a meeting date of 7/29/16 was received from the DON at 10:00 a.m. on 8/11/16. The persons in attendance were the Administrator, DON and the Medical Director. Blood Sugar was one of the items identified for opportunity of improvement and the date the PIP was initiated was 7/29/16. On 8/10/16 at 7:08 a.m., the Medical Director stated, he attended Quality Assurance (QA) and at every meeting nursing staff, medication issues and pharmacy issues were brought up. He stated the sliding scale protocol was that anything below 70 if alert, awake and talking, the resident should be given something to eat or given [MEDICATION NAME]. If over 400 they notify the MD as there is no hours of sleep (HS) coverage. He was informed the facility's Diabetes Management (DM) policy did not match the parameter on the MAR and the parameter did not address what a low BS was and what to do. The Medical Director was not aware the policy and parameters differed and he was not aware nursing staff had different responses to what constituted a low BS. He said the facility needed to be concerned with [DIAGNOSES REDACTED] as nursing needs to notify the MD, re-check the BS and document in the nursing notes. The Medical Director stated, they (the facility) can't get people to work, many nurses have been fired for not performing and they have been forced to use agency staff. On 8/11/16 at 3:05 p.m., the Administrator and DON were asked about the Quality Assurance (QA) process. At 3:06 p.m. the Administrator stated the QA committee members included the Administrator, Medical Director, DON, Medical Records staff (S163), MDS and the Social Worker (SW158). The Administrator stated he was in the process of bringing back resident interviews related to the ABAQIS questions done and these will be done randomly throughout the month. The QA team reviews the previous health surveys monthly until the next visit. The agenda is the tool used to review month to month. The QA team used different tools, such as clinical issues, discuss any other topics discussed in stand up meetings, CASPER reports and they try to get at the root causes. The Medical Director will bring issues that he has been running into from residents and his peers. They look for patterns of non-compliance. S163 reviews different resident medical records audits and brings issue to QA. He discussed that action plans are developed when the committee decides what issues need to have QAPI/PIP plans. At times, the QA team will decide that a concentrated focus on areas they feel are critical will require a plan and will continue to focus on solutions for other non-pressing issues unless they continue to see the same problem. He further discussed the facility has had some periodic issues before but really noticed the issue in June/July. He stated he waited until July as he was looking for the root cause and pattern. On 8/11/16 at 3:16 p.m., the DON stated, she knew she had to address critical issues the day she came in the door. On 8/11/16 at 3:17 p.m., the Administrator did not have an answer for why he did not have a plan in place prior other than he was trying to determine the root cause. He stated, he felt the holes in the MAR and BS issues were first noticed in July but, he did not have the minutes in front of him. He stated the previous DON was responsible for ensuring that the MAR's were being reviewed. He discussed he did not feel he was getting the right answer from the DON, and that he had a philosophy, trust but verify and he started doing random MAR checks himself. He was unable to find a direct answer of why the issue was occurring. The issue was discussed in the July QA and the plan was held for a week so the new DON could give input into the plan. The Corporate RN Clinical Auditor (S155) was also assisting, as does the corporation's regulatory compliance and he wanted her input. He discussed that S155 was there in May 2016 for another unrelated issue. He requested she stay to give a more detailed focus to the current identified issues. He discussed that although he had not implemented any changes the team had been monitoring. The DON and Administrator both stated the plan was to be implemented this week, but survey delayed this. When asked why they had not implemented part of their QAPI that was identified in late July and signed by him, DON and S161 on 7/29/16, a week before survey team entered, he stated, they had begun the 2 hour training with the agency staff. He also felt there had been many staff challenges, education gaps regarding documenting in the Electronic Medication Administration Record (EMAR) and the use and high percentage of unit agency in the building. Currently they are using multiple agencies to cover the staffing issues. It is currently the DON who will ensure the education regarding the identified issues are being done and she will do that by being present with the Staffing Development Coordinator (SDC) during the education. 3. Treatment/Services to Prevent and/or Heal Pressure Ulcers: The facility failed to ensure residents without pressure ulcers did not develop pressure ulcers, and failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for six (6) residents (R18, R20, R22, R23, R25 and R28). The facility's failures to measure and treat pressure ulcers for 6 residents and provide consistent power sources for an air mattress for 1 (R28) resident with numerous medical devices/equipment to prevent the worsening of 2 pressure ulcers (Stage 2 and Stage 4), created a situation of Immediate Jeopardy for serious harm to the residents. Reference F314 for additional information. On 8/12/16 at 1:45 p.m., staff physician165 (R28's primary care physician) stated R28 was a very sick man when he was admitted due to having a Stage 4 and a Stage 2 pressure ulcer, as well as history of acute [MEDICAL CONDITION] and that he was a quadriplegic. Physician165 stated he had suggested, on more than one occasion, that the son move R28 to a more prominent facility that was staffed with more skilled staff to [MEDICAL CONDITION] wound care, but the son refused to move his father. Physician165 stated he also wanted the resident transferred to a higher acuity level of care as the wounds were not improving as much as he had wanted them to. When asked if he was aware there were no wound measurements in the medical record he stated, No, I was not aware there were not any measurements. He stated he believed the wound doctor, Physician166 (wound doctor) was taking measurements but, he had not seen those measurements. He discussed that resident 28's wife had told him she did not feel the wound was getting any worse so, he was not overly concerned as the resident was being followed by the facility wound doctor and staff wound care nurse (LPN117). Physician165 stated he knew the resident was admitted with a Stage 4 wound on his coccyx and a Stage 2 on his upper right thigh. He stated he was not consulted regarding whether or not to accept R28 into the facility. Physician165 stated that he had many discussions with the residents' son and had advised the family R28 would benefit from a facility that provides a higher level of care such as a hospital or long-term acute care (LTAC). He also stated that on 8/6/16 he had requested the resident go to the hospital to be evaluated by an infection disease doctor as he suspected R28 had a colonized infection in his trach. He explained the son requested they wait until the following Monday as he wanted to consult some others and decide if he wanted his father sent to the hospital. The Administrator was interviewed on 8/12/16 at approximately 3:36 p.m. The Administrator said there were not enough outlets for R28 or his roommate, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and he directed the Maintenance Director to install a power strip in R28's room. The Administrator said both R28 and his roommate had more medical equipment than they had outlets in the room, so the decision was made to unplug R28's air mattress. He stated the air mattress was uninflated for a couple of days. The Administrator stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The Administrator and the Maintenance Director were interviewed on 8/13/16 at approximately 10:30 a.m. The Administrator confirmed F1 talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed. The Administrator also confirmed a few days went by before he became aware the power strip was not installed. The Administrator said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place. The Medical Director was interviewed on 8/10/16 at 7:05 a.m. He said he was aware of some holes on MARs/Treatment Administration Record (TARs) and they discussed in the monthly QA meetings. The Medical Director said they should do a head to toe assessment with every admission. The Administrator and DON were interviewed together on 8/11/16 at 12:55 p.m. The DON said she started on 7/25/16 and she identified immediately holes in MARs/TARs. She said she was planning on doing weekly audits . getting people in place . takes a little time . 1 QAPI (Quality Assurance Performance Improvement) ready to implement and do skin sweep on Monday (8/8/16) when you all walked in . if I had a month, I could've gotten my hands around it . hired a wound nurse . Wound Doctor comes weekly - will see who we need. The DON said she thought the problems arose from staffing challenges, switching to an electronic medical record and increased use of agency nurses. The DON said she wanted to make sure the treatments were being done, making rounds, monitoring the wound nurse, measuring appropriately, started going through pressure ulcers, discussing in At Risk meeting, developed wound log for pressure ulcers with resident name, type of wound, measurement and treatment . treatments were now being done on a consistent basis; however, the investigation revealed multiple problems with measuring, assessing, providing treatments and preventing new or worsening pressure ulcers. 4. Treatment/Care for Special Needs, Respiratory/[MEDICAL CONDITION] Care: The facility failed to ensure all necessary respiratory related medical equipment was readily available for two (R28 and R29) of 2 sample residents reviewed with tracheostomies; and failed to ensure a safe and appropriate power source was available for their medical equipment. The failures put these residents at risk of serious harm or death. Necessary equipment for potential respiratory distress was not available to include required back-up replacement inner cannulas in the event theirs became dislodged and required emergency replacement (Ambu bags -manual resuscitators- for both residents, and correctly sized replacement inner cannulas for their tracheostomies). These residents were roommates and both required more electrical outlets (7 for R28 and 6 for R29) than the room provided (4 were available per resident). The facility used power strips to provide the extra power source for medical equipment which did not meet Life Safety Code standards. Refer F328 On 8/12/16, at approximately 1:00 p.m., the Director of Nursing (DON) was interviewed and informed they did not have the properly sized inner cannulas in the room. She immediately went to the room with the same staff nurse (LPN117) observed during wound care, and returned with a size 4 cannula that she said was found in a drawer. That observation was not confirmed and the equipment needed to be readily accessible (as in taped above the bed of each [MEDICAL CONDITION] patient) was not available when surveyors observed the room. Nor was LPN117 able to verbalize where that cannula was when asked by the surveyor during the initial observation of R28 during wound care. When notified of the IJ situation (F328), on 8/12/16, at approximately 3:36 p.m., the Administrator stated that they did not have enough outlets for either resident to accommodate their medically necessary, physician ordered, equipment. He stated that when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to take and install a power strip in R28's room. The NHA stated that both R28 and R29 had more medical equipment than they had outlets for and the decision was made to unplug the air mattress for R28. He stated the air mattress was uninflated for a couple of days. R28 had both a Stage 4 and a Stage 2 decubitus ulcer (located on the sacrum area and the upper right thigh). R28 had a physician's orders [REDACTED]. Record review revealed that his wounds had doubled in size as a result. Cross refer F314. 5. F281, Services Provided Meet Professional Standards: Based on interview and record review, the facility failed to ensure acceptable professional standards were implemented for 1 of 29 sampled residents (R21). Specifically, failed to ensure changes in respiratory status were assessed and monitored as expected for R21, and; failed to ensure timely administration of medication to residents. This had the potential to affect the residents on the unit who received medications. Reference F281 for additional information. 6. Free of Accident Hazards/Supervision/Devices: Based on interview and record review, the facility failed to ensure a safe environment for 3 of 29 sampled residents (R15, R28 and R29). Specifically, failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. The resident fell again contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise; and failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip. Reference F323 for additional information. 7. Nurse Aide Competency: Based on record review and staff interview, the facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 16 hours of training before any direct contact with the resident. Specifically, they did not ensure their CNAs were proficient in the [MEDICATION NAME] maneuver. This failure put all residents at potential risk for adverse outcome in a choking event. Reference F495 for additional information. The facility failed to ensure that all Certified Nurse Aides (CNAs) received the required 16 hours of training before any direct contact with residents. Specifically, they did not ensure their CNAs were proficient in the [MEDICATION NAME] maneuver. This failure put all residents at potential risk for adverse outcome in a choking event. According to the Resident Census and Conditions Report completed by the facility during the survey, the facility census was 149. Both the NHA and the HMR stated they were not aware of the specific requirement to ensure their CNA staff were proficient in the [MEDICATION NAME] maneuver. They both acknowledged that residents in their facility were at a higher risk of choking due to age, [DIAGNOSES REDACTED]. They were also not aware that an evaluation of competency (for all skills required) was necessary to ensure their ability to provide this life-saving technique in an emergency where a resident might be choking. Reference F495 for additional information. 8. Responsibilities of Medical Director: Based on observation, interview and record review, the Medical Director failed to ensure that residents received the appropriate treatment and care to achieve the highest possible well-being as evidenced by the number of residents affected by Immediate Jeopardy (IJ). Reference F501 for additional information. 9. Resident Records-Complete and Accurate: Based on observation, interview and record review, the facility failed to ensure electronic Medication Administration Records (MAR) for 4 Residents (R) (R11, R20, R23 and R27), and the Kiosk Care Tracker/Plan of Care (POC) utilized for documenting Activities of Daily Living (ADL) for 3 Residents (R11, R20, and R23) of 30 residents reviewed were complete; and failed to document the admission of enteral feedings for 1 resident (R9) who had a feeding tube out of 30 sampled residents during the Complaint Survey. The information contained in these documents is essential for determining the resident's progress including response to treatment, change in condition, and changes in treatment. Reference F514 for additional information. 10. Written Plans to Meet Emergency/Disaster Needs: Based on observation, staff interviews and record review, the facility failed to ensure they had a Disaster Manual readily available on all units; that the staff knew where to obtain that information; and that their Emergency Contact list of phone numbers was accurate and up-to-date. Reference F517 for additional information. Each of the aforementioned surveys had a plan of correction which included monitoring and reporting to QAPI, based on the evidence of the current survey and the repeated serious deficiencies QAPI is not monitoring, evaluating and implementing changes in the facility. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by August 13, 2016. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. III. A facility wide skin sweep was conducted for residents at risk for pressure sores (PS) on 8/12/16, 8/13/16 and 8/14/16. Current dressings were observed for placement and appropriate dates by facility staff on 8/13/16. Unit managers will observe a minimum of five (5) dressings per week for appropriate placement and dates. Audits of current PS were completed 8/16/16 to assure treatments are in place for each wound and are written appropriately. PS will be reviewed by the interdisciplinary team weekly at the scheduled AT RISK meetings. The facility Medical Director will be notified for any needed changes. An audit was conducted by the District Director of Clinical Services on 8/13/16 for wounds assessed by the wound physician to determine if there was any deterioration of existing wounds since his visit on 8/5/16. The District Director of Clinical Services (DDCS) and/or designee will attend at least one at Risk meeting per month to determine if further audits are needed. The following education began on 8/12/16 and will be completed by 9/2/16 for the licensed nurses by the DON/Nursing Administration including: Assessment, measurements, staging and documentation of wounds upon admission; Obtaining/entering treatment orders into the computer upon admission/identification of new pressure areas, and; Documentation of treatments provided. Licensed staff not scheduled to work on 8/12/16, will receive education prior to the start of their next shift. Training and education regarding the Skin System has been integrated into the orientation process of new licensed nursing staff and agency nurses. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting was held 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee meeting for review and further reco

Based on record review and interview, the facility failed to notify family and/or the physician of incidents or changes in resident status. Specifically: the facility failed to notify the family in a timely manner of an allegation of abuse for one (1) resident (R6); the facility failed to ensure timely notification of responsible parties/family members when the resident developed a pressure ulcer for one (1) resident (R22); and the facility failed to notify the physician when the blood sugars of R10, R19 and R24 were below 70. The sample was seventy-seven (77) residents. Refer F223, 225, 226, 309 and 314 A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F157 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Findings include: 1. Review of R6's clinical record revealed a [DIAGNOSES REDACTED]. R6 was verbally, physically and emotionally abused on 6/9/16. The facility staff became aware of the abuse on 6/9/16, however they did not notify the physician until a day or two later, nor the responsible party until 6/17/16. Interview conducted with the family during complaint triage on 7/18/16 at 9:10 a.m. revealed that the family was not notified of the abuse which occurred on 6/9/16 incident until 6/17/16. Interview on 8/8/16 at 1:55 p.m., the resident's family member indicated she was not notified of the allegation until 6/17/16. This was 8 days after the allegation of abuse had been made. Refer to F223, 225, 226 2. Review of the Transfer/ Discharge Report revealed R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The only person listed as responsible party was R22's wife (F5). The resident was discharged from the facility on 8/12/16 to an assisted living facility. Review of the 4/30/16 Nursing Admission Data Collection revealed R22 was admitted without pressure ulcers. Review of the clinical record revealed R22 had a an unstageable area to left buttock, Cleanse area with Normal Saline Solution (NSS), pat dry, apply santyl to wound bed, cover with dry dressing. Even though this treatment was ordered on [DATE], there was no documented evidence of family notification. Review of the 6/19/16 Nursing Daily Skilled Charting revealed, PS to back side, R22 was totally dependent on staff for bed mobility, toileting and transfers - even though this was the first documentation of a PS, there was still no documented evidence of family notification. Review of the 6/23/16 Skin - Head to Toe Skin Checks revealed, R22 had a new and an existing PS, the L butt has a necrotic area to the middle of the wound, L buttock UTS PS is being treated by the wound doctor, there were no evidence the family was notified about the PS. Family member (F4) was interviewed on 8/12/16 at 9:00 a.m., F4 said R22 was denied readmission to the assisted living facility because R22 developed an unstageable pressure ulcer. F4 said he and F5 were not notified in a timely manner about the pressure ulcer. Refer to F314 3. R24 was admitted to the facility on [DATE] with a diagnosis, according to the 8/9/16 Admission Record, of diabetes mellitus due to underlying condition with [MEDICAL CONDITION]. The quarterly Minimum Data Set (MDS - a comprehensive assessment completed by facility staff that drives the care planning process), with an Assessment Reference Date (ARD) of 6/30/16, documented R24 had a [DIAGNOSES REDACTED]. The 8/17/16 Medication Review Report documented the following physician orders [REDACTED].*150 - 200 = 2 units; *201 - 250 = 4 units; *251 - 300 = 6 units; *301 - 350 = 8 units; *351 - 400 = 10 units blood sugar (BS) greater (>) *400 call medical doctor (MD), subcutaneously (under the skin) before meals and at bedtime for diabetes mellitus. Review of the June, 2016 Electronic Medication Administration Record [REDACTED]. There was a lack of documentation to indicate whether the physician was notified. Review of the June, 2016 EMAR indicated R24's BS was 52 on 6/23/2016. There was a lack of documentation to indicate whether the physician was notified. Review of the June, 2016 EMAR indicated R24's BS was 59 on 6/24/16. Review of a progress note dated 6/24/16 at 5:01 a.m. indicated, insulin held at this time. There was no evidence to determine that the MD had been notified. Refer F309 4. R10 was re-admitted to the facility on [DATE] with a diagnosis, according to the 8/16/16 Admission Record, of type II diabetes mellitus with other specified complications. The 8/16/16 Medication Review Report documented the following physician orders [REDACTED].*150 - 199 = 2 units; *200 - 249 = 4 units; *250 - 299 = 6 units; *300 - 349 = 8 units; *350 - 399 = 10 units; *400+ = 12 units; Subcutaneously before meals and at bedtime related to type II diabetes mellitus with other specified complications. Accucheck AC (before meals) and HS (hours of sleep) cover per S/S (sliding scale) except no coverage at HS. HS blood sugar notify MD for BS > 250, no coverage at HS unless ordered by MD. BS less than (<) 70 give 4 oz. juice with snack if awake. If not alert give [MEDICATION NAME] 1 mg IM. Review of the August, 2016 EMAR revealed on 8/9/16 at 4:30 p.m. and 9:00 p.m., a BS of there was no evidence to show that the MD had been notified. Refer to F309 5. R19 was admitted to the facility on [DATE] with a diagnosis, according to the 8/9/16 Admission Record, of diabetes mellitus with diabetic [MEDICAL CONDITION]. The 8/10/16 Medication Review Report documented the following physician orders [REDACTED].*150 - 200 = 2 units; *201 - 250 = 4 units; *251 - 300 = 6 units; *301 - 350 = 8 units; *351 - 400 = 10 units; Subcutaneously before meals and at bedtime related to Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. Review of the August, 2016 EMAR indicated on 8/1/16 at 4:30 p.m. the BS was 69, there was no evidence that the physician was notified. Refer to F309 Review of the facility's Diabetic Management Policy most recently revised in June 2008 indicated, Assessment: Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: Blood glucose orders should include parameters to follow and when to notify the physician; Results outside of ordered parameters are communicated to the physician immediately; Notify the physician of abnormal blood glucose test results and symptoms exhibited; Notify the physician of abnormal blood glucose test results, symptoms exhibited and interventions implemented. Interview on 8/9/16 at 2:55 p.m., East Unit Manager LPN60 if BS is > 400 call the MD and get an order and document in the progress note. Interview on 8/9/16 at 3:10 p.m., LPN174 reported that if the BS < 60 notify the MD, if > 400 notify the MD. LPN174 if > 250 call the MD. Interview on 8/9/16 at 3:34 p.m., LPN2 stated if > 400 call MD and if BS is 45 or < call the MD. Interview on 8/10/16 at 5:25 a.m., LPN119 stated that for any BS < 60 you call the MD and if > 400 and call MD. Interview on 8/10/16 at 6:10 a.m., LPN169 stated that if the BS > 400 you need to call the MD, < 40-50 give them oxygen and re-check BS, if the BS does not come up call MD.

Based on observation, interview, record review, including review of the Georgia Nurse Practice Act, Chapter 410-10, Lippincott's 8 Rights of Medication Administration, the policy titled Respiration assessment, long-term care Revised: October 02, 2015, the facility failed to ensure acceptable professional standards were implemented to meet the needs of the residents. Specifically, the facility failed to; a. failed to ensure changes in respiratory status were assessed and monitored as expected for one resident (R21); b. failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two (2) of 2 residents (R28, R29) that had tracheostomies and required multiple medical apparatus; Refer to F328. c. failed to ensure residents with pressure sores (PS) received necessary treatment and services to promote healing for six (6) of thirty (30) sampled residents (R18, R20, R22, R23, R25 and R28). Refer to F314, and; d. ensure eleven (11) of thirteen (13) residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27) who were reviewed for sliding scale insulin, received the appropriate care to stabilize blood sugar (BS). Review of a list provided by the DON on 8/11/16 at 5:20 p.m., revealed that 40 residents had physician orders [REDACTED]. Refer to F309. e. Failed to ensure timely administration of medications to residents. This had the potential to affect the residents on the unit. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 on 6/9/16 at(F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of PS to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F281 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Findings include: Review of the Georgia Nurse Practice Act, Chapter 410-10 revealed, Practice nursing as a registered professional nurse means to practice nursing by performing for compensation any of the following: Assessing the health status of individuals, groups, or both throughout the life span; Establishing a nursing diagnosis; Establishing nursing goals to meet identified health care needs; Planning, implementing, and evaluating nursing care; Providing for safe and effective nursing care rendered directly or indirectly; Managing and supervising the practice of nursing; Collaborating with other members of the health care team in the management of care, and; Teaching the theory and practice of nursing. Review of the facility's Respiration assessment, long-term care Revised: October 02, 2015 revealed: Age-related changes can complicate the early detection of respiratory problems in older adults; while assessing respirations, listen for abnormal breath sounds, such as: stertor - a snoring sound that results from the presence of secretions in the trachea and large bronchi; stridor - an inspiratory crowing sound occurring with upper airway obstruction; wheezing - high-pitched, musical sound; expiratory grunt - a deep, low-pitched sound heard at the end of each breath. Then use your stethoscope to auscultate for abnormal breath sounds, such as: crackles - discontinuous sounds heard on inspiration; rhonchi - low-pitched rumbling sounds. Observe the resident's chest movements to assess the depth of respirations. Listen to the resident's breathing to determine the rhythm and sound of respirations. Use a stethoscope to auscultate anterior and posterior chest surfaces to assess for the presence of abnormal breath sounds. Observe the resident for accessory muscle use. 1. R21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the memory care unit. Review of the 7/4/16 Situation, Background, Assessment and Recommendation Communication Form (SBAR) and progress note documented at 3:11 p.m. for R21 revealed, vital signs (VS): blood pressure (BP) 126/76; pulse (P) 76; Pulse Type: Regular, respirations (R) 18; temperature (T) 97.6; oxygen saturation level (SPO2) 95.0 %; Method: Room air, observed coughing. Lungs sounds wet with water eyes, back to bed with head of bed (HOB) elevated, abnormal lung sounds, cough, non-productive, primary care clinician notified at 1:30 p.m. Review of the 7/4/16 at 9:57 p.m. nursing note revealed, R21 lung sounds congested. Order for chest x-ray (CXR) in place, to do CXR tomorrow due to 4th July holiday. The note did not include the oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/5/16 at 6:13 a.m. nursing note revealed, stable up in wheelchair, observed, trying to clear her throat a couple of times but no coughing noted, will continue to monitor. Verbal no complaints of pain or discomfort at this time. VS BP - 124/59, P - 62, R - 18, T - 98.0. The note did not include the oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/5/16 at 3:22 p.m. nursing note revealed, CXR result with subsegmental atelectasis versus pneumonia in the lung bases called to the physician and no new order received. Responsible party made aware via voice mail. Review of the 7/6/16 at 2:30 p.m. nursing note revealed, Repeat x-ray done. Son notified of previous CXR result and new orders. VS: T - 96.4, P - 66, R - 20, BP - 130/67. The note did not include the resident's oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/7/16 at 7:56 a.m. nursing note revealed, received in bed eyes opened awake alert oriented verbally responsive. Respiration even and unlabored. Skin warm and dry to touch. Denies any pain distress discomfort. Will continue to monitor. T - 98.3, P - 77, R - 20, BP - 123/76, SPO2 - 97% R/A (room air). The note did not include an appropriate respiratory assessment for R21. Review of the 7/7/16 at 10:06 p.m. nursing note revealed, second CXR result shows very slight right lower lobe atelectasis and mild cardiomegaly, no infiltrate or congestion. Physician and responsible party was notified, no new orders given. Will continue to monitor. The note did not include the oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/8/16 through 7/15/16 nursing notes revealed no evidence that the respiratory status was assessed or monitored for R21. Review of the 7/16/16 at 12:18 p.m. nursing note for R21 revealed, resident has a very slight right lower lobe atelectasis according to the last CXR on 7/7/16. R21 is not showing any signs or symptoms of respiratory distress. Family member (F6) here visiting and express concerns about CXR results. Current vital signs: BP - 103/56, P - 72, R - 12 and SPO2 - 83%. R21 is not deep breathing to help resolve atelectasis. Oxygen administered at two liters (2L) via cannula. Review of the note did not include an appropriate respiratory assessment. Review of the 7/17/16 at 2:36 p.m. nursing note revealed, R21 is removing her oxygen ad lib and it has to be replaced. R21 does not understand to deep breathe. CXR results from 7/5/16 and 7/6/16 were again reported to the physician. New order received for a computerized tomography (CT) of the lung before he speaks with the son. R21 is afebrile at this time. VS: T - 97.0, R - 20, P- 70, BP - 118/56. Son visited and received the CXR copies. Will monitor. The note did not include the SPO2 or a respiratory assessment. F6 was interviewed on 7/18/16 at 11:05 a.m. (by the State Survey Agency complaint intake staff) F6 said the facility notified him R21 had a wet cough and wanted to get a CXR to find out if R21 had pneumonia. F6 stated being told they are monitoring her. F6 stated when he asked one of the nurses what did the monitoring entail, the nurse did not seem to know the R21 was being monitored. F6 said he asked the DON what the monitoring entailed and she said they were monitoring her oxygen concentration in her blood and they did not have to ask the doctor for an order to place her on oxygen.F6 said he went with the DON to check her oxygen saturation level and it was 83% on room air. The DON ordered the resident to start on oxygen via nasal cannula. Review of the 7/18/16 at 3:12 p.m., on 7/18/16 at 10:26 p.m. on 7/19/16 at 3:49 a.m., 7/19/16 at 6:40 a.m., on 7/20/16 at 6:36 a.m., on 7/21/16 at 7:45 a.m., on 7/22/16 at 6:39 p.m. and 7/23/16 through 7/27/16 nursing notes revealed no evidence the resident's respiratory status was assessed or monitored. Review of the 7/19/16 at 2:36 p.m. nursing note revealed, R21 continues to be non-compliant with her O2. This author spoke with resident son about sending his mother to the hospital emergency room to get the CT scan done. Son did not want her to go to the ER and sit for long hours when we could get it scheduled and approved. Physician was notified and ask to get it approved and scheduled at the hospital. All paperwork was faxed to the scheduling at the radiology at the hospital. Son and physician made aware. Will await appointment date. The note did not include an appropriate respiratory assessment or whether R21 was receiving oxygen therapy. Review of the 7/28/16 at 2:42 p.m. nursing note revealed CT report of the chest called to the physician and F6 with no new orders. However at 9:23 p.m. R21 was seen by physician and new orders written to discontinue oxygen, check oxygen saturation every shift. If oxygen saturation is less than 88%, restart oxygen via nasal cannula. 2. Review of the clinical record for R28 revealed the presence of the [MEDICAL CONDITION], but it did not list the type or size of the inner cannula. There was no mention of having a back-up inner cannula or Ambu bag available for respiratory emergencies, or what do if the inner cannula became dislodged. There was no documentation of a pressure relieving air mattress, although ordered by the physician. F1 of R28 was interviewed on 8/12/16 at 12:45 p.m. he said after his father was admitted on [DATE], he asked every day for two weeks to get a power strip for the numerous items his father required for his care equipment in his room. F1 stated there were too many items to plug in and means for plugging in only 4 items - staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in before they left the room, which caused R28 to sink down onto the bedframe on the deflated air mattress. F1 said his father needed the air mattress for treating two severe PS. F1 said he finally complained to the NHA and requested the power strip; F1 said the NHA said he was unaware this was an issue and he would find a power strip as soon as possible. F1 said it took a few more days after speaking to the administrator to get the power strip in the room. Refer to F314 and F328. 3. R29 was a readmit from an acute hospital stay. Review of the progress note dated 5/23/16, and as documented on the care plan, R29 pulled his [MEDICAL CONDITION] out and was sent to hospital, where they replaced it and sent him back to the facility. There was no evidence that R29 the facility attempted to [MEDICAL CONDITION]. R29 was care planned for history of self extubation (removing his own trachea tubing and cannula) as a behavior; the facility did not have the appropriate size inner cannula ready at the bedside. As evidenced by documentation of having to be hospitalized for [REDACTED]. Refer to F328 4. R25 was interviewed on 8/8/16 at 10:00 a.m.; he said he was admitted last Tuesday 8/2/16 with a dressing covering his PS on his bottom - he said the dressing fell off on Friday (8/5/16) and he asked the nursing staff to replace the dressing, but no one replaced it, yet, it was bleeding and it hurt. The charge nurse was interviewed immediately after the resident interview and said she was aware R25 had a PS on admission and it had slough (non-viable tissue) in the wound bed. Refer to F314. 5. Review of the admission documentation did not include the presence of a PS, no treatments were in place until 4 days after the resident's admission, the wounds may have developed after admission and treatments were not consistently performed Review of the nurse notes between 3/25/16 and 4/1/16 revealed no documented evidence of a wound, skin problems or dressing changes for R23. Refer to F314. 6. Review of the clinical record revealed PS were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed for R20. Refer to F314. 7. R22 was admitted without PS, he developed two unstageable PS, one of which was subsequently a stage 4, there was no evidence of assessing or measuring the PS upon discovery, the PS were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed. Refer to F314. 8. R18 was readmitted to the facility from the hospital on [DATE] with multiple unmeasured, unassessed and untreated PS that became worse and became infected, necessitating a trip to the emergency room for assessment, treatment and antibiotics, the PS were not assessed or measured weekly. Refer to F314. 9. Review of the clinical record for R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27 revealed that the sliding scale insulin and blood sugar assessments was not administered as ordered by the physician, including many gaps of documentation on the Medication Administration Record (MAR) during the months of June, July and August 2016, nursing staff were inconsistent in documenting and treating hypo/hyper glycemic episodes. Physicians were not notified of blood sugars below ordered parameters. The interventions and blood sugar re-checks were not implemented consistently per facility policy to address low and high blood sugars. The facility also failed to ensure that a parameter regarding low blood sugars was documented on the MAR to address what interventions and treatment needed to be completed. The facility was not following their diabetic management policy. Refer to F309 10. An agency Licensed Practical Nurse (LPN) 176 was observed on 8/8/16 at 11:00 a.m., passing a resident's medication. LPN176 indicated she had 7 pills to pass for a resident. LPN 176 indicated the medications were scheduled for 9:00 a.m. She indicated she knew it was 11:00 a.m. LPN176 stated, do the best I can. Interview with the West Hall Unit Manager on 8/8/16 at 11:35 a.m., when informed LPN 176 was still passing medications, she shook her head and stated I did not know that. The Unit Manager did not offer to help LPN176 pass the medications. Interview on 8/12/16 at 10:10 a.m., Registered Nurse (RN) 157 indicated nurses have one hour before and one hour after when passing medications. RN157 indicated the 9:00 a.m. medications should be passed by 10:00 a.m. Review of a facility policy, received from RN175, titled Medication Management and dated June 2008, indicated, to administer medication within 60 minutes of the scheduled time, for example if the medication is ordered for 8:00 a.m., it must be given between 7:00 a.m. and 9:00 a.m. in order to be considered timely. Review of Lippincott's 8 Rights of Medication Administration, dated 5/27/11 indicated, check the frequency of the ordered medication, double check that you are giving the ordered dose at the correct time. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by August 13, 2016. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. III. A facility wide skin sweep was conducted for residents at risk for pressure sores (PS) on 8/12/16, 8/13/16 and 8/14/16. Current dressings were observed for placement and appropriate dates by facility staff on 8/13/16. Unit managers will observe a minimum of five (5) dressings per week for appropriate placement and dates. Audits of current PS were completed 8/16/16 to assure treatments are in place for each wound and are written appropriately. PS will be reviewed by the interdisciplinary team weekly at the scheduled AT RISK meetings. The facility Medical Director will be notified for any needed changes. An audit was conducted by the District Director of Clinical Services on 8/13/16 for wounds assessed by the wound physician to determine if there was any deterioration of existing wounds since his visit on 8/5/16. The District Director of Clinical Services (DDCS) and/or designee will attend at least one at Risk meeting per month to determine if further audits are needed. The following education began on 8/12/16 and will be completed by 9/2/16 for the licensed nurses by the DON/Nursing Administration including: Assessment, measurements, staging and documentation of wounds upon admission; Obtaining/entering treatment orders into the computer upon admission/identification of new pressure areas, and; Documentation of treatments provided. Licensed staff not scheduled to work on 8/12/16, will receive education prior to the start of their next shift. Training and education regarding the Skin System has been integrated into the orientation process of new licensed nursing staff and agency nurses. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting was held 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee meeting for review and further recommendations. ***The State survey agency validated the corrective action taken by the facility as follows: I. Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ, observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA

Based on record review including Fall Management, Overview, Practice Guidelines and interviews, the facility failed to follow the care plan (CP) which identified individualized interventions developed by the Interdisciplinary Team (IDT) to assist staff to care for the residents, for nine (9) residents (R15, R18, R20, R22, R23, R25, R28, R29, and R183) specifically: a. failed to ensure that the CP included necessary emergency respiratory interventions to address the need of an emergency i.e. inner cannula re-insertion, ambu bags for each resident, and electrical outlets to supply power sources to the needed equipment for two (2) of 2 (R28, R29) residents that had tracheostomies, pressure sores (PS) and required multiple medical apparatus; Refer to F328. b. failed to CP including interventions for prevention, detection, weekly assessments were implement to ensure that residents without PS did not develop PS, failed to ensure residents with PS did not worsen, and failed to ensure residents with PS received necessary treatment and services to promote healing for 6 residents (R18, R20, R22, R23, R25 and R28); Refer to F314. c. failed to ensure that the CP included individualized interventions for R15 who had a history of [REDACTED].e. more frequent monitoring, they failed to determine the actual cause of the falls, failed to use their own Fall Management, Overview, Practice Guidelines therefore R15 fell multiple times while in the facility, contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise, and; Refer to F323. d. failed to apply a right hand splint to prevent contractures for one resident (R 183). Refer to F318. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. On [DATE] at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on [DATE] (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On [DATE] at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of PSs to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on [DATE], the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on [DATE] and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on [DATE], as alleged. Findings include: 1. Review of CP documented the presence of the [MEDICAL CONDITION] for R28, but it did not list the type or size of the inner cannula. There was no mention of having a back-up inner cannula or Ambu bag available for respiratory emergencies, or what do if the inner cannula became dislodged. There was no evidence of a pressure relieving air mattress on the CP, although it was ordered by the physician. Interview on [DATE] at 12:45 p.m. with family member (F1) revealed R28 was admitted on [DATE], he asked every day for two weeks to get a power strip for the numerous items required for the care equipment in the room. F1 stated there were too many items to plug in and means for plugging in only 4 items and staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in before they left the room, which caused R28 to sink down onto the bedframe on the deflated air mattress. F1 said R28 needed the air mattress for treating two severe PS. F1 said he finally complained to the NHA and requested the power strip; F1 said the NHA said he was unaware this was an issue and he would find a power strip as soon as possible. F1 said it took a few more days after speaking to the administrator to get the power strip in R28's room. Review of the record revealed R28 was admitted on [DATE] with a stage 4 PS on his buttocks and a stage 2 PS on his posterior thigh, neither wound was measured at this time or at any time after admission by the nursing staff. There were numerous omissions for the PS treatments. The Wound Doctor measured the PS on [DATE] and again on [DATE] the sacral wound had doubled in size and the stage 2 was actually a stage 3. R28 had two PS, a sacral stage 4 and a posterior right thigh stage 2. R28 had a physician's orders [REDACTED]. . R28's PS were not measured or adequately assessed upon admission, they were not measured/assessed weekly, the initial inaccurate staging of the posterior thigh wound was carried over to the Minimum Data Set (MDS) and care plan, treatment orders were omitted, two different treatment orders were in place at one time for the same PS, and the air mattress was allowed to deflate leaving the resident to sink down onto the bedframe on the deflated air mattress. Review of the current CP initiated on [DATE], revealed R28 was admitted with one Stage 4 PS on the sacrum and admitted with one Stage 2 PS (which was inaccurately assessed upon admission and should have been documented at a Stage 3) on the right (R) posterior thigh. The care plan also included the [DATE] Wound Specialist report: R (right) Posterior Thigh PS stage 3 w/100% gran (granulation - viable) tissue; Sacrum/Buttock PS stage 4 w/100% gran tissue; on [DATE] Wound Report: Stage 4 R Perineum Buttock/Sacrum PS, 100% gran tissue, Stage 3 R Posterior Thigh PS, 15% necrotic non-viable tissue, debrided [DATE], 20% gran tissue, indicating the PS deteriorated since admission going from 100% granulation/viable tissue to 15% necrotic/non-viable tissue with only 20% granulation tissue. The goal was PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were to administer treatments as ordered and observe for effectiveness, complete a full body check weekly and document, follow facility policies/protocols for the prevention/treatment of [REDACTED].e., registered dietitian (RD), physical therapy (PT), occupational therapy (OT) or Wound Specialist, observe dressing every shift/prn to ensure it is intact and adhering. Report lose dressing to Treatment nurse, provide incontinence care after each incontinence episode, or per established toileting plan. Review of the [DATE] Treatment Administration Record (TAR) for R28 revealed: No evidence of treatments completed on the above treatment order for the right posterior thigh PS was omitted on [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or R29, who were roommates, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to install a power strip in the room. The NHA said both R28 and R29 had more medical equipment than they had outlets in the room, so the decision was made to unplug the air mattress of R28. He stated the air mattress was uninflated for a couple of days. Cross refer to F314 2. R29 was a readmit from an acute hospital stay. Review of a progress note dated [DATE], and as documented on the CP, R29 pulled his [MEDICAL CONDITION] out and was sent to hospital, where they replaced it and sent him back to the facility. R29 was care planned for history of self extubation (removing his own trachea tubing and cannula) as a behavior, the facility did not have the appropriate size inner cannula ready at his bedside. Refer to F328. 3. Review of the Transfer/ Discharge Report revealed R25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current CP initiated on [DATE], revealed R25 has a PS to buttocks related to immobility, incontinence. The goal was PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were to administer treatments as ordered and observe for effectiveness; complete a full body check weekly and document; IDT referrals as indicated, i.e., RD, PT, OT or other; provide incontinence care after each incontinence episode, or per established toileting plan; reposition in chair frequently for comfort and pressure reduction. Provide resident/ family education as needed. R25 was interviewed on [DATE] at 10:00 a.m.; he said he was admitted on [DATE] with a dressing covering his PS on his bottom and it fell off on [DATE]. R25 stated he asked the nursing staff to replace the dressing, but no one replaced it, yet, it was bleeding and it hurt. Review of his record confirmed he was admitted on [DATE] with an unstageable PS on the buttocks, and there were no treatment orders in place, even though the resident had been in the facility for 6 days. Review of the August, 2016 TAR on [DATE] at approximately 3:30 p.m., revealed no documented evidence R28 received any treatments to the PS on his buttocks. Refer to F314. Cross refer to F314 4. Review of the admission for R23 did not include the presence of a PS, no treatments were in place until 4 days after the resident's admission, the wounds may have developed after admission and treatments were not consistently performed. Review of the Transfer/ Discharge Report revealed R23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R23 was transferred to the hospital on [DATE]. Review of the current CP initiated on [DATE], revealed R23 has 3 stage 2 PS on admission to the L and R buttocks, sacrum, and has potential for further skin breakdown related to decreased mobility. The goal was PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were to administer medications as ordered. Observe/document for side effects and effectiveness, administer treatments as ordered and observe for effectiveness, complete a full body check weekly and document, educate the resident/family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention treatment of [REDACTED]. Serve diet as ordered, observe intake and record, observe/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs/ symptoms of infection, wound size (length x width x depth), stage, provide incontinence care after each incontinence episode, or per established toileting plan, the resident requires pressure relieving/reducing device on bed/chair. Review of physician's orders [REDACTED]. Review of the nurses notes for R23 between [DATE] and [DATE] revealed no documented evidence of a wound, skin problems or dressing changes. The April, 2016 TAR for R23 revealed no evidence of treatments completed on [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. Cross refer to F314 5. Review of the Transfer/ Discharge Report revealed R20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R20 expired in the facility on [DATE]. Review of the CP initiated on [DATE] revealed R20, has actual impairment to skin integrity of the (see below) r/t incontinence: on [DATE], stage 2 right buttocks with TX; on [DATE] wound right buttock stage 2 and stage 2 to coccyx with TX; on [DATE] wound right buttock stage 2, stage 2 sacrum, TX with hydrogel; on [DATE] wound areas to buttocks and sacrum healed; on [DATE] wound stage 2 open area to fissure of buttocks. The CP goal was R20, will maintain or develop clean and intact skin by the review date. Some of the interventions listed were to assess for pain and medicate as ordered, assist with incontinent and TX as ordered. Review of the [DATE] TAR for R20 revealed no evidence of treatments completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the June, 2016 TAR for R20 revealed no evidence of treatments completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] for R20. Review of the July, 2016 TAR for R20 revealed no evidence of treatments was for the entire month. Cross refer to F314 6. R22 was admitted without PSs, he developed two unstageable PSs - one of which was subsequently a stage 4, there was no evidence of assessing or measuring the PUs upon discovery, the PSs were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed. Review of the Transfer/ Discharge Report revealed R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on [DATE] to an assisted living facility. Review of the [DATE] Nursing Admission Data Collection revealed, R22 was admitted without PS. Review of the physician's orders [REDACTED]. Even though this treatment was ordered on [DATE], there was no documented evidence of measurements or wound description elsewhere in the clinical record and there was no evidence of family notification. Review of the [DATE] TAR for R22 revealed no treatments were documented for the entire month; in fact, even though there was a treatment ordered on [DATE], there were no treatments entered on the TAR. Review of the current CP initiated on [DATE] revealed, R22 is at risk for PS development related to Immobility, incontinence bowel and bladder; Noncompliance with going back to bed, wanting to sit up in wheel chair for longer periods than recommended; on [DATE] the IDT discussed the PS as follows: L buttocks stage 4, L heel unstageable DTI continue to tx, on wound MD caseload, on specialty mattress. The care plan goal was R22, will have intact skin, free of redness, blisters or discoloration by/through review date. Some of the interventions listed were on [DATE], wound supplements added, administer medications as ordered. Observe/document for side effects and effectiveness, administer treatments as ordered and observe for effectiveness when there is an open area, complete a full body check weekly and document, follow facility policies/protocols for the prevention/treatment of [REDACTED].e., RD, PT, OT or other. Review of the [DATE] TAR for R22 revealed no evidence of treatments completed for 18 out of 31 opportunities during July. Review of the [DATE] TAR for R22 revealed no evidence of a treatment on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Cross refer to F314 7. R18 was readmitted to the facility from the hospital on [DATE] with multiple unmeasured, unassessed and untreated PSs, the PSs worsened and became infected, and necessitating an emergency room for assessment, treatment and antibiotics, the wounds were not assessed or measured weekly. Review of the Transfer/ Discharge Report revealed R18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current CP initiated on [DATE] and revised on [DATE] revealed R18, has actual PS development related to readmission status, immobility, incontinence of bowel and bladder, [DIAGNOSES REDACTED]. The goal was R18 will have intact skin, free of redness, blisters or discoloration by/through review date; PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were, administer medications as ordered. Observe/document for side effects and effectiveness, administer treatments as ordered and observe for effectiveness, complete a full body check weekly and document, follow facility policies/protocols for the prevention/treatment of [REDACTED].e., RD, PT, OT or Wound MD, observe/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage, provide incontinence care after each incontinence episode, or per established toileting plan, reposition in chair frequently for comfort and pressure reduction. Provide resident/ family education as needed, the resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. The resident requires: Pressure relieving/reducing device on bed and matrix cushion in wheel chair, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Review of the [DATE] TAR for R18 revealed no treatments were documented for the entire month; in fact, even though treatment orders were in place, there were no treatments entered on the TARs. Review of the [DATE] TAR revealed no evidence of a treatment to one or more of the PS to the left 2nd toe, left outer ankle, right top of foot, right outer ankle and right lateral foot on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on [DATE] for R18. Review of the [DATE] TAR revealed no evidence of a treatment to one or more of the PS to the left 2nd toe, left outer ankle, right top of foot, right outer ankle and right lateral foot on ,[DATE] through [DATE] for R18. The Medical Director was interviewed on [DATE] at 7:05 a.m. he said he was aware of some holes on TAR and they discussed in the monthly QA meetings. The Medical Director said they should do a head to toe assessment with every admission. The Administrator and DON were interviewed together on [DATE] at 12:55 p.m. ad confirmed knowledge of the PS problem. Cross refer to F 314 interview 8. The facility failed to provide adequate supervision prevent accidents for R15 who had a history of [REDACTED]. Fall Management, Overview, Practice Guidelines. The resident fell again contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise. Review of the Transfer/ Discharge Report revealed Resident 15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a [MEDICAL CONDITION]. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the [DATE] Care Plan for R15 revealed, which was revised on [DATE], revealed R15 had an actual fall Risk related to: Falls related to her legs giving in the bathroom on [DATE] fall with complaints of pain to right hip. The goal was for R15 to be free from acute fall related injury through next review. The interventions included assist transfers as needed; call light within reach; doctor will review medications and make recommendation if necessary; interdisciplinary team (IDT) referral as needed; refer to rehab for evaluate; use stand up lift as needed. The facility was aware R15 had a history of [REDACTED]. Review of the [DATE] SBAR Communication Form and Progress Note for R15 documented at 4:23 p.m. revealed, at 11:15 a.m. R15 had to be lowered to the floor today while being transferred from bed to her wheelchair. The form did not include what interventions could be put in place to prevent recurrence. Review of the [DATE] SBAR Communication Form and Progress Note documented at 4:39 a.m. revealed, R15 was yelling and found on the floor, needs more constant monitoring and redirection at all times. The form did not indicate what interventions were put in place to prevent recurrence. The Corporate Clinical Auditor (CCA), who was also a registered nurse, was interviewed on [DATE] at approximately 11:30 a.m. She said the SBARs are investigations into the falls and there were no other investigations. She said the process was to discuss the previous day's falls at the daily clinical meeting and weekly at the At Risk meeting. The CCA said, generally, they discussed where the resident was, what happened, was there any injury, what can we do, have interventions worked. She was unable to provide evidence that R15 was discussed at the daily clinical meetings and weekly At Risk meetings regarding R15. Cross refer to F323. Review of the August, 2012, Fall Management, Overview, Practice Guidelines revealed: Each facility will take a proactive approach for new residents admitted and will consider all residents to be at risk for falls until reviewed by the IDT. Each resident is assisted in attaining maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The DON/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Initiate the Interdisciplinary Post Fall Evaluation including the IDT will review all resident falls within ,[DATE] hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. The IDT modifies and implements a CP and treatment approach to minimize repeat falls. The CP will be reviewed/revised as indicated. 10. Review of the Admission Record indicated Resident (R) 183 was admitted with a [DIAGNOSES REDACTED]. Review of the [DATE] quarterly Minimum Data Set (MDS) indicated R183 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated R183 had cognitive impairment. Review of the current CP that was not dated indicated R183 received restorative care, which included a right hand splint per the order. Review of the [DATE] physician order [REDACTED]. Review of the Restorative Aide (RA) [DATE] to [DATE] weekly Restorative Service Delivery Records regarding restorative services did not include information on the use of a splint for R 183. Review of the [DATE], Rehab to Restorative Transition Record indicated the RA was to place the right hand splint on R 183 for 8 hours (off at night) for 12 weeks. Interview with RA170 on [DATE] at 10:13 a.m. and [DATE] at 8:06 a.m., he said on [DATE], he was not educated to place the splint on R 183 and therefore, he did not apply a splint to the R hand of R183. RA 170 said when he was assigned to work as a Certified Nursing Assistant (CNA) and not a RA, the CNA assigned to R183 was to provide restorative services. Interview with CNA181 on [DATE] at 8:28 a.m. and interview with CNA183 on [DATE] at 8:16 a.m., they said although they were assigned to R183, they did not apply a splint to R183. Interview with Unit Manager (UM)162 on [DATE] at 8:32 a.m., she said she did not read the [DATE], Rehab to Restorative Transition Record, until her discussion with the surveyor on [DATE] and therefore, did not educate the RAs regarding the new information on the splint until [DATE]. There were no Resident Restorative Charts prior to [DATE], which included daily restorative documentation. The [DATE] to [DATE] Restorative Charts did not indicate R183 used a splint. The [DATE] Rehab to Restorative Transition Record indicated the RA was to place the R hand splint on R183 for 8 hours (off at night) for 12 weeks. Interview with UM 162 on [DATE] at 8:32 a.m., she said there was no evidence the RAs or CNAs placed a splint on R 183 per the physician order [REDACTED]. R 183 was observed several times during the survey, on [DATE], at 1:55 p.m. and 4:00 p.m., on [DATE] at 9:30 a.m., 1:09 p.m., and 5:00 p.m., and on [DATE], at 10:07 a.m., R183 had his arm placed on the tray on the wheelchair and had no splint on his right arm. Interview with the DON on [DATE] at 12:00 p.m., she said there was poor communication between the therapy department, restorative services, and the nursing department regarding the use of the splint for R 183. The DON said the staff did not apply the right hand splint to R183 per the physician order [REDACTED]. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on [DATE]. Additional training was completed with all active staff by [DATE] including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of [DATE]. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on [DATE] and training was initiated for charge nurses on [DATE] by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by [DATE]. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on [DATE] to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by [DATE]. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on [DATE]. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on [DATE]. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on [DATE]. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on [DATE] to review and approve the plan. The plan was reviewed and approved by the Medical Director. III. A facility wide skin sweep was conducted for residents at risk for pressure sores (PS) on [DATE], [DATE] and [DATE]. Current dressings were observed for placement and appropriate dates by facility staff on [DATE]. Unit managers will observe a minimum of five (5) dressings per week for appropriate placement and dates. Audits of current PS were

Based on observation, interview and record review, the facility failed to ensure residents without pressure sores (PS) did not develop PS; failed to ensure residents with PS did not worsen, and; failed to ensure residents with PS received necessary treatment and services to promote healing for six (6) residents (R18, R20, R22, R23, R25 and R28). The sample was seventy-seven (77) residents. Review of the CMS Form 671, signed and dated by the Director of Nursing revealed a total of ten (10) residents with PS, five (5) of which were acquired within the facility, 109 residents receiving preventative skin care, 2 residents are bed-fast, 94 residents in the bed/chair most of the time, 79 residents incontinent of urine and 68 incontinent of bowel, with 2 residents on a toileting program. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 3:36 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed the facility's failures in measuring, treating, providing consistent power sources for an air mattress, and preventing worsening of pressure sores created a situation of Immediate Jeopardy for serious harm to the residents. Findings include: 1. Review of the clinical record for R28 revealed he was admitted on [DATE] with a stage 4 PS on the buttocks and a stage 2 pressure ulcer on his posterior thigh the PS was not measured at this time or at any time after admission by the nursing staff. There were numerous omissions for the wound treatments. The Wound Doctor (WD) measured the wounds on [DATE] and again on [DATE], the sacral wound had doubled in size and the stage II was actually a stage III. R28's PS were not measured or adequately assessed upon admission, they were not measured/assessed weekly, the initial inaccurate staging of the posterior thigh wound was carried over to the Minimum Data Set (MDS) and Care Plan, treatment orders were omitted, two different treatment orders were in place at one time for the same pressure ulcer, and the air mattress was allowed to deflate leaving the resident to sink down onto the bedframe on the deflated air mattress. R28 was admitted with one (1) Stage 4 PS and one Stage 2 PS (which was inaccurately assessed upon admission and should have been documented as a stage 3). R28 was to have a pressure relieving device for his bed and receive PS care. R28 received suctioning, [MEDICAL CONDITION] and oxygen therapy care. Review of the profile tab in the Electronic Health Record (EHR) revealed R28 was his own responsible party. Review of the [DATE] admission MDS revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS - a cognitive status assessment) meaning he was cognitively intact. R28 was totally dependent on two (2) or more persons for bed mobility and toilet use. R28 received intermittent catherzation and was always incontinent of bowel. R28 was 69 inches tall and weighed 177 pounds. Review of the Transfer/ Discharge Report revealed R28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Nursing Admission Data Collection, revealed R28 was admitted with a PS on the coccyx, which was also described as large sacral wound and a PS on the posterior right thigh however there was no evidence of measurements or further descriptions of the PS. Review of the [DATE] nurse's note for R28 documented at 12:27 p.m., revealed the R28 arrived at facility via stretcher with son and transport, he is alert and verbal with clear speech; has open area to coccyx, packed with hydrogel impregnated gauze and area on R rear thigh, covered with hydrogel and dry dressing. Review of the [DATE] Skin - Head to Toe Skin Checks for R28 revealed a stage 4 on the sacrum and a stage 2 on the posterior right thigh, however there was no evidence of measurements or further descriptions of the wounds. Review of the PS revealed the following: a) Right (R) Posterior Thigh PS: Review of the June, 2016 Treatment Administration Record (TAR) for R28 revealed a the physician order [REDACTED]. Review of the Wound Specialist report dated [DATE] revealed a stage 3 with 100% (w/) granulation (gran) viable tissue; Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, Stage 3 PS; 3 x 3 x 0.1 cm; surface area: 9.0 cm (squared) exudate: Moderate Serous; gran tissue: 100%; dressing: Hydrogel, once daily, dry protective dressing; recommendation: group 2 mattress, off-load wound, reposition per facility protocol. Review of the Wound Report dated on [DATE] revealed a Stage 3 with 15% necrotic (non-viable) tissue, debrided, 20% gran tissue, indicating the PS deteriorated since admission going from 100% granulation/viable tissue to 15% necrotic/non-viable tissue with only 20% granulation tissue; Review of the [DATE], VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed Stage 3; 9 x 1 x 0.1 cm; surface area: 9.0 cm (squared); cluster wound; exudate: light serous, thick adherent devitalized necrotic tissue: 25% gran tissue: 15%; skin: 60%; Wound Progress: no Change; dressing: Hydrogel once daily, dry protective dressing; recommendation: group 2 mattress, off-load wound, reposition per facility protocol; Procedure: Surgical Excisional Debridement of Subcutaneous Tissue; Indication: remove necrotic tissue and establish the Margins of viable tissue; Post-debridement depth (in cm): 0.2. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation revealed a Stage 3; 8 x 1 x 0.1 cm; surface area: 8.0 cm (squared); cluster wound; exudate: light serous thick adherent devitalized necrotic tissue: 15% gran tissue: 20%; skin: 65%; Wound Progress: Improved; Findings that indicate improvement: decreased surface area; dressing: Hydrogel once daily, dry protective dressing; recommendation: off-load wound, reposition per facility protocol; procedure: surgical excisional debridement of subcutaneous tissue; indication: remove necrotic tissue and establish the margins of viable tissue; post-debridement depth (cm): 0.2. Review of the July, 2016 TAR for R28 revealed no evidence of treatment administration to the R posterior thigh PU on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation revealed a Stage 3; 7 x 1 x 0.1 cm; surface area: 7.0 cm (squared); cluster wound; exudate: Light Serous; thick adherent devitalized necrotic tissue: 10% gran tissue: 10% skin: 80%; Wound Progress: Improved; Findings that indicate improvement: decreased surface area; dressing: Hydrogel once daily, dry protective dressing; recommendation: group-2 mattress, off-load wound, reposition per facility protocol; Procedure: surgical excisional debridement of Subcutaneous Tissue; Indication: remove necrotic tissue and establish the margins of viable tissue; Post-debridement depth(cm): 0.2. Review of the August, 2016 TAR for R28 revealed no evidence of treatment administration on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. b) Sacrum/Buttock PS: Review of the [DATE] TAR for R28 revealed an treatment order to cleanse sacral wound with NS, pat dry, pack with hydrogel impregnated gauze, cover with dry dressing every day shift related to pressure ulcer of sacral region unspecified stage. The treatments were provided on [DATE]. Review of the Wound Specialist report dated [DATE] revealed a stage 4 w/100% gran tissue. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed, Stage 4; 4 x 4.5 x 2 cm surface area; 18.00 cm (squared); exudate: Moderate Serosanguinous; gran tissue: 100%; dressing: Silver Absorbing Agent every (Q) shift, dry protective dressing; recommendation: group 2 mattress, limit sitting to 60 minutes, off-load wound, reposition per facility protocol. Review of the [DATE], VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed Stage 4; 8 x 3.5 x 2 cm surface area: 28.00 cm (squared); exudate: Moderate Serosanguinous gran tissue: 100%; wound progress: deteriorated with the findings that indicate deterioration: generalized decline of patient, nutritional compromise, dressing: dry protective dressing change Q shift, leptospermum honey change Q shift; Calcium Alginate; recommendation: group 2 mattress, off-load wound, reposition per facility protocol. Review of the Wound Report dated on [DATE] revealed a Stage 4, with 100% gran tissue, continue TX (treatment) as ordered. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed Stage 4; 7 x 4.5 x 3 cm surface area: 31.5 cm (squared); exudate: Moderate Serous gran tissue: 100% ; wound progress: no change, dressing: dry protective dressing Q shift; leptospermum honey Q shift, Calcium Alginate; recommendation: group 2 mattress, off-load wound, reposition per facility protocol. Review of the July, 2016 TAR for R28 revealed no evidence of treatment administration on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the TAR revealed the treatment for [REDACTED]. [DATE] however there was no evidence of the treatment administered at 9:00 p.m. on [DATE], 9:00 a.m. on [DATE] and 1:00 p.m. on [DATE]. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, Stage 4; 5.5 x 5 x 3 cm; surface area: 27.5 cm (squared); exudate: Moderate Serous; yellow necrotic: 10% gran tissue: 90%; wound progress: improved; findings that indicate improvement: decreased surface area; dressing: dry protective dressing Q shift, leptospermum honey Q shift, Calcium Alginate; recommendation: group 2 mattress, off-load wound, reposition per facility protocol; Procedure: surgical excisional debridement of muscle; Indication: remove necrotic tissue and establish the margins of viable tissue; post-debridement depth (in cm) 3. Review of the August, 2016 TAR for R28 revealed e treatment order for the sacral PU was omitted on [DATE], [DATE], [DATE], [DATE], ,[DATE], ,[DATE], ,[DATE], [DATE], [DATE] and [DATE]. Review of the EHRs progress notes for R28 revealed on [DATE] at 2:29 p.m. revealed a new order for wound vac to Stage IV wound to coccyx, awaiting supplies at this time, MD (physician) and family aware. Review of the EHRs progress notes revealed on [DATE] nurse's note for R28 documented at 3:43 p.m. revealed wound vac applied at this time with no c/o (complaints of) pain or discomfort noted. Review of the EHRs progress notes revealed on [DATE] at 3:29 p.m. revealed wound vac continues to come off with each BM (bowel movement), wound MD to reevaluate today, son aware. The DON was interviewed on [DATE] at 10:25 a.m. She said an X on the TARs and Medication Administration Records (MARs) meant the med/treatment was not due, a check with initials meant the med/treatment was given, a 10 meant the resident refused, and a blank was an omission, That's a hole. The DON also said, regarding medications and treatments, if it was not documented, it didn't happen. Interview with the family member (F1) for R28 on [DATE] at 12:45 p.m. revealed that after admission on [DATE], he asked every day for two weeks to get a power strip for the numerous items R28 required for his care equipment in his room. F1 stated there were too many items to plug in and means for plugging in only 4 items, staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in before they left the room, which caused R28 to sink down onto the bedframe on the deflated air mattress. F1 said R28 needed the air mattress for treating two severe PS. F1 said he finally complained to the NHA and requested the power strip; F1 said the NHA said he was unaware this was an issue and he would find a power strip as soon as possible. F1 said it took a few more days after speaking to the NHA to get the power strip in the room. Even though F1 expressed concerns and staff were aware, there was no documented evidence of staff following up with the concerns to ensure resolution. Specifically: Review of the [DATE] Social Service Note, documented at 9:46 p.m., revealed R28 and family invited to meeting. F1 attended meeting discussed the past medical history and family issue pertaining to health declines for R28. F1 also voiced issue [MEDICAL CONDITION] and wound vac issues. F1 stated that he believe there are disconnects and communication problems within staff members pertaining to care of R28, he also stated that he will hire an investigator and place camera in the room for observation purposes. R28 was observed on [DATE] at 1:35 p.m., with the wound care nurse. The wound care nurse said R28 was admitted with both of his PS, a stage 4 on his sacrum and a stage 2 on his right posterior thigh. She said she did not measure either the wounds, but the Wound Doctor saw R28 weekly, and recommended changes. The wound care nurse said the Wound Doctor also measured the wounds, but did not document in Point Click Care (the facility ' s EHR program), but rather, documented in another computer program for which staff had access ,[DATE]. She said R28's wounds were getting better, initially the posterior thigh wound was much larger and the sacral stage 4 was healing. There was an 8 outlet yellow surge protector power strip taped to the floor between R28 and his roommate - plugged in to the power strip were R28's suction machine, R28's humidifier and the roommate's oxygen concentrator. On [DATE] at 1:45 p.m., staff physician165 (R28's primary care physician) stated R28 was a very sick man when he was admitted due to having a Stage 4 and a Stage 2 pressure ulcer, as well as history of acute [MEDICAL CONDITION] and that he was a quadriplegic. Physician165 stated he had suggested, on more than one occasion, that the son move R28 to a more prominent facility that was staffed with more skilled staff to [MEDICAL CONDITION] wound care, but the son refused to move his father. Physician165 stated he also wanted the resident transferred to a higher acuity level of care as the wounds were not improving as much as he had wanted them to. When asked if he was aware there were no wound measurements in the medical record he stated, No, I was not aware there were not any measurements. He stated he believed the wound doctor, Physician166 was taking measurements but, he had not seen those measurements. He discussed that resident 28's wife had told him she did not feel the wound was getting any worse so, he was not overly concerned as the resident was being followed by the facility wound doctor and staff wound care nurse (LPN117). Physician165 stated that he had many discussions with the son and had advised the family R28 would benefit from a facility that provides a higher level of care such as a hospital or long-term acute care (LTAC). He also stated that on [DATE] he had requested the resident go to the hospital to be evaluated by an infection disease doctor as he suspected R28 had a colonized infection in his trach. He explained the son requested they wait until the following Monday as he wanted to consult some others and decide if he wanted his father sent to the hospital. Physician 165 stated he did not receive a call back from the son, so he ordered a consult from an infectious disease physician to take place at the nursing home. He stated R28 was stable but he continued to believe the resident would benefit from a higher level of care, but family would not allow, so his best course of action was to request the consult. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or his roommate (R29), to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and he directed the Maintenance Director to install a power strip in R28's room. The NHA said both R28 and his roommate (R29) had more medical equipment than they had outlets in the room, so the decision was made to unplug R28's air mattress. He stated the air mattress for R28 was uninflated for a couple of days. The NHA stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The NHA and the Maintenance Director were interviewed on [DATE] at approximately 10:30 a.m. The NHA confirmed F1 talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed for R28. The NHA also confirmed a few days went by before he became aware the power strip was not installed. The NHA said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place for R28. The NHA stated that both R28 and R29 had more medical equipment than they had outlets for and the decision was made to unplug the air mattress for R28. He stated the air mattress was uninflated for a couple of days. R28 had both a Stage 4 and a Stage 2 decubitus ulcer (located on the sacrum area and the upper right thigh). R28 had a physician's orders [REDACTED]. Record review revealed that his wounds had doubled in size as a result. Therefore, R28 was admitted on [DATE], indicating a total of over thirteen (13) weeks, the facility had known that the R28 and R29 did not have enough electrical power outlets to support the ventilator equipment and other needed equipment including pressure prevention mattress for residents with pressure sores, suctioning equipment. cross refer to F 282 for CP details 2. Review of the clinical record for R23 revealed the admission documentation did not include the presence of a PS, there was no evidence of treatments for 4 days after admission, and the PS treatments were not consistently performed. Specifically: Review of the Transfer/ Discharge Report revealed R23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R23 was transferred to the hospital on [DATE]. Review of the [DATE] Nursing Admission Data Collection revealed R23 was admitted with one healed PS on the coccyx with dry [MEDICATION NAME] dressing, however there was no evidence of measurements or further descriptions of the PS. Review of physician's orders [REDACTED]. Review of the nurses' notes for R23 between [DATE] and [DATE] revealed no evidence of a PS, or other skin problems or dressing changes. a) PS to back of inner right thigh: Review of the March, 2016 TAR for R23 revealed an order on [DATE] to cleanse PS to back of inner right thigh with Normal Saline (NS) or Sterile Water. Pat dry. Apply Hydro-Gel and cover with Bordered Opti-Foam Dressing every day shift; then another order on [DATE] for the same wound to cleanse PS to back of inner right thigh with NS or Sterile Water. Pat dry. Apply Hydro-Gel and cover with Bordered Opti-Foam Dressing every day shift, however there is no evidence that this treatment was completed on [DATE]. Review of the April, 2016 TAR for R23 revealed an order to cleanse PS to back of inner right thigh with NS or Sterile Water. Pat dry. Apply Hydro-Gel and cover with Bordered Opti-Foam Dressing every day shift however there is no evidence that this treatment was completed on [DATE], [DATE] and [DATE]. b) PS to the bilateral inner buttock: Review of the March, 2016 TAR for R23 revealed an order on [DATE] to cleanse PS to the bilateral inner buttock with sterile water or NS. Pat dry. Apply Hydro-gel and cover with [MEDICATION NAME] dressing. Secure with [MEDICATION NAME] tape every day shift; then another order on [DATE] for the same wound to cleanse PS to bilateral inner buttock with sterile water or NS. Pat dry. Apply Hydro-gel and cover with [MEDICATION NAME] dressing. Secure with [MEDICATION NAME] tape every day shift, however there is no evidence that this treatment was completed on [DATE]. Review of the April, 2016 TAR for R23 revealed an order to cleanse PS to bilateral inner buttock with sterile water or NS. Pat dry. Apply Hydro-gel and cover with [MEDICATION NAME] dressing. Secure with [MEDICATION NAME] tape every day shift, however there is no evidence that this treatment was completed on [DATE], [DATE] and [DATE]. c) PS to the right buttock: Review of the [DATE] Skin - Weekly PS Record for R23 revealed the resident had a right buttock PS with date of onset as [DATE], continued review revealed that the PS was marked as both existing pressure ulcer and admitted with, however R23 had a PS to the bilateral inner buttock verified by a physician order [REDACTED]. The measurements were 8.0 x 8.0 x 0.3 cm stage II (which was incorrect as an ulcer with depth would not be a stage 2), description of site was R23 admitted here on [DATE] from the hospital, no undermining/tunneling, the wound bed is bright red with a little slough (non-viable tissue also not stage 2) noted, no drainage/ exudate, the Physician and responsible party/ family was notified on [DATE]. R23 cannot feel because of the [MEDICAL CONDITION] diagnosis. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to clean right buttock PS with NS/wound cleanser. Apply skin prep to surrounding skin. Apply Hydrogel to wound bed. Cover with dry dressing. Change daily and as needed (PRN) every day shift, however there is no evidence that this treatment was completed on [DATE] prior to transfer to the hospital. Review of the [DATE] nurse's note for R23 documented at 10:52 p.m. revealed, the daughter complained about the dressing not being changed. CNA remove dressing. Wound clean with wound cleanser hydrogel with dry dressing applied. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to cleanse left and right buttocks with NS or wound cleanser, pat dry. Apply a small amount of [MEDICATION NAME] to wound bed. Cover with [MEDICATION NAME], 4x4s and abdominal (ABD- a broad multilayered absorbent bandage) pad. Secure with tape daily and PRN if soiled every day shift for wound healing, however there no evidence of the treatment was not administered prior to being discontinued on [DATE]. d) PS to the sacrum: Review of the [DATE], Skin - Weekly PS Record for R23 revealed the resident had a sacrum PS with a date of onset on [DATE], continue review revealed that it was recorded as both existing and admitted with. The measurements were 2.5 x 2.0 x 0 cm stage II, description of site included no undermining/tunneling, and the wound bed is red with some pink tissue noted, no drainage / exudate. The physician and responsible party/ family notification date notified on [DATE]. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to cleanse the back of the right thigh with NS. Pat dry. Apply a small amount of triple antibiotic ointment to the wound bed. Cover with bordered gauze daily until healed every day shift for non-pressure wound healing related to PS of sacral region stage 2. The treatment was administered on [DATE], and omitted on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to cleanse sacral area with normal saline or wound cleanser. Pat dry. Apply a small amount of [MEDICATION NAME] to the wound bed. Cover with [MEDICATION NAME] and 4x4s. Cover with a small bordered gauze daily and PRN if soiled every day shift for wound healing, however there no evidence of the treatment administered on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. e) PS to the left buttock: Review of the [DATE] Skin - Weekly PS Record revealed the R23 had a left buttock PS ulcer with onset date of [DATE], continued review of the document revealed the documented was both an existing pressure ulcer and admitted with. The measurements were 5.0 x 3.0 x 0.1 cm stage II, description of site was R23 admitted on [DATE], no undermining/tunneling, the wound bed is red with pink tissue present, no drainage/ exudate. The physician and responsible party/ family were notified on date [DATE]. The next nurse's note for R23 regarding PS, skin problems or dressing changes was documented on [DATE] at 2:07 p.m. Review of resident's wounds on buttocks and sacrum revealed measurements they were listed on weekly report. New treatment orders noted. Spoke with both daughters regarding the wounds. Family member (F2) was interviewed on [DATE] at 9:30 a.m. related to R23 (by State Survey Agency complaint intake staff). F2 said R23 was a nurse and kept asking the staff nurses what the foul smell was, and the staff nurses told her it was nothing. F2 said she pulled off dressing of R23 and found it was oozing pus and had feces in it. F2 said she asked the staff nurse to change the dressing, but the nurse said she would be back because she was busy, F2 left at 11:30 p.m. and the staff nurse still had not returned to change the dressing, so the wound was left open to air and oozing. F2 said the dressing was to be changed daily, but it was not getting done. Review of the subsequent nurses' notes for R23 dated [DATE] transfer to the hospital revealed no documented evidence of wounds, skin problems or dressing changes. The NHA was interviewed on [DATE] at approximately 3:45 p.m. He said there were no wound assessments for R23 by the Wound Doctor. cross refer to F 282 for CP details 3. R25 was interviewed on [DATE] at 10:00 a.m.; he said he was admitted last Tuesday ([DATE]) with a dressing covering his PS on his bottom, he said the dressing fell off on Friday ([DATE]) and he asked the nursing staff to replace the dressing, but no one replaced it, yet, it was bleeding and it hurt. The charge nurse was interviewed immediately after the resident interview, she said she was aware R25 had a PS on admission and it had slough (non-viable tissue) in the wound bed. Review of his record confirmed he was admitted on [DATE] with an unstageable pressure ulcer on his buttocks, and there were no treatment orders in place, even though the resident had been in the facility for 6 days. Specifically: Review of the Transfer/ Discharge Report revealed R25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Nursing Admission Data Collection revealed R25 was admitted with one unstageable PS to buttocks there were no measurements or further descriptions of the wound. Review of the [DATE] nurse's note documented at 11:01 p.m., revealed R25 was alert and oriented x3 (person, place and time). Review on [DATE], of the physician's orders [REDACTED]. The Unit Manager was observed on [DATE] at approximately 10:30 a.m., measuring the PS and applying a dressing. The Unit Manager said the wound measurements were 4.5 x 1.0 cm; she did not give a depth, she did not stage the wound, and she did not describe the PS of R25. She was interviewed immediately after the procedure and confirmed there was no treatment order in place since admission and they just received treatment orders. The Unit Manager provided a copy of the new treatment orders to cleanse right buttock with NS. Pat dry. Apply a small amount of hydrogel to the wound bed using a Q tip. Cover with 4x4s and bordered gauze daily until healed Q day shift for wound care right buttock related to PS of unspecified buttock, unspecified stage. Subsequent record review on [DATE] revealed the nurse did not document her wound measurements or wound assessment. Review of an [DATE] nurse's note documented at 2:20 p.m., revealed R25 has refused to allow CNA (certified nurse aide) to get him cleaned up this entire shift. Nurse has requested that he get up but he has continued to refuse. Review of the August, 2016 MAR/TAR on [DATE] at approximately 3:30 p.m., revealed no documented evidence R28 received any treatments to the PS on his buttocks. cross refer to F 282 for CP details 4. Review of the record for R20 PS were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed. Specifically: Review of the Transfer/ Discharge Report revealed 101year old was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R20 expired in the facility on [DATE]. Review of the PS revealed the following: a). R lower buttock: Review of a [DATE] nurse's note for R20 documented at 7:50 a.m. revealed, CNA was doing pericare for resident for morning care. CNA summoned nurse into room, upon assessment noted to R lower buttock an open area measuring 1.5 cm long x 1.5 long. Physician made aware new order to cleanse with normal saline and apply duoderm and change Q 3 days. Family member needs to be made aware. Made oncoming nurse aware. Review of a [DATE] nurse's note for R20 documented at 8:20 a.m. revealed, spoke with responsible party for R20 made aware of occurrence with open area. Family member is requesting that resident no longer get up with ,[DATE] AM shift. Made oncoming nurse aware to inform Unit Manager of request. Review of the May, 2016 TAR for R20 revealed an order from [DATE] to, cleanse R lower buttock area with NS and apply Duoderm to area every 72 hours. The treatment was administered on [DATE] and on [DATE], there was no evidence of TX administration on [DATE], [DATE] and [DATE]. Review of the May, 2016 TAR for R20 also revealed an order from [DATE] to, Area: R buttock, cleanse area with NS, pat dry, apply hydrogel and cover with adhesive 4x4, change every other day for open area to R buttock. The treatment was administered on [DATE], [DATE], [DATE], and [DATE] and [DATE], there was no evidence of TX administration on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the June, 2016 TAR for R20 revealed an order from [DATE] to, Cleanse R lower buttock area with normal saline and apply duoderm to area every 72 hours. The treatment was administered on [DATE], [DATE], [DATE], [DATE], and [DATE] and on [DATE], and there was no evidence of TX administration on [DATE], [DATE] and [DATE] for R20. Review of the [DATE], the [DATE] Skin - Head to Toe Sk

Based on record review and staff interview, the facility failed to assure that one (1) resident (R6) was free from verbal, rough handling abuse on 6/9/16 by a Certified Nursing Assistant (CNA) 68. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. This failure caused actual harm to R6. The facility failed to prevent R6 from verbal, emotional and physical abuse by staff, failed to investigate the allegation of abuse in a timely manner, failed to take immediate action to suspend the alleged perpetrator and protect other residents during the investigation, according to the facility policy, placed other residents at risk for serious injury or harm. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F223 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). Cross refer to F225 and F226 Findings include: Review of a facility policy, dated 7/16/16, received on 8/8/16 at 4:40 p.m., from the Corporate Nurse as current, indicated: Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Nursing Home Administrator (NHA) and/or Director of Nursing (DON). Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Injuries of unknown origin may occur as a result of abuse. The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility. Prevention includes: 1. Residents, families, and staff will be able to report incidents and concerns without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring Investigation includes: 1. the facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. 2. The facility will report such allegations to the state within 24 hours. 3. The facility will report all investigation findings to the state within 5 calendar days; Protection includes: 1. the facility will protect residents from harm during the investigation .Reporting and Response 1. The facility will report all allegations and substantiated occurrences of abuse, neglect .to the state agency and law enforcement officials within 24 hours of identification. Review of the Facility Incident Report Form faxed to the State Survey Agency (SSA), dated 6/17/16, indicated, the date and time of incident was on 6/9/16 during the 7-3 shift; Details of incident indicated that a new Certified Nursing Assistant (CNA) ZZ wrote statement, stating that during her orientation, while precepting with another CNA68 she witnessed CNA68 be rough while dressing R6. And stated to R6 'we not going to do this[***]' Continued review of the Facility Incident Report Form revealed that the Steps taken by facility to prevent further incidents: This CNA68 was removed from the schedule pending investigation. R6 was assessed for any physical injury, none noted. Review of a fax, dated 6/22/16, to the SSA indicated (the final five (5) day report of the investigation); The Event report was discovered on 6/16/16 from a new CNA ZZ who reported an incident that happened while she precept with another CNA68 during her orientation. On 6/9/16, she observed a resident (R6) being handled rough and that CNA68 stated to R6 'we are not going to do this[***]today.' The orientee noticed that R6 had tears in her eyes after they put the resident in her wheelchair. The DON went to assess R6 for any signs of and or visible injuries. None were noted. A review of the record for R6 revealed that she had her skin assessment completed by the charge nurse on 6/15/16, which did not indicate any injuries. The physician and family member of R6 was notified of the reported incident. Investigation: CNA ZZ is new to the facility and was in orientation/precepting with CNA68 who has been employed for two (2) years. The Unit Manger spoke with CNA68 who was suspended pending investigation of patient care issues. The Staff Development Nurses and Unit Manager spoke with the new CNA ZZ who identified the resident as being R6 she provided a statement under the NHA's door. Upon the DON getting the statement it did not identify the resident. Question as to what was doing and she stated, CNA68 leaning over R6 trying to put her top on. She saw CNA68 snatch R6 arm while putting her clothes on and said to her We are not going to do this[***]today. CNA ZZ stated that she started to put the pants on R6 and then transferred her to the chair, then she noticed tears on her face. She gave R6 a wash cloth to clean her face and R6 stated to her 'no you do it.' Question as to, if R6 said anything during the care with CNA68, she said no. Conclusion based on the investigation the allegation of physical and verbal abuse can be substantiated, CNA68 employment will be separated from the facility and her name will be reported to the local police and Certified Nursing Board registry. R6 and her family will be notified of facility finding. Review of the statement by CNA ZZ, dated 6/15/16, indicated I am writing this statement in reference to an incident in which I witnessed on 6/9/16. I was helping R6 with an RCA (Resident Care Assistant) or (CNA); CNA68 while dressing the resident CNA68 snatched the residents arm and pulled her around and stated 'we are not going to do this[***]' After we got the resident in her wheelchair I noticed she had tears going down her face. This situation made me very uncomfortable. Review of the nurses notes, dated 6/17/16, and documented the resident was identified by a CNA ZZ that the R6 was mishandled by another CNA68 in an on-going investigation of patient care. R6 was assessed for any visible bodily injuries, none noted. A review of her weekly Skin Assessment on 6/15/16 did not reveal any injuries, nor skin impairments. Medical Doctor (MD) and family made aware of investigation. Review of a statement from the family of R6, dated 6/20/16, indicated documented on Tuesday 6/14/16 her mother (R6) was more agitated and didn't want CNA68 to touch her, as reported 6/17/16. Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. Review of a quarterly MDS (Minimum Data Set) assessment, dated 7/20/16, indicated that R6 was unable to complete the interview for mental status. She was dependent with two (2) person assist for transfers, dressing, toilet use, and bathing. Review of a Kronos Punch Detail (time report) for June 2016, indicated CNA68 had worked at the facility on 6/9/16, 6/10/16, 6/14/16, and had worked on 6/15/16 from 6:34 a.m. to 3:06 p.m. During an interview on 8/9/16 at 11:00 a.m., the NHA indicated he had been on vacation when the abuse allegation was reported on 6/17/16. During an interview on 8/9/16 at 11:45 a.m., the Unit Manager (UM), Registered Nurse (RN) 60, indicated she found out about the incident on 6/9/16 by CNA ZZ. The Unit Manager RN60 indicated she had changed the assignment for CNA68 to the top of the hall so she would not be taking care of the resident. Unit Manager RN60, indicated she then realized she had the wrong resident and found out on 6/10/16 it was R6. She indicated the CNA ZZ had told another CNA that CNA68 had handled R6 rough. The Unit Manager indicated she had told the Staff Development Coordinator (SDC) and the DON about the abuse incident on 6/10/16. The Unit Manager indicated CNA ZZ was off the next day and they had called her to come in to Get a statement. The Unit Manager RN60 stated I was in the office when the DON called her. CNA ZZ came in on the 15th or 16th for the statement. The Unit Manager RN60 indicated CNA68 had worked on the 14th and 15th of June 2016. The Unit Manager indicated she had suspended CNA68 on 6/15/16. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. ***The State survey agency validated the corrective action taken by the facility as follows: Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ, observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report.

Based on staff interview and record review, the facility failed to follow their policy and procedure for investigation of allegations of abuse, reporting allegations to the state agency (SSA) within twenty-four (24) hours, failed to provide protection of residents during investigation of alleged abuse, for one (1) resident (R6) who was verbally, emotionally and physically abused on 6/9/16. The facility failed to report the incident to the State Survey Agency (SSA) in accordance with their policy, failed to implement their policy on abuse including reporting, investigating, and failed to assure protection of R6 and other residents in the facility immediately following the report of alleged abuse and failed to train all staff members in Abuse Policies and Procedures. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) related to failure to report, failure to protect residents from abusive behavior by a Certified Nursing Assistant (CNA) who verbally, emotionally and physically abused R6; failed to investigate the allegation of the abuse within twenty-four (24) hours of becoming aware of the abuse; failed to adhere to the facility's policy related to abuse and failed to report to the SSA within the 4 hours of becoming aware. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F226 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). Cross refer to F223 and F225 Findings include: Review of a facility policy, dated 7/16/16, received, from the Corporate Nurse as current, indicated; Each Resident has the right to be free from mistreatment, neglect, abuse .; Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Administrator and/or Director of Nursing; Abuse means the willful infliction of injury .; The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility; Prevention includes; Residents, families, and staff will be able to report incidents and concerns without fear of retribution; Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect .; Investigation includes; The facility will conduct an investigation of any alleged abuse/neglect . in accordance with state law. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated; The facility will report such allegations to the state within 24 hours; The facility will report all investigation findings to the state within 5 calendar days .; Protection includes, The facility will protect residents from harm during the investigation .Reporting and Response includes, The facility will report all allegations and substantiated occurrences of abuse, neglect .to the state agency and law enforcement officials within 24 hours of identification. Review of the statement by CNA ZZ, dated 6/15/16, revealed .I am writing this statement in reference to an incident in which I witnessed on 6/9/16. I was helping R6 with an RCA (Resident Care Assistant) or (CNA); CNA68 while dressing the resident CNA68 snatched the residents arm and pulled her around and stated 'we are not going to do this[***]' After we got the resident in her wheelchair I noticed she had tears going down her face. This situation made me very uncomfortable. Review of a Facility Incident Report Form faxed to the SSA, dated 6/17/16, indicated, A new Certified Nurse Aide (CNA) ZZ wrote statement, stating that during her orientation, while precepting with another CNA68 she witnessed CNA68 be rough with resident (R6) while dressing her and stated to the resident 'we are not going to do this[***]' Review of a statement from R6 family, dated 6/20/16, revealed on Tuesday 6/14/16 her mother was more agitated and didn't want CNA68 to touch her, as reported 6/17/16 Review of the clinical record for revealed a [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment, dated 7/20/16, indicated the resident was unable to complete the interview for mental status. She was dependent with two person assist for transfers, dressing, toilet use, and bathing. Interview on 8/9/16 at 11:45 a.m., the Unit Manager Registered Nurse (RN) 60, confirmed that she found out about the incident on 6/9/16. RN60 reported the event to the Staff Development Coordinator and the DON, however, review of the record for R6 revealed that she had her skin assessment completed by the charge nurse on 6/15/16, which did not indicate any injuries. Review of the nurses notes, dated 6/17/16, and documented the resident was identified by a CNA ZZ that the R6 was mishandled by another CNA68 in an on-going investigation of patient care. R6 was assessed for any visible bodily injuries, none noted. A review of her weekly Skin Assessment on 6/15/16 did not reveal any injuries, nor skin impairments. M.D. and family made aware of investigation. Review of a Kronos Punch Detail (time report) for June 2016, revealed CNA68 had worked at the facility on 6/9/16, 6/10/16, 6/14/16, and had worked from 6:34 a.m. to 3:06 p.m. on 6/15/16. Interview on 8/9/16 at 11:45 a.m., the Unit Manager Registered Nurse (RN) 60 indicated she found out about the incident on 6/9/16. The Unit Manager RN60 indicated she had changed CNA68's assignment to the top of the hall so she would not be taking care of the resident. Unit Manager RN60 indicated she then realized she had the wrong resident and found out on 6/10/16 it was R6. She indicated the new CNA had told another CNA that CNA68 had handled R6 rough. The Unit Manager RN60 indicated she had told the Staff Development Coordinator and the DON about the abuse incident on 6/10/16. The Unit Manager indicated the new CNA was off the next day and they had called her to come in and get a statement. The Unit Manager RN60 stated I was in the office when the DON called her. The Unit Manager RN60 indicated the new CNA came in on the 15th or 16th for the statement. The Unit Manager RN60 indicated CNA68 had worked on the 14th and 15th of June 2016. The Unit Manager indicated she had suspended CNA 68 on 6/15/16. Review of the resident's record indicated a lack of documentation of any Social Service notes for the month of June 2016. Interview on 8/9/16 at 11:00 a.m., the Administrator confirmed he reported the abuse allegation on 6/17/16, which was 8 days after the abuse, and 8 days after the Unit Manager RN 60, reported it to the DON. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. ***The State survey agency validated the corrective action taken by the facility as follows: Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ - observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report.

Based on record review and interviews, the facility failed to investigate an allegation of abuse, failed to report to the State Survey Agency (SSA) within twenty-four (24) hours, failed to protect residents from during the investigation of alleged abuse, failed to report the findings of a substantiated allegation of verbal and physical abuse, which occurred on 6/9/16, within 24 hours for one (1) resident (R6) reviewed for abuse. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). The facility failed to report to the State Survey Agency (SSA) in a timely manner, a substantiated allegation of verbal and physical abuse, which occurred 6/9/16. The facility incident report was not sent to the SSA until 6/17/16, which was eight (8) days after the incident. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F225 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). cross refer to F223 and F226 Findings include: Review of a fax sent to the SSA Complaint and Intake Unit, dated 6/22/16, indicated: a report was discovered on 6/16/16 from a new Certified Nursing Assistant (CNA) ZZ who reported an incident that happened involving her preceptor CNA68 during her orientation. On 6/9/16, she observed R6 being handled rough and that CNA68 stated to the resident We are not gonna do this[***]today. CNA ZZ noticed R6 had tears in her eyes after they put the resident in her wheelchair. The DON (Director of Nursing) went to assess R6 for any signs of and or visible injuries. None were noted. (cross refer F223 for details and interviews). Conclusion: Based on the investigation the allegation of physical and verbal abuse can be substantiated. CNA68 employment will be separated from the facility and her name will be reported to the local police and Certified Nursing Board registry. Review of the clinical record for R6 included [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment, dated 7/20/16, indicated the resident was unable to complete the interview for mental status. She was dependent with two (2) person assist for transfers, dressing, toilet use, and bathing. Review of a facility policy, dated 7/16/16, received on 8/8/16 at 4:40 p.m., from the Corporate Nurse as current, indicated; the facility will report such allegations to the state within 24 hours. The facility will report all investigation findings to the state within 5 calendar days. The facility will report all allegations and substantiated occurrences of abuse, neglect to the state agency and law enforcement officials within 24 hours of identification. Interview on 8/9/16 at 11:00 a.m., the NHA indicated he had been on vacation and reported the abuse allegation on 6/17/16 to the SSA. Interview on 8/9/16 at 11:45 a.m., the Unit Manager Registered Nurse (RN) 60, indicated she found out about the incident on 6/9/16. Unit Manager RN60 indicated she then realized she had the wrong resident and found out on 6/10/16 it was R6. The Unit Manager RN60 indicated she had told the Staff Development Coordinator (SDC) and the DON about the abuse incident on 6/10/16. The Unit Manager RN60 indicated the new CNA (referring to CNA ZZ) was off the next day and they had called her to come in and get a statement. Unit Manager RN60 indicated the new CNA ZZ came in on the 15th or 16th for the statement. Unit Manager RN60 indicated CNA68 had worked on the 14th and 15th of June 2016. The Unit Manager indicated she had suspended CNA68 on 6/15/16. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. ***The State survey agency validated the corrective action taken by the facility as follows: Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is NHA and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ - observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report.

Based on interview and record review, the facility failed to ensure a safe environment for three (3) residents (R15, R28 and R29). Specifically, the facility: a). failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. R15 sufferred actual harm when she fell again contributing to an additional hip fracture which led to her ultimate demise, and; b). failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip, this resulted in actual harm when the facility unplugged the pressure prevention mattress used for R28 who had severe pressure sores. (cross refer to F314) The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Review of the CMS Form 672, signed and dated on [DATE] by the Director of Nursing revealed a total of 10 residents ambulated, 3 ambulated with assistance, 2 are bedfast, and therefore at least a total of 97 residents are at fall risk. Findings include: 1. Review of the Transfer/ Discharge Report revealed R15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a fractured hip. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the hospital records [DATE] History and Physical revealed This patient is a very pleasant, [AGE] year-old with a known history of heart failure, chronic pain, neuropathy, spinal stenosis, and generalized debility, who apparently has been having pain in her right lower extremity for the past several days. According to her son, the R15 has not incurred any falls; however, he was informed last Thursday that the R15 had gently slumped to the ground. He states that ever since that time, she has been having severe right lower extremity pain. She has been working with physical therapy with regards to the pain, but it has not gotten any better. He reports that over the last couple of days, the mental status of R15 has somewhat declined and she has become a little bit more confused. This is usually indicative of a urinary tract infection and this prompted the nursing facility to send R15 to the emergency room , R15 underwent a workup, which revealed a distal femur fracture, as well as a urinary tract infection, acute kidney injury and hyperkalemia. Given these issues, the patient has been admitted for further evaluation and treatment. Review of the [DATE] nursing note for R15 documented at 7:25 a.m. revealed, on last rounds at about 6:50 am, assessment the right hip surgical site staples intact, moderate amount dark colored blood was observed sipping out from between the staples. The surgical site surrounding skin was also noted to be warm and tender to touch with slight discoloration. Resident c/o pain to area; Percocet ,[DATE] mg given and she was repositioned with assistance of another nurse for comfort; administered analgesic result pending. BLE (bilateral lower extremity) also remain edematous (non-pitting), both elevated on pillow and heels floated on pillow. No noted acute respiratory distress. O2 (oxygen) via NC (nasal cannula) at 2L/min (2 liters per minute). HOB (head of bed) remains elevated. AM nurse arrived on the unit early and went in the room with writer to assess as well; she took over resident's care at this time - following up with (physician). Unit manager was also made aware/assess site. Review of subsequent nursing notes on [DATE] for R15 revealed a wound culture was taken of the right leg surgical wound. Doppler results were negative for blood clot and the resident was started on an antibiotic to rule out infection. Review of the [DATE] Situation, Background, Assessment and Recommendation Communication Form (SBAR) and Progress Note for R15 revealed documented at 4:23 p.m. revealed, at 11:15 a.m. R15 had to be lowered to the floor today while being transferred from bed to her wheelchair. The operation site on her right hip was bleeding. She also has a skin tear on her right ankle that was bleeding. Vitals are within normal limits. Resident's (son) and (physician) notified. A stat X-ray of right hip and femur has been ordered. Skin tear on right ankle has been cleaned with normal saline and covered with a bandage. Operation site on right hip has been cleaned with normal saline and covered with a bandage. The form did not include evidence of a thorough investigation into the root cause of lowering her to the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what staff thought happened, whether staff education would be beneficial or what interventions could be put in place to prevent recurrence. Review of nursing notes on [DATE] for R15, revealed the hip wound was monitored, there was no drainage, an X-ray revealed intact hip arthroplasty no change and no new orders. Review of the [DATE] X-ray results for R15 revealed, anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Conclusion: Intact bilateral hip prostheses. Review of the nursing notes on [DATE] for R15 revealed the resident was sent to the hospital and returned without new orders. Review of the nursing notes for R15 between [DATE] and [DATE], revealed R15 continued on antibiotic for right thigh surgical site infection, diagnosed with [REDACTED]. ([DATE] CXR right lower lobe infiltrate) Review of the [DATE] nursing note for R15 documented at 2:49 p.m. revealed, resident alert, returned from (orthopedics appointment) during this some discomfort noted - PRN (as needed) medication administered during this time. Resident sutures removed and TX (treatment) to lower right leg is to be d/c (discontinued), also noted resident is to have :no weight bearing until follow-up visit on [DATE]. Review of the [DATE] SBAR Communication Form and Progress Note for R15 documented at 4:39 a.m. revealed, R15 was yelling and found on the floor, resident was re-directed to call for assistance and continuous monitoring; said she wanted to get out of the bed, was very anxious yelling (did) not pay attention at all when (being) directed with what to do, needs more constant monitoring and redirection at all times. Frequent family visits to keep resident accompany. The form did not include evidence of a thorough investigation into the root cause of how she ended up on the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what the resident was doing last time staff checked on her, what staff thought happened, whether staff education would be beneficial or what interventions were put in place to prevent recurrence. Review of the [DATE] nursing note for R15 documented at 8:41 a.m. revealed, R15 was very anxious, yelling and was found on the floor at 4:30 am by the charged nurse and resident care specialist. Assessment was done and vital signs taken. Assisted back to bed with hoyer lift. Denies any pain distress discomfort. Redirected to call for assistance and safety intervention for floor mat to be on the floor while resident in the bed. Will continue with plan of care. Review of the [DATE] X-ray results for R15 revealed, there is prosthetic right femoral head in proper alignment with respect to the acetabulum. There is no fracture or acute dislocation. The prosthesis is properly situated without any loosening. Pubic rami are normal. Conclusion: Intact right hip arthroplasty, unchanged from [DATE]. Review of subsequent nursing notes for R15 on [DATE] revealed the resident was confused, calling out for help throughout the night, received an order for [REDACTED]. Review of the [DATE] nursing note for R15 documented at 12:48 a.m., revealed the physician was called about the resident's complaints of pain and ordered an X-ray of the right hip. Review of the [DATE] nursing note for R15 documented at 11:46 a.m. revealed, R15 continues to c/o pain to her left hip per therapy. This author asked resident if she was having pain now. Resident stated, 'No not when I am sitting down.' This author notified MD and new order was received for an AP and lat (X-ray) of the left hip. Resident continues to yell out when someone goes into her room she is quiet asking them to keep her company. Will continue to monitor. Review of the [DATE] X-ray results for R15 revealed, Hip unilateral w (with) pelvis ,[DATE] V (view) left; comparison: [DATE]/ 2016; Findings: Anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Review of the [DATE] nursing note for R15 documented at 2:57 p.m. revealed, report of the entire xray was read to (physician). No new orders recd (received) for the UA results which was called to the (physician). This author called the residents granddaughter (name) who said my dad is on a plane and he will not be back for a week. Labs were drawn and she understands that the results will be recd on tomorrow. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 7:48 a.m. revealed, R15 is alert, yelling please get me out of bed. Nurse noted resident has legs on the side of the bed, with linen covers off of her. Nurse place resident legs into bed. Nurse returned to find resident had removed her legs to the rt. side of bed. Floor mat is in place, bed is in lowest position for safety precautions. Nurse will continue to monitor. Review of the [DATE] nursing note for R15 documented at 8:24 a.m. revealed, noted left lower leg black bruised. Edema in both lower legs. Resident is very agitated vitals not stable, in bed sleeping legs elevated. Review of the [DATE] nursing note for R15 documented at 8:27 a.m. revealed, upon assessment noted dark purple discoloration noted to left lower extremity. 3+edema noted to bilateral lower extremity. Denies pain/discomfort. Foot of the bed elevated. Called the physician made aware. New order noted venous Doppler done to bilateral lower extremities. Review of the [DATE] nursing note for R15 documented at 6:50 a.m. revealed, called the X-ray provider to receive copy of result from venous Doppler. Awaiting results. Resident rested well throughout the shift. Received results. Passing along to day shift nurse to report results to physician. Review of the [DATE] nursing note for R15 documented at 8:19 a.m. revealed, gave report to (physician) about resident's results from venous Doppler lower bilateral extremities. Made aware that results stated indeterminate for deep vein thrombosis and it recommends for test to be repeated. New order to have test repeated and begin resident on (blood thinners). Review of the [DATE] nursing note for R15 documented at 11:45 a.m. revealed, report was called to the hospital at 11 am and resident left the facility via ambulance accompanied by two emergency medical technicians (EMTs). Review of the [DATE] nursing note for R15 documented at 12:03 p.m. revealed, R15 was admitted to the hospital today. Review of the [DATE] nursing note for R15 documented at 3:55 p.m. revealed, abnormal lab work returned and call placed to physician informed of possible Deep Vein Thrombosis (DVT) per Doppler results study. New order noted to send out to hospital emergency room for evaluation and repeat Doppler study related to left (L) lower extremity. Review of the hospital record's for R15 dated [DATE] documented, history and physical revealed Chief Complaint: leg pain. History of present illness: This is a [AGE] year-old with a history of congestive heart failure, hip fracture, which was apparently atraumatic. The patient had an ORIF performed on [DATE]. The patient had a hospitalization complicated by a urinary tract infection. The patient has a questionable history of diastolic heart failure and was on lasix and the patient was discharged to a rehab facility. At the rehab facility, the patient was sub acutely complaining of pain around the prosthesis. The patient's complaints got worse. The patient had no [DIAGNOSES REDACTED], wound drainage, etc. No shortness of breath, no chest pain, no fever, no chills. She was brought back to the emergency room and a periprosthetic fracture was noted, Past surgical history: ORIF in [DATE], right hip fracture and repair in 2008 is status [REDACTED]. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. They have decided on palliative care on left lower extremity (LLE), pain with motion at L hip, right lower extremity (RLE) , incision healed well. RLE; R15 is non-ambulatory at baseline. Proceed (with) palliative care as decided by family. NWB (non-weight bearing) LLE and NWB RLE; May work on transfers and pain control. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. NWB status. Palliative care managing pain. Review of the [DATE] nursing note for R15 documented at 8:22 p.m. revealed, return from hospital at this time, Resident was admitted to hospice at this time see new orders in place. Review of nursing notes between [DATE] and [DATE] for R15 revealed the resident was in a lot of pain, medicated for pain with routine and PRN meds, and frequently called out in pain. Review of the [DATE] nursing notes for R15 documented at 9:58 a.m. revealed, Placed a call to physician to verify medication made physician aware that the resident is on scheduled medication, educated physician the resident is yelling help, help, and she is in pain. Family member had concerns resident is in pain was not being controlled. Resident has no labored breathing. Resident is in bed in lowest position with mats in place. Will continue to monitor resident. Review of the [DATE] nursing note for R15 documented at 4:58 a.m. revealed, Resident was yelling throughout the night. Upon entering resident's room she stated I don't know what's wrong with me. Stated she was in pain, gave PRN methadone, also gave Ativan 1 mg due to anxiety. Bed in lowest position with mats in place. Resident is on 3L of O2 via nasal cannula. No shortness of breath noted. Respirations even and unlabored. Will continue to monitor resident. An anonymous interested party (AIP) was interviewed on [DATE] at 9:00 a.m., by the State Survey Agency complaint intake staff. The AIP said the facility was responsible for R15's recent hip fracture, due to gross negligence and the resident was subsequently put on hospice services. Review of the [DATE] nursing note for R15 documented at 11:36 p.m. revealed, Resident and family members invited to 72 hr (hour) care conference meeting today, discussed in details hospice procedure and services that will be provided for resident. Also discussed pain and agitation medication that's will be provided by hospice. Social Worker requested that family provide personal sitter for resident for so many hours throughout the day according to their preference, (family member) stated that it's very hard to see his mother decline and he's unable to do more for her, he latter stated that he will sit down with his family and discuss issues and concerns that was discussed in this meeting. Review of the [DATE] nursing note for R15 documented at 9:58 a.m. revealed, Resident is in coma state at this time, hospice nurse at bedside, son at bedside. Review of the [DATE] nursing note for R15 documented at 7:52 p.m. revealed, On arrival today to 2nd shift, resident was unresponsive, (about 5:45 p.m.) Resident began moving around and yelling as usual. She received her afternoon meds as requested per (family). For now her vitals look ok and she is alert and stable. Review of the [DATE] nursing note documented at 2:52 p.m. revealed, Resident has eyes open-glossy and fixated, respirations labored. Resident has family at bedside during this time. Review of the [DATE] nursing note for R15 documented at 11:32 p.m. revealed, Resident alert new orders in place. Resident condition changed hospice notified. resident pain meds administered tolerated well, family members at bedside will continue to monitor. Review of the [DATE] nursing note for R15 documented at 6:20 a.m. revealed, Resident was alert and speaking out hello. Family member at bedside. Review of the [DATE] nursing note for R15 documented at 11:44 a.m. revealed, Resident is on Hospice. Moaning and body movements noted . Resident is resting peacefully . Family at bedside. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 4:24 p.m. revealed, Resident awake and alert at intervals. Total care provided per nursing and hospice care in all aspects of daily living. Resident turned and repositioned for comfort q (every) 2 hrs and as requested. Pain medication administered as scheduled, to include break thru pain relief. Medication effective. Review of the [DATE] nursing note for R15 documented at 2:45 p.m. revealed, resident in comatose state . labored breathing upon assessment wet. (R15) has family member at bedside at this time. Review of the [DATE] nursing note for R15 documented at 5:47 p.m. revealed, no pulse no respiration no blood pressure. (Hospice) notified to come to facility to pronounce patient at this time. Hospice nurse arrived at 6:00 pm. to assess patient and to do pronouncing of patient family at bedside. The Corporate Clinical Auditor (CCA), who was also a registered nurse, was interviewed on [DATE] at approximately 11:30 a.m. She said the SBARs are investigations into the falls and there were no other investigations. She said the process was to discuss the previous day's falls at the daily clinical meeting and weekly at the At Risk meeting. The CCA said, generally, they discussed where the resident was, what happened, was there any injury, what can we do, have interventions worked, some will fall, prevent injuries. She said she was not there when R15's falls were discussed. When asked for evidence of what was discussed at the daily clinical meetings and weekly At Risk meetings regarding R15, the CCA said she could provide fall protocols, but did not have documented evidence of the meetings. Review of the August, 2012 Fall Management, Overview, Practice Guidelines revealed: Each resident is assisted in attaining maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Each facility will take a proactive approach for new residents admitted and will consider all residents to be at risk for falls until reviewed by the IDT. A fall Care Plan will be initiated upon admission for each resident. When a fall occurs, assess resident for injury. The Licensed Nurse will complete: Incident/ Accident Report (Briggs); 24 Hour Report (Briggs); and Initiate the Interdisciplinary Post Fall Review. Communicate all resident falls to the attending physician and the resident's family and document on the Interdisciplinary Post Fall Review form . The licensed nurse documents family/responsible party and physician notification on the Interdisciplinary Post-Fall Review form and places the completed form in the Nurse's Notes section of the Medical Record. The nurse will communicate the resident fall to the IDT via the 24 Hour Report (Briggs). The IDT will review all resident falls within ,[DATE] hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. OPTIONAL: Fall information may be added to the Electronic Care Management Board (ECMB) if so desired for tracking purposes. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. The RCS (certified nurse aide) Assignment Sheets/ Care Kardex are updated as appropriate. The IDT will complete the Interdisciplinary Post Fall Review (see forms tab). The In-House Communicator form (Briggs) should be used to make referrals to appropriate IDT members. IMPORTANT: A Change of Condition form must be completed, if indicated by resident assessment. The Director of Nursing or designee will document falls on the Incident/Accident Report QA&A (Quality Assurance & Assessment) Log and the Individual Resident Fall QA&A Log (see forms tab) as they occur and submit reports to risk management system as indicated. Risk management system reports may be used, if desired, to complete tracking/trending reports for QAPI (Quality Assurance Performance Improvement). The NHA was interviewed on [DATE] at approximately 4:00 p.m. He said the facility was already cited deficient practice for R15 on a previous complaint ending on [DATE]. 2. R28 was observed on [DATE] at 1:35 p.m. with the wound care nurse. The wound care nurse said R28 was admitted with both of his pressure ulcers, a stage 4 on his sacrum and a stage 2 on his right posterior thigh. The wound care nurse confirmed there was an 8 outlet yellow surge protector power strip taped to the floor between R28 and his roommate - plugged in to the power strip were R28's suction machine, R28's humidifier and the roommate's oxygen concentrator. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or R29, who were roommates, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to install a power strip in R28's room. The NHA said both R28 and R29 had more medical equipment than they had outlets in the room. The NHA stated that a decision was made to unplug the bed of R28 for a few days. The NHA stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The NHA and the Maintenance Director were interviewed on [DATE] at approximately 10:30 a.m. The NHA confirmed R28's family member (F1) talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed. The NHA also confirmed a few days went by before he became aware the power strip was not installed. The NHA said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place.

Based on the findings of deficient practices identified during the Complaint Survey, from 8/8/16 through 11/9/16, demonstrated that the facility failed to ensure the Quality Assurance Committee developed and implemented appropriate plans of action to correct identified quality deficiencies to attain the residents' highest practicable physical, mental, and psychosocial well-being. The facility also failed to identify additional quality deficiencies which had the potential to affect all residents. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on 6/9/16 (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of pressure ulcers to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. Findings include: Non-compliance was determined to constitute substandard quality of care and Immediate Jeopardy to resident health and safety for the following requirements: F223, failure to protect residents from abuse; F225, failure to investigate and report substantiated abuse in a timely manner; F226 Abuse, failure to implement the facility policy for abuse to protect all residents during the investigation of an allegation of abuse; F314 Pressure Ulcers, failure to prevent development of pressure ulcers,failure to prevent worsening of pressure ulcers, and failure to provide treatments as ordered; and F328 Respiratory/Tracheostomies, failure to ensure respiratory equipment needed was available. Additional deficient practices cited that had the potential to affect all 149 residents included: F495, Nurse Aide Competency, failure to provide new Certified Nurse Aides (CNAs) with 16 hours of training prior to direct contact with residents and failure to ensure CNAs were proficient in performing the [MEDICATION NAME] Maneuver; and Findings include: 1. The QaPI committee failed to ensure that residents were free of abuse. On 6/9/16, R6 was verbally, emotionally and physically abused by facility staff. In addition, this is a repeat deficiency which was cited on 1/21/16, related to abuse, which was cited at IJ, and the facility achieved compliance on 3/10/16, this was discussed in QaPI, including an action plan, and QaPI reporting for 3 months, at which time QaPI would determine any additional recommendations. Once the NHA was made aware of the alleged neglect/abuse the perpetrators continued to work at the facility. Additionally, once becoming aware of the allegations, the administrator failed to notify the SSA, there was no documented evidence the NHA suspended the alleged perpetrators, investigated the incident and reported the incident to the appropriate SSA. It is noted that the NHA was not present at the time of the incident, however the NHA was the NHA at the facility when the allegation was made, and is responsible for the lack of action and compliance with the Federal Guidelines. Cross refer F 157, F223, F225 and F226 for details 2. Resident Rights/Notification of Changes: The facility failed to notify the family and physician in a timely manner of an allegation of abuse for 1 (R6) cross refer to F223, 225, F226; failed to notify responsible parties of a residents with a pressure ulcer cross refer to F314; and failed to notify the physician as ordered related to insulin and when blood sugar assessment (cross refer to F309. Quality Assurance Performance Improvement (QAPI) Review of the QAPI meeting minute's summary, dated 6/22/16 revealed the facility had identified a system issue in regards to Medication Management/[MEDICAL CONDITION] Management during this meeting. The comments/documentation section revealed the following findings in pertinent part; Identified issue with blood sugar and insulin; Plan to Discuss B/S policy and potential issues; Discuss changes in practice and process with Medical Director. Initiate follow up BS process auditing for August 2016 (Standing Order Process with expectations of delivery) Revisit and Reeducate on sliding scale protocol. Education to clinical team on process/policy. Implementing a random audit to review BS's weekly or monthly as identified to assure clinical compliance. Create Performance Improvement Project when interim DON starts. Adding clinical team audit of glucose/glucometer review. Review of the QAPI Performance Improvement Project (PIP), with an initiated date of 7/26/16, with, Medication Administration Part 2, identified under the heading, Opportunity for Improvement. The PIP team members identified were the interdisciplinary team, DON, Unit Managers and the Pharmacy. The status identified that it was in process with an anticipated completion date of 8/30/16. The Plan identified the following 5 headings; SMART Goal (Objective for Improvement) Diabetes Management; Baseline Measure: Holes in the Medication Administration Record (MAR), Inconsistent documentation of interventions initiated for high BS and Low BS and Medical Doctor (MD) notification of any new orders, Inconsistent documentation of follow up. All BS over 250 at HS require MD notification; Root Cause: Inconsistent staffing-Unit managers working the floor at times. Multiple medications per resident, multiple interruptions during med pass. Nurses not documenting and following up; Obstacles: Agency nurses used. Inconsistent staffing, and knowledge deficits; Projected Outcome: Diabetes management requires both preventative measures and treatment of [REDACTED]. The PIP identified the following 4 action items: Additional training specific to diabetes management, to include appropriate assessment of hypo/hyperglycemic episodes; Agency nurses to have minimum of 2 hours of orientation prior to working the floor; Ensure accuchecks are being done consistently and timely, through daily audits and weekly thereafter; Daily monitoring of nurse ' s progress notes, and holes in the MAR and weekly thereafter. A document titled, Ad Hoc QAPI Meeting Agenda/Summary with a meeting date of 7/29/16 was received from the DON at 10:00 a.m. on 8/11/16. The persons in attendance were the Administrator, DON and the Medical Director. Blood Sugar was one of the items identified for opportunity of improvement and the date the PIP was initiated was 7/29/16. On 8/10/16 at 7:08 a.m., the Medical Director stated, he attended Quality Assurance (QA) and at every meeting nursing staff, medication issues and pharmacy issues were brought up. He stated the sliding scale protocol was that anything below 70 if alert, awake and talking, the resident should be given something to eat or given [MEDICATION NAME]. If over 400 they notify the MD as there is no hours of sleep (HS) coverage. He was informed the facility's Diabetes Management (DM) policy did not match the parameter on the MAR and the parameter did not address what a low BS was and what to do. The Medical Director was not aware the policy and parameters differed and he was not aware nursing staff had different responses to what constituted a low BS. He said the facility needed to be concerned with [DIAGNOSES REDACTED] as nursing needs to notify the MD, re-check the BS and document in the nursing notes. The Medical Director stated, they (the facility) can't get people to work, many nurses have been fired for not performing and they have been forced to use agency staff. On 8/11/16 at 3:05 p.m., the Administrator and DON were asked about the Quality Assurance (QA) process. At 3:06 p.m. the Administrator stated the QA committee members included the Administrator, Medical Director, DON, Medical Records staff (S163), MDS and the Social Worker (SW158). The Administrator stated he was in the process of bringing back resident interviews related to the ABAQIS questions done and these will be done randomly throughout the month. The QA team reviews the previous health surveys monthly until the next visit. The agenda is the tool used to review month to month. The QA team used different tools, such as clinical issues, discuss any other topics discussed in stand up meetings, CASPER reports and they try to get at the root causes. The Medical Director will bring issues that he has been running into from residents and his peers. They look for patterns of non-compliance. S163 reviews different resident medical records audits and brings issue to QA. He discussed that action plans are developed when the committee decides what issues need to have QAPI/PIP plans. At times, the QA team will decide that a concentrated focus on areas they feel are critical will require a plan and will continue to focus on solutions for other non-pressing issues unless they continue to see the same problem. He further discussed the facility has had some periodic issues before but really noticed the issue in June/July. He stated he waited until July as he was looking for the root cause and pattern. On 8/11/16 at 3:16 p.m., the DON stated, she knew she had to address critical issues the day she came in the door. On 8/11/16 at 3:17 p.m., the Administrator did not have an answer for why he did not have a plan in place prior other than he was trying to determine the root cause. He stated, he felt the holes in the MAR and BS issues were first noticed in July but, he did not have the minutes in front of him. He stated the previous DON was responsible for ensuring that the MAR's were being reviewed. He discussed he did not feel he was getting the right answer from the DON, and that he had a philosophy, trust but verify and he started doing random MAR checks himself. He was unable to find a direct answer of why the issue was occurring. The issue was discussed in the July QA and the plan was held for a week so the new DON could give input into the plan. The Corporate RN Clinical Auditor (S155) was also assisting, as does the corporation's regulatory compliance and he wanted her input. He discussed that S155 was there in May 2016 for another unrelated issue. He requested she stay to give a more detailed focus to the current identified issues. He discussed that although he had not implemented any changes the team had been monitoring. The DON and Administrator both stated the plan was to be implemented this week, but survey delayed this. When asked why they had not implemented part of their QAPI that was identified in late July and signed by him, DON and S161 on 7/29/16, a week before survey team entered, he stated, they had begun the 2 hour training with the agency staff. He also felt there had been many staff challenges, education gaps regarding documenting in the Electronic Medication Administration Record (EMAR) and the use and high percentage of unit agency in the building. Currently they are using multiple agencies to cover the staffing issues. It is currently the DON who will ensure the education regarding the identified issues are being done and she will do that by being present with the Staffing Development Coordinator (SDC) during the education. 3. Treatment/Services to Prevent and/or Heal Pressure Ulcers: The facility failed to ensure residents without pressure ulcers did not develop pressure ulcers, and failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for six (6) residents (R18, R20, R22, R23, R25 and R28). The facility's failures to measure and treat pressure ulcers for 6 residents and provide consistent power sources for an air mattress for 1 (R28) resident with numerous medical devices/equipment to prevent the worsening of 2 pressure ulcers (Stage 2 and Stage 4), created a situation of Immediate Jeopardy for serious harm to the residents. Reference F314 for additional information. On 8/12/16 at 1:45 p.m., staff physician165 (R28's primary care physician) stated R28 was a very sick man when he was admitted due to having a Stage 4 and a Stage 2 pressure ulcer, as well as history of acute [MEDICAL CONDITION] and that he was a quadriplegic. Physician165 stated he had suggested, on more than one occasion, that the son move R28 to a more prominent facility that was staffed with more skilled staff to [MEDICAL CONDITION] wound care, but the son refused to move his father. Physician165 stated he also wanted the resident transferred to a higher acuity level of care as the wounds were not improving as much as he had wanted them to. When asked if he was aware there were no wound measurements in the medical record he stated, No, I was not aware there were not any measurements. He stated he believed the wound doctor, Physician166 (wound doctor) was taking measurements but, he had not seen those measurements. He discussed that resident 28's wife had told him she did not feel the wound was getting any worse so, he was not overly concerned as the resident was being followed by the facility wound doctor and staff wound care nurse (LPN117). Physician165 stated he knew the resident was admitted with a Stage 4 wound on his coccyx and a Stage 2 on his upper right thigh. He stated he was not consulted regarding whether or not to accept R28 into the facility. Physician165 stated that he had many discussions with the residents' son and had advised the family R28 would benefit from a facility that provides a higher level of care such as a hospital or long-term acute care (LTAC). He also stated that on 8/6/16 he had requested the resident go to the hospital to be evaluated by an infection disease doctor as he suspected R28 had a colonized infection in his trach. He explained the son requested they wait until the following Monday as he wanted to consult some others and decide if he wanted his father sent to the hospital. The Administrator was interviewed on 8/12/16 at approximately 3:36 p.m. The Administrator said there were not enough outlets for R28 or his roommate, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and he directed the Maintenance Director to install a power strip in R28's room. The Administrator said both R28 and his roommate had more medical equipment than they had outlets in the room, so the decision was made to unplug R28's air mattress. He stated the air mattress was uninflated for a couple of days. The Administrator stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The Administrator and the Maintenance Director were interviewed on 8/13/16 at approximately 10:30 a.m. The Administrator confirmed F1 talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed. The Administrator also confirmed a few days went by before he became aware the power strip was not installed. The Administrator said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place. The Medical Director was interviewed on 8/10/16 at 7:05 a.m. He said he was aware of some holes on MARs/Treatment Administration Record (TARs) and they discussed in the monthly QA meetings. The Medical Director said they should do a head to toe assessment with every admission. The Administrator and DON were interviewed together on 8/11/16 at 12:55 p.m. The DON said she started on 7/25/16 and she identified immediately holes in MARs/TARs. She said she was planning on doing weekly audits . getting people in place . takes a little time . 1 QAPI (Quality Assurance Performance Improvement) ready to implement and do skin sweep on Monday (8/8/16) when you all walked in . if I had a month, I could've gotten my hands around it . hired a wound nurse . Wound Doctor comes weekly - will see who we need. The DON said she thought the problems arose from staffing challenges, switching to an electronic medical record and increased use of agency nurses. The DON said she wanted to make sure the treatments were being done, making rounds, monitoring the wound nurse, measuring appropriately, started going through pressure ulcers, discussing in At Risk meeting, developed wound log for pressure ulcers with resident name, type of wound, measurement and treatment . treatments were now being done on a consistent basis; however, the investigation revealed multiple problems with measuring, assessing, providing treatments and preventing new or worsening pressure ulcers. 4. Treatment/Care for Special Needs, Respiratory/[MEDICAL CONDITION] Care: The facility failed to ensure all necessary respiratory related medical equipment was readily available for two (R28 and R29) of 2 sample residents reviewed with tracheostomies; and failed to ensure a safe and appropriate power source was available for their medical equipment. The failures put these residents at risk of serious harm or death. Necessary equipment for potential respiratory distress was not available to include required back-up replacement inner cannulas in the event theirs became dislodged and required emergency replacement (Ambu bags -manual resuscitators- for both residents, and correctly sized replacement inner cannulas for their tracheostomies). These residents were roommates and both required more electrical outlets (7 for R28 and 6 for R29) than the room provided (4 were available per resident). The facility used power strips to provide the extra power source for medical equipment which did not meet Life Safety Code standards. Refer F328 On 8/12/16, at approximately 1:00 p.m., the Director of Nursing (DON) was interviewed and informed they did not have the properly sized inner cannulas in the room. She immediately went to the room with the same staff nurse (LPN117) observed during wound care, and returned with a size 4 cannula that she said was found in a drawer. That observation was not confirmed and the equipment needed to be readily accessible (as in taped above the bed of each [MEDICAL CONDITION] patient) was not available when surveyors observed the room. Nor was LPN117 able to verbalize where that cannula was when asked by the surveyor during the initial observation of R28 during wound care. When notified of the IJ situation (F328), on 8/12/16, at approximately 3:36 p.m., the Administrator stated that they did not have enough outlets for either resident to accommodate their medically necessary, physician ordered, equipment. He stated that when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to take and install a power strip in R28's room. The NHA stated that both R28 and R29 had more medical equipment than they had outlets for and the decision was made to unplug the air mattress for R28. He stated the air mattress was uninflated for a couple of days. R28 had both a Stage 4 and a Stage 2 decubitus ulcer (located on the sacrum area and the upper right thigh). R28 had a physician's orders [REDACTED]. Record review revealed that his wounds had doubled in size as a result. Cross refer F314. 5. F281, Services Provided Meet Professional Standards: Based on interview and record review, the facility failed to ensure acceptable professional standards were implemented for 1 of 29 sampled residents (R21). Specifically, failed to ensure changes in respiratory status were assessed and monitored as expected for R21, and; failed to ensure timely administration of medication to residents. This had the potential to affect the residents on the unit who received medications. Reference F281 for additional information. 6. Free of Accident Hazards/Supervision/Devices: Based on interview and record review, the facility failed to ensure a safe environment for 3 of 29 sampled residents (R15, R28 and R29). Specifically, failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. The resident fell again contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise; and failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip. Reference F323 for additional information. 7. Nurse Aide Competency: Based on record review and staff interview, the facility failed to ensure that all Certified Nursing Assistants (CNAs) received the required 16 hours of training before any direct contact with the resident. Specifically, they did not ensure their CNAs were proficient in the [MEDICATION NAME] maneuver. This failure put all residents at potential risk for adverse outcome in a choking event. Reference F495 for additional information. The facility failed to ensure that all Certified Nurse Aides (CNAs) received the required 16 hours of training before any direct contact with residents. Specifically, they did not ensure their CNAs were proficient in the [MEDICATION NAME] maneuver. This failure put all residents at potential risk for adverse outcome in a choking event. According to the Resident Census and Conditions Report completed by the facility during the survey, the facility census was 149. Both the NHA and the HMR stated they were not aware of the specific requirement to ensure their CNA staff were proficient in the [MEDICATION NAME] maneuver. They both acknowledged that residents in their facility were at a higher risk of choking due to age, [DIAGNOSES REDACTED]. They were also not aware that an evaluation of competency (for all skills required) was necessary to ensure their ability to provide this life-saving technique in an emergency where a resident might be choking. Reference F495 for additional information. 8. Responsibilities of Medical Director: Based on observation, interview and record review, the Medical Director failed to ensure that residents received the appropriate treatment and care to achieve the highest possible well-being as evidenced by the number of residents affected by Immediate Jeopardy (IJ). Reference F501 for additional information. 9. Resident Records-Complete and Accurate: Based on observation, interview and record review, the facility failed to ensure electronic Medication Administration Records (MAR) for 4 Residents (R) (R11, R20, R23 and R27), and the Kiosk Care Tracker/Plan of Care (POC) utilized for documenting Activities of Daily Living (ADL) for 3 Residents (R11, R20, and R23) of 30 residents reviewed were complete; and failed to document the admission of enteral feedings for 1 resident (R9) who had a feeding tube out of 30 sampled residents during the Complaint Survey. The information contained in these documents is essential for determining the resident's progress including response to treatment, change in condition, and changes in treatment. Reference F514 for additional information. 10. Written Plans to Meet Emergency/Disaster Needs: Based on observation, staff interviews and record review, the facility failed to ensure they had a Disaster Manual readily available on all units; that the staff knew where to obtain that information; and that their Emergency Contact list of phone numbers was accurate and up-to-date. Reference F517 for additional information. Each of the aforementioned surveys had a plan of correction which included monitoring and reporting to QAPI, based on the evidence of the current survey and the repeated serious deficiencies QAPI is not monitoring, evaluating and implementing changes in the facility.

Based on observation, interview, and record review, the facility was not administered in an effective manner, utilizing all its resources, [MEDICAL CONDITION] care, insulin and blood sugar monitoring, pressure sore management, completion of medical record, supervision to prevent accidents, privacy/dignity, indwelling urinary catheter management, contracture management, medication administration timely, development/revision and implementation of care planning, for twenty-four (24) residents (R4, R5, R6, R9, R10, R14, R15, R18, R19, R22, R10, R18, R19, R20, R22, R23, R24, R25, R27, R28, R29, R32, R183 and R231), and dietary management to prevent food borne pathogens. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on 6/9/16 (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of pressure ulcers to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. Findings include: 1. The NHA failed to ensure that a family was notified of an allegation of abuse (R6), development of pressure sores, and blood sugar monitoring results below seventy (70) for five (5) residents (R6, R22, R10, R19, R24). Cross refer to F157 for details Review of the facility's Diabetic Management Policy most recently revised in June 2008 Notify the physician of abnormal blood glucose test results and symptoms exhibited; Notify the physician of abnormal blood glucose test results, symptoms exhibited and interventions implemented. Cross refer to F157 Review of a facility policy, dated 7/16/16, received, from the Corporate Nurse as current, indicated; Each Resident has the right to be free from mistreatment, neglect, abuse. Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Administrator and/or Director of Nursing. 2. The NHA failed to ensure that one resident (R6) on 6/9/16 from verbal, emotional and physical abuse by staff. The facility was aware of the alleged abuse on 6/9/16, the perpetrator continued to work. Interview on 11/8/16 at 2:20 p.m. with the NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Cross refer to F223 for details The NHA failed to report to the State Survey Agency (SSA) a substantiated allegation of verbal and physical abuse, which occurred on 6/9/16. The facility incident report was not sent to the SSA until 6/17/16, which was eight (8) days after the incident. The final investigation report was not sent to the SSA until 6/22/16, which was thirteen (13) days after the incident. Cross refer to F225 for details The NHA failed to report, failed to protect residents from the increased likelihood of abusive behavior by a Certified Nursing Assistant (CNA) who verbally, emotionally and physically abused (R6), failed to investigate the allegation of the abuse timely, failed to adhere to the facility's policy related to abuse and failed to report to the SSA as required. Review of a facility policy, dated 7/16/16, received, from the Corporate Nurse as current, indicated; Each Resident has the right to be free from mistreatment, neglect, abuse. Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the NHA and/or Director of Nursing. Interview on 11/8/16 at 2:20 p.m. with the NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Cross refer to F226 for details In addition, this is a repeat deficiency which was cited on 1/21/16, related to abuse, once the NHA was made aware of the alleged neglect/abuse the perpetrators continued to work at the facility. Additionally, once becoming aware of the allegations, the administrator failed to notify the SSA, there was no documented evidence the NHA suspended the alleged perpetrators, investigated the incident and reported the incident to the appropriate SSA. It is noted that the NHA was not present at the time of the incident, however the NHA was the NHA at the facility when the allegation was made, and is responsible for the lack of action and compliance with the Federal Guidelines. 3. The NHA failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two residents (R28, R29) that had tracheostomies and required multiple medical apparatus. Interview on 8/12/16, at approximately 12:45 p.m., with the son went on to state the facility did not have enough electrical sockets to plug in all of the equipment need for R28. The son explained the NHA had stated he was unaware that this was an issue and he would find a power strip as soon as possible. The son reported it took a few more days after speaking to the NHA to get the power strip. Cross refer to F281, F328, and F 517 for details The NHA failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for six residents (R18, R20, R22, R23, R25 and R28). The NHA was interviewed on 8/12/16 at approximately 3:36 p.m. and said there were not enough outlets for R28 or his roommate (R29), the NHA said both R28 and his roommate (R29) had more medical equipment than they had outlets in the room, so the decision was made to unplug R28's air mattress. He stated the air mattress for R28 was uninflated for a couple of days. The DON and NHA were interviewed on 8/11/16 at 12:55 p.m. The DON said she started on 7/25/16 and she identified immediately the holes in TARs. Interview on 8/11/16 at 3:17 p.m., the NHA did not have an answer for why he did not have a plan in place prior other than, he was trying to determine the root cause. He stated, he feels that the holes in the MAR and BS issues were first noticed in July 2016 but, he did not have the minutes in front of him. The failed to ensure residents without pressure ulcers did not develop pressure ulcers, failed to ensure residents with pressure ulcers did not worsen, and failed to ensure residents with pressure ulcers received necessary treatment and services to promote healing for six residents (R18, R20, R22, R23, R25 and R28); failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two (R28, R29) residents that had tracheostomies and required multiple medical apparatus. Cross refer to F 282, F314 for details 4. The NHA failed to ensure that residents who receive insulin and blood glucose monitoring were completed according to facility policy for eleven residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27). Interview on 8/11/16 at 3:17 p.m., the NHA did not have an answer for why he did not have a plan in place prior other than, he was trying to determine the root cause. He stated, he feels that the holes in the MAR and BS issues were first noticed in July 2016 but, he did not have the minutes in front of him. Cross refer to F281, F309, and F514 5. The NHA failed to ensure that privacy was provided for R30 and R10 during activities of daily living (ADL's) during personal care, and failed to respect the privacy for R4 with an uncovered indwelling catheter bag being exposed while up in the common areas. Cross refer to F164 6. The NHA failed to ensure that a Care Plan (CP) was initiated and/or revise related to use of a right arm sling for R183 and failed to ensure that a CP was developed and/or revise Care Plan related to behaviors for R39. Cross refer to F279 and F318 7. The NHA failed to ensure there was a physician's orders [REDACTED]. 8. The NHA failed to ensure adequate supervision to prevent accidents/falls, and failed to ensure the Fall Management policy was implemented including investigation of falls for R15 suffered actual harm when she fell again contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise. 9. The NHA failed to ensure cold foods were stored, served at appropriate temperatures and failed to ensure food holding temperatures were measured and recorded per the facility policy, therefore a total of one-hundred-three (103) residents are at risk to food borne pathogens. 10. The NHA failed to ensure the Quality Assurance Committee developed and implemented plans of action to correct identified quality deficiencies. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by August 13, 2016. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. III. A facility wide skin sweep was conducted for residents at risk for pressure sores (PS) on 8/12/16, 8/13/16 and 8/14/16. Current dressings were observed for placement and appropriate dates by facility staff on 8/13/16. Unit managers will observe a minimum of five (5) dressings per week for appropriate placement and dates. Audits of current PS were completed 8/16/16 to assure treatments are in place for each wound and are written appropriately. PS will be reviewed by the interdisciplinary team weekly at the scheduled AT RISK meetings. The facility Medical Director will be notified for any needed changes. An audit was conducted by the District Director of Clinical Services on 8/13/16 for wounds assessed by the wound physician to determine if there was any deterioration of existing wounds since his visit on 8/5/16. The District Director of Clinical Services (DDCS) and/or designee will attend at least one at Risk meeting per month to determine if further audits are needed. The following education began on 8/12/16 and will be completed by 9/2/16 for the licensed nurses by the DON/Nursing Administration including: Assessment, measurements, staging and documentation of wounds upon admission; Obtaining/entering treatment orders into the computer upon admission/identification of new pressure areas, and; Documentation of treatments provided. Licensed staff not scheduled to work on 8/12/16, will receive education prior to the start of their next shift. Training and education regarding the Skin System has been integrated into the orientation process of new licensed nursing staff and agency nurses. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting was held 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee meeting for review and further recommendations. ***The State survey agency validated the corrective action taken by the facility as follows: I. Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ, observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report II. Review of physician orders [REDACTED]. Observation on 8/18/16 at 9:00 a.m. verified that both R28 and R29 were not in the facility. Interview on 8/18/16 at 9:05 a.m. with Admissions Coordinator verified that the facility had not admitted any future residents with higher acuity of tracheotomies until additional specialized training is completed for licensed nurses. Observation on 08/18/16 at 9:10 a.m. with DON, revealed that the Admission Grid was updated to include rooms that could be used to admit any future high risk respiratory tracheotomies (trach) residents to facility. The DON confirmed that the facility will not admit residents [MEDICAL CONDITION] trained Respiratory Therapist being on staff and all licensed nurses have completed specialized training. Review of a skills check list related to the treatment of [REDACTED]. III. Review of the PS education re-training in-service sign in sheet revealed any employee that has not received the education will not work until the education is completed with competence exam check off signatures. Interview on 8/16/16 at 10:14 a.m. with the DON, NHA verified the facility implemented the updated policy on dressing changing and proper dressing placement for all licensed nursing staff members. Interview on 8/18/16 at 10:00 a.m. the NHA verified the facility conducted an Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting. Review of the signature sheet revealed all disciplines signatures were present on 8/12/16, and that the Medical Director was in attendance. The NHA stated that if a serious situation occurred he notified the Medical Director. Interview on 8/19/2016 at 11:04 a.m. with the Administrator revealed there has not been another QAPI committee meetings since the meeting on 8/12/16 to evaluate reports, audits and monitoring tools, and this will be reviewed in the next monthly QAPI meeting. Review of the sign in sheets revealed that thirty nine (39) out of sixty-five (65) Licensed Nurses (LNs) received education on Wound Care Prevention and Treatment on 08/12/16, including that all current and newly admitted residents would be provided wound care treatments as ordered by Physician and weekly skin documentation will be completed, including; Assessment, measurements, staging and documentation of wounds upon admission; Obtaining/entering treatment orders into the computer upon admission/identification of new pressure areas, and; Documentation of treatments provided. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed he was made aware during survey in August 2016 of the concerns related to the PS. The PS were discussed in the QA meeting and a plan was made to do a skin sweep. The Medical Director stated he was satisfied with the skin sweep, and they changed their wound care physician. The Medical Director stated that everyone should be notified immediately as soon as a PS is found, including the family. The Medical Director stated that he is receiving the PS report every week and was seeing great improvement overall. He revealed that he was involved with the plan to complete a skin sweep and over saw the project. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON was conducted. NHA stated the problem with PS had been identified in July 2016, however it was decided to wait until the current DON (started employment on 7/26/16) was present to implement any plans of improvement. When notified, a skin sweep of entire facility residents occurred, during the skin sweep, the physician and families were notified. An Ad Hoc 8/1/2016 QA meeting was conducted and plan of action and/or Allegation of Compliance (AoC) was developed, approved and implemented. The NHA and DON confirmed that the Quality Improvement Organization (QIO) was contacted immediately following the August 2016 survey. Interview on 8/18/16 at 9:15 a.m. with DON and Admission Coordinator provided education to all licensed staff to ensure all high acuity residents with tracheotomies will not be admitted to the facility without trained Respiratory Therapist being on staff and all licensed nurses completed specialized training. Review of employee training education signature sheets verified the facility implemented new protocol on [MEDICAL CONDITION] for [MEDICAL CONDITION]. Interview on 8/18/16 at 9:25 a.m. the Nursing Home Administrator (NHA) confirmed he is actively recruiting respiratory therapist. Review of the Northeast Atlanta Health and Rehabilitation Center Electrical Safety/Non-Use of Power Strips for Medical Equipment log training log verified that two (2) of two maintenance staff received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16. In addition, it was verified that ninety-six (96) of a total of one-hundred ninety-one (191) facility employees received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16 and 8/13/16. Interview on 8/19/16 at 11:04 a.m. with the facility NHA confirmed a 100% room audit was completed for appropriate electrical outlets and all power strips were removed from resident rooms on/or before 8/13/16. Observation on 8/19/16 beginning at 11:04 a.m. with the facility NHA and Maintenance Director confirmed there were no power strips in any resident rooms on the East, West and Terrace Units of the facility therefore validating there were no rooms with power strips; the Admission Board, in the Admissions Office to have blue dots identifying a total of eight (8) rooms with red emergency electrical boxes capable of safely providing power to suctioning and similar equipment related to tracheotomy care. Review of the Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting signature sheet revealed all disciplines signatures were present. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director acknowledged becoming aware of the ventilator issues during the survey. He continued to state it is never ok to use a power strip for medical equipment, and the residents were immediately they were transferred. The facility p

Based on observation, interview and record review, the facility failed to ensure residents without pressure sores (PS) did not develop PS; failed to ensure residents with PS did not worsen, and; failed to ensure residents with PS received necessary treatment and services to promote healing for six (6) residents (R18, R20, R22, R23, R25 and R28). The sample was seventy-seven (77) residents. Review of the CMS Form 671, signed and dated by the Director of Nursing revealed a total of ten (10) residents with PS, five (5) of which were acquired within the facility, 109 residents receiving preventative skin care, 2 residents are bed-fast, 94 residents in the bed/chair most of the time, 79 residents incontinent of urine and 68 incontinent of bowel, with 2 residents on a toileting program. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On [DATE] at 3:36 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed the facility's failures in measuring, treating, providing consistent power sources for an air mattress, and preventing worsening of pressure sores created a situation of Immediate Jeopardy for serious harm to the residents. Findings include: 1. Review of the clinical record for R28 revealed he was admitted on [DATE] with a stage 4 PS on the buttocks and a stage 2 pressure ulcer on his posterior thigh the PS was not measured at this time or at any time after admission by the nursing staff. There were numerous omissions for the wound treatments. The Wound Doctor (WD) measured the wounds on [DATE] and again on [DATE], the sacral wound had doubled in size and the stage II was actually a stage III. R28's PS were not measured or adequately assessed upon admission, they were not measured/assessed weekly, the initial inaccurate staging of the posterior thigh wound was carried over to the Minimum Data Set (MDS) and Care Plan, treatment orders were omitted, two different treatment orders were in place at one time for the same pressure ulcer, and the air mattress was allowed to deflate leaving the resident to sink down onto the bedframe on the deflated air mattress. R28 was admitted with one (1) Stage 4 PS and one Stage 2 PS (which was inaccurately assessed upon admission and should have been documented as a stage 3). R28 was to have a pressure relieving device for his bed and receive PS care. R28 received suctioning, [MEDICAL CONDITION] and oxygen therapy care. Review of the profile tab in the Electronic Health Record (EHR) revealed R28 was his own responsible party. Review of the [DATE] admission MDS revealed he scored 15 out of 15 on the Brief Interview for Mental Status (BIMS - a cognitive status assessment) meaning he was cognitively intact. R28 was totally dependent on two (2) or more persons for bed mobility and toilet use. R28 received intermittent catherzation and was always incontinent of bowel. R28 was 69 inches tall and weighed 177 pounds. Review of the Transfer/ Discharge Report revealed R28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Nursing Admission Data Collection, revealed R28 was admitted with a PS on the coccyx, which was also described as large sacral wound and a PS on the posterior right thigh however there was no evidence of measurements or further descriptions of the PS. Review of the [DATE] nurse's note for R28 documented at 12:27 p.m., revealed the R28 arrived at facility via stretcher with son and transport, he is alert and verbal with clear speech; has open area to coccyx, packed with hydrogel impregnated gauze and area on R rear thigh, covered with hydrogel and dry dressing. Review of the [DATE] Skin - Head to Toe Skin Checks for R28 revealed a stage 4 on the sacrum and a stage 2 on the posterior right thigh, however there was no evidence of measurements or further descriptions of the wounds. Review of the PS revealed the following: a) Right (R) Posterior Thigh PS: Review of the June, 2016 Treatment Administration Record (TAR) for R28 revealed a the physician order [REDACTED]. Review of the Wound Specialist report dated [DATE] revealed a stage 3 with 100% (w/) granulation (gran) viable tissue; Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, Stage 3 PS; 3 x 3 x 0.1 cm; surface area: 9.0 cm (squared) exudate: Moderate Serous; gran tissue: 100%; dressing: Hydrogel, once daily, dry protective dressing; recommendation: group 2 mattress, off-load wound, reposition per facility protocol. Review of the Wound Report dated on [DATE] revealed a Stage 3 with 15% necrotic (non-viable) tissue, debrided, 20% gran tissue, indicating the PS deteriorated since admission going from 100% granulation/viable tissue to 15% necrotic/non-viable tissue with only 20% granulation tissue; Review of the [DATE], VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed Stage 3; 9 x 1 x 0.1 cm; surface area: 9.0 cm (squared); cluster wound; exudate: light serous, thick adherent devitalized necrotic tissue: 25% gran tissue: 15%; skin: 60%; Wound Progress: no Change; dressing: Hydrogel once daily, dry protective dressing; recommendation: group 2 mattress, off-load wound, reposition per facility protocol; Procedure: Surgical Excisional Debridement of Subcutaneous Tissue; Indication: remove necrotic tissue and establish the Margins of viable tissue; Post-debridement depth (in cm): 0.2. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation revealed a Stage 3; 8 x 1 x 0.1 cm; surface area: 8.0 cm (squared); cluster wound; exudate: light serous thick adherent devitalized necrotic tissue: 15% gran tissue: 20%; skin: 65%; Wound Progress: Improved; Findings that indicate improvement: decreased surface area; dressing: Hydrogel once daily, dry protective dressing; recommendation: off-load wound, reposition per facility protocol; procedure: surgical excisional debridement of subcutaneous tissue; indication: remove necrotic tissue and establish the margins of viable tissue; post-debridement depth (cm): 0.2. Review of the July, 2016 TAR for R28 revealed no evidence of treatment administration to the R posterior thigh PU on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation revealed a Stage 3; 7 x 1 x 0.1 cm; surface area: 7.0 cm (squared); cluster wound; exudate: Light Serous; thick adherent devitalized necrotic tissue: 10% gran tissue: 10% skin: 80%; Wound Progress: Improved; Findings that indicate improvement: decreased surface area; dressing: Hydrogel once daily, dry protective dressing; recommendation: group-2 mattress, off-load wound, reposition per facility protocol; Procedure: surgical excisional debridement of Subcutaneous Tissue; Indication: remove necrotic tissue and establish the margins of viable tissue; Post-debridement depth(cm): 0.2. Review of the August, 2016 TAR for R28 revealed no evidence of treatment administration on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. b) Sacrum/Buttock PS: Review of the [DATE] TAR for R28 revealed an treatment order to cleanse sacral wound with NS, pat dry, pack with hydrogel impregnated gauze, cover with dry dressing every day shift related to pressure ulcer of sacral region unspecified stage. The treatments were provided on [DATE]. Review of the Wound Specialist report dated [DATE] revealed a stage 4 w/100% gran tissue. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed, Stage 4; 4 x 4.5 x 2 cm surface area; 18.00 cm (squared); exudate: Moderate Serosanguinous; gran tissue: 100%; dressing: Silver Absorbing Agent every (Q) shift, dry protective dressing; recommendation: group 2 mattress, limit sitting to 60 minutes, off-load wound, reposition per facility protocol. Review of the [DATE], VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed Stage 4; 8 x 3.5 x 2 cm surface area: 28.00 cm (squared); exudate: Moderate Serosanguinous gran tissue: 100%; wound progress: deteriorated with the findings that indicate deterioration: generalized decline of patient, nutritional compromise, dressing: dry protective dressing change Q shift, leptospermum honey change Q shift; Calcium Alginate; recommendation: group 2 mattress, off-load wound, reposition per facility protocol. Review of the Wound Report dated on [DATE] revealed a Stage 4, with 100% gran tissue, continue TX (treatment) as ordered. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, revealed Stage 4; 7 x 4.5 x 3 cm surface area: 31.5 cm (squared); exudate: Moderate Serous gran tissue: 100% ; wound progress: no change, dressing: dry protective dressing Q shift; leptospermum honey Q shift, Calcium Alginate; recommendation: group 2 mattress, off-load wound, reposition per facility protocol. Review of the July, 2016 TAR for R28 revealed no evidence of treatment administration on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the TAR revealed the treatment for [REDACTED]. [DATE] however there was no evidence of the treatment administered at 9:00 p.m. on [DATE], 9:00 a.m. on [DATE] and 1:00 p.m. on [DATE]. Review of the [DATE] VOHRA Wound Physicians Wound Care Specialist Evaluation, Stage 4; 5.5 x 5 x 3 cm; surface area: 27.5 cm (squared); exudate: Moderate Serous; yellow necrotic: 10% gran tissue: 90%; wound progress: improved; findings that indicate improvement: decreased surface area; dressing: dry protective dressing Q shift, leptospermum honey Q shift, Calcium Alginate; recommendation: group 2 mattress, off-load wound, reposition per facility protocol; Procedure: surgical excisional debridement of muscle; Indication: remove necrotic tissue and establish the margins of viable tissue; post-debridement depth (in cm) 3. Review of the August, 2016 TAR for R28 revealed e treatment order for the sacral PU was omitted on [DATE], [DATE], [DATE], [DATE], ,[DATE], ,[DATE], ,[DATE], [DATE], [DATE] and [DATE]. Review of the EHRs progress notes for R28 revealed on [DATE] at 2:29 p.m. revealed a new order for wound vac to Stage IV wound to coccyx, awaiting supplies at this time, MD (physician) and family aware. Review of the EHRs progress notes revealed on [DATE] nurse's note for R28 documented at 3:43 p.m. revealed wound vac applied at this time with no c/o (complaints of) pain or discomfort noted. Review of the EHRs progress notes revealed on [DATE] at 3:29 p.m. revealed wound vac continues to come off with each BM (bowel movement), wound MD to reevaluate today, son aware. The DON was interviewed on [DATE] at 10:25 a.m. She said an X on the TARs and Medication Administration Records (MARs) meant the med/treatment was not due, a check with initials meant the med/treatment was given, a 10 meant the resident refused, and a blank was an omission, That's a hole. The DON also said, regarding medications and treatments, if it was not documented, it didn't happen. Interview with the family member (F1) for R28 on [DATE] at 12:45 p.m. revealed that after admission on [DATE], he asked every day for two weeks to get a power strip for the numerous items R28 required for his care equipment in his room. F1 stated there were too many items to plug in and means for plugging in only 4 items, staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in before they left the room, which caused R28 to sink down onto the bedframe on the deflated air mattress. F1 said R28 needed the air mattress for treating two severe PS. F1 said he finally complained to the NHA and requested the power strip; F1 said the NHA said he was unaware this was an issue and he would find a power strip as soon as possible. F1 said it took a few more days after speaking to the NHA to get the power strip in the room. Even though F1 expressed concerns and staff were aware, there was no documented evidence of staff following up with the concerns to ensure resolution. Specifically: Review of the [DATE] Social Service Note, documented at 9:46 p.m., revealed R28 and family invited to meeting. F1 attended meeting discussed the past medical history and family issue pertaining to health declines for R28. F1 also voiced issue [MEDICAL CONDITION] and wound vac issues. F1 stated that he believe there are disconnects and communication problems within staff members pertaining to care of R28, he also stated that he will hire an investigator and place camera in the room for observation purposes. R28 was observed on [DATE] at 1:35 p.m., with the wound care nurse. The wound care nurse said R28 was admitted with both of his PS, a stage 4 on his sacrum and a stage 2 on his right posterior thigh. She said she did not measure either the wounds, but the Wound Doctor saw R28 weekly, and recommended changes. The wound care nurse said the Wound Doctor also measured the wounds, but did not document in Point Click Care (the facility ' s EHR program), but rather, documented in another computer program for which staff had access ,[DATE]. She said R28's wounds were getting better, initially the posterior thigh wound was much larger and the sacral stage 4 was healing. There was an 8 outlet yellow surge protector power strip taped to the floor between R28 and his roommate - plugged in to the power strip were R28's suction machine, R28's humidifier and the roommate's oxygen concentrator. On [DATE] at 1:45 p.m., staff physician165 (R28's primary care physician) stated R28 was a very sick man when he was admitted due to having a Stage 4 and a Stage 2 pressure ulcer, as well as history of acute [MEDICAL CONDITION] and that he was a quadriplegic. Physician165 stated he had suggested, on more than one occasion, that the son move R28 to a more prominent facility that was staffed with more skilled staff to [MEDICAL CONDITION] wound care, but the son refused to move his father. Physician165 stated he also wanted the resident transferred to a higher acuity level of care as the wounds were not improving as much as he had wanted them to. When asked if he was aware there were no wound measurements in the medical record he stated, No, I was not aware there were not any measurements. He stated he believed the wound doctor, Physician166 was taking measurements but, he had not seen those measurements. He discussed that resident 28's wife had told him she did not feel the wound was getting any worse so, he was not overly concerned as the resident was being followed by the facility wound doctor and staff wound care nurse (LPN117). Physician165 stated that he had many discussions with the son and had advised the family R28 would benefit from a facility that provides a higher level of care such as a hospital or long-term acute care (LTAC). He also stated that on [DATE] he had requested the resident go to the hospital to be evaluated by an infection disease doctor as he suspected R28 had a colonized infection in his trach. He explained the son requested they wait until the following Monday as he wanted to consult some others and decide if he wanted his father sent to the hospital. Physician 165 stated he did not receive a call back from the son, so he ordered a consult from an infectious disease physician to take place at the nursing home. He stated R28 was stable but he continued to believe the resident would benefit from a higher level of care, but family would not allow, so his best course of action was to request the consult. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or his roommate (R29), to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and he directed the Maintenance Director to install a power strip in R28's room. The NHA said both R28 and his roommate (R29) had more medical equipment than they had outlets in the room, so the decision was made to unplug R28's air mattress. He stated the air mattress for R28 was uninflated for a couple of days. The NHA stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The NHA and the Maintenance Director were interviewed on [DATE] at approximately 10:30 a.m. The NHA confirmed F1 talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed for R28. The NHA also confirmed a few days went by before he became aware the power strip was not installed. The NHA said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place for R28. The NHA stated that both R28 and R29 had more medical equipment than they had outlets for and the decision was made to unplug the air mattress for R28. He stated the air mattress was uninflated for a couple of days. R28 had both a Stage 4 and a Stage 2 decubitus ulcer (located on the sacrum area and the upper right thigh). R28 had a physician's orders [REDACTED]. Record review revealed that his wounds had doubled in size as a result. Therefore, R28 was admitted on [DATE], indicating a total of over thirteen (13) weeks, the facility had known that the R28 and R29 did not have enough electrical power outlets to support the ventilator equipment and other needed equipment including pressure prevention mattress for residents with pressure sores, suctioning equipment. cross refer to F 282 for CP details 2. Review of the clinical record for R23 revealed the admission documentation did not include the presence of a PS, there was no evidence of treatments for 4 days after admission, and the PS treatments were not consistently performed. Specifically: Review of the Transfer/ Discharge Report revealed R23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R23 was transferred to the hospital on [DATE]. Review of the [DATE] Nursing Admission Data Collection revealed R23 was admitted with one healed PS on the coccyx with dry [MEDICATION NAME] dressing, however there was no evidence of measurements or further descriptions of the PS. Review of physician's orders [REDACTED]. Review of the nurses' notes for R23 between [DATE] and [DATE] revealed no evidence of a PS, or other skin problems or dressing changes. a) PS to back of inner right thigh: Review of the March, 2016 TAR for R23 revealed an order on [DATE] to cleanse PS to back of inner right thigh with Normal Saline (NS) or Sterile Water. Pat dry. Apply Hydro-Gel and cover with Bordered Opti-Foam Dressing every day shift; then another order on [DATE] for the same wound to cleanse PS to back of inner right thigh with NS or Sterile Water. Pat dry. Apply Hydro-Gel and cover with Bordered Opti-Foam Dressing every day shift, however there is no evidence that this treatment was completed on [DATE]. Review of the April, 2016 TAR for R23 revealed an order to cleanse PS to back of inner right thigh with NS or Sterile Water. Pat dry. Apply Hydro-Gel and cover with Bordered Opti-Foam Dressing every day shift however there is no evidence that this treatment was completed on [DATE], [DATE] and [DATE]. b) PS to the bilateral inner buttock: Review of the March, 2016 TAR for R23 revealed an order on [DATE] to cleanse PS to the bilateral inner buttock with sterile water or NS. Pat dry. Apply Hydro-gel and cover with [MEDICATION NAME] dressing. Secure with [MEDICATION NAME] tape every day shift; then another order on [DATE] for the same wound to cleanse PS to bilateral inner buttock with sterile water or NS. Pat dry. Apply Hydro-gel and cover with [MEDICATION NAME] dressing. Secure with [MEDICATION NAME] tape every day shift, however there is no evidence that this treatment was completed on [DATE]. Review of the April, 2016 TAR for R23 revealed an order to cleanse PS to bilateral inner buttock with sterile water or NS. Pat dry. Apply Hydro-gel and cover with [MEDICATION NAME] dressing. Secure with [MEDICATION NAME] tape every day shift, however there is no evidence that this treatment was completed on [DATE], [DATE] and [DATE]. c) PS to the right buttock: Review of the [DATE] Skin - Weekly PS Record for R23 revealed the resident had a right buttock PS with date of onset as [DATE], continued review revealed that the PS was marked as both existing pressure ulcer and admitted with, however R23 had a PS to the bilateral inner buttock verified by a physician order [REDACTED]. The measurements were 8.0 x 8.0 x 0.3 cm stage II (which was incorrect as an ulcer with depth would not be a stage 2), description of site was R23 admitted here on [DATE] from the hospital, no undermining/tunneling, the wound bed is bright red with a little slough (non-viable tissue also not stage 2) noted, no drainage/ exudate, the Physician and responsible party/ family was notified on [DATE]. R23 cannot feel because of the [MEDICAL CONDITION] diagnosis. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to clean right buttock PS with NS/wound cleanser. Apply skin prep to surrounding skin. Apply Hydrogel to wound bed. Cover with dry dressing. Change daily and as needed (PRN) every day shift, however there is no evidence that this treatment was completed on [DATE] prior to transfer to the hospital. Review of the [DATE] nurse's note for R23 documented at 10:52 p.m. revealed, the daughter complained about the dressing not being changed. CNA remove dressing. Wound clean with wound cleanser hydrogel with dry dressing applied. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to cleanse left and right buttocks with NS or wound cleanser, pat dry. Apply a small amount of [MEDICATION NAME] to wound bed. Cover with [MEDICATION NAME], 4x4s and abdominal (ABD- a broad multilayered absorbent bandage) pad. Secure with tape daily and PRN if soiled every day shift for wound healing, however there no evidence of the treatment was not administered prior to being discontinued on [DATE]. d) PS to the sacrum: Review of the [DATE], Skin - Weekly PS Record for R23 revealed the resident had a sacrum PS with a date of onset on [DATE], continue review revealed that it was recorded as both existing and admitted with. The measurements were 2.5 x 2.0 x 0 cm stage II, description of site included no undermining/tunneling, and the wound bed is red with some pink tissue noted, no drainage / exudate. The physician and responsible party/ family notification date notified on [DATE]. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to cleanse the back of the right thigh with NS. Pat dry. Apply a small amount of triple antibiotic ointment to the wound bed. Cover with bordered gauze daily until healed every day shift for non-pressure wound healing related to PS of sacral region stage 2. The treatment was administered on [DATE], and omitted on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the April, 2016 TAR for R23 revealed an order on [DATE] to cleanse sacral area with normal saline or wound cleanser. Pat dry. Apply a small amount of [MEDICATION NAME] to the wound bed. Cover with [MEDICATION NAME] and 4x4s. Cover with a small bordered gauze daily and PRN if soiled every day shift for wound healing, however there no evidence of the treatment administered on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. e) PS to the left buttock: Review of the [DATE] Skin - Weekly PS Record revealed the R23 had a left buttock PS ulcer with onset date of [DATE], continued review of the document revealed the documented was both an existing pressure ulcer and admitted with. The measurements were 5.0 x 3.0 x 0.1 cm stage II, description of site was R23 admitted on [DATE], no undermining/tunneling, the wound bed is red with pink tissue present, no drainage/ exudate. The physician and responsible party/ family were notified on date [DATE]. The next nurse's note for R23 regarding PS, skin problems or dressing changes was documented on [DATE] at 2:07 p.m. Review of resident's wounds on buttocks and sacrum revealed measurements they were listed on weekly report. New treatment orders noted. Spoke with both daughters regarding the wounds. Family member (F2) was interviewed on [DATE] at 9:30 a.m. related to R23 (by State Survey Agency complaint intake staff). F2 said R23 was a nurse and kept asking the staff nurses what the foul smell was, and the staff nurses told her it was nothing. F2 said she pulled off dressing of R23 and found it was oozing pus and had feces in it. F2 said she asked the staff nurse to change the dressing, but the nurse said she would be back because she was busy, F2 left at 11:30 p.m. and the staff nurse still had not returned to change the dressing, so the wound was left open to air and oozing. F2 said the dressing was to be changed daily, but it was not getting done. Review of the subsequent nurses' notes for R23 dated [DATE] transfer to the hospital revealed no documented evidence of wounds, skin problems or dressing changes. The NHA was interviewed on [DATE] at approximately 3:45 p.m. He said there were no wound assessments for R23 by the Wound Doctor. cross refer to F 282 for CP details 3. R25 was interviewed on [DATE] at 10:00 a.m.; he said he was admitted last Tuesday ([DATE]) with a dressing covering his PS on his bottom, he said the dressing fell off on Friday ([DATE]) and he asked the nursing staff to replace the dressing, but no one replaced it, yet, it was bleeding and it hurt. The charge nurse was interviewed immediately after the resident interview, she said she was aware R25 had a PS on admission and it had slough (non-viable tissue) in the wound bed. Review of his record confirmed he was admitted on [DATE] with an unstageable pressure ulcer on his buttocks, and there were no treatment orders in place, even though the resident had been in the facility for 6 days. Specifically: Review of the Transfer/ Discharge Report revealed R25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the [DATE] Nursing Admission Data Collection revealed R25 was admitted with one unstageable PS to buttocks there were no measurements or further descriptions of the wound. Review of the [DATE] nurse's note documented at 11:01 p.m., revealed R25 was alert and oriented x3 (person, place and time). Review on [DATE], of the physician's orders [REDACTED]. The Unit Manager was observed on [DATE] at approximately 10:30 a.m., measuring the PS and applying a dressing. The Unit Manager said the wound measurements were 4.5 x 1.0 cm; she did not give a depth, she did not stage the wound, and she did not describe the PS of R25. She was interviewed immediately after the procedure and confirmed there was no treatment order in place since admission and they just received treatment orders. The Unit Manager provided a copy of the new treatment orders to cleanse right buttock with NS. Pat dry. Apply a small amount of hydrogel to the wound bed using a Q tip. Cover with 4x4s and bordered gauze daily until healed Q day shift for wound care right buttock related to PS of unspecified buttock, unspecified stage. Subsequent record review on [DATE] revealed the nurse did not document her wound measurements or wound assessment. Review of an [DATE] nurse's note documented at 2:20 p.m., revealed R25 has refused to allow CNA (certified nurse aide) to get him cleaned up this entire shift. Nurse has requested that he get up but he has continued to refuse. Review of the August, 2016 MAR/TAR on [DATE] at approximately 3:30 p.m., revealed no documented evidence R28 received any treatments to the PS on his buttocks. cross refer to F 282 for CP details 4. Review of the record for R20 PS were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed. Specifically: Review of the Transfer/ Discharge Report revealed 101year old was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R20 expired in the facility on [DATE]. Review of the PS revealed the following: a). R lower buttock: Review of a [DATE] nurse's note for R20 documented at 7:50 a.m. revealed, CNA was doing pericare for resident for morning care. CNA summoned nurse into room, upon assessment noted to R lower buttock an open area measuring 1.5 cm long x 1.5 long. Physician made aware new order to cleanse with normal saline and apply duoderm and change Q 3 days. Family member needs to be made aware. Made oncoming nurse aware. Review of a [DATE] nurse's note for R20 documented at 8:20 a.m. revealed, spoke with responsible party for R20 made aware of occurrence with open area. Family member is requesting that resident no longer get up with ,[DATE] AM shift. Made oncoming nurse aware to inform Unit Manager of request. Review of the May, 2016 TAR for R20 revealed an order from [DATE] to, cleanse R lower buttock area with NS and apply Duoderm to area every 72 hours. The treatment was administered on [DATE] and on [DATE], there was no evidence of TX administration on [DATE], [DATE] and [DATE]. Review of the May, 2016 TAR for R20 also revealed an order from [DATE] to, Area: R buttock, cleanse area with NS, pat dry, apply hydrogel and cover with adhesive 4x4, change every other day for open area to R buttock. The treatment was administered on [DATE], [DATE], [DATE], and [DATE] and [DATE], there was no evidence of TX administration on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the June, 2016 TAR for R20 revealed an order from [DATE] to, Cleanse R lower buttock area with normal saline and apply duoderm to area every 72 hours. The treatment was administered on [DATE], [DATE], [DATE], [DATE], and [DATE] and on [DATE], and there was no evidence of TX administration on [DATE], [DATE] and [DATE] for R20. Review of the [DATE], the [DATE] Skin - Head to Toe Skin C

Based on record review including Fall Management, Overview, Practice Guidelines and interviews, the facility failed to follow the care plan (CP) which identified individualized interventions developed by the Interdisciplinary Team (IDT) to assist staff to care for the residents, for nine (9) residents (R15, R18, R20, R22, R23, R25, R28, R29, and R183) specifically: a. failed to ensure that the CP included necessary emergency respiratory interventions to address the need of an emergency i.e. inner cannula re-insertion, ambu bags for each resident, and electrical outlets to supply power sources to the needed equipment for two (2) of 2 (R28, R29) residents that had tracheostomies, pressure sores (PS) and required multiple medical apparatus; Refer to F328. b. failed to CP including interventions for prevention, detection, weekly assessments were implement to ensure that residents without PS did not develop PS, failed to ensure residents with PS did not worsen, and failed to ensure residents with PS received necessary treatment and services to promote healing for 6 residents (R18, R20, R22, R23, R25 and R28); Refer to F314. c. failed to ensure that the CP included individualized interventions for R15 who had a history of [REDACTED].e. more frequent monitoring, they failed to determine the actual cause of the falls, failed to use their own Fall Management, Overview, Practice Guidelines therefore R15 fell multiple times while in the facility, contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise, and; Refer to F323. d. failed to apply a right hand splint to prevent contractures for one resident (R 183). Refer to F318. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. On [DATE] at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on [DATE] (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On [DATE] at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of PSs to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on [DATE], the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on [DATE] and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on [DATE], as alleged. Findings include: 1. Review of CP documented the presence of the [MEDICAL CONDITION] for R28, but it did not list the type or size of the inner cannula. There was no mention of having a back-up inner cannula or Ambu bag available for respiratory emergencies, or what do if the inner cannula became dislodged. There was no evidence of a pressure relieving air mattress on the CP, although it was ordered by the physician. Interview on [DATE] at 12:45 p.m. with family member (F1) revealed R28 was admitted on [DATE], he asked every day for two weeks to get a power strip for the numerous items required for the care equipment in the room. F1 stated there were too many items to plug in and means for plugging in only 4 items and staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in before they left the room, which caused R28 to sink down onto the bedframe on the deflated air mattress. F1 said R28 needed the air mattress for treating two severe PS. F1 said he finally complained to the NHA and requested the power strip; F1 said the NHA said he was unaware this was an issue and he would find a power strip as soon as possible. F1 said it took a few more days after speaking to the administrator to get the power strip in R28's room. Review of the record revealed R28 was admitted on [DATE] with a stage 4 PS on his buttocks and a stage 2 PS on his posterior thigh, neither wound was measured at this time or at any time after admission by the nursing staff. There were numerous omissions for the PS treatments. The Wound Doctor measured the PS on [DATE] and again on [DATE] the sacral wound had doubled in size and the stage 2 was actually a stage 3. R28 had two PS, a sacral stage 4 and a posterior right thigh stage 2. R28 had a physician's orders [REDACTED]. . R28's PS were not measured or adequately assessed upon admission, they were not measured/assessed weekly, the initial inaccurate staging of the posterior thigh wound was carried over to the Minimum Data Set (MDS) and care plan, treatment orders were omitted, two different treatment orders were in place at one time for the same PS, and the air mattress was allowed to deflate leaving the resident to sink down onto the bedframe on the deflated air mattress. Review of the current CP initiated on [DATE], revealed R28 was admitted with one Stage 4 PS on the sacrum and admitted with one Stage 2 PS (which was inaccurately assessed upon admission and should have been documented at a Stage 3) on the right (R) posterior thigh. The care plan also included the [DATE] Wound Specialist report: R (right) Posterior Thigh PS stage 3 w/100% gran (granulation - viable) tissue; Sacrum/Buttock PS stage 4 w/100% gran tissue; on [DATE] Wound Report: Stage 4 R Perineum Buttock/Sacrum PS, 100% gran tissue, Stage 3 R Posterior Thigh PS, 15% necrotic non-viable tissue, debrided [DATE], 20% gran tissue, indicating the PS deteriorated since admission going from 100% granulation/viable tissue to 15% necrotic/non-viable tissue with only 20% granulation tissue. The goal was PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were to administer treatments as ordered and observe for effectiveness, complete a full body check weekly and document, follow facility policies/protocols for the prevention/treatment of [REDACTED].e., registered dietitian (RD), physical therapy (PT), occupational therapy (OT) or Wound Specialist, observe dressing every shift/prn to ensure it is intact and adhering. Report lose dressing to Treatment nurse, provide incontinence care after each incontinence episode, or per established toileting plan. Review of the [DATE] Treatment Administration Record (TAR) for R28 revealed: No evidence of treatments completed on the above treatment order for the right posterior thigh PS was omitted on [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE] [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or R29, who were roommates, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to install a power strip in the room. The NHA said both R28 and R29 had more medical equipment than they had outlets in the room, so the decision was made to unplug the air mattress of R28. He stated the air mattress was uninflated for a couple of days. Cross refer to F314 2. R29 was a readmit from an acute hospital stay. Review of a progress note dated [DATE], and as documented on the CP, R29 pulled his [MEDICAL CONDITION] out and was sent to hospital, where they replaced it and sent him back to the facility. R29 was care planned for history of self extubation (removing his own trachea tubing and cannula) as a behavior, the facility did not have the appropriate size inner cannula ready at his bedside. Refer to F328. 3. Review of the Transfer/ Discharge Report revealed R25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the current CP initiated on [DATE], revealed R25 has a PS to buttocks related to immobility, incontinence. The goal was PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were to administer treatments as ordered and observe for effectiveness; complete a full body check weekly and document; IDT referrals as indicated, i.e., RD, PT, OT or other; provide incontinence care after each incontinence episode, or per established toileting plan; reposition in chair frequently for comfort and pressure reduction. Provide resident/ family education as needed. R25 was interviewed on [DATE] at 10:00 a.m.; he said he was admitted on [DATE] with a dressing covering his PS on his bottom and it fell off on [DATE]. R25 stated he asked the nursing staff to replace the dressing, but no one replaced it, yet, it was bleeding and it hurt. Review of his record confirmed he was admitted on [DATE] with an unstageable PS on the buttocks, and there were no treatment orders in place, even though the resident had been in the facility for 6 days. Review of the August, 2016 TAR on [DATE] at approximately 3:30 p.m., revealed no documented evidence R28 received any treatments to the PS on his buttocks. Refer to F314. Cross refer to F314 4. Review of the admission for R23 did not include the presence of a PS, no treatments were in place until 4 days after the resident's admission, the wounds may have developed after admission and treatments were not consistently performed. Review of the Transfer/ Discharge Report revealed R23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R23 was transferred to the hospital on [DATE]. Review of the current CP initiated on [DATE], revealed R23 has 3 stage 2 PS on admission to the L and R buttocks, sacrum, and has potential for further skin breakdown related to decreased mobility. The goal was PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were to administer medications as ordered. Observe/document for side effects and effectiveness, administer treatments as ordered and observe for effectiveness, complete a full body check weekly and document, educate the resident/family/caregivers as to causes of skin breakdown, including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention treatment of [REDACTED]. Serve diet as ordered, observe intake and record, observe/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs/ symptoms of infection, wound size (length x width x depth), stage, provide incontinence care after each incontinence episode, or per established toileting plan, the resident requires pressure relieving/reducing device on bed/chair. Review of physician's orders [REDACTED]. Review of the nurses notes for R23 between [DATE] and [DATE] revealed no documented evidence of a wound, skin problems or dressing changes. The April, 2016 TAR for R23 revealed no evidence of treatments completed on [DATE], [DATE], [DATE], [DATE], [DATE], and on [DATE]. Cross refer to F314 5. Review of the Transfer/ Discharge Report revealed R20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R20 expired in the facility on [DATE]. Review of the CP initiated on [DATE] revealed R20, has actual impairment to skin integrity of the (see below) r/t incontinence: on [DATE], stage 2 right buttocks with TX; on [DATE] wound right buttock stage 2 and stage 2 to coccyx with TX; on [DATE] wound right buttock stage 2, stage 2 sacrum, TX with hydrogel; on [DATE] wound areas to buttocks and sacrum healed; on [DATE] wound stage 2 open area to fissure of buttocks. The CP goal was R20, will maintain or develop clean and intact skin by the review date. Some of the interventions listed were to assess for pain and medicate as ordered, assist with incontinent and TX as ordered. Review of the [DATE] TAR for R20 revealed no evidence of treatments completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Review of the June, 2016 TAR for R20 revealed no evidence of treatments completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] for R20. Review of the July, 2016 TAR for R20 revealed no evidence of treatments was for the entire month. Cross refer to F314 6. R22 was admitted without PSs, he developed two unstageable PSs - one of which was subsequently a stage 4, there was no evidence of assessing or measuring the PUs upon discovery, the PSs were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed. Review of the Transfer/ Discharge Report revealed R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on [DATE] to an assisted living facility. Review of the [DATE] Nursing Admission Data Collection revealed, R22 was admitted without PS. Review of the physician's orders [REDACTED]. Even though this treatment was ordered on [DATE], there was no documented evidence of measurements or wound description elsewhere in the clinical record and there was no evidence of family notification. Review of the [DATE] TAR for R22 revealed no treatments were documented for the entire month; in fact, even though there was a treatment ordered on [DATE], there were no treatments entered on the TAR. Review of the current CP initiated on [DATE] revealed, R22 is at risk for PS development related to Immobility, incontinence bowel and bladder; Noncompliance with going back to bed, wanting to sit up in wheel chair for longer periods than recommended; on [DATE] the IDT discussed the PS as follows: L buttocks stage 4, L heel unstageable DTI continue to tx, on wound MD caseload, on specialty mattress. The care plan goal was R22, will have intact skin, free of redness, blisters or discoloration by/through review date. Some of the interventions listed were on [DATE], wound supplements added, administer medications as ordered. Observe/document for side effects and effectiveness, administer treatments as ordered and observe for effectiveness when there is an open area, complete a full body check weekly and document, follow facility policies/protocols for the prevention/treatment of [REDACTED].e., RD, PT, OT or other. Review of the [DATE] TAR for R22 revealed no evidence of treatments completed for 18 out of 31 opportunities during July. Review of the [DATE] TAR for R22 revealed no evidence of a treatment on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. Cross refer to F314 7. R18 was readmitted to the facility from the hospital on [DATE] with multiple unmeasured, unassessed and untreated PSs, the PSs worsened and became infected, and necessitating an emergency room for assessment, treatment and antibiotics, the wounds were not assessed or measured weekly. Review of the Transfer/ Discharge Report revealed R18 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the current CP initiated on [DATE] and revised on [DATE] revealed R18, has actual PS development related to readmission status, immobility, incontinence of bowel and bladder, [DIAGNOSES REDACTED]. The goal was R18 will have intact skin, free of redness, blisters or discoloration by/through review date; PS will show signs of healing and remain free from infection by/through review date. Some of the interventions listed were, administer medications as ordered. Observe/document for side effects and effectiveness, administer treatments as ordered and observe for effectiveness, complete a full body check weekly and document, follow facility policies/protocols for the prevention/treatment of [REDACTED].e., RD, PT, OT or Wound MD, observe/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage, provide incontinence care after each incontinence episode, or per established toileting plan, reposition in chair frequently for comfort and pressure reduction. Provide resident/ family education as needed, the resident requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. The resident requires: Pressure relieving/reducing device on bed and matrix cushion in wheel chair, treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort. Review of the [DATE] TAR for R18 revealed no treatments were documented for the entire month; in fact, even though treatment orders were in place, there were no treatments entered on the TARs. Review of the [DATE] TAR revealed no evidence of a treatment to one or more of the PS to the left 2nd toe, left outer ankle, right top of foot, right outer ankle and right lateral foot on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and on [DATE] for R18. Review of the [DATE] TAR revealed no evidence of a treatment to one or more of the PS to the left 2nd toe, left outer ankle, right top of foot, right outer ankle and right lateral foot on ,[DATE] through [DATE] for R18. The Medical Director was interviewed on [DATE] at 7:05 a.m. he said he was aware of some holes on TAR and they discussed in the monthly QA meetings. The Medical Director said they should do a head to toe assessment with every admission. The Administrator and DON were interviewed together on [DATE] at 12:55 p.m. ad confirmed knowledge of the PS problem. Cross refer to F 314 interview 8. The facility failed to provide adequate supervision prevent accidents for R15 who had a history of [REDACTED]. Fall Management, Overview, Practice Guidelines. The resident fell again contributing to an additional [MEDICAL CONDITION] which led to her ultimate demise. Review of the Transfer/ Discharge Report revealed Resident 15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a [MEDICAL CONDITION]. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the [DATE] Care Plan for R15 revealed, which was revised on [DATE], revealed R15 had an actual fall Risk related to: Falls related to her legs giving in the bathroom on [DATE] fall with complaints of pain to right hip. The goal was for R15 to be free from acute fall related injury through next review. The interventions included assist transfers as needed; call light within reach; doctor will review medications and make recommendation if necessary; interdisciplinary team (IDT) referral as needed; refer to rehab for evaluate; use stand up lift as needed. The facility was aware R15 had a history of [REDACTED]. Review of the [DATE] SBAR Communication Form and Progress Note for R15 documented at 4:23 p.m. revealed, at 11:15 a.m. R15 had to be lowered to the floor today while being transferred from bed to her wheelchair. The form did not include what interventions could be put in place to prevent recurrence. Review of the [DATE] SBAR Communication Form and Progress Note documented at 4:39 a.m. revealed, R15 was yelling and found on the floor, needs more constant monitoring and redirection at all times. The form did not indicate what interventions were put in place to prevent recurrence. The Corporate Clinical Auditor (CCA), who was also a registered nurse, was interviewed on [DATE] at approximately 11:30 a.m. She said the SBARs are investigations into the falls and there were no other investigations. She said the process was to discuss the previous day's falls at the daily clinical meeting and weekly at the At Risk meeting. The CCA said, generally, they discussed where the resident was, what happened, was there any injury, what can we do, have interventions worked. She was unable to provide evidence that R15 was discussed at the daily clinical meetings and weekly At Risk meetings regarding R15. Cross refer to F323. Review of the August, 2012, Fall Management, Overview, Practice Guidelines revealed: Each facility will take a proactive approach for new residents admitted and will consider all residents to be at risk for falls until reviewed by the IDT. Each resident is assisted in attaining maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The DON/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Initiate the Interdisciplinary Post Fall Evaluation including the IDT will review all resident falls within ,[DATE] hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. The IDT modifies and implements a CP and treatment approach to minimize repeat falls. The CP will be reviewed/revised as indicated. 10. Review of the Admission Record indicated Resident (R) 183 was admitted with a [DIAGNOSES REDACTED]. Review of the [DATE] quarterly Minimum Data Set (MDS) indicated R183 had a Brief Interview of Mental Status (BIMS) score of 5 out of 15, which indicated R183 had cognitive impairment. Review of the current CP that was not dated indicated R183 received restorative care, which included a right hand splint per the order. Review of the [DATE] physician order [REDACTED]. Review of the Restorative Aide (RA) [DATE] to [DATE] weekly Restorative Service Delivery Records regarding restorative services did not include information on the use of a splint for R 183. Review of the [DATE], Rehab to Restorative Transition Record indicated the RA was to place the right hand splint on R 183 for 8 hours (off at night) for 12 weeks. Interview with RA170 on [DATE] at 10:13 a.m. and [DATE] at 8:06 a.m., he said on [DATE], he was not educated to place the splint on R 183 and therefore, he did not apply a splint to the R hand of R183. RA 170 said when he was assigned to work as a Certified Nursing Assistant (CNA) and not a RA, the CNA assigned to R183 was to provide restorative services. Interview with CNA181 on [DATE] at 8:28 a.m. and interview with CNA183 on [DATE] at 8:16 a.m., they said although they were assigned to R183, they did not apply a splint to R183. Interview with Unit Manager (UM)162 on [DATE] at 8:32 a.m., she said she did not read the [DATE], Rehab to Restorative Transition Record, until her discussion with the surveyor on [DATE] and therefore, did not educate the RAs regarding the new information on the splint until [DATE]. There were no Resident Restorative Charts prior to [DATE], which included daily restorative documentation. The [DATE] to [DATE] Restorative Charts did not indicate R183 used a splint. The [DATE] Rehab to Restorative Transition Record indicated the RA was to place the R hand splint on R183 for 8 hours (off at night) for 12 weeks. Interview with UM 162 on [DATE] at 8:32 a.m., she said there was no evidence the RAs or CNAs placed a splint on R 183 per the physician order [REDACTED]. R 183 was observed several times during the survey, on [DATE], at 1:55 p.m. and 4:00 p.m., on [DATE] at 9:30 a.m., 1:09 p.m., and 5:00 p.m., and on [DATE], at 10:07 a.m., R183 had his arm placed on the tray on the wheelchair and had no splint on his right arm. Interview with the DON on [DATE] at 12:00 p.m., she said there was poor communication between the therapy department, restorative services, and the nursing department regarding the use of the splint for R 183. The DON said the staff did not apply the right hand splint to R183 per the physician order [REDACTED]. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on [DATE]. Additional training was completed with all active staff by [DATE] including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of [DATE]. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on [DATE] and training was initiated for charge nurses on [DATE] by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by [DATE]. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on [DATE] to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by [DATE]. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on [DATE]. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on [DATE]. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on [DATE]. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on [DATE] to review and approve the plan. The plan was reviewed and approved by the Medical Director. III. A facility wide skin sweep was conducted for residents at risk for pressure sores (PS) on [DATE], [DATE] and [DATE]. Current dressings were observed for placement and appropriate dates by facility staff on [DATE]. Unit managers will observe a minimum of five (5) dressings per week for appropriate placement and dates. Audits of current PS were completed

Based on observation, interview, record review, including review of the Georgia Nurse Practice Act, Chapter 410-10, Lippincott's 8 Rights of Medication Administration, the policy titled Respiration assessment, long-term care Revised: October 02, 2015, the facility failed to ensure acceptable professional standards were implemented to meet the needs of the residents. Specifically, the facility failed to; a. failed to ensure changes in respiratory status were assessed and monitored as expected for one resident (R21); b. failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two (2) of 2 residents (R28, R29) that had tracheostomies and required multiple medical apparatus; Refer to F328. c. failed to ensure residents with pressure sores (PS) received necessary treatment and services to promote healing for six (6) of thirty (30) sampled residents (R18, R20, R22, R23, R25 and R28). Refer to F314, and; d. ensure eleven (11) of thirteen (13) residents (R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27) who were reviewed for sliding scale insulin, received the appropriate care to stabilize blood sugar (BS). Review of a list provided by the DON on 8/11/16 at 5:20 p.m., revealed that 40 residents had physician orders [REDACTED]. Refer to F309. e. Failed to ensure timely administration of medications to residents. This had the potential to affect the residents on the unit. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were notified that the failure to prevent, protect, investigate, report alleged abuse and follow the facility ' s policy and procedure related to abuse to R6 beginning on 6/9/16 (F223, F225, F226 at scope and severity (S/S: J) constituted IJ and SQC at 483.13. On 8/12/16 at 3:36 p.m., the NHA and DON were notified that the failure in measuring, treating, providing consistent power sources for air mattress, and preventing worsening of PS to six (6) residents constituted IJ when R23 was admitted to the facility with [DIAGNOSES REDACTED]. The facility failed to ensure all necessary respiratory related medical equipment for two resident (R28, R29) with tracheostomies were readily available; and that a safe and appropriate power source was available for their medical equipment, which placed residents at risk for serious harm or death. IJ was identified in effective on 6/29/16, the day R28 was admitted to the facility, placed in the room without the needed power sources at F238 S/S:K. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F281 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Findings include: Review of the Georgia Nurse Practice Act, Chapter 410-10 revealed, Practice nursing as a registered professional nurse means to practice nursing by performing for compensation any of the following: Assessing the health status of individuals, groups, or both throughout the life span; Establishing a nursing diagnosis; Establishing nursing goals to meet identified health care needs; Planning, implementing, and evaluating nursing care; Providing for safe and effective nursing care rendered directly or indirectly; Managing and supervising the practice of nursing; Collaborating with other members of the health care team in the management of care, and; Teaching the theory and practice of nursing. Review of the facility's Respiration assessment, long-term care Revised: October 02, 2015 revealed: Age-related changes can complicate the early detection of respiratory problems in older adults; while assessing respirations, listen for abnormal breath sounds, such as: stertor - a snoring sound that results from the presence of secretions in the trachea and large bronchi; stridor - an inspiratory crowing sound occurring with upper airway obstruction; wheezing - high-pitched, musical sound; expiratory grunt - a deep, low-pitched sound heard at the end of each breath. Then use your stethoscope to auscultate for abnormal breath sounds, such as: crackles - discontinuous sounds heard on inspiration; rhonchi - low-pitched rumbling sounds. Observe the resident's chest movements to assess the depth of respirations. Listen to the resident's breathing to determine the rhythm and sound of respirations. Use a stethoscope to auscultate anterior and posterior chest surfaces to assess for the presence of abnormal breath sounds. Observe the resident for accessory muscle use. 1. R21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident resided on the memory care unit. Review of the 7/4/16 Situation, Background, Assessment and Recommendation Communication Form (SBAR) and progress note documented at 3:11 p.m. for R21 revealed, vital signs (VS): blood pressure (BP) 126/76; pulse (P) 76; Pulse Type: Regular, respirations (R) 18; temperature (T) 97.6; oxygen saturation level (SPO2) 95.0 %; Method: Room air, observed coughing. Lungs sounds wet with water eyes, back to bed with head of bed (HOB) elevated, abnormal lung sounds, cough, non-productive, primary care clinician notified at 1:30 p.m. Review of the 7/4/16 at 9:57 p.m. nursing note revealed, R21 lung sounds congested. Order for chest x-ray (CXR) in place, to do CXR tomorrow due to 4th July holiday. The note did not include the oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/5/16 at 6:13 a.m. nursing note revealed, stable up in wheelchair, observed, trying to clear her throat a couple of times but no coughing noted, will continue to monitor. Verbal no complaints of pain or discomfort at this time. VS BP - 124/59, P - 62, R - 18, T - 98.0. The note did not include the oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/5/16 at 3:22 p.m. nursing note revealed, CXR result with subsegmental atelectasis versus pneumonia in the lung bases called to the physician and no new order received. Responsible party made aware via voice mail. Review of the 7/6/16 at 2:30 p.m. nursing note revealed, Repeat x-ray done. Son notified of previous CXR result and new orders. VS: T - 96.4, P - 66, R - 20, BP - 130/67. The note did not include the resident's oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/7/16 at 7:56 a.m. nursing note revealed, received in bed eyes opened awake alert oriented verbally responsive. Respiration even and unlabored. Skin warm and dry to touch. Denies any pain distress discomfort. Will continue to monitor. T - 98.3, P - 77, R - 20, BP - 123/76, SPO2 - 97% R/A (room air). The note did not include an appropriate respiratory assessment for R21. Review of the 7/7/16 at 10:06 p.m. nursing note revealed, second CXR result shows very slight right lower lobe atelectasis and mild cardiomegaly, no infiltrate or congestion. Physician and responsible party was notified, no new orders given. Will continue to monitor. The note did not include the oxygen saturation level or an appropriate respiratory assessment for R21. Review of the 7/8/16 through 7/15/16 nursing notes revealed no evidence that the respiratory status was assessed or monitored for R21. Review of the 7/16/16 at 12:18 p.m. nursing note for R21 revealed, resident has a very slight right lower lobe atelectasis according to the last CXR on 7/7/16. R21 is not showing any signs or symptoms of respiratory distress. Family member (F6) here visiting and express concerns about CXR results. Current vital signs: BP - 103/56, P - 72, R - 12 and SPO2 - 83%. R21 is not deep breathing to help resolve atelectasis. Oxygen administered at two liters (2L) via cannula. Review of the note did not include an appropriate respiratory assessment. Review of the 7/17/16 at 2:36 p.m. nursing note revealed, R21 is removing her oxygen ad lib and it has to be replaced. R21 does not understand to deep breathe. CXR results from 7/5/16 and 7/6/16 were again reported to the physician. New order received for a computerized tomography (CT) of the lung before he speaks with the son. R21 is afebrile at this time. VS: T - 97.0, R - 20, P- 70, BP - 118/56. Son visited and received the CXR copies. Will monitor. The note did not include the SPO2 or a respiratory assessment. F6 was interviewed on 7/18/16 at 11:05 a.m. (by the State Survey Agency complaint intake staff) F6 said the facility notified him R21 had a wet cough and wanted to get a CXR to find out if R21 had pneumonia. F6 stated being told they are monitoring her. F6 stated when he asked one of the nurses what did the monitoring entail, the nurse did not seem to know the R21 was being monitored. F6 said he asked the DON what the monitoring entailed and she said they were monitoring her oxygen concentration in her blood and they did not have to ask the doctor for an order to place her on oxygen.F6 said he went with the DON to check her oxygen saturation level and it was 83% on room air. The DON ordered the resident to start on oxygen via nasal cannula. Review of the 7/18/16 at 3:12 p.m., on 7/18/16 at 10:26 p.m. on 7/19/16 at 3:49 a.m., 7/19/16 at 6:40 a.m., on 7/20/16 at 6:36 a.m., on 7/21/16 at 7:45 a.m., on 7/22/16 at 6:39 p.m. and 7/23/16 through 7/27/16 nursing notes revealed no evidence the resident's respiratory status was assessed or monitored. Review of the 7/19/16 at 2:36 p.m. nursing note revealed, R21 continues to be non-compliant with her O2. This author spoke with resident son about sending his mother to the hospital emergency room to get the CT scan done. Son did not want her to go to the ER and sit for long hours when we could get it scheduled and approved. Physician was notified and ask to get it approved and scheduled at the hospital. All paperwork was faxed to the scheduling at the radiology at the hospital. Son and physician made aware. Will await appointment date. The note did not include an appropriate respiratory assessment or whether R21 was receiving oxygen therapy. Review of the 7/28/16 at 2:42 p.m. nursing note revealed CT report of the chest called to the physician and F6 with no new orders. However at 9:23 p.m. R21 was seen by physician and new orders written to discontinue oxygen, check oxygen saturation every shift. If oxygen saturation is less than 88%, restart oxygen via nasal cannula. 2. Review of the clinical record for R28 revealed the presence of the [MEDICAL CONDITION], but it did not list the type or size of the inner cannula. There was no mention of having a back-up inner cannula or Ambu bag available for respiratory emergencies, or what do if the inner cannula became dislodged. There was no documentation of a pressure relieving air mattress, although ordered by the physician. F1 of R28 was interviewed on 8/12/16 at 12:45 p.m. he said after his father was admitted on [DATE], he asked every day for two weeks to get a power strip for the numerous items his father required for his care equipment in his room. F1 stated there were too many items to plug in and means for plugging in only 4 items - staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in before they left the room, which caused R28 to sink down onto the bedframe on the deflated air mattress. F1 said his father needed the air mattress for treating two severe PS. F1 said he finally complained to the NHA and requested the power strip; F1 said the NHA said he was unaware this was an issue and he would find a power strip as soon as possible. F1 said it took a few more days after speaking to the administrator to get the power strip in the room. Refer to F314 and F328. 3. R29 was a readmit from an acute hospital stay. Review of the progress note dated 5/23/16, and as documented on the care plan, R29 pulled his [MEDICAL CONDITION] out and was sent to hospital, where they replaced it and sent him back to the facility. There was no evidence that R29 the facility attempted to [MEDICAL CONDITION]. R29 was care planned for history of self extubation (removing his own trachea tubing and cannula) as a behavior; the facility did not have the appropriate size inner cannula ready at the bedside. As evidenced by documentation of having to be hospitalized for [REDACTED]. Refer to F328 4. R25 was interviewed on 8/8/16 at 10:00 a.m.; he said he was admitted last Tuesday 8/2/16 with a dressing covering his PS on his bottom - he said the dressing fell off on Friday (8/5/16) and he asked the nursing staff to replace the dressing, but no one replaced it, yet, it was bleeding and it hurt. The charge nurse was interviewed immediately after the resident interview and said she was aware R25 had a PS on admission and it had slough (non-viable tissue) in the wound bed. Refer to F314. 5. Review of the admission documentation did not include the presence of a PS, no treatments were in place until 4 days after the resident's admission, the wounds may have developed after admission and treatments were not consistently performed Review of the nurse notes between 3/25/16 and 4/1/16 revealed no documented evidence of a wound, skin problems or dressing changes for R23. Refer to F314. 6. Review of the clinical record revealed PS were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed for R20. Refer to F314. 7. R22 was admitted without PS, he developed two unstageable PS, one of which was subsequently a stage 4, there was no evidence of assessing or measuring the PS upon discovery, the PS were not consistently monitored, treatments were not administered, and weekly assessments of the wounds were not performed. Refer to F314. 8. R18 was readmitted to the facility from the hospital on [DATE] with multiple unmeasured, unassessed and untreated PS that became worse and became infected, necessitating a trip to the emergency room for assessment, treatment and antibiotics, the PS were not assessed or measured weekly. Refer to F314. 9. Review of the clinical record for R32, R5, R7, R9, R10, R14, R18, R19, R231, R25 and R27 revealed that the sliding scale insulin and blood sugar assessments was not administered as ordered by the physician, including many gaps of documentation on the Medication Administration Record (MAR) during the months of June, July and August 2016, nursing staff were inconsistent in documenting and treating hypo/hyper glycemic episodes. Physicians were not notified of blood sugars below ordered parameters. The interventions and blood sugar re-checks were not implemented consistently per facility policy to address low and high blood sugars. The facility also failed to ensure that a parameter regarding low blood sugars was documented on the MAR to address what interventions and treatment needed to be completed. The facility was not following their diabetic management policy. Refer to F309 10. An agency Licensed Practical Nurse (LPN) 176 was observed on 8/8/16 at 11:00 a.m., passing a resident's medication. LPN176 indicated she had 7 pills to pass for a resident. LPN 176 indicated the medications were scheduled for 9:00 a.m. She indicated she knew it was 11:00 a.m. LPN176 stated, do the best I can. Interview with the West Hall Unit Manager on 8/8/16 at 11:35 a.m., when informed LPN 176 was still passing medications, she shook her head and stated I did not know that. The Unit Manager did not offer to help LPN176 pass the medications. Interview on 8/12/16 at 10:10 a.m., Registered Nurse (RN) 157 indicated nurses have one hour before and one hour after when passing medications. RN157 indicated the 9:00 a.m. medications should be passed by 10:00 a.m. Review of a facility policy, received from RN175, titled Medication Management and dated June 2008, indicated, to administer medication within 60 minutes of the scheduled time, for example if the medication is ordered for 8:00 a.m., it must be given between 7:00 a.m. and 9:00 a.m. in order to be considered timely. Review of Lippincott's 8 Rights of Medication Administration, dated 5/27/11 indicated, check the frequency of the ordered medication, double check that you are giving the ordered dose at the correct time. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by August 13, 2016. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. III. A facility wide skin sweep was conducted for residents at risk for pressure sores (PS) on 8/12/16, 8/13/16 and 8/14/16. Current dressings were observed for placement and appropriate dates by facility staff on 8/13/16. Unit managers will observe a minimum of five (5) dressings per week for appropriate placement and dates. Audits of current PS were completed 8/16/16 to assure treatments are in place for each wound and are written appropriately. PS will be reviewed by the interdisciplinary team weekly at the scheduled AT RISK meetings. The facility Medical Director will be notified for any needed changes. An audit was conducted by the District Director of Clinical Services on 8/13/16 for wounds assessed by the wound physician to determine if there was any deterioration of existing wounds since his visit on 8/5/16. The District Director of Clinical Services (DDCS) and/or designee will attend at least one at Risk meeting per month to determine if further audits are needed. The following education began on 8/12/16 and will be completed by 9/2/16 for the licensed nurses by the DON/Nursing Administration including: Assessment, measurements, staging and documentation of wounds upon admission; Obtaining/entering treatment orders into the computer upon admission/identification of new pressure areas, and; Documentation of treatments provided. Licensed staff not scheduled to work on 8/12/16, will receive education prior to the start of their next shift. Training and education regarding the Skin System has been integrated into the orientation process of new licensed nursing staff and agency nurses. An Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting was held 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee meeting for review and further recommendations. ***The State survey agency validated the corrective action taken by the facility as follows: I. Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ, observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the

Based on record review and interview, the facility failed to notify family and/or the physician of incidents or changes in resident status. Specifically: the facility failed to notify the family in a timely manner of an allegation of abuse for one (1) resident (R6); the facility failed to ensure timely notification of responsible parties/family members when the resident developed a pressure ulcer for one (1) resident (R22); and the facility failed to notify the physician when the blood sugars of R10, R19 and R24 were below 70. The sample was seventy-seven (77) residents. Refer F223, 225, 226, 309 and 314 A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F157 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Findings include: 1. Review of R6's clinical record revealed a [DIAGNOSES REDACTED]. R6 was verbally, physically and emotionally abused on 6/9/16. The facility staff became aware of the abuse on 6/9/16, however they did not notify the physician until a day or two later, nor the responsible party until 6/17/16. Interview conducted with the family during complaint triage on 7/18/16 at 9:10 a.m. revealed that the family was not notified of the abuse which occurred on 6/9/16 incident until 6/17/16. Interview on 8/8/16 at 1:55 p.m., the resident's family member indicated she was not notified of the allegation until 6/17/16. This was 8 days after the allegation of abuse had been made. Refer to F223, 225, 226 2. Review of the Transfer/ Discharge Report revealed R22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The only person listed as responsible party was R22's wife (F5). The resident was discharged from the facility on 8/12/16 to an assisted living facility. Review of the 4/30/16 Nursing Admission Data Collection revealed R22 was admitted without pressure ulcers. Review of the clinical record revealed R22 had a an unstageable area to left buttock, Cleanse area with Normal Saline Solution (NSS), pat dry, apply santyl to wound bed, cover with dry dressing. Even though this treatment was ordered on [DATE], there was no documented evidence of family notification. Review of the 6/19/16 Nursing Daily Skilled Charting revealed, PS to back side, R22 was totally dependent on staff for bed mobility, toileting and transfers - even though this was the first documentation of a PS, there was still no documented evidence of family notification. Review of the 6/23/16 Skin - Head to Toe Skin Checks revealed, R22 had a new and an existing PS, the L butt has a necrotic area to the middle of the wound, L buttock UTS PS is being treated by the wound doctor, there were no evidence the family was notified about the PS. Family member (F4) was interviewed on 8/12/16 at 9:00 a.m., F4 said R22 was denied readmission to the assisted living facility because R22 developed an unstageable pressure ulcer. F4 said he and F5 were not notified in a timely manner about the pressure ulcer. Refer to F314 3. R24 was admitted to the facility on [DATE] with a diagnosis, according to the 8/9/16 Admission Record, of diabetes mellitus due to underlying condition with [MEDICAL CONDITION]. The quarterly Minimum Data Set (MDS - a comprehensive assessment completed by facility staff that drives the care planning process), with an Assessment Reference Date (ARD) of 6/30/16, documented R24 had a [DIAGNOSES REDACTED]. The 8/17/16 Medication Review Report documented the following physician orders [REDACTED].*150 - 200 = 2 units; *201 - 250 = 4 units; *251 - 300 = 6 units; *301 - 350 = 8 units; *351 - 400 = 10 units blood sugar (BS) greater (>) *400 call medical doctor (MD), subcutaneously (under the skin) before meals and at bedtime for diabetes mellitus. Review of the June, 2016 Electronic Medication Administration Record [REDACTED]. There was a lack of documentation to indicate whether the physician was notified. Review of the June, 2016 EMAR indicated R24's BS was 52 on 6/23/2016. There was a lack of documentation to indicate whether the physician was notified. Review of the June, 2016 EMAR indicated R24's BS was 59 on 6/24/16. Review of a progress note dated 6/24/16 at 5:01 a.m. indicated, insulin held at this time. There was no evidence to determine that the MD had been notified. Refer F309 4. R10 was re-admitted to the facility on [DATE] with a diagnosis, according to the 8/16/16 Admission Record, of type II diabetes mellitus with other specified complications. The 8/16/16 Medication Review Report documented the following physician orders [REDACTED].*150 - 199 = 2 units; *200 - 249 = 4 units; *250 - 299 = 6 units; *300 - 349 = 8 units; *350 - 399 = 10 units; *400+ = 12 units; Subcutaneously before meals and at bedtime related to type II diabetes mellitus with other specified complications. Accucheck AC (before meals) and HS (hours of sleep) cover per S/S (sliding scale) except no coverage at HS. HS blood sugar notify MD for BS > 250, no coverage at HS unless ordered by MD. BS less than (<) 70 give 4 oz. juice with snack if awake. If not alert give [MEDICATION NAME] 1 mg IM. Review of the August, 2016 EMAR revealed on 8/9/16 at 4:30 p.m. and 9:00 p.m., a BS of there was no evidence to show that the MD had been notified. Refer to F309 5. R19 was admitted to the facility on [DATE] with a diagnosis, according to the 8/9/16 Admission Record, of diabetes mellitus with diabetic [MEDICAL CONDITION]. The 8/10/16 Medication Review Report documented the following physician orders [REDACTED].*150 - 200 = 2 units; *201 - 250 = 4 units; *251 - 300 = 6 units; *301 - 350 = 8 units; *351 - 400 = 10 units; Subcutaneously before meals and at bedtime related to Type 2 diabetes mellitus with diabetic [MEDICAL CONDITION]. Review of the August, 2016 EMAR indicated on 8/1/16 at 4:30 p.m. the BS was 69, there was no evidence that the physician was notified. Refer to F309 Review of the facility's Diabetic Management Policy most recently revised in June 2008 indicated, Assessment: Upon admission the interdisciplinary team evaluates the diabetic resident and implements a plan of care to ensure: Blood glucose orders should include parameters to follow and when to notify the physician; Results outside of ordered parameters are communicated to the physician immediately; Notify the physician of abnormal blood glucose test results and symptoms exhibited; Notify the physician of abnormal blood glucose test results, symptoms exhibited and interventions implemented. Interview on 8/9/16 at 2:55 p.m., East Unit Manager LPN60 if BS is > 400 call the MD and get an order and document in the progress note. Interview on 8/9/16 at 3:10 p.m., LPN174 reported that if the BS < 60 notify the MD, if > 400 notify the MD. LPN174 if > 250 call the MD. Interview on 8/9/16 at 3:34 p.m., LPN2 stated if > 400 call MD and if BS is 45 or < call the MD. Interview on 8/10/16 at 5:25 a.m., LPN119 stated that for any BS < 60 you call the MD and if > 400 and call MD. Interview on 8/10/16 at 6:10 a.m., LPN169 stated that if the BS > 400 you need to call the MD, < 40-50 give them oxygen and re-check BS, if the BS does not come up call MD.

Based on observation, interview and record review, the facility failed to ensure they provided necessary emergency respiratory supplies as well as an adequate power source to meet the needs of two residents (R28 and R29) residents that had tracheotomies (trachs) and required multiple medical apparatus including ventilator (machine to aid and/or deliver respirations). Review of the CMS Form 672, signed and dated by the Director of Nursing on 11/1/16, revealed no evidence of trachs, and 5 receiving respiratory treatments. The sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/12/16 at 3:36 p.m. the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) situation. The facility's failure to ensure all necessary respiratory related medical equipment for two residents (R28 and R29) with tracheotomies were readily available; and that a safe and appropriate power source was available for their medical equipment, placed residents at risk of serious harm or death. Those failures left residents vulnerable to respiratory distress, and/or death. This failure increased the likelihood for serious harm to two (2) of 2 residents (R28 and R29) with tracheotomies, who: Required back-up replacement inner cannulas in the event their cannulas became dislodged and required emergency replacement. The facility did not ensure the necessary equipment for potential respiratory distress (Ambu bags -manual resuscitators- for both residents, and correctly sized replacement inner cannulas for their tracheotomies) was available, and; Required more electrical outlets to ensure effective delivery of care via medical apparatus than was available. The facility used power strips to provide the extra power that did not meet safety standards. It was not acceptable to obtain power for medical equipment other than directly from the wall. R28 and R29 required multiple medical apparatus (requiring a safe and reliable power source). Since some of their required equipment (oxygen, suction and nebulizers) were directly related to their compromised breathing status, that failure also rose to the level of immediate jeopardy (IJ). The residents were roommates and both required more electrical outlets (seven for R28 and six for R29) than the room provided (4 were available per resident). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F328 was lowered to an E, while the facility develops and implements the Plan of Correction (PoC). Review of the CMS Form 671 signed and dated on 11/1/16 by the DON revealed there are no residents with trachs, and four (4) residents receiving respiratory treatments. Findings include: 1. On 8/12/16, at approximately 12:30 p.m., a family member (F1) of R28, came to the survey team and expressed his concern over the facility being able to provide the needed care for his family member. R28 was admitted to the facility on [DATE] from an acute hospital, out of state, without an onsite assessment. He had [DIAGNOSES REDACTED]. According to his admission Minimum Data Set (MDS) assessment, completed 7/6/16, his [DIAGNOSES REDACTED]. R28 was totally dependent on staff for all Activities of Daily Living (ADLs). Review of the care plan for R28 revealed the presence of the [MEDICAL CONDITION], but it did not list the type or size of the inner cannula. There was evidence to include having a back-up inner cannula or Ambu bag available for respiratory emergencies, or what to do if the inner cannula became dislodged. There was no evidence of a pressure relieving air mattress, although it was ordered by the physician. On 8/12/16, at approximately 12:30 p.m., F1 of R28 stated that he wanted to find out who he needed to call to address some concerns he had regarding care of R28. He stated the facility staff had, almost killed R28 three (3) times, if I had not been here then R28 would not still be here. He stated he was going to talk to the doctor and requested the complaint line number. On 8/12/16, at approximately 12:45 p.m., F1 stated that awhile back, maybe around mid-July, he entered the room of R28 to find him in bed. He appeared to be choking. When F1 asked R28 if he was choking, F1 stated R28 nodded yes. F1 ran to get the nursing staff for assistance. He stated they were not able to clear the airway with suctioning and the staff had called 911. F1 stated that someone from the facility had also called the respiratory therapist (RT) who stated she was close by and would come to the building. F1 also stated the RT was able to clear a mucus plug (an accumulation of mucus in the airway that occurs because a patient can't cough to clear their own airway) and his father was not transported to the emergency room per his request as he was no longer at risk. F1 described a second occasion where he had entered the room if R28 to find the water bottle (humidifier) on the tubing empty and he found a hole in the humidifier bag that hangs in between the tubing, he observed R28 was having difficulty breathing. F1 called the nurses and the West unit manager (UM) and another nurse did not know how to use the Ambu bag (a manual resuscitator, used to provide positive pressure ventilation to patients who are not breathing or not breathing adequately) to assist his father with breathing. The son stated he had to show the nurses how to use it. F1 stated those were just two (2) examples of how the staff were not taking care of R28. The son went on to state the facility did not have enough electrical sockets to plug in all of the equipment need for R28. He stated he had asked every day for two (2) weeks to get a power strip as staff keep unplugging the air mattress when they needed to plug something else in and would forget to plug the air mattress back in. He stated the air mattress was needed for R28 as he had two severe pressure ulcers. F1 stated he finally complained to the NHA and requested the power strip. F1 explained the NHA had stated he was unaware that this was an issue and he would find a power strip as soon as possible. The son reported it took a few more days after speaking to the NHA to get the power strip. Observation on 8/12/16, at approximately 12:45 p.m., when returning to observe R28 and do a cursory review of the room to ensure all necessary equipment for a patient with a [MEDICAL CONDITION] was available, he was observed lying slightly turned to his left side facing the window. He was lying on what appeared to be an air mattress with the head of the bed elevated at approximately a 30-degree angle. R28 had a [MEDICAL CONDITION] and received oxygen via a Tran'[MEDICAL CONDITION] set up which was on the right side of the bed when standing at the end of the bed facing R28. There was a humidifier bottle attached at the top of the tubing which was about one-quarter full. Further down the tubing, there was an air pouch which appeared to be a plastic bag humidifier attached that contained moisture. The two residents shared a room and both had tracheotomies. They were required to have replacement inner cannulas for the residents, in the event their [MEDICAL CONDITION] cannulas became dislodged and needed to be replaced to ensure adequate breathing. A facility Licensed Practical Nurse (LPN117) was providing wound care for R28, with the assistance of a Certified Nursing Assistant. When asked where the extra cannulas were stored, LPN117 indicated the top of a dresser, located on side of the room nearest R28. There were various supplies (dressings, tubing, etc.) jumbled together in a disorderly fashion. What was found by the surveyors were inner cannulas size 8 and size 6. R28 required a size 8 and R29 required a size 4. The room was crowded with equipment and supplies and a power strip was observed taped to the floor with multiple cords plugged into it. The suction machine was on the left side of the bed and back, there was other equipment in front of the suction machine. On 8/12/16, at approximately 1:00 p.m., the DON was interviewed and informed they did not have the proper sized inner cannulas in the room. She immediately went to the room with the same staff nurse (LPN117) observed during wound care, and returned with a size 4 cannula that she said was found in a drawer. That observation was not confirmed and the equipment needed to be readily accessible (as in taped above the bed of each [MEDICAL CONDITION] patient) was not available when surveyors observed the room. Nor was LPN117 able to verbalize where that cannula was when asked by the surveyor during the initial observation of the wound care for R28. The DON confirmed the following pieces of equipment were needed for R28: Oxygen concentrator to deliver oxygen [MEDICAL CONDITION]; A suction machine/aspirator (used to clear the airway of blood, saliva, mucus, vomit or other secretions); A pressure relieving air mattress (used to prevent pressure ulcers by dispersing pressure away from the affected areas and bony prominences); A nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs, or in the case of R28, used to deliver medication via his [MEDICAL CONDITION]); An intravenous (IV) administration set up (to infuse liquid substances directly in to a vein, for R28 it was used to administer antibiotics) - though not in use during the survey; A Negative-pressure wound therapy (NPWT) machine (a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of second and third degree burns); and An electric hospital bed (which allowed for raising and lowering of the bed itself, as well as the ability to raise and lower both the head and foot of the bed). On 8/12/16 at 1:45 p.m., staff physician 165 (primary care physician for R28) stated R28 was a very sick man when he was admitted due to having a Stage 4 and a Stage 2 pressure ulcer, as well as history of acute [MEDICAL CONDITION] and that he was a quadriplegic. Physician 165 stated he had suggested, on more than one occasion, that the son move R28 to a more prominent facility that was staffed with more skilled staff to [MEDICAL CONDITION] wound care, but the son refused to move his father. Physician 165 stated he also wanted the resident transferred to a higher acuity level of care as the wounds were not improving as much as he had wanted them to. He stated he was not consulted regarding whether or not to accept R28 into the facility. Physician 165 stated that he had many discussions with the son and had advised the family R28 would benefit from a facility that provides a higher level of care such as a hospital or long-term acute care (LTAC). He also stated that on 8/6/16 he had requested the resident go to the hospital to be evaluated by an infection disease doctor as he suspected R28 had a colonized infection in his trach. He explained the son requested they wait until the following Monday as he wanted to consult some others and decide if he wanted his father sent to the hospital. Physician 165 stated he did not receive a call back from the son, so he ordered a consult from an infectious disease physician to take place at the nursing home. He stated R28 was stable but he continued to believe the resident would benefit from a higher level of care, but family would not allow, so his best course of action was to request the consult 2. R29 was most recently admitted to the facility on [DATE] (he had resided there previously) with [DIAGNOSES REDACTED]. R29 was a readmit from an acute hospital stay. According to a progress note dated 5/23/16, and as documented on the care plan, R29 pulled his [MEDICAL CONDITION] out and was sent to hospital, where they replaced it and sent him back to the facility. Documentation showed the resident was not in respiratory distress and yet the facility still did not attempt to [MEDICAL CONDITION]. R29 was care planned for history of self extubation (removing his own trachea tubing and cannula) as a behavior, the facility did not have the appropriate size inner cannula ready at his bedside. As evidenced by documentation of having to be hospitalized for [REDACTED]. His Admission Minimum Data Set (MDS), competed on 5/20/16, showed R29 was extensively to totally dependent on staff for all ADLs. He was also fed via a gastrostomy feeding tube. Observation on 8/12/16, at approximately 12:45 p.m., R29 (roommate of R28) also had a [MEDICAL CONDITION]. Their supplies were co-mingled together on a dresser on the side of the room of R28. There was only one (1) Ambu bag present, and there should have been one (1) for each resident. They also needed to have back up inner cannulas readily accessible in the event [MEDICAL CONDITION] dislodged and needed to be replaced to ensure breathing. There were two (2) different sizes in the room - a size 8 and a size 6. R28 required a size 8 and R29 required a size 4. LPN117 (who was the facility wound care nurse) was asked where the needed cannulas might be, and stated they should be in the pile of supplies. She could not state the required size for each resident, so in the event of an emergency the correct sized inner cannula would not be used. Interview on 8/12/16, at approximately 3:36 p.m., the NHA stated that they did not have enough outlets for either resident (R28 or R29) to accommodate their medically necessary, physician ordered, equipment. He stated that when R28 (on 6/26/16) was admitted they realized they did not have enough outlets and directed the Maintenance Director to take and install a power strip in the room. The NHA stated that both R28 and R29 had more medical equipment than they had outlets for and the decision was made to unplug the air mattress for R28. He stated the air mattress was uninflated for a couple of days. (cross refer to F314). Therefore, R28 was admitted on [DATE], indicating a total of over thirteen (13) weeks, the facility had known that the R28 and R29 did not have enough electrical power outlets to support the ventilator equipment, other needed equipment including pressure prevention mattress for residents with pressure sores, and suctioning equipment. The NHA stated he had checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He indicated he was not aware that a power strip could not be used in lieu of proper connectivity to the facility power source (the wall outlets). On 8/12/16, at approximately 1:00 p.m., the Director of Nursing (DON) was interviewed and confirmed the following pieces of equipment were needed for R29: Oxygen concentrator to deliver oxygen [MEDICAL CONDITION]; A suction machine/aspirator (used to clear the airway of blood, saliva, mucus, vomit or other secretions); A nebulizer machine (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs; An electric hospital bed (which allowed for raising and lowering of the bed itself, as well as the ability to raise and lower both the head and foot of the bed), and: A feeding tube administration set up (to infuse liquid nourishment directly into his stomach via a gastrostomy tube). The DON had just started work at the facility approximately one week prior to the survey start date and had no direct observation of the specifics of the allegations made by F1 for R28, but was aware of the issues via record review and her nursing staff. She also stated she had heard there was a problem with having enough outlets for all needed medical equipment and they had power strips in place to meet their needs. She stated she was not aware that a power strip was contraindicated for use with medical equipment. On 8/13/16, at approximately 10:30 a.m., the Maintenance Director was interviewed with the NHA. He confirmed he had been directed to install a power strip in the room of R28. He stated when he went to deliver the power strip, the staff were providing cares to R28, so he left the power strip at the West Wing Nurses station and the nursing staff was supposed to hook up the power strip. A few days went by before it was discovered the power strip had not been installed. The NHA also stated a few days went by before he was made aware of the fact the power strip had still not been installed. As soon as he was aware, he took immediate action to have it put in place. ***The facility implemented the following actions to remove the Immediate Jeopardy: II. Both residents (R28 and R29) identified were sent to the hospital on [DATE] for the needed higher level of care. The two identified residents R28 and R29 are no longer at this facility. A 100% room audit was completed for appropriate electrical audits by August 13, 2016. Maintenance Department staff members were educated on the inability to use power strips for medical equipment on 8/12/16. The Plant Operations Director initiated staff education on the inability to use power strips with medical equipment on 8/12/16. The Plant Operations Director and/or designee will educate new staff members during the orientation process. Plant Operations Director and/or designee will perform monthly audits of all rooms looking for power strips and report findings to monthly QAPI committee meetings. Any variance will be addressed immediately. Rooms with red emergency electrical outlets were identified and given to the Admissions Coordinator for appropriate resident placement on 8/14/16. Identified with blue dots on our admission board located in admission department. Our Clinical Admission Grid was updated to reflect high risk respiratory residents would be reviewed by the DON before admission. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. No residents will be admitted into the facility with high acuity of tracheotomies until additional specialized training is completed for the licensed nurses. A licensed respiratory therapist from (Name deleted) will be contracted to provide in-house education for the licensed nurses on [MEDICAL CONDITION] care and equipment. For future [MEDICAL CONDITION] residents admitted into the facility, an individualized [MEDICAL CONDITION] kit will be kept at the bedside of each resident. This will include replacement inner cannulas with the correct size. A skills check list will be developed and utilized by the DON and/or Registered Nurse designee to ensure the competency levels of license nurses providing care [MEDICAL CONDITION]. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve the plan. The plan was reviewed and approved by the Medical Director. ***The State survey agency validated the corrective action taken by the facility as follows: Review of physician orders [REDACTED]. Observation on 8/18/16 at 9:00 a.m. verified that both R28 and R29 were not in the facility. Interview on 8/18/16 at 9:05 a.m. with Admissions Coordinator verified that the facility had not admitted any future residents with higher acuity of tracheotomies until additional specialized training is completed for licensed nurses. Observation on 08/18/16 at 9:10 a.m. with DON, revealed that the Admission Grid was updated to include rooms that could be used to admit any future high risk respiratory tracheotomies (trach) residents to facility. The DON confirmed that the facility will not admit residents [MEDICAL CONDITION] trained Respiratory Therapist being on staff and all licensed nurses have completed specialized training. Review of a skills check list related to the treatment of [REDACTED]. Interview on 8/18/16 at 9:15 a.m. with DON and Admission Coordinator provided education to all licensed staff to ensure all high acuity residents with tracheotomies will not be admitted to the facility without trained Respiratory Therapist being on staff and all licensed nurses completed specialized training. Review of employee training education signature sheets verified the facility implemented new protocol on [MEDICAL CONDITION] for [MEDICAL CONDITION]. Interview on 8/18/16 at 9:25 a.m. the Nursing Home Administrator (NHA) confirmed he is actively recruiting respiratory therapist. Review of the Northeast Atlanta Health and Rehabilitation Center Electrical Safety/Non-Use of Power Strips for Medical Equipment log training log verified that two (2) of two maintenance staff received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16. In addition, it was verified that ninety-six (96) of a total of one-hundred ninety-one (191) facility employees received in-service training on electrical safety and the non-use of power strips for electrical equipment on 8/12/16 and 8/13/16. Interview on 8/19/16 at 11:04 a.m. with the facility NHA confirmed a 100% room audit was completed for appropriate electrical outlets and all power strips were removed from resident rooms on/or before 8/13/16. Observation on 8/19/16 beginning at 11:04 a.m. with the facility NHA and Maintenance Director confirmed there were no power strips in any resident rooms on the East, West and Terrace Units of the facility therefore validating there were no rooms with power strips; the Admission Board, in the Admissions Office to have blue dots identifying a total of eight (8) rooms with red emergency electrical boxes capable of safely providing power to suctioning and similar equipment related to tracheotomy care. Review of the Ad Hoc QAPI (Quality Assurance and Performance Improvement) Committee Meeting signature sheet revealed all disciplines signatures were present. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director acknowledged becoming aware of the ventilator issues during the survey. He continued to state it is never ok to use a power strip for medical equipment, and the residents were immediately they were transferred. The facility presently will not admit any residents with trachs until sufficient training and the availability of a Respiratory Therapist for consultation. The Medical Director revealed that the QA Committee discussed Respiratory during the meetings held on 8/24/16, 9/21/16 and 10/12/16. Interview on 11/8/16 at 2:20 p.m. With the NHA and the DON revealed that they were not aware of the problems with the ventilator residents until the survey in August 2016. Per DON she immediately located the correct cannula; re-organized the room and sorted their supplies and reported to the family and the physician.

Based on record review and interviews, the facility failed to investigate an allegation of abuse, failed to report to the State Survey Agency (SSA) within twenty-four (24) hours, failed to protect residents from during the investigation of alleged abuse, failed to report the findings of a substantiated allegation of verbal and physical abuse, which occurred on 6/9/16, within 24 hours for one (1) resident (R6) reviewed for abuse. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). The facility failed to report to the State Survey Agency (SSA) in a timely manner, a substantiated allegation of verbal and physical abuse, which occurred 6/9/16. The facility incident report was not sent to the SSA until 6/17/16, which was eight (8) days after the incident. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F225 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). cross refer to F223 and F226 Findings include: Review of a fax sent to the SSA Complaint and Intake Unit, dated 6/22/16, indicated: a report was discovered on 6/16/16 from a new Certified Nursing Assistant (CNA) ZZ who reported an incident that happened involving her preceptor CNA68 during her orientation. On 6/9/16, she observed R6 being handled rough and that CNA68 stated to the resident We are not gonna do this[***]today. CNA ZZ noticed R6 had tears in her eyes after they put the resident in her wheelchair. The DON (Director of Nursing) went to assess R6 for any signs of and or visible injuries. None were noted. (cross refer F223 for details and interviews). Conclusion: Based on the investigation the allegation of physical and verbal abuse can be substantiated. CNA68 employment will be separated from the facility and her name will be reported to the local police and Certified Nursing Board registry. Review of the clinical record for R6 included [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment, dated 7/20/16, indicated the resident was unable to complete the interview for mental status. She was dependent with two (2) person assist for transfers, dressing, toilet use, and bathing. Review of a facility policy, dated 7/16/16, received on 8/8/16 at 4:40 p.m., from the Corporate Nurse as current, indicated; the facility will report such allegations to the state within 24 hours. The facility will report all investigation findings to the state within 5 calendar days. The facility will report all allegations and substantiated occurrences of abuse, neglect to the state agency and law enforcement officials within 24 hours of identification. Interview on 8/9/16 at 11:00 a.m., the NHA indicated he had been on vacation and reported the abuse allegation on 6/17/16 to the SSA. Interview on 8/9/16 at 11:45 a.m., the Unit Manager Registered Nurse (RN) 60, indicated she found out about the incident on 6/9/16. Unit Manager RN60 indicated she then realized she had the wrong resident and found out on 6/10/16 it was R6. The Unit Manager RN60 indicated she had told the Staff Development Coordinator (SDC) and the DON about the abuse incident on 6/10/16. The Unit Manager RN60 indicated the new CNA (referring to CNA ZZ) was off the next day and they had called her to come in and get a statement. Unit Manager RN60 indicated the new CNA ZZ came in on the 15th or 16th for the statement. Unit Manager RN60 indicated CNA68 had worked on the 14th and 15th of June 2016. The Unit Manager indicated she had suspended CNA68 on 6/15/16. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. ***The State survey agency validated the corrective action taken by the facility as follows: Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is NHA and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ - observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report.

Based on record review and staff interview, the facility failed to assure that one (1) resident (R6) was free from verbal, rough handling abuse on 6/9/16 by a Certified Nursing Assistant (CNA) 68. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. This failure caused actual harm to R6. The facility failed to prevent R6 from verbal, emotional and physical abuse by staff, failed to investigate the allegation of abuse in a timely manner, failed to take immediate action to suspend the alleged perpetrator and protect other residents during the investigation, according to the facility policy, placed other residents at risk for serious injury or harm. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ). An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F223 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). Cross refer to F225 and F226 Findings include: Review of a facility policy, dated 7/16/16, received on 8/8/16 at 4:40 p.m., from the Corporate Nurse as current, indicated: Each Resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Nursing Home Administrator (NHA) and/or Director of Nursing (DON). Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain or mental anguish. Injuries of unknown origin may occur as a result of abuse. The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility. Prevention includes: 1. Residents, families, and staff will be able to report incidents and concerns without fear of retribution. 2. Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation of resident property is at risk for occurring Investigation includes: 1. the facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. 2. The facility will report such allegations to the state within 24 hours. 3. The facility will report all investigation findings to the state within 5 calendar days; Protection includes: 1. the facility will protect residents from harm during the investigation .Reporting and Response 1. The facility will report all allegations and substantiated occurrences of abuse, neglect .to the state agency and law enforcement officials within 24 hours of identification. Review of the Facility Incident Report Form faxed to the State Survey Agency (SSA), dated 6/17/16, indicated, the date and time of incident was on 6/9/16 during the 7-3 shift; Details of incident indicated that a new Certified Nursing Assistant (CNA) ZZ wrote statement, stating that during her orientation, while precepting with another CNA68 she witnessed CNA68 be rough while dressing R6. And stated to R6 'we not going to do this[***]' Continued review of the Facility Incident Report Form revealed that the Steps taken by facility to prevent further incidents: This CNA68 was removed from the schedule pending investigation. R6 was assessed for any physical injury, none noted. Review of a fax, dated 6/22/16, to the SSA indicated (the final five (5) day report of the investigation); The Event report was discovered on 6/16/16 from a new CNA ZZ who reported an incident that happened while she precept with another CNA68 during her orientation. On 6/9/16, she observed a resident (R6) being handled rough and that CNA68 stated to R6 'we are not going to do this[***]today.' The orientee noticed that R6 had tears in her eyes after they put the resident in her wheelchair. The DON went to assess R6 for any signs of and or visible injuries. None were noted. A review of the record for R6 revealed that she had her skin assessment completed by the charge nurse on 6/15/16, which did not indicate any injuries. The physician and family member of R6 was notified of the reported incident. Investigation: CNA ZZ is new to the facility and was in orientation/precepting with CNA68 who has been employed for two (2) years. The Unit Manger spoke with CNA68 who was suspended pending investigation of patient care issues. The Staff Development Nurses and Unit Manager spoke with the new CNA ZZ who identified the resident as being R6 she provided a statement under the NHA's door. Upon the DON getting the statement it did not identify the resident. Question as to what was doing and she stated, CNA68 leaning over R6 trying to put her top on. She saw CNA68 snatch R6 arm while putting her clothes on and said to her We are not going to do this[***]today. CNA ZZ stated that she started to put the pants on R6 and then transferred her to the chair, then she noticed tears on her face. She gave R6 a wash cloth to clean her face and R6 stated to her 'no you do it.' Question as to, if R6 said anything during the care with CNA68, she said no. Conclusion based on the investigation the allegation of physical and verbal abuse can be substantiated, CNA68 employment will be separated from the facility and her name will be reported to the local police and Certified Nursing Board registry. R6 and her family will be notified of facility finding. Review of the statement by CNA ZZ, dated 6/15/16, indicated I am writing this statement in reference to an incident in which I witnessed on 6/9/16. I was helping R6 with an RCA (Resident Care Assistant) or (CNA); CNA68 while dressing the resident CNA68 snatched the residents arm and pulled her around and stated 'we are not going to do this[***]' After we got the resident in her wheelchair I noticed she had tears going down her face. This situation made me very uncomfortable. Review of the nurses notes, dated 6/17/16, and documented the resident was identified by a CNA ZZ that the R6 was mishandled by another CNA68 in an on-going investigation of patient care. R6 was assessed for any visible bodily injuries, none noted. A review of her weekly Skin Assessment on 6/15/16 did not reveal any injuries, nor skin impairments. Medical Doctor (MD) and family made aware of investigation. Review of a statement from the family of R6, dated 6/20/16, indicated documented on Tuesday 6/14/16 her mother (R6) was more agitated and didn't want CNA68 to touch her, as reported 6/17/16. Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. Review of a quarterly MDS (Minimum Data Set) assessment, dated 7/20/16, indicated that R6 was unable to complete the interview for mental status. She was dependent with two (2) person assist for transfers, dressing, toilet use, and bathing. Review of a Kronos Punch Detail (time report) for June 2016, indicated CNA68 had worked at the facility on 6/9/16, 6/10/16, 6/14/16, and had worked on 6/15/16 from 6:34 a.m. to 3:06 p.m. During an interview on 8/9/16 at 11:00 a.m., the NHA indicated he had been on vacation when the abuse allegation was reported on 6/17/16. During an interview on 8/9/16 at 11:45 a.m., the Unit Manager (UM), Registered Nurse (RN) 60, indicated she found out about the incident on 6/9/16 by CNA ZZ. The Unit Manager RN60 indicated she had changed the assignment for CNA68 to the top of the hall so she would not be taking care of the resident. Unit Manager RN60, indicated she then realized she had the wrong resident and found out on 6/10/16 it was R6. She indicated the CNA ZZ had told another CNA that CNA68 had handled R6 rough. The Unit Manager indicated she had told the Staff Development Coordinator (SDC) and the DON about the abuse incident on 6/10/16. The Unit Manager indicated CNA ZZ was off the next day and they had called her to come in to Get a statement. The Unit Manager RN60 stated I was in the office when the DON called her. CNA ZZ came in on the 15th or 16th for the statement. The Unit Manager RN60 indicated CNA68 had worked on the 14th and 15th of June 2016. The Unit Manager indicated she had suspended CNA68 on 6/15/16. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. ***The State survey agency validated the corrective action taken by the facility as follows: Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA) revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ, observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report. CNA 68 member (facility) CNA 68 spoke with CNA 68 and CNA 68 CNA 68 was CNA 68 CNA 68, CNA ZZ stated no. . CNA 68 RN 60 CNA 165 CNA 165 RN 60, RN 60 RN 60 RN 60, RN 60 RN 60 interviewable

Based on staff interview and record review, the facility failed to follow their policy and procedure for investigation of allegations of abuse, reporting allegations to the state agency (SSA) within twenty-four (24) hours, failed to provide protection of residents during investigation of alleged abuse, for one (1) resident (R6) who was verbally, emotionally and physically abused on 6/9/16. The facility failed to report the incident to the State Survey Agency (SSA) in accordance with their policy, failed to implement their policy on abuse including reporting, investigating, and failed to assure protection of R6 and other residents in the facility immediately following the report of alleged abuse and failed to train all staff members in Abuse Policies and Procedures. The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. A determination was made that the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. On 8/11/16 at 3:30 p.m., the Nursing Home Administrator (NHA) and the Director of Nursing (DON), were informed by the survey team of an Immediate Jeopardy (IJ) related to failure to report, failure to protect residents from abusive behavior by a Certified Nursing Assistant (CNA) who verbally, emotionally and physically abused R6; failed to investigate the allegation of the abuse within twenty-four (24) hours of becoming aware of the abuse; failed to adhere to the facility's policy related to abuse and failed to report to the SSA within the 4 hours of becoming aware. An acceptable Allegation of Compliance (AoC) was received on 8/19/16 and Healthcare Management Solutions, LLC in conjunction with the Georgia State Survey Agency validated that the Immediate Jeopardy was removed on 9/14/16, as alleged. However, to ensure that the education continues, policy and procedures are implemented, and the QAPI is implemented and functional, the scope and severity (S/S) for F226 was lowered to a D, while the facility develops and implements the Plan of Correction (PoC). Cross refer to F223 and F225 Findings include: Review of a facility policy, dated 7/16/16, received, from the Corporate Nurse as current, indicated; Each Resident has the right to be free from mistreatment, neglect, abuse .; Any observations or allegations of abuse, neglect, or mistreatment must be immediately reported to the Administrator and/or Director of Nursing; Abuse means the willful infliction of injury .; The facility will ensure that such training is provided during orientation, annually, and more often as determined by the facility; Prevention includes; Residents, families, and staff will be able to report incidents and concerns without fear of retribution; Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect .; Investigation includes; The facility will conduct an investigation of any alleged abuse/neglect . in accordance with state law. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated; The facility will report such allegations to the state within 24 hours; The facility will report all investigation findings to the state within 5 calendar days .; Protection includes, The facility will protect residents from harm during the investigation .Reporting and Response includes, The facility will report all allegations and substantiated occurrences of abuse, neglect .to the state agency and law enforcement officials within 24 hours of identification. Review of the statement by CNA ZZ, dated 6/15/16, revealed .I am writing this statement in reference to an incident in which I witnessed on 6/9/16. I was helping R6 with an RCA (Resident Care Assistant) or (CNA); CNA68 while dressing the resident CNA68 snatched the residents arm and pulled her around and stated 'we are not going to do this[***]' After we got the resident in her wheelchair I noticed she had tears going down her face. This situation made me very uncomfortable. Review of a Facility Incident Report Form faxed to the SSA, dated 6/17/16, indicated, A new Certified Nurse Aide (CNA) ZZ wrote statement, stating that during her orientation, while precepting with another CNA68 she witnessed CNA68 be rough with resident (R6) while dressing her and stated to the resident 'we are not going to do this[***]' Review of a statement from R6 family, dated 6/20/16, revealed on Tuesday 6/14/16 her mother was more agitated and didn't want CNA68 to touch her, as reported 6/17/16 Review of the clinical record for revealed a [DIAGNOSES REDACTED]. Review of a quarterly MDS (Minimum Data Set) assessment, dated 7/20/16, indicated the resident was unable to complete the interview for mental status. She was dependent with two person assist for transfers, dressing, toilet use, and bathing. Interview on 8/9/16 at 11:45 a.m., the Unit Manager Registered Nurse (RN) 60, confirmed that she found out about the incident on 6/9/16. RN60 reported the event to the Staff Development Coordinator and the DON, however, review of the record for R6 revealed that she had her skin assessment completed by the charge nurse on 6/15/16, which did not indicate any injuries. Review of the nurses notes, dated 6/17/16, and documented the resident was identified by a CNA ZZ that the R6 was mishandled by another CNA68 in an on-going investigation of patient care. R6 was assessed for any visible bodily injuries, none noted. A review of her weekly Skin Assessment on 6/15/16 did not reveal any injuries, nor skin impairments. M.D. and family made aware of investigation. Review of a Kronos Punch Detail (time report) for June 2016, revealed CNA68 had worked at the facility on 6/9/16, 6/10/16, 6/14/16, and had worked from 6:34 a.m. to 3:06 p.m. on 6/15/16. Interview on 8/9/16 at 11:45 a.m., the Unit Manager Registered Nurse (RN) 60 indicated she found out about the incident on 6/9/16. The Unit Manager RN60 indicated she had changed CNA68's assignment to the top of the hall so she would not be taking care of the resident. Unit Manager RN60 indicated she then realized she had the wrong resident and found out on 6/10/16 it was R6. She indicated the new CNA had told another CNA that CNA68 had handled R6 rough. The Unit Manager RN60 indicated she had told the Staff Development Coordinator and the DON about the abuse incident on 6/10/16. The Unit Manager indicated the new CNA was off the next day and they had called her to come in and get a statement. The Unit Manager RN60 stated I was in the office when the DON called her. The Unit Manager RN60 indicated the new CNA came in on the 15th or 16th for the statement. The Unit Manager RN60 indicated CNA68 had worked on the 14th and 15th of June 2016. The Unit Manager indicated she had suspended CNA 68 on 6/15/16. Review of the resident's record indicated a lack of documentation of any Social Service notes for the month of June 2016. Interview on 8/9/16 at 11:00 a.m., the Administrator confirmed he reported the abuse allegation on 6/17/16, which was 8 days after the abuse, and 8 days after the Unit Manager RN 60, reported it to the DON. ***The facility implemented the following actions to remove the Immediate Jeopardy: I. Initial abuse training began on June 20, 2016. Additional training was completed with all active staff by 8/11/16 including: Abuse Coordinator for the facility is the Nursing Home NHA; Types of abuse, and: Immediate notification of abuse to the immediate supervisor and/or Abuse Coordinator. Abuse education signage was posted at the employee time clock, employee restrooms and nursing stations. Abuse training has been incorporated into the orientation process for all new employees and annually and as needed for current employees. Education was provided to the Nursing Home Administrator (NHA), who is also the Abuse Coordinator and to the Director of Nursing (DON) by the District Director of Clinical Services (DDCS). Alleged abuse concerns are to be reviewed and reported immediately to the State Agency. If employees are involved in the allegation, that person/s will be sent home and then the allegation will be investigated completely. The Abuse Policy was printed and reviewed with both the NHA and DON effective as of 8/11/16. Random ABAQIS (a Quality Management System) resident interviews will be completed by Social Services and/or designee on five interviewable residents weekly for four (4) weeks, then monthly for two (2) months, then quarterly for one (1) year. The checklist and ABAQIS resident interviews will be reviewed at the monthly QAPI (Quality Assurance and Performance Improvement) Committee Meeting and changes made as needed. Burn out prevention and recovery training was completed by the NHA for all department heads on 8/16/16 and training was initiated for charge nurses on 8/16/16 by the Staff Development Coordinator (SDC) with a 100% expected completion of all charge nurses by 9/14/2016. The Abuse Coordinator will make rounds to quiz employees on abuse policies and procedures daily for one (1) week, weekly for four (4) weeks, then monthly. An Ad Hoc QAPI Committee Meeting was held on 8/12/16 to review and approve this plan. The plan was reviewed and approved by the Medical Director. Reports, audits and monitoring tools will be brought to the monthly QAPI Committee Meetings for review and recommendations of changes as needed. ***The State survey agency validated the corrective action taken by the facility as follows: Review of an Abuse Training record dated 6/21/16 indicated that forty-eight (48) employees were given abuse education on 6/21/16. In addition, review of sign in sheets revealed that Abuse training was conducted on 6/29/16, 7/12/16, 7/26/16, 8/3/16, 8/10/16 and 8/11/16. Review of the Abuse Training sign in sheets dated 6/21/2016 revealed that forty-eight (48) employees attended the education, and that any employee who had not received the education would not work if the education was not completed by September 2, 2016. The education was conducted by the Nursing Home NHA. Review of an Abuse Training record dated 8/11/16, indicated fifty-four (54) of one-hundred-fifty-six (156) employees were in-serviced for abuse on 8/11/16. Interview on 8/11/16 at 9:00 a.m. the NHA revealed the facility conducted all staff meeting that was mandatory and Resident Abuse and Neglect in-service training which included facility polices, test, signature sign in attendance sheets. Interviews of staff conducted on 8/11/16 (4 CNAs, 1 Therapist, and 3 Nurses) of staff burnout, were able to provide 2 examples of staff burnout and were confident about reporting possible burnout to management Interview on 8/16/14 at 11:30 p.m. with the NHA revealed on 8/11/16 that the facility did conduct Abuse Competence Audit tool in-service to all employees on types of abuse, including when do the employees are to report any alleged abuse, the types of abuse and neglect, who are the abuse coordinators, and the facility Abuse policy on mandated reporting and prevention of any abuse. Employee signature sign in sheets were provided upon completion for the abuse weekly quizzes conducted by the Abuse Coordinator. Review of the sign-in sheet dated 8/16/16 and 8/17/16 revealed Review of the sign in sheets dated 8/16/16 revealed a total of forty (40) staff attended a twenty (20) minute inservice titled, Burnout completed by the NHA for all department heads on 8/16/16 and began for nurses on 8/16/16 by the Staff Development Coordinator (SDC). Interview on 8/19/16 at 11:04 a.m. with the NHA /Abuse Coordinator revealed expected 100% completion of training for all charge nurses by 9/14/16 related to Abuse training. Interview on 8/16/16 at 10:14 a.m. with the NHA and review of QAPI meeting signature sheet the verified that the facility held an Ad Hoc QAPI Committee Meeting on 8/12/16. Observations on 8/18/16 at 9:30 a.m. and on 8/19/16 at 8:15 a.m. with the NHA and DON revealed the abuse education signage was posted at the employee ' s time clock, all employees ' restrooms, all break rooms, and all nursing stations all signage posting was still posted and visible Interview on 8/18/16 at 12:30 p.m. with the Abuse Coordinator/NHA and review of the facilities Abuse and Neglect Training employee attendance signature sheets. It revealed a total of 12 Administration Staff was in-serviced on 8/11/16. The facility has 16 Registered Nurses as charge nursing 13 out of 16 charge nurses was in-serviced on 8/11/16 with signed signatures during the survey process. Review on 8/19/16 at 10:25 a.m. review of the of the in-service grid and signatures on sign in logs revealed that one-hundred seventy-six (176) of one-hundred ninety-one (191) facility staff including twelve (12) of 12 administrative staff; sixty-nine (69) of 72 Certified Nursing Assistants (CNAs); forty-three (43) of 49 Licensed Practical Nurses (LPNs); thirteen (13) of 16 Registered Nurses (RNs); two (2) of 2 maintenance; and thirty-seven (37) of 40 therapy staff attended the Abuse education including; Immediate Notification of Abuse to the Supervisor and/or the Abuse Coordinator, and Abuse Training. Interview with the Social Services Director (44) on 11/3/16 at 11:30 a.m. confirmed receiving education related to staff burnout to instruct staff to notify immediate supervisors/ nurse if feeling overwhelmed, encourage to use EAP services, identifying triggers to promote healthy work-life balance. The SSD stated that NHA is the abuse coordinator and any type of abuse should be reported immediately for investigation. Interview with LPN (169) on 11/4/16 at 6:18 a.m. confirmed receiving education on abuse upon hire and every 2-3 weeks. LPN stated that the abuse coordinator is the NHA; two types of abuse include but were not limited to verbal and physical. LPN confirmed that he would separate anyone from the resident upon suspecting of abuse and report immediately to the NHA. LPN revealed that if no action was taken by the NHA, he would then report to the state agency. Interview with LPN (184) on 11/4/16 at 6:30 a.m. confirmed receiving education weekly on abuse policy and prevention by in-service. LPN stated that two types of abuse included verbal and physical abuse. LPN informed that she would report any forms of abuse to the NHA. Interview with the Director of clinical services (DDCS) on 11/4/16 at 8:40 a.m. - received education related to staff burnout including monitoring the schedule/ time report, ensuring staff are not overworked or working doubles, etc. Staff are monitored daily by observation. All managers are to discuss, report, and address any issues related to staff burnout. Interview with LPN (170) on 11/4/16 at 11:36 a.m. confirmed receiving education in August/Sept related to the citations and prior to that -quarterly. Two types of abuse described by the staff were mental and physical abuse. The abuse coordinator is the NHA any report any forms of abuse immediately. Interview with CNA (185) at 11/7/16 at 10:00 a.m. and CNA (59) on 11/7/16 at 10:20 a.m. confirmed receiving in-services weekly and continuously, report any forms of abuse, physical, verbal, sexual, or misappropriation of resident ' s property immediately to the NHA. If no action was taken, abuse would be reported immediately to the state. Interview with RN (157), a resource nurse on 11/7/16 at 2:53 p.m. received education related to staff burnout including a list highlighting s/sx and the importance of reporting those s/sx; and to also incorporate HR for assistance. RN stated abuse coordinator is Patrick fell ers and any form of abuse should be reported immediately. Interview on 11/8/16 at 1:00 p.m. via telephone with the Medical Director revealed that he became aware of the incident/abuse that occurred on 6/9/16, by the DON (former), a day or two after the event. The Medical Director stated that it was discussed at the next QA meeting after the incident, at that time, a correction plan was discussed. The Medical Director stated he had a copy of the Plan of Correction (POC). He also stated that the staff had a meeting with Ums, DON and NHA and all deficiencies were discussed - sometime within last month. Long, but good meeting. Allegations of abuse require immediate notification once aware. Interview on 11/8/16 at 2:20 p.m. with the NHA and the DON revealed the following related to CNAZZ - observed CNA68 mishandle R6: The DON did not start at this facility 7/26/16, so therefore she was not aware on 6/9/16 about the abuse to R6. The NHA stated that he was on vacation at the time of the incident and became aware on 6/15/16 (or thereabouts). Once the DON and NHA became aware of the incident on 6/9/16, the employee was suspended pending investigation and education began including Inservices to all staff re: Abuse Reporting. All allegations of abuse are to be reported immediately to NHA. During an Ad QAPI on 8/12/16, the incident was probably discussed as a case reported in July 2016. Interview with dietary staff (187) 11/09/2016 at 8:14 a.m. revealed that abuse training had been provided including the NHA and separate the residents and call for help. Verbal, physical types of abuse. Interview with HK (188) on 11/09/2016 at 8:25 a.m. confirmed receiving abuse training, to notify the NHA immediately, or any other manager, some types of abuse include physical, verbal, and sexual. Interview maintenance staff (189) on 11/09/2016 at 8:28 a.m. confirmed receiving abuse education and the NHA is the abuse coordinator, if you see anything with any resident to report immediately, some types of abuse include physical and mental. Interview with LPN (190) on 11/09/2016 8:34 a.m. confirmed receiving abuse training focused on keeping resident safe, to remove the threat, take the threat out of the building, assess the resident, document, report to manager, call the police notified. Different types of abuse include Physical, mental, and verbal. Interview LPN (160) from Terrace on 11/09/2016 8:48 a.m. confirmed receiving Abuse training, if see abuse, report to NHA immediately, staff abusing patient, protect resident first, call someone immediately to remove that person then report.

Based on interview and record review, the facility failed to ensure a safe environment for three (3) residents (R15, R28 and R29). Specifically, the facility: a). failed to provide adequate supervision and assistive devices to prevent accidents for R15 who had a history of [REDACTED]. R15 sufferred actual harm when she fell again contributing to an additional hip fracture which led to her ultimate demise, and; b). failed to ensure the environment remained as free from accident hazards as possible for R28 and R29 who required multiple electrical devices when their medical equipment was plugged in to a power strip, this resulted in actual harm when the facility unplugged the pressure prevention mattress used for R28 who had severe pressure sores. (cross refer to F314) The facility census was one-hundred-nine (109) and the sample was seventy-seven (77) residents. Review of the CMS Form 672, signed and dated on [DATE] by the Director of Nursing revealed a total of 10 residents ambulated, 3 ambulated with assistance, 2 are bedfast, and therefore at least a total of 97 residents are at fall risk. Findings include: 1. Review of the Transfer/ Discharge Report revealed R15 was re-admitted to the facility on [DATE] from the hospital after having Open Reduction and Internal Fixation (ORIF) surgery to repair a fractured hip. R15 had [DIAGNOSES REDACTED]. The resident expired on [DATE]. Review of the hospital records [DATE] History and Physical revealed This patient is a very pleasant, [AGE] year-old with a known history of heart failure, chronic pain, neuropathy, spinal stenosis, and generalized debility, who apparently has been having pain in her right lower extremity for the past several days. According to her son, the R15 has not incurred any falls; however, he was informed last Thursday that the R15 had gently slumped to the ground. He states that ever since that time, she has been having severe right lower extremity pain. She has been working with physical therapy with regards to the pain, but it has not gotten any better. He reports that over the last couple of days, the mental status of R15 has somewhat declined and she has become a little bit more confused. This is usually indicative of a urinary tract infection and this prompted the nursing facility to send R15 to the emergency room , R15 underwent a workup, which revealed a distal femur fracture, as well as a urinary tract infection, acute kidney injury and hyperkalemia. Given these issues, the patient has been admitted for further evaluation and treatment. Review of the [DATE] nursing note for R15 documented at 7:25 a.m. revealed, on last rounds at about 6:50 am, assessment the right hip surgical site staples intact, moderate amount dark colored blood was observed sipping out from between the staples. The surgical site surrounding skin was also noted to be warm and tender to touch with slight discoloration. Resident c/o pain to area; Percocet ,[DATE] mg given and she was repositioned with assistance of another nurse for comfort; administered analgesic result pending. BLE (bilateral lower extremity) also remain edematous (non-pitting), both elevated on pillow and heels floated on pillow. No noted acute respiratory distress. O2 (oxygen) via NC (nasal cannula) at 2L/min (2 liters per minute). HOB (head of bed) remains elevated. AM nurse arrived on the unit early and went in the room with writer to assess as well; she took over resident's care at this time - following up with (physician). Unit manager was also made aware/assess site. Review of subsequent nursing notes on [DATE] for R15 revealed a wound culture was taken of the right leg surgical wound. Doppler results were negative for blood clot and the resident was started on an antibiotic to rule out infection. Review of the [DATE] Situation, Background, Assessment and Recommendation Communication Form (SBAR) and Progress Note for R15 revealed documented at 4:23 p.m. revealed, at 11:15 a.m. R15 had to be lowered to the floor today while being transferred from bed to her wheelchair. The operation site on her right hip was bleeding. She also has a skin tear on her right ankle that was bleeding. Vitals are within normal limits. Resident's (son) and (physician) notified. A stat X-ray of right hip and femur has been ordered. Skin tear on right ankle has been cleaned with normal saline and covered with a bandage. Operation site on right hip has been cleaned with normal saline and covered with a bandage. The form did not include evidence of a thorough investigation into the root cause of lowering her to the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what staff thought happened, whether staff education would be beneficial or what interventions could be put in place to prevent recurrence. Review of nursing notes on [DATE] for R15, revealed the hip wound was monitored, there was no drainage, an X-ray revealed intact hip arthroplasty no change and no new orders. Review of the [DATE] X-ray results for R15 revealed, anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Conclusion: Intact bilateral hip prostheses. Review of the nursing notes on [DATE] for R15 revealed the resident was sent to the hospital and returned without new orders. Review of the nursing notes for R15 between [DATE] and [DATE], revealed R15 continued on antibiotic for right thigh surgical site infection, diagnosed with [REDACTED]. ([DATE] CXR right lower lobe infiltrate) Review of the [DATE] nursing note for R15 documented at 2:49 p.m. revealed, resident alert, returned from (orthopedics appointment) during this some discomfort noted - PRN (as needed) medication administered during this time. Resident sutures removed and TX (treatment) to lower right leg is to be d/c (discontinued), also noted resident is to have :no weight bearing until follow-up visit on [DATE]. Review of the [DATE] SBAR Communication Form and Progress Note for R15 documented at 4:39 a.m. revealed, R15 was yelling and found on the floor, resident was re-directed to call for assistance and continuous monitoring; said she wanted to get out of the bed, was very anxious yelling (did) not pay attention at all when (being) directed with what to do, needs more constant monitoring and redirection at all times. Frequent family visits to keep resident accompany. The form did not include evidence of a thorough investigation into the root cause of how she ended up on the floor or any information regarding who was involved, witness statements, what the resident was wearing on her feet, what the resident was doing last time staff checked on her, what staff thought happened, whether staff education would be beneficial or what interventions were put in place to prevent recurrence. Review of the [DATE] nursing note for R15 documented at 8:41 a.m. revealed, R15 was very anxious, yelling and was found on the floor at 4:30 am by the charged nurse and resident care specialist. Assessment was done and vital signs taken. Assisted back to bed with hoyer lift. Denies any pain distress discomfort. Redirected to call for assistance and safety intervention for floor mat to be on the floor while resident in the bed. Will continue with plan of care. Review of the [DATE] X-ray results for R15 revealed, there is prosthetic right femoral head in proper alignment with respect to the acetabulum. There is no fracture or acute dislocation. The prosthesis is properly situated without any loosening. Pubic rami are normal. Conclusion: Intact right hip arthroplasty, unchanged from [DATE]. Review of subsequent nursing notes for R15 on [DATE] revealed the resident was confused, calling out for help throughout the night, received an order for [REDACTED]. Review of the [DATE] nursing note for R15 documented at 12:48 a.m., revealed the physician was called about the resident's complaints of pain and ordered an X-ray of the right hip. Review of the [DATE] nursing note for R15 documented at 11:46 a.m. revealed, R15 continues to c/o pain to her left hip per therapy. This author asked resident if she was having pain now. Resident stated, 'No not when I am sitting down.' This author notified MD and new order was received for an AP and lat (X-ray) of the left hip. Resident continues to yell out when someone goes into her room she is quiet asking them to keep her company. Will continue to monitor. Review of the [DATE] X-ray results for R15 revealed, Hip unilateral w (with) pelvis ,[DATE] V (view) left; comparison: [DATE]/ 2016; Findings: Anatomic alignment is maintained. There is osteopenia noted. There is no acute fracture or dislocation. Prosthesis is noted with no lucency around the hardware. There are no erosive changes seen. Review of the [DATE] nursing note for R15 documented at 2:57 p.m. revealed, report of the entire xray was read to (physician). No new orders recd (received) for the UA results which was called to the (physician). This author called the residents granddaughter (name) who said my dad is on a plane and he will not be back for a week. Labs were drawn and she understands that the results will be recd on tomorrow. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 7:48 a.m. revealed, R15 is alert, yelling please get me out of bed. Nurse noted resident has legs on the side of the bed, with linen covers off of her. Nurse place resident legs into bed. Nurse returned to find resident had removed her legs to the rt. side of bed. Floor mat is in place, bed is in lowest position for safety precautions. Nurse will continue to monitor. Review of the [DATE] nursing note for R15 documented at 8:24 a.m. revealed, noted left lower leg black bruised. Edema in both lower legs. Resident is very agitated vitals not stable, in bed sleeping legs elevated. Review of the [DATE] nursing note for R15 documented at 8:27 a.m. revealed, upon assessment noted dark purple discoloration noted to left lower extremity. 3+edema noted to bilateral lower extremity. Denies pain/discomfort. Foot of the bed elevated. Called the physician made aware. New order noted venous Doppler done to bilateral lower extremities. Review of the [DATE] nursing note for R15 documented at 6:50 a.m. revealed, called the X-ray provider to receive copy of result from venous Doppler. Awaiting results. Resident rested well throughout the shift. Received results. Passing along to day shift nurse to report results to physician. Review of the [DATE] nursing note for R15 documented at 8:19 a.m. revealed, gave report to (physician) about resident's results from venous Doppler lower bilateral extremities. Made aware that results stated indeterminate for deep vein thrombosis and it recommends for test to be repeated. New order to have test repeated and begin resident on (blood thinners). Review of the [DATE] nursing note for R15 documented at 11:45 a.m. revealed, report was called to the hospital at 11 am and resident left the facility via ambulance accompanied by two emergency medical technicians (EMTs). Review of the [DATE] nursing note for R15 documented at 12:03 p.m. revealed, R15 was admitted to the hospital today. Review of the [DATE] nursing note for R15 documented at 3:55 p.m. revealed, abnormal lab work returned and call placed to physician informed of possible Deep Vein Thrombosis (DVT) per Doppler results study. New order noted to send out to hospital emergency room for evaluation and repeat Doppler study related to left (L) lower extremity. Review of the hospital record's for R15 dated [DATE] documented, history and physical revealed Chief Complaint: leg pain. History of present illness: This is a [AGE] year-old with a history of congestive heart failure, hip fracture, which was apparently atraumatic. The patient had an ORIF performed on [DATE]. The patient had a hospitalization complicated by a urinary tract infection. The patient has a questionable history of diastolic heart failure and was on lasix and the patient was discharged to a rehab facility. At the rehab facility, the patient was sub acutely complaining of pain around the prosthesis. The patient's complaints got worse. The patient had no [DIAGNOSES REDACTED], wound drainage, etc. No shortness of breath, no chest pain, no fever, no chills. She was brought back to the emergency room and a periprosthetic fracture was noted, Past surgical history: ORIF in [DATE], right hip fracture and repair in 2008 is status [REDACTED]. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. They have decided on palliative care on left lower extremity (LLE), pain with motion at L hip, right lower extremity (RLE) , incision healed well. RLE; R15 is non-ambulatory at baseline. Proceed (with) palliative care as decided by family. NWB (non-weight bearing) LLE and NWB RLE; May work on transfers and pain control. Review of the hospital records for R15 on [DATE] physician progress notes [REDACTED]. NWB status. Palliative care managing pain. Review of the [DATE] nursing note for R15 documented at 8:22 p.m. revealed, return from hospital at this time, Resident was admitted to hospice at this time see new orders in place. Review of nursing notes between [DATE] and [DATE] for R15 revealed the resident was in a lot of pain, medicated for pain with routine and PRN meds, and frequently called out in pain. Review of the [DATE] nursing notes for R15 documented at 9:58 a.m. revealed, Placed a call to physician to verify medication made physician aware that the resident is on scheduled medication, educated physician the resident is yelling help, help, and she is in pain. Family member had concerns resident is in pain was not being controlled. Resident has no labored breathing. Resident is in bed in lowest position with mats in place. Will continue to monitor resident. Review of the [DATE] nursing note for R15 documented at 4:58 a.m. revealed, Resident was yelling throughout the night. Upon entering resident's room she stated I don't know what's wrong with me. Stated she was in pain, gave PRN methadone, also gave Ativan 1 mg due to anxiety. Bed in lowest position with mats in place. Resident is on 3L of O2 via nasal cannula. No shortness of breath noted. Respirations even and unlabored. Will continue to monitor resident. An anonymous interested party (AIP) was interviewed on [DATE] at 9:00 a.m., by the State Survey Agency complaint intake staff. The AIP said the facility was responsible for R15's recent hip fracture, due to gross negligence and the resident was subsequently put on hospice services. Review of the [DATE] nursing note for R15 documented at 11:36 p.m. revealed, Resident and family members invited to 72 hr (hour) care conference meeting today, discussed in details hospice procedure and services that will be provided for resident. Also discussed pain and agitation medication that's will be provided by hospice. Social Worker requested that family provide personal sitter for resident for so many hours throughout the day according to their preference, (family member) stated that it's very hard to see his mother decline and he's unable to do more for her, he latter stated that he will sit down with his family and discuss issues and concerns that was discussed in this meeting. Review of the [DATE] nursing note for R15 documented at 9:58 a.m. revealed, Resident is in coma state at this time, hospice nurse at bedside, son at bedside. Review of the [DATE] nursing note for R15 documented at 7:52 p.m. revealed, On arrival today to 2nd shift, resident was unresponsive, (about 5:45 p.m.) Resident began moving around and yelling as usual. She received her afternoon meds as requested per (family). For now her vitals look ok and she is alert and stable. Review of the [DATE] nursing note documented at 2:52 p.m. revealed, Resident has eyes open-glossy and fixated, respirations labored. Resident has family at bedside during this time. Review of the [DATE] nursing note for R15 documented at 11:32 p.m. revealed, Resident alert new orders in place. Resident condition changed hospice notified. resident pain meds administered tolerated well, family members at bedside will continue to monitor. Review of the [DATE] nursing note for R15 documented at 6:20 a.m. revealed, Resident was alert and speaking out hello. Family member at bedside. Review of the [DATE] nursing note for R15 documented at 11:44 a.m. revealed, Resident is on Hospice. Moaning and body movements noted . Resident is resting peacefully . Family at bedside. Will continue to monitor. Review of the [DATE] nursing note for R15 documented at 4:24 p.m. revealed, Resident awake and alert at intervals. Total care provided per nursing and hospice care in all aspects of daily living. Resident turned and repositioned for comfort q (every) 2 hrs and as requested. Pain medication administered as scheduled, to include break thru pain relief. Medication effective. Review of the [DATE] nursing note for R15 documented at 2:45 p.m. revealed, resident in comatose state . labored breathing upon assessment wet. (R15) has family member at bedside at this time. Review of the [DATE] nursing note for R15 documented at 5:47 p.m. revealed, no pulse no respiration no blood pressure. (Hospice) notified to come to facility to pronounce patient at this time. Hospice nurse arrived at 6:00 pm. to assess patient and to do pronouncing of patient family at bedside. The Corporate Clinical Auditor (CCA), who was also a registered nurse, was interviewed on [DATE] at approximately 11:30 a.m. She said the SBARs are investigations into the falls and there were no other investigations. She said the process was to discuss the previous day's falls at the daily clinical meeting and weekly at the At Risk meeting. The CCA said, generally, they discussed where the resident was, what happened, was there any injury, what can we do, have interventions worked, some will fall, prevent injuries. She said she was not there when R15's falls were discussed. When asked for evidence of what was discussed at the daily clinical meetings and weekly At Risk meetings regarding R15, the CCA said she could provide fall protocols, but did not have documented evidence of the meetings. Review of the August, 2012 Fall Management, Overview, Practice Guidelines revealed: Each resident is assisted in attaining maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Interdisciplinary Team (IDT) evaluates each resident's fall risks. A Plan of Care is developed and implemented, based on this evaluation, with ongoing review. If a fall occurs, the IDT conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. The Director of Nursing/designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Each facility will take a proactive approach for new residents admitted and will consider all residents to be at risk for falls until reviewed by the IDT. A fall Care Plan will be initiated upon admission for each resident. When a fall occurs, assess resident for injury. The Licensed Nurse will complete: Incident/ Accident Report (Briggs); 24 Hour Report (Briggs); and Initiate the Interdisciplinary Post Fall Review. Communicate all resident falls to the attending physician and the resident's family and document on the Interdisciplinary Post Fall Review form . The licensed nurse documents family/responsible party and physician notification on the Interdisciplinary Post-Fall Review form and places the completed form in the Nurse's Notes section of the Medical Record. The nurse will communicate the resident fall to the IDT via the 24 Hour Report (Briggs). The IDT will review all resident falls within ,[DATE] hours at the morning Interdisciplinary Team meeting to evaluate circumstances and probable cause for the fall. OPTIONAL: Fall information may be added to the Electronic Care Management Board (ECMB) if so desired for tracking purposes. The IDT modifies and implements a Care Plan and treatment approach to minimize repeat falls. The Care Plan will be reviewed/revised as indicated. The RCS (certified nurse aide) Assignment Sheets/ Care Kardex are updated as appropriate. The IDT will complete the Interdisciplinary Post Fall Review (see forms tab). The In-House Communicator form (Briggs) should be used to make referrals to appropriate IDT members. IMPORTANT: A Change of Condition form must be completed, if indicated by resident assessment. The Director of Nursing or designee will document falls on the Incident/Accident Report QA&A (Quality Assurance & Assessment) Log and the Individual Resident Fall QA&A Log (see forms tab) as they occur and submit reports to risk management system as indicated. Risk management system reports may be used, if desired, to complete tracking/trending reports for QAPI (Quality Assurance Performance Improvement). The NHA was interviewed on [DATE] at approximately 4:00 p.m. He said the facility was already cited deficient practice for R15 on a previous complaint ending on [DATE]. 2. R28 was observed on [DATE] at 1:35 p.m. with the wound care nurse. The wound care nurse said R28 was admitted with both of his pressure ulcers, a stage 4 on his sacrum and a stage 2 on his right posterior thigh. The wound care nurse confirmed there was an 8 outlet yellow surge protector power strip taped to the floor between R28 and his roommate - plugged in to the power strip were R28's suction machine, R28's humidifier and the roommate's oxygen concentrator. The NHA was interviewed on [DATE] at approximately 3:36 p.m. The NHA said there were not enough outlets for R28 or R29, who were roommates, to accommodate their medically necessary, physician ordered, equipment. He stated when R28 was admitted they realized they did not have enough outlets and directed the Maintenance Director to install a power strip in R28's room. The NHA said both R28 and R29 had more medical equipment than they had outlets in the room. The NHA stated that a decision was made to unplug the bed of R28 for a few days. The NHA stated he checked with the Fire Marshall and based on the amperage of the power strips, felt the need was met. He said he was not aware a power strip could not be used for medical equipment. The NHA and the Maintenance Director were interviewed on [DATE] at approximately 10:30 a.m. The NHA confirmed R28's family member (F1) talked to him about the power strip, and he told the Maintenance Director to install a power strip in R28's room. However, the Maintenance Director said he got the power strip right away and left it at the nurses' station for the nurses to install in the room because R28 was receiving care at that time and he did not want to interrupt and a few days went by before it was discovered the power strip had not been installed. The NHA also confirmed a few days went by before he became aware the power strip was not installed. The NHA said as soon as he found out the power strip had not been installed, he took immediate action to have the power strip put in place.

Based on record review and interview it was determined that the facility failed to provide professional quality of care for one (1 ) resident (R1) of the seven (7) sampled who suffered a fractured femur by not reporting an x-rays report to the physician correctly for additional intervention. This caused actual harm to R1 for nine (9) days at which time the resident was transferred to an acute care facility. Findings include: Review of the Medical Record for R1 revealed nurses notes dated February 3, 2016, indicating that Certified Nursing Assistant (CNA) AA was assisting R1 to transfer from the wheelchair to the toilet, when the R1 became weak and had to be lowered to the the floor. AA then notified the LPN, BB to help her with R1. BB found R1 on the floor. At that time they assisted R1 from the bathroom floor into the wheelchair. The Medical Doctor (MD) and Responsible Party (RP) were notified. Further Medical record review revealed that R1 complained of right hip pain the next morning on 02/04/16, after receiving regularly scheduled pain medication of [MEDICATION NAME] - [MEDICATION NAME] 5/325 mg and an as needed dose of pain medication. Further Medical Record Review revealed nurses note dated 02/04/16, resident complained of pain to the right hip due to fall from yesterday. Right hip noted to be swollen X-ray of the hip ordered. A new order was received for an x-ray of the hip was ordered and was obtained on 02/04/16 and was subsequently reported from the nursing staff to the Medical doctor (MD) to be negative for any fractures. However, review of the Mobilex Radiology report dated 02/08/16 revealed, stamped POSITIVE. Two x-ray reports noted on one page. On the upper page radiology report for knee 1-2 views (right) and on the lower half of the page radiology report results for Tibia/Fibula. The upper Knee report is noted to read: Results: Fracture lucency of the distal tibial shaft. Soft tissue swelling. No gross malalignment. Conclusion: Acute distal femoral shaft, incompletely visualized with single view. Consider full exam when able. The Radiology report on the lower half of the page is noted to be for the Tibia/Fibula and reads: Tibia/Fibula (Right) Conclusion: No acute osseous abnormality. [MEDICAL CONDITION] changes. Further Medical Record review revealed nurses note for R1 dated 02/15/16, for a urine analysis was ordered. Review of a Nurses noted on 02/16/16 at 11:51 a.m. revealed the resident appears confused, altered mental status, involuntary jerking, shaking and left facility via stretcher to local acute care hospital. MD and RP notified. Interview on 03/01/16 at 1:00 p.m. with Licensed Practical Nurse (LPN) DD while reviewing the x-ray report of the knee dated 02/08/16, DD stated she does not know what fracture lucency means. DD stated that, incompletely visualized with a single view meant that additional x-rays should have been done, but were not done. Interview on 03/01/16 at 1:13 p.m. with the Director of Nursing (DON). While reviewing the x-ray report for R1 ' s knee the DON stated she was not sure what fracture lucency meant but stated according to the conclusion on the radiology report of the knee that the x-ray was inconclusive and that R1 needed additional x-rays, that were not done. The DON stated her expectations of her staff are that when radiology reports are received that read: incompletely visualized consider a full exam, then she expected the nurses to call the physician and read the physician the entire report, not just a portion of the report, and ask the physician for an order for [REDACTED]. Interview on 03/02/16 at 9:00 a.m. with Physical Therapist EE revealed that the Rehabilitation Director had received, in report, during the morning meeting, on 02/10/16, that R1 had fallen on 02/03/16, but had not incurred any injuries and that she needed to be evaluated for physical therapy. EE stated R1 was referred to him/her on 02/10/16 for a physical therapy evaluation. EE stated he/she assessed R1 and completed a physical therapy evaluation on R1 on 02/10/16. EE stated that during the physical therapy evaluation he/she determined that R1 had range of motion impairment of the right knee. The right knee had ninety degree of knee flexion and you would expect to find one hundred and ten (110) to one hundred and twenty-five (125) degree of knee flexion. R1 was unable to stand and pain was nine out of ten 9/10. R1 was assessed to need diathermy (heat) treatment, biofreeze massage to the right knee, and strengthening exercises for the left leg. R1 was gotten out of bed, with a hoyer lift, and seen in the gym for physical therapy on 02/10/16, 02/11/16, and 02/15/16. EE stated that on 02/12/16 and 02/16/16 the resident remained in his/her bed and therapy was provided in the resident ' s room while the resident remained in the bed. EE stated that R1 had severe and excruciating pain every day, from the day of the initial evaluation on 02/10/16, until the resident was discharged from the facility to the hospital on [DATE]. EE stated he/she had access to the residents x-ray report but that he/she never reviewed the x-ray report dated 02/08/16, and that he/she never discussed R1 ' s pain with the resident ' s nurses or with the resident ' s physician. EE stated that if he/she had read R1 ' s x-ray report dated 02/08/16, then the resident would not have been picked up for physical therapy and that no physical therapy services would have been provided for R1. EE stated that he/she would have insisted that R1 needed to have additional x-rays and that no physical therapy services would have been provided until after the additional x-rays had been completed and it was determined that the resident was free of any injuries such as fractures. Interview on 03/02/16 at 10:32 a.m. with Unit Manger revealed that the nurses working the medication carts are responsible for ordering, receiving and reporting the radiology reports. The Unit Manager stated the nurse told him/her that the x-ray report was called in to the physician and that he/she never read R1 ' s x-ray report of the right knee. Interview on 03/03/16 at 11:34 a.m. with the Rehab Program Manager revealed that falls are reported in the morning meeting and that it was reported that the resident had a fall on 02/03/16, but that there were no injuries. The resident was evaluated for physical therapy and began physical therapy services on 02/10/16, after the resident had x-rays taken on 02/08/16. The Rehab Program Manager stated that she did not read the resident ' s x-ray report and that if he/she had read the resident ' s x-ray report then the resident would absolutely not have had therapy. The resident should have had additional x-rays, either in-house or the resident should have been sent out for additional x-rays. The Rehab Program Manager stated because we thought we were dealing with a negative x-ray we did not call the physician about the resident ' s continued excruciating pain. Interview on 03/03/16 at 2:00 p.m. with J revealed that I don ' t know what happened on 02/03/16, whether R1 was lowered to the floor of if she fell ; however the surgeon told me that R1 ' s femur bone was shattered. J stated that the facility did not call him/her with the x-ray results for the x-rays obtained on 02/08/16. Interview on 03/03/16 at 2:08 p.m. with MD revealed that he/she usually visits the resident every couple of weeks. MD stated that when the nurse called him on 02/08/16, regarding the x-ray report that was received on 02/08/16, that the nurse told him/her that there was no osseous abnormalities. MD stated that a few days after the nurse called him with the x-ray report he came into the facility and that he read the x-ray report and signed off on the report. MD stated that when he read the report he did not realize that there were two x-ray reports on the one page and that he skimmed to the bottom of the page and only read the conclusion for the Tibia/Fibula and that he missed reading the conclusion for the knee. MD stated that he/she saw R1 on 02/12/16, but that he/she did not examine the resident ' s leg because he thought the x-rays taken of the resident ' s leg was negative (free from any fractures). Interview on 03/03/16 at 4:26 p.m. with the Administrator when reviewing R1 ' s radiology report dated 02/08/16, that the Administrator stated he/she does not know what fracture lucency means but when the conclusion, on the x-ray report, of the knee reads: Conclusion: Acute distal femoral shaft, incompletely visualized with single view that meant that R1 needed additional x-rays. We should have had follow up x-rays done because that was what was being recommended, by the radiologist, in the radiology report.

Bases on record review and interview it was determined the facility failed to report one (1) radiology report of the knee and failed to obtain additional x-rays as recommended by the radiologist report for one (1) resident (R1) of the seven (7) sampled. This failure caused actualharm to R1, for nine (9) days after a fall with fracture. Findings include: Record review of nurses notes dated February 3, 2016 for R1 revealed: Certified Nursing Assistant (CNA) AA was assisting R1 to transfer from the wheelchair to the toilet, in the bathroom, when R1 became weak and has lowered to the floor. CNA AA then notified the Licensed Practical Nurse (LPN) BB to help her with R1. BB found R1 on the floor. At that time they assisted R1 from the bathroom floor into wheel the wheelchair. The Medical Doctor (MD) and Responsible Party (RP) were notified. Further record review revealed that R1 complained of right hip pain the next morning on 02/04/16, after receiving regularly scheduled pain medication of [MEDICATION NAME] - [MEDICATION NAME] 5/325 mg and an as needed dose of pain medication. A new order was received for an x-ray of the hip was ordered and was obtained on 02/04/16 and was subsequently found to be negative for any fractures. Further Medical Record Review revealed nurses note dated 02/04/16, resident complained of pain to the right hip due to fall from yesterday. Right hip noted to be swollen X-ray of the hip ordered. R1 continued to complain of pain to the right leg until 02/08/16, when LPN, DD called the MD and received a new order for x-rays to be obtained of the right knee, right tibia, fibula and ankle. The Radiology report was received from the radiologist on 02/08/16, and was called in to the MD on 02/08/16. Review of the nurses note dated 02/09/16, revealed that LPN CC, called the MD on 02/09/16 at 2:18 p.m. and reported that lab results stated no acute osseous abnormality, with [MEDICAL CONDITION] changes. Review of the Mobilex Radiology report dated 02/08/16 revealed a stamped POSITIVE comment. On the upper page radiology report revealed right knee 1-2 views and on the lower half of the page radiology report results for Tibia/Fibula. The upper Knee report is noted to read: Results: Fracture lucency of the distal tibial shaft. Soft tissue swelling. No gross malalignment. Conclusion: Acute distal femoral shaft, incompletely visualized with single view. Consider full exam when able. The Radiology report on the lower half of the page is noted to be for the Tibia/Fibula as follows: Tibia/Fibula (Right) Conclusion: No acute osseous abnormality. [MEDICAL CONDITION] changes. Continued Record Review revealed the R1 continued to receive regularly scheduled pain medication, [MEDICATION NAME] - [MEDICATION NAME] 5/325 mg twice daily for chronic pain, yet R1 continued to complain of pain and was administered [MEDICATION NAME] 325 mg two (2) tabs for pain on 02/04/16, 02/07/16, and 02/12/16, in an addition to the regularly scheduled pain medication. Review of Nurses note dated 02/12/16 at 3:00 p.m. revealed: R1 was yelling in pain and first shift nurse had already treated for [REDACTED]. LPN BB tried therapeutic measures first, Ice pack on the localized area that was reported of pain as well as elevating the pillow. Review of Nurses note dated 02/12/16 at 3:03 p.m. revealed R1 is complaining of pain in left lower extremity 650 mg of [MEDICATION NAME] was administered at 2:50 p.m. Resident advised that [MEDICATION NAME] isn ' t due until 8:00 p.m. resident requested to have [MEDICATION NAME] early, advised that wasn ' t possible. Further Medical Record review revealed nurses note dated 02/12/16 at 5:02 p.m. MD notified about R1 localized pain in the right knee. A new order received from the MD for a one time dose of [MEDICATION NAME] 5-325 mg to be administered, in addition to her regularly scheduled dose of pain medication. There was no further nursing notes for R1 until 02/15/16, when an order for [REDACTED]. Nurses note dated 02/16/16 at 11:51 a.m. revealed R1 left facility via stretcher to local acute care hospital. MD and RP notified. Interview on 03/01/16 at 1:00 p.m. with LPN DD while reviewing the x-ray report of the knee dated 02/08/16, DD stated she does not know what fracture lucency means. DD stated that, incompletely visualized with a single view meant that additional x-rays should have been done, but were not done. Interview on 03/01/16 at 1:13 p.m. with the Director of Nursing (DON) revealed, while reviewing the x-ray report of the knee, the DON stated she was not sure what fracture lucency meant but stated according to the conclusion on the radiology report for knee that the x-ray was inconclusive and that R1 needed additional x-rays, that were not done. The DON stated her expectations of her staff are that when radiology reports are received that read: incompletely visualized consider a full exam, then she expected the nurses to call the physician and read the physician the entire report, not just a portion of the report, and ask the physician for an order for [REDACTED]. The DON stated she had not in-serviced the staff regarding the correct reading and reporting of x-ray reports but instructed the East Wing Unit Manager to in-service (educate) the staff regarding correctly reading and reporting x-rays to the physicians. At that time, the DON called the Unit Manager and asked the Unit Manger if he/she had in-serviced (educated) the staff regarding correctly reading and reporting radiology reports? The Unit Manger stated he had talked with the staff but did not have any sign-in sheets showing that he had in-serviced the staff. The Unit Manger went on to say he spoke with the staff but he/she thought that he/she needed to speak with the staff again about this topic. On 03/02/16, after stating on 03/01/16 that he/she had not in-serviced (educated) the staff regarding correctly reading and reporting radiology reports, the DON presented the surveyor with a copy of in-services dated 02/10/16 with a typed list of topics which included Lab Processes, and stated that she had in-serviced the staff on correctly reading and reporting radiology reports. Interview on 03/02/16 at 9:00 a.m. with Physical Therapist EE revealed that the Rehabilitation Director had received, in report, during the morning meeting, on 02/10/16, that R1 had fallen on 02/03/16, but had not incurred any injuries and that she needed to be evaluated for physical therapy. EE stated R1 was referred to him/her on 02/10/16 for a physical therapy evaluation. EE stated he/she assessed R1 and completed a physical therapy evaluation on R1 on 02/10/16. EE stated that during the physical therapy evaluation he/she determined that R1 had range of motion impairment of the right knee. The right knee had ninety degree of knee flexion and you would expect to find one hundred and ten (110) to one hundred and twenty-five (125) degree of knee flexion. R1 was unable to stand and pain was nine out of ten 9/10. R1 was assessed to need diathermy (heat) treatment, biofreeze massage to the right knee, and strengthening exercises for the left leg. R1 was gotten out of bed, with a hoyer lift, and seen in the gym for physical therapy on 02/10/16, 02/11/16, and 02/15/16. EE stated that on 02/12/16 and 02/16/16 the resident remained in his/her bed and therapy was provided in the resident ' s room while the resident remained in the bed. EE stated that R1 had severe and excruciating pain every day, from the day of the initial evaluation on 02/10/16, until the resident was discharged from the facility to the hospital on [DATE]. EE stated he/she had access to the residents x-ray report but that he/she never reviewed the x-ray report dated 02/08/16, and that he/she never discussed R1 ' s pain with the resident ' s nurses or with the resident ' s physician. EE stated that if he/she had read R1 ' s x-ray report dated 02/08/16, then the resident would not have been picked up for physical therapy and that no physical therapy services would have been provided for R1. EE stated that he/she would have insisted that R1 needed to have additional x-rays and that no physical therapy services would have been provided until after the additional x-rays had been completed and it was determined that the resident was free of any injuries such as fractures. Interview on 03/02/16 at 10:32 a.m. with Unit Manger revealed that the nurses working the medication carts are responsible for ordering, receiving and reporting the radiology reports. As the Unit Manager, he/she is responsible for making sure that if an order for [REDACTED].-ray report of the right knee. Interview on 03/02/16 at 11:00 a.m. with Certified Nursing Assistant CNA, FF that he/she was the CNA for R1 on a regular basis and that after the resident had the fall on 02/03/16 that R1 was complaining of pain in the leg a lot and that he/she had reported that pain to the resident ' s nurse. FF did not remember who he/she had reported R1 ' s pain to. Interview on 03/02/16 at 2:02 p.m. with the RN Staff Development Manager revealed that he/she is responsible for keeping up with all in-services that are given in the facility and that he/she keeps a copy of all of the in-services that had been given in a binder. The RN Staff Development Manager stated that if there had been any in-services regarding correctly reading and reporting radiology reports since the resident fell on [DATE] he/she was not aware of it. Interview on 03/02/16 at 2:31 p.m. with CNA, GG revealed that after the resident fell that she would complain and say her/his hip hurt and I knew that wasn ' t usual for R1 and I knew that something was wrong. I told the nurse on duty that the resident was hurting and that he/she didn ' t want to get out of bed. GG said, I don ' t know which nurse I told but I told one of the nurses. Interview on 03/03/16 at 11:02 a.m. with LPN, HH revealed that prior to the resident falling on 02/03/16, resident was able to stand, pivot, turn and sit him/herself on the toilet with one person standby assistance, but after the fall, now we have to use a hoyer lift to get the resident out of bed. Interview on 03/03/16 at 11:34 a.m. with the Rehab Program Manager revealed that falls are reported in the morning meeting and that it was reported that the resident had a fall on 02/03/16, but that there were no injuries. The resident was evaluated for physical therapy and began physical therapy services on 02/10/16, after the resident had x-rays taken on 02/08/16. The Rehab Program Manager stated that she did not read the resident ' s x-ray report and that if he/she had read the resident ' s x-ray report then the resident would absolutely not have had therapy. The resident should have had additional x-rays, either in-house or the resident should have been sent out for additional x-rays. The Rehab Program Manager stated because we thought we were dealing with a negative x-ray we did not call the physician about the resident ' s continued excruciating pain. Interview on 03/03/16 at 2:00 p.m. with J revealed that I don ' t know what happened on 02/03/16, whether R1 was lowered to the floor of if she fell ; however the surgeon told me that R1 ' s femur bone was shattered. J stated that the facility did not call him/her with the x-ray results for the x-rays obtained on 02/08/16. However, J stated a friend was visiting R1 on 02/12/16, and called me and told me that R1 was in a lot of pain so I called the facility and spoke with the nurse BB. BB told me that R1 had an x-ray done but that the x-ray didn ' t show any broken bones so he/she didn ' t know why R1 was complaining of pain. Interview on 03/03/16 at 2:08 p.m. with MD revealed that he/she usually visits the resident every couple of weeks. MD stated that when the nurse called him on 02/08/16, regarding the x-ray report that was received on 02/08/16, that the nurse told him/her that there was no osseous abnormalities. MD stated that a few days after the nurse called him with the x-ray report he came into the facility and that he read the x-ray report and signed off on the report. MD stated that when he read the report he did not realize that there were two x-ray reports on the one page and that he skimmed to the bottom of the page and only read the conclusion for the Tibia/Fibula and that he missed reading the conclusion for the knee. MD stated that he/she saw R1 on 02/12/16, but that he/she did not examine the resident ' s leg because he thought the x-rays taken of the resident ' s leg was negative (free from any fractures). Interview on 03/03/16 at 3:06 p.m. with CNA, AA revealed that he/she has been a CNA for six months and that he/she was the CNA that assisted R1 to the bathroom on the night of 02/03/16. AA stated that when he/she had previously taken R1 to the bathroom that R1 would push to the rail and stand and bear his/her own weight but AA stated that on 02/03/16, R1 stated she couldn ' t hang on anymore and that AA tried, but could not reach R1 ' s wheelchair, so she lowered R1 to the floor. AA stated R1 complained of pain after he/she was lowered to the floor. AA stated he/she went to get the nurse and they assisted R1 back into his/her wheelchair. AA stated he/she had been R1 ' s CNA one other time, since the fall, and that was the day R1 was sent out to the hospital. AA stated that the day R1 was sent out of the facility, to the hospital, that R1 kept saying that he/she was in pain and saying that his/her knee was hurting. AA stated since R1 has gotten back to the facility from being admitted to the hospital that he/she cries a lot and R1 states he/she doesn ' t know what ' s going on and that asks, what ' s wrong with me? Interview on 03/03/16 at 4:26 p.m. with the Administrator when reviewing R1 ' s radiology report dated 02/08/16, that the Administrator stated he/she does not know what fracture lucency means but when the conclusion, on the x-ray report, of the knee reads: Conclusion: Acute distal femoral shaft, incompletely visualized with single view that meant that R1 needed additional x-rays. We should have had follow up x-rays done because that was what was being recommended, by the radiologist, in the radiology report. Interview on 03/03/16 at 5:02 p.m. with LPN, BB revealed that BB was working the night of 02/03/16, when the CNA AA came and got BB and said that he/she had lowered R1 to the floor. BB stated that when he/she entered R1 ' s bathroom R1 was in a sitting position on the floor with both legs in a straight position. BB stated they lifted the resident up into the wheelchair and R1 said his/her leg was hurting. BB said that R1 said, I fell , but that CNA, AA redirected R1 and said no, you didn ' t fall I helped you and I lowered you to the floor. BB said that R1 kept saying, I fell , I fell but that R1 was redirected and told no, you didn ' t fall that AA lowered you to the floor. BB stated that another CAN, came into the room, and that the resident told that CNA that she fell but AA again told R1 that no, you didn ' t fall I helped you and I lowered you to the floor. BB stated that she did not know who the other CNA was. BB stated that after the resident fell on [DATE], that he/she worked with R1 again on 02/12/16. BB stated that when he/she came onto shift that afternoon that he/she could hear R1 yelling, in pain, all the way to the nurses station. BB stated that the nurse, on the first shift, stated he/she had already given R1 pain medication and that BB and the first shift nurse went in and told R1 that he/she had already been given pain medication and that R1 could not get any more pain medication. BB stated he/she had to go in to the residents room and tell the resident four more times that he/she had already had her pain medicine and could not have any more pain medicine at that time. BB stated she put ice on R1 ' s knee and elevated the pillow under R1 ' s right leg but that the visitor, that was visiting R1, removed the ice pack. BB stated after she had told R1 that R1 could not have any more pain medication that R1 called her son and told her son that she was in pain. BB stated then R1 ' s son called BB and asked what was going on? BB stated that he/she had received in report, from the first shift nurse, that R1 ' s x-ray had come back with no fractures and that BB did not know why the resident was complaining of pain. BB told R1 ' s son that BB would call the physician. BB stated that he/she called the physician and got an order for [REDACTED]. BB said, the last time I worked with R1 I knew something wasn ' t right. Cross refer 281

Based on interview, record review, review of policy and procedure and review of the National Council of State Boards of Nursing [DATE] Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure services provided met professional standards for one(1) of twenty-five (25) sampled residents (Resident #1). Observation of video surveillance of Resident #1's care on [DATE] revealed the resident pushing his call button and calling out Help Me multiple times for symptoms of shortness of breath and chest discomfort. Licensed Practical Nurse (LPN) MM told resident #1 to Stop pushing call light, what is wrong now? Resident #1 replied My heart at 4:46 a.m. LPN MM checked Resident #1's blood pressure at 4:54 a.m. and told Resident #1 that there was nothing wrong with him, he was having anxiety and that he just needed to calm down. Resident #1 continued to summon for help and call out Help Me. Certified Nursing Assistant (CNA) 11 entered Resident #1's room, asked him what he wanted, changed the resident's brief and removed his oxygen nasal cannula. Resident #1 was unresponsive when CNA 11 completed the brief change. CNA 11 called for the nurse and when LPN MM responded CNA 11 said, I came in, he died !. LPN MM appeared to check Resident #1's chest for respirations by placing her ear over his chest. LPN MM and CNA 11 left Resident #1's room, leaving him unattended. They did not perform CPR. CNA 11 returned to Resident #1's room and put the resident's pillow under his head, put his oxygen nasal cannula on his face, covered the resident with a sheet and raised the head of his bed. LPN LL entered Resident #1's room at 6:15 a.m. She placed a back board behind Resident #1 in bed. LPN LL manipulated an oxygen tank but was unable get it operational. The first chest compressions for CPR were performed by LPN LL at 6:34 a.m. The paramedics arrived at 6:38 a.m. Resident #1 was pronounced dead at 7:00 a.m. on [DATE]. (Refer F155, F157, F223) The facility failed to ensure professional staff provided timely necessary care and services to Resident #1 who requested assistance from LPN MM for shortness of breath and chest discomfort. The facility failed to identify a change of condition in Resident #1 and notify the Physician. The facility failed to perform Cardiopulmonary Resuscitation (CPR) when Resident #1 was first identified as having no pulse or respirations. The facility's failure has caused, or had the likelihood to cause, serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. (Refer F155, F223, F282) Findings include: Review of the policy titled Medical Emergency Management, revised [DATE] (SSP 0201.00) documented: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff take action to ensure that the residents Airway, Breathing and Circulation are maintained until emergency personnel arrive. Staff is aware of each residents advance directives prior to the administration of cardio [MEDICAL CONDITION] resuscitation. Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure (s) and calls 911. The staff continues to provide care and monitor the resident until emergency personnel arrive. Review of the facility policy titled Changes in Resident Condition documented: The resident, physician and legal representative or designated family member are notified when changes in condition or certain events occur. Assess and document changes in condition in an efficient and effective manner. Provide assessment information to the physician, and provide clear comprehensive documentation Review of the National Council of State Boards of Nursing [DATE] Georgia Practical Nurses Practice Act revealed that LPNs may participate in the assessment, planning, implementation and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations. Record review for Resident #1 revealed an Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt dated [DATE] indicated that the resident was a Full Code. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] indicated that his Brief Interview Mental Status Score (BIMS) summary score was three (3), indicating severe cognitive impairment. Shortness of breath and trouble breathing were indicated on the assessment. The resident received oxygen therapy. The facility care planned Resident #1 for Respiratory Problems on [DATE] with Approaches/Interventions that included: Assess for shortness of breath and notify MD of any changes. Observation of the video surveillance was conducted on [DATE] at 1:00 p.m. in the office of the Attorneys representing Resident #1 and his family revealed on [DATE], CNA 11 notified LPN MM that Resident #1 was unresponsive at 5:28 a.m. CPR did not begin until 6:34 a.m. LPN 'LL and CNA 11 could be heard on the video discussing how long they would tell Emergency Medical Service (EMS) they performed CPR. They agreed to report that CPR had been performed on Resident #1 for one (1) hour. The paramedics arrived at 6:38 a.m. Resident #1 did not respond to resuscitation efforts of the paramedics and was pronounced dead at 7:00 a.m. Review of the Nursing Daily Skilled Summary dated [DATE] at 5:40 a.m. LPN MM documented that she was notified that the resident was not breathing by Resident Care Specialist/ CNA 11. LPN MM documented that Resident #1 had no pulse or respirations. LPN MM documented at 6:20 a.m. that the supervisor talked with the resident's son and informed him of Code in progress then son gave the address and name of mortician to call. LPN MM documented that 911 was called at 6:25 a.m. According to the Nurse's Notes documentation by LPN MM, the paramedics arrived at 6:40 a.m. and Resident #1 was pronounced via telephone by a hospital physician at 7:06 a.m. Interview with LPN LL on [DATE] at 5:33 a.m. revealed that she did not remember the night of [DATE] but that was her with the oxygen tank in the video. LPN LL stated that around that time the oxygen tanks were faulty. The oxygen was coming out where it should not have been. The tanks have been replaced since that time and they don't have the same type regulators. LPN LL said that she did not write any nurses notes about the events of [DATE]. Interview with LPM MM on [DATE] at 10:27 a.m. revealed she recalled that CNA 11 called her into Resident #1's room. CNA 11 told her that something seems to be wrong with Resident #1. LPN MM said that she went into the room, checked his pulse and looked for rise and fall of his chest. She added that Resident #1's skin looked ashen. She stated that when she observed that he wasn't breathing she went to the nurse's station and called LPN LL to tell her that they had to do CPR, then grabbed the chart to check if the resident was deemed a Full Code. She called the son to determine whether Resident #1 was a Do Not Resuscitate (DNR). The son said that he thought resident #1 was a DNR. LPN MM explained further that the Code status was under the Advance Directives tab in the record. She said there must have been a discrepancy with the paperwork. According to LPN MM when the nursing supervisor LPN LL arrived she started the Code and called 911; placed Resident #1 on a backboard and hooked the oxygen up to the resuscitation (Ambu) bag. LPN MM said that she was unsure how long the delay was to actually start the CPR. LPN MM admitted that she did not perform vital signs when she assessed Resident #1 and that there was no step by step documentation of the events of the night. Interview with the Medical Director on [DATE] at 2:30 p.m. revealed that CPR should have been initiated on Resident #1. Resident #1 was a Full Code according to the Medical Director, there was nothing on the chart otherwise. Interview with the Medical Director on [DATE] at 10:26 a.m. revealed that he did not recall being notified of Resident #1 ' s complaint of shortness of breath, anxiousness or chest discomfort on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on record review, review of policy and procedure and interviews, the facility failed to immediately report and thoroughly investigate allegations of abuse/neglect of one (1) of twenty five (25) sampled residents (Resident #1). The facility was made aware of a pending litigation related to the allegation of abuse/neglect on [DATE] by the representing Attorney for Resident #1 and his family. The facility failed to report the allegations of abuse and neglect to the State Survey Agency until the first day of the Abbreviated/Partial Extended survey which began on [DATE]. Licensed Practical Nurse (LPN) LL, LPN MM, and Certified Nursing Assistant (CNA) 11 were alleged to have verbally abused and neglected the needs of Resident #1 when he became short of breath, anxious and complained of chest discomfort. The alleged perpetrators worked on the third (3rd) shift together and the alleged abuse occurred on the third shift on [DATE]. (Refer F155, F223, F226, F281, F282) The facility's failure to immediately report to the State Survey Agency and investigate allegations of abuse/neglect has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility's policy titled, Abuse and Neglect Prohibition revised on [DATE], documented: The facility will conduct an investigation of any alleged abuse/neglect in accordance with state law. Any employee alleged to be involved in an instance of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. The facility will report such allegations to the state, in accordance with state regulation. The Abuse and Neglect Prohibition Policy included protection of residents: the facility will protect residents from harm during the investigation. Interview on [DATE] at 1:00 p.m. with the Attorney representing Resident #1 and his family revealed the facility was made aware that there was a surveillance video and depositions were obtained from the alleged perpetrators, two LPN's (LL and MM) and one (1) CNA (11) on [DATE]. Interview with the facility Administrator on [DATE] at 1:32 p.m. revealed that when he became aware of the allegations of abuse/neglect due to the [DATE] incident involving Resident #1, he contacted the corporate legal department. The compliance team met with the individuals named in the complaint. He did not file a report with the State Agency at that time. Review of the facility self-report regarding the allegations of abuse/neglect of Resident #1 revealed that though the facility was made aware of the allegations of Abuse and Neglect and the impending litigation the facility report was not sent to the State Agency until [DATE] which is greater than the mandated twenty-four hours after becoming aware of the allegations. The subsequent five (5) day report filed by the facility, revealed no documentation of the facility investigation but referred to the State Survey findings referenced on [DATE] and [DATE] survey findings. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on interview, record review and review of policy and procedure, it was determined the facility failed to have an effective system to ensure the implementation of the facility's Abuse and Neglect Prohibition policy for one (1) of twenty-five (25) sampled residents (Resident #1). Licensed Practical Nurses (LPN) MM and LL and Certified Nursing Assistant (CNA) 11 were alleged to have verbally abused and neglected Resident (#1). The alleged abusers worked on the third shift (11 p.m. until 7 a.m.) The facility's corporate office and Administrator had been aware of the alleged abuse since [DATE] but failed to follow the facility's policy and protect the residents from the alleged perpetrators, when they allowed LPN MM, LPN LL and CNA 11 to continue to work and provide direct care to residents. (Refer F155,F281 F223, F225) The facility's failure to implement the facility's Abuse and Neglect Prohibition policy to protect residents from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. The findings include: A review of the facility's Abuse and Neglect Prohibition policy defined Abuse as: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish. The facility will conduct an investigation of any alleged abuse/neglect, injuries of unknown origin, or misappropriation of resident property in accordance with state law. Any employee alleged to be involved in an instance (s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. The facility will report such allegations to the state, in accordance with state regulation. The facility will protect residents from harm during the investigation. Interview with the Administrator on [DATE] at 1:32 p.m. revealed when he became aware of the allegations of abuse/neglect related to the incident involving Resident #1 on [DATE], he contacted the corporate legal department. The compliance team met with the individuals named in the complaint. The Administrator further revealed some employees in the facility had been terminated due to behaviors that could impact resident care. Out of the three (3) staff persons identified in the video, only one, LPN MM, was suspended due to documentation concerns. LPN MM and LPN LL were allowed to return to work after coaching. LPN LL was observed and interviewed while on duty on third shift [DATE] at 5:30 a.m. Review of the Daily Assignment Sheets dated [DATE] through [DATE] indicated that LPN MM was scheduled to work sixteen (16) times. LPN LL was scheduled to work twenty-seven (27) times. CNA 11 was scheduled to work twenty (20) times. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on review of policy and procedure and interviews, it was determined that the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for residents in the facility. The Administrator was made aware of allegations of abuse/neglect of Resident #1 on [DATE] when the Attorney, representing Resident #1 and his family, divulged there was video surveillance of the alleged abuse/neglect and obtained depositions from the alleged perpetrators, Licensed Practical Nurse (LPN) MM, LPN LL and Certified Nursing Assistant (CNA) 11 . The Administrator failed to suspend the alleged perpetrator, investigate and report the alleged abuse to the appropriate State Agencies per the facility ' s policy. (Refer to F155, F157, F223, F225, F226, F281, F282) The facility ' s failure to ensure the Administrator administered the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility ' s Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility ' s Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility's policy titled, Abuse and Neglect Prohibition documented: each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator or Director of Nursing (DON). The facility Administrator is the Abuse Prevention Coordinator . The facility Quality Assurance and Performance Improvement (QAPI) Committee will investigate occurrences, patterns and trends that may indicate the presence of abuse, neglect injuries of unknown origin, or misappropriation of property to determine the direction of the investigation/intervention, through analysis of systems, audits and reports. Any employee alleged to be involved in an instance(s) of abuse and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations are unsubstantiated. The facility will report such allegations to the state, in accordance with state regulation. The facility will protect residents from harm during the investigation. Review of facility self-report GA 932 dated [DATE] intake details documented: This is a self-reportable from the facility for Resident #1. During a media news story it was brought to the current administrations attention about the incident being an alleged neglect. At this time the facility is submitting a self-reportable for the identified alleged neglectful incident. On February 27, 2014 the resident was identified with a change in condition. The nurse assessed the resident, notified the family and physician. The nurse placed the resident on oxygen and continued to monitor the resident. The resident became unresponsive. The family and MD were notified that the resident was being coded and 911 was called. EMS arrived and the resident was not revived. Interview on [DATE] at 1:00 p.m. with the Attorney representing Resident #1 and his family revealed the facility was made aware that there was a surveillance video and depositions were obtained from the alleged perpetrators, two (2) Licensed Practical Nurses (LPN) (LL and MM) and one (1) Certified Nursing Assistant (CNA) (11) on [DATE]. Interview with the Administrator on [DATE] at 1:32 p.m. revealed that when he became aware of the [DATE] incident via media coverage on [DATE] involving Resident #1, he contacted the legal department and the compliance team met with the individuals named in the complaint. The Administrator said that he held two large meetings and a couple town hall meetings with staff, specifically bringing up the video and media coverage. He said that he addressed call light responses at the generalized town hall meetings and a few one to one meetings. The Administrator further explained that some staff members were identified with inappropriate behaviors and were terminated. However, the staff members named in the complaint (LL, MM, and 11) were currently still scheduled and assigned at the facility. According to the Administrator, LPN MM had been suspended and allowed to return to the facility for a different concern. LPN LL was counseled regarding oxygen therapy. Further interview with the administrator on [DATE] at 5:00 p.m. revealed that LPN LL, LPN MM and Certified Nursing Assistant (CNA) 11 had since been terminated. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on record review, review of policy and procedure and interviews, it was determined the facility failed to ensure services provided or arranged by the facility were provided by qualified persons in accordance with written plan of for one (1) of twenty five (25) residents sampled (Resident #1). The facility care planned Resident #1 for Respiratory Problems on [DATE] with Approaches that included: Assess for shortness of breath and notify MD of any changes. On [DATE], Resident #1 repeatedly pressed his call button and complained of respiratory distress and chest discomfort. The LPN MM on duty documented Resident #1's vital signs in the Nurse's Notes at 3:00 a.m. The Blood Pressure (BP) was ,[DATE], Pulse (P) was 72 and Respirations (R) were 20. At 5:00 a.m. the BP was ,[DATE], Pulse was 100 and Respirations were 26. Review of video surveillance revealed from 4:34 a.m. through 5:28 a.m., Resident #1 was calling out for help, struggling to breath, pointing to and stating My heart , panicking, pushing the call light, grunting and moaning. Despite Resident #1's repeated calls for help and clinical change of condition as evidenced by an increase in pulse, respirations and decrease in BP, the Licensed Practical Nurse (LPN) MM failed to notify the Physician in accordance to the written Care Plan. LPN MM was summoned into Resident #1's room by the Certified Nursing Assistant (CNA) 11 at 5:43 a.m. because Resident #1 was unresponsive. LPN MM assessed Resident #1 and found no pulse or respirations. (Refer to F155, F157, F223, F281) The facility's failure to provide services in accordance with each resident's written plan of care has caused, or had the likelihood to cause, serious harm, injury, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility ' s Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the policy titled Comprehensive Plan of Care documented: Each resident will have a comprehensive care plan developed that includes goals, measurable objectives, and timetables to meet their medical, nursing, mental and psychosocial needs identified during the comprehensive assessment. The care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well being. The plan of care must reflect current standards of professional practice, include interventions to prevent avoidable decline in function or functional level. Record review revealed the facility admitted Resident #1 in January of 2014. His [DIAGNOSES REDACTED]. Review of the Physician's notes dated [DATE] indicated that Resident #1 had additional [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had no behavioral symptoms. He required assistance for all activities of daily living. His Brief Interview for Mental Status (BIMS) summary score was three (3), indicating severe cognitive impairment. Resident #1 was assessed with [REDACTED]. Review of the Care Plan dated [DATE] identified Resident #1 had a Problem/Need for Oxygen (02) at 2 liters per minute (2 LPM) with Approaches/Interventions that included: Assess for Shortness of Breath, Diaphoresis/Skin Changes as needed, Apply 02 as needed and Notify MD of any Changes. Review of video surveillance conducted on [DATE] in the office of the Attorney representing Resident #1 and his family revealed, at 4:34 a.m., Resident #1 was calling out for help, struggling to breath and pushing his call light. This continued until LPN MM came in to the room at 4:43 a.m., repositioned the resident and told him it's going to be alright. At 4:46 a.m. LPN MM entered the resident's room and told him to stop pushing the call light. Resident #1 again said to LPN MM, My heart. LPN MM did not assess the resident until 4:54 a.m. by checking the resident's blood pressure. At 4:58 a.m. LPN MM told Resident #1 there was nothing wrong with him, he was having anxiety and needed to calm down. Resident #1 continued to summon for help and call out Help Me. CNA 11 entered Resident #1's room, asked him what he wanted, changed his brief and removed his oxygen nasal cannula. Resident #1 was unresponsive when CNA 11 completed the brief change. Review of the Nursing Daily Skilled Summary Notes dated [DATE] at 3:00 a.m. and 5:00 a.m. revealed no documentation that the Physician was notified of Resident #1's complaints of shortness of breath and chest discomfort. Interview on [DATE] at 10:27 a.m. with LPN MM who was Resident #1's direct care nurse on [DATE] revealed that she had been in the room several times to answer his call light. She explained that she was trying to get him to calm down. She said that she did not document each time that she responded to Resident #1. LPN MM stated that Yes, I told Resident #1 to stop pushing his call light . Interview on [DATE] at 10:26 a.m. with the Medical Director revealed that he did not recall being notified of resident #1 ' s complaints of shortness of breath or chest pain. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on interview, record review, review of policy and procedure, review of Emergency Medical System (EMS) records and video surveillance review, it was determined the facility failed to honor the explicit Advance Directive wishes of one (1) of twenty-five (25) sampled residents (Resident #1). Resident #1 had an Advanced Directive which specified he desired to be provided Cardio [MEDICAL CONDITION] Resuscitation (CPR) if cardiac or respiratory arrest occurred. However, on [DATE], LPN MM and LPN LL failed to initiate CPR for Resident #1 when he was found unresponsive at 5:28 a.m. 911 Emergency was not called until 6:25 a.m. LPN LL began chest compressions at 6:34 a.m. EMS arrived at 6:38 a.m. and determined Resident #1 had no pulse and was not breathing. Resident #1 did not respond to the resuscitation efforts of the paramedics and was pronounced dead at 7:00 a.m. (Refer F223, F281, F282) The facility's failure to ensure residents' Advance Directives were honored has caused, or had the likelihood to cause, serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility policy for Advance Directives (OP2 0303.00 Release Date: [DATE] Chapter: Resident Rights) documented: The resident has a right to accept or refuse medical or surgical treatment and to formulate an advance directive in accordance with state and federal law. The facility uses its best efforts to comply with the wishes of a resident as expressed in an advance directive and will not condition the provision of care or otherwise discriminate against an individual based on whether the individual has executed an advance directive. The facility must document in a prominent part of the resident's clinical record whether the resident has issued an advance directive and; the facility's copy of the advance directive must be filed in the resident's clinical record. Review of the policy titled Medical Emergency Management, revised [DATE] (SSP 0201.00) documented: The facility ensures residents receive timely and appropriate interventions in the event of a medical emergency. The staff takes actions to ensure that the resident's Airway, Breathing, and Circulation are maintained until emergency personnel arrive. Staff is aware of each resident's advance directives prior to the administration of cardio-pulmonary resuscitation. Once a medical emergency is identified, qualified staff assesses the resident, initiates the appropriate emergency procedure (s), and calls 911. The staff continues to provide care and monitor the resident until the emergency personnel arrive. Record review indicated that the facility admitted Resident #1 in January of 2014 with [DIAGNOSES REDACTED]. Review of the Physician's notes dated [DATE] documented that Resident #1 had additional [DIAGNOSES REDACTED]. Review of Resident #1's Advance Directives/Medical Treatment Decisions Acknowledgment of Receipt dated [DATE] indicated that the resident was a Full Code. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed resident #1 with no behavioral symptoms. He required assistance for all activities of daily living. His Brief Interview for Mental Status (BIMS) summary score was three (3), indicating severe cognitive impairment. Resident #1 was assessed on the MDS with shortness of breath and trouble breathing. Review of the Nurse's Notes for Resident #1 dated [DATE] at 5:40 a.m. revealed that Licensed Practical Nurse (LPN) MM was called into the resident's room by the Certified Nursing Assistant (CNA) 11. CNA 11 stated Resident #1 was not breathing. LPN MM assessed Resident #1 and found no pulse, no respirations and no blood pressure. Continued documentation revealed that the resident's skin was ashen and mouth was open but his skin was warm to the touch. LPN MM documented at 5:43 a.m. that she called the nursing supervisor and made her aware and called the resident's son. The son stated he thought his father was a Do Not Resuscitate (DNR). LPN MM instructed the son to call the mortuary to pick up the remains of Resident #1. LPN MM then called the Assistant Director of Nursing (ADON) to pronounce Resident #1 dead and notified the Physician on his beeper. Subsequent Nurse's Notes on [DATE] revealed: At 6:20 a.m., LPN MM documented that the supervisor notified the resident's son of a Code in progress and gave him the name and address of a mortician to call. At 6:25 a.m., LPN MM documented 911 was called. At 6:40 a.m., LPN MM documented the paramedics arrived and assessed the resident. The paramedics called the hospital and pronounced the resident at 7:00 a.m. Observation of the video surveillance was conducted on [DATE] at 1:00 p.m. in the office of the Attorney representing Resident #1 and his family. The incident took place on [DATE] and revealed the following events beginning at 4:34 a.m. and ending at 6:38 a.m. At 4:34 a.m. Resident #1 was lying in bed with the over-bed light on, television was audible. Resident #1 appeared agitated and called out Help Me, Help Me and pressed his call button. At 4:35 a.m. Resident #1 was breathing heavily and pushed his call button again, he removed his oxygen by nasal cannula and then tried to replace the nasal cannula himself. At 4:36 a.m. Resident #1 struggled with the nasal cannula and appeared panicky as he tried to put the oxygen by nasal cannula back on. At 4:37 a.m. Resident #1 called out Help Me, Help Me, Help Me . At 4:38 a.m. Resident #1 was heard grunting three times the started struggling with the nasal cannula again. At 4:39 a.m. Resident #1 was panicky At 4:40 A.M. Resident #1 was mouth breathing. At 4:42 a.m. LPN MM entered Resident #1's room and administered medications. Resident #1 said to her My heart. At 4:43 a.m. LPN MM repositioned Resident #1 onto his right side and placed a wedge cushion behind his back. The nurse could be heard telling Resident #1 going to be alright . At 4:44 a.m. Resident #1 was visibly struggling to breathe, however, LPN MM left the room. At 4:45 a.m. Heavy mouth breathing could be heard coming from Resident #1 and he was trying to push his call button. At 4:46 a.m. LPN MM returned to Resident #1's room and said Stop pushing call light, what is wrong now? Resident #1 responded My Heart . LPN MM then responded to Resident #1 Let me get my stethoscope, turned the call light off and left the room. At 4:48 a.m. Resident #1 observed struggling to breath and moaning. At 4:50 a.m. Resident #1 pushed the call button and could be heard moaning. At 4:54 a.m. LPN MM returned to Resident #1's room with the Blood Pressure (BP) machine. She took the resident's BP in both arms. At 4:58 a.m. LPN MM could be heard telling Resident #1 Anxiety, nothing wrong with your heart, blood pressure not elevated, nothing wrong with your heart . Then LPNMM could be heard telling Resident #1 You're having anxiety, that's all, you just need to calm down . At 4:58 a.m. Resident #1 pressed the call button. At 5:03 a.m. Resident #1 could be heard moaning and sounded like he said Help me. At 5:04 a.m. Resident #1 called out Help me, help me. At 5:06 a.m. Resident #1 pressed the call button, again. At 5:23 a.m. CNA 11 entered Resident #1's room and asked What do you want? and changed the resident's brief. At 5:24 a.m. Resident #1 appeared disoriented. At 5:27 a.m. CNA 11 removed Resident #1's oxygen nasal cannula. At 5:28 a.m. Resident #1 appears to be unresponsive. At 5:29 a.m. CNA 11 calls out for help, then proceeds to put the oxygen nasal cannula back into the resident's nose. At 5:30 a.m. LPN MM entered Resident #1's room and asked CNA 11, What happened? CNA 11 threw her hands into the air and replied, I came in, he died ! At 5:30 a.m. both CNA 11 and LPN MM left the room. No CPR was administered. The CNA returned and put a pillow case on the resident's pillow and placed under the resident ' s head. At 5:31 a.m. CNA 11 adjusted the nasal cannula in Resident #1's nostrils, covered him with a sheet and raised the head of his bed. At 5:33 a.m. a conversation could be heard between CNA 11 and Nurse MM that Resident #1 is dead. At 5:52 a.m. CNA 11 washed Resident #1's face and lips, lowers the head of bed and leaves the room. At 6:01 a.m. CNA 11 removed the nasal cannula and pulls the sheet up to Resident #1 ' s neck., then leaves the room. At 6:15 a.m. LPN LL arrived with a CPR backboard. At 6:22 a.m. both LPN MM and LPN LL entered the room, looked at resident #1 but did nothing. At 6:24 a.m. LPN LL began manipulating an oxygen tank. She then gives up on the oxygen tank and laughs. LPN LL proceeded to rearrange the CPR backboard under Resident #1. At 6:27 a.m. it appeared that LPN LL was unable to determine whether oxygen tank is empty or full. She stopped working on the oxygen tank, closes the curtain around resident #1's bed obscuring the picture from the video but not the sound. At 6:28 a.m. LPN LL gives up on oxygen tank and could be heard laughing. At 6:30 a.m. a new oxygen tank was brought to the room and laughing could be heard. At 6:31 a.m. air escaping the round the oxygen tank could be heard. At 6:32 a.m. a comment could be heard to get a missing piece Off the one we had. A different voice responded, Didn't see one on the one we had. At 6:33 a.m. oxygen tubing was placed back on the oxygen concentrator the room. and back on Resident #1. At 6:34 a.m. the first chest compressions were administered x six (6) compressions. At 6:36 a.m. LPN LL performed chest compressions with one hand until the paramedics arrived. At 6:37 a.m. LPN LL was heard asking the CNA 11, How long have I been doing this since? An hour? Asks CNA 11 if they want to say and the hours. CNA 11 responded, An hour. At 6:37 a.m. CPR continued At 6:38 a.m. paramedics entered the room. Review of the ambulance Patient Care Report dated [DATE] documented on page 1 that Resident #1 had a presumed [MEDICAL CONDITION], he had no pulse at 6:40 a.m. and the time of first Cardiopulmonary Resuscitation was 6:40 a.m. CPR was abandoned at 7:00 a.m. Resident #1 was pronounced dead in the field (facility). Additionally, review of the untimed Narrative from the Ambulance report of [DATE] documented that Resident #1 was not breathing and had no pulse. Staff reported unknown downtime. Resident had no response to resuscitation efforts of intubation, intravenous epi and [MEDICATION NAME] as above. Field termination via doctor at hospital at 0700. Review of the Medical Examiner's Inquiry dated [DATE] documented the Cause of Death: Delayed complications of Left [MEDICAL CONDITION], Other Significant Conditions: Coronary Artery [MEDICAL CONDITIONS]. Interview on [DATE] at 10:27 a.m. with LPN MM who was on duty on [DATE] and responded to Resident #1's frequent pushing of his call light revealed that she had been in the room several times to answer his call light. She explained that she was trying to get him to calm down. She did not document each time that she responded to his call light. Nurse MM stated that Yes, I told Resident #1 to stop pushing his call light . LPN MM said that the Resident Care Specialist/CNA called her to Resident #1's room and that something seemed to be wrong with him. LPN MM checked his pulse and looked for rise and fall of his chest. He seemed ashen. LPN MM then went to the nurse's station and called the nurse supervisor to tell her that they had to do CPR. LPN MM said that she did not do vital signs and that when she left the room the CNA 11 was still in the room with the resident. She grabbed Resident #1's chart to check if he was a Full Code then called his son to determine whether he was DNR or not. According to LPN MM the resident's son said that he thought his father was a DNR. LPN MM said that she was not sure if the Code Sheet was on the chart and not sure how long the delay was to actually start the CPR. LPN MM said there must have been a discrepancy with the paperwork. There was no step by step documentation written for that night of [DATE] about Resident #1 according to LPNMM. Further, LPN MM added that when the nurse supervisor LPN LL arrived, she started the Code-911; put him on a backboard, hooked up the resuscitation bag (Ambu bag) to the oxygen concentrator at 2 liters per minute (2/LPM). LPN MM added that the oxygen tank was for use with the Ambu bag but she could not recall why additional oxygen was needed for the Ambu bag. LPN MM said that she was sure that she called the doctor. Interview on [DATE] at 5:33 a.m. with LPN LL revealed that she did not remember much about [DATE] but that around that time the oxygen tanks were faulty and did not work well. The oxygen tanks had been replaced since that time. LPN LL stated that she was the supervisor on the night of [DATE] and was working on a different floor when she was summoned to help the other LPN MM. Interview with the Director of Nursing (DON) on [DATE] at 8:00 a.m. revealed that the residents' code status is normally in the health record in the Advance Directive section. She said the staff must start CPR when residents have no vital signs until the code status is determined. She added that the residents that are Do Not Resuscitate (DNR) are indicated by a red sticker/name tape on their doorjamb. Residents that are Full Code have white name tapes on their doorjambs. The DON said that she expected one staff member to start CPR while other staff check the health record for CPR status. The DON revealed that Resident #1's code status was Full Code as indicated in the [DATE] record. Interview with the Director of Nursing (DON) on [DATE] at 11:20 a.m. revealed that the facility follows the American Heart Association guidelines that if there is only one rescuer present they go call 911 then start CPR. The DON could offer no explanation of the events in February of 2014 because she was newly hired at the facility. Interview with the Medical Director on [DATE] at 2:30 p.m. revealed that Resident #1 was a Full Code and was to receive CPR. He stated that there was nothing in the chart otherwise. The Medical Director added that CPR should have been initiated until the DNR status was determined instead of looking around for a chart. The Medical Director said that regardless of the situation, start CPR and call 911. An attempt was made to contact CNA 11 by telephone on [DATE] twice without a response. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on record review, interview, video surveillance review, review of facility policy and procedure, it was determined that the facility failed to notify the Physician of a change in condition for one (1) of twenty-five (25) sampled residents (Resident #1). Review of video surveillance (form a hidden camera that was installed by a family member) conducted on [DATE] in the office of the Attorney representing Resident #1 and his family revealed: From 4:34 a.m., Resident #1 made multiple requests for assistance on the night of [DATE] through 5:28 a.m., when the resident became unresponsive. Resident #1 was struggling to breath, was calling out for help and reported to the direct care Licensed Practical Nurse (LPN) MM on multiple occasions; Help me, Help me, Help me and My heart . There was no documented evidence that the Physician was notified of changes in the resident's condition. Resident #1 was pronounced dead at 7:00 a.m. by the paramedics. (Refer to F155, F223, F281, F282). The facility's failure to report Resident #1's change in medical condition to the Physician has caused, or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility policy titled Changes in Resident Condition documented: The resident, attending physician and legal representative or designated family member are notified when changes in condition or certain events occur. For life-threatening events call 911 if initial assessment indicates that such action is necessary. The Change of Condition Forms are used to assess and document changes in condition in an efficient and effective manner, provide assessment information to the physician, and provide clear comprehensive documentation. Resident #1 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) for Resident #1 indicated that his Brief Interview Mental Status (BIMS) summary score was three (3), indicating severe cognitive impairment. Further review of the MDS indicated that Resident #1 had no behavioral symptoms directed toward himself or others. According to the MDS he required assistance for bed mobility, transfers and all activities of daily living. Shortness of breath and trouble breathing was indicated. Resident #1 received oxygen and [MEDICAL TREATMENT] therapies. Review of the Care Plan for Respiratory Problems Resident #1 dated [DATE] indicated that he had [DIAGNOSES REDACTED]. Approaches to his respiratory needs included to assess for shortness of breath (SOB) and to notify MD of any changes, to notify family of any changes, apply oxygen as needed and pulse oximetry as ordered. However, on [DATE] Resident #1 requested assistance from the nurse for shortness of breath and chest pain and there was no documented evidence that the Physician was notified of the resident's symptoms. There was no evidence of the Change of Condition Form dated [DATE] in Resident #1's closed health record. Review of the Nursing Daily Skilled Summary Notes on [DATE] documented: At 3:00 a.m. Resident #1 was constantly pressing the call light many times for no reason. At 5:00 a.m. Resident #1 accepted his medication and was alert and anxious. At 5:40 a.m. LPN MM documented that she was notified that the Resident #1 was not breathing by the Resident Care Specialist (RCS/Certified Nursing Assistant (CNA). LPN MM documented that Resident #1 had no pulse or respirations. Further review of the Nursing Daily Skilled Summary notes for [DATE] revealed no documentation that the Physician was notified of Resident #1's change in respiratory condition, increased anxiousness or chest discomfort. There was one note at 5:43 a.m. on [DATE] which documented a call to the Physician ' s beeper to notify him of the resident's death. Review of the vital signs for Resident #1 on [DATE] documented at 3:00 a.m., the Pulse was 72, Respirations were 20 and Blood Pressure was ,[DATE]. At 5:00 a.m., the Pulse was 100, Respirations were 26 and Blood Pressure was ,[DATE]. Interview on [DATE] at 10:27 a.m. with LPN MM revealed that she had been in Resident #1's room several times to answer his call light. She explained that she was trying to get him to calm down. She did not document each time that she responded to his call light. LPN MM stated that Yes, I told Resident #1 to stop pushing his call light . Interview with the Medical Director on [DATE] at 10:26 a.m. revealed that he did not recall being notified of Resident #1's complaint of shortness of breath, anxiousness or chest discomfort on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on review of video surveillance, review of policy and procedure and interviews, it was determined the facility failed to have an effective system in place to ensure one (1) of twenty five (25) sampled residents (Resident #1) was free from abuse/neglect by staff. On [DATE], Resident #1 was having difficulty breathing and chest discomfort. The resident was constantly calling out for help, panicking, struggling to breath and pushing his call light. Resident #1 was told by Licensed Practical Nurse (LPN) MM at 4:43 a.m. that he was going to be alright and left the room. At 4:46 a.m. LPN MM told Resident #1 to Stop pushing the call light, what is wrong now? At 4:58 a.m. LPN MM told Resident #1 that he was having anxiety and there was nothing wrong with his heart. LPN MM further told Resident #1 that he just needed to calm down and left the room. Resident #1 continued to call out Help me, Help me , appeared mentally anguished, was moaning, groaning and pushing his call light. At 5:23 a.m., CNA 11 entered Resident #1's room and asked What do you want? CNA 11 changed the resident's brief and removed his oxygen nasal cannula. At 5:28 a.m., Resident #1 was unresponsive and Cardiopulmonary Resuscitation (CPR) was not performed until 6:34 a.m., one hour and six minutes (1:06) after Resident #1 was identified with no pulse and no respirations. (Refer F155, F281, F282) The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE]. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on [DATE] at 8:45 a.m. An acceptable Allegation of Compliance (AoC) was received on [DATE] and the State Survey Agency validated the Immediate Jeopardy was removed on [DATE] as alleged, The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility's Quality Assurance (QA) monitors the effectiveness of the systemic changes. Findings include: Review of the facility's policy titled, Abuse and Neglect Prohibition revised on [DATE], documented: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Further review of the policy revealed verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. Additionally neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of the Facility Incident Report Form (initial report) revealed there was an allegation of staff to resident neglect on [DATE]. Further review of the incident report revealed that there was media coverage that brought the incident to the attention of the facility Administration. The incident report /self-report revealed that on [DATE] the resident was identified with a change in condition. The nurse assessed the resident and notified family and physician. The nurse placed the resident on oxygen and continued to monitor the resident. The resident became unresponsive. The family and MD were notified that the resident was being coded and 911 was called. EMS arrived and the resident was not revived. Observation of the video surveillance was conducted on [DATE] at 1:00 p.m. in the Attorneys office, representing Resident #1 and his family. The incident took place on [DATE] and revealed at 4:34 a.m., Resident #1 was calling out for help, struggling to breath and pushing his call light. Resident appeared to be panicking. and anguished. Licensed Practical Nurse (LPN) MM responded to the resident at 4:42 a.m. and administered medications. At 4:43 a.m., LPN MM repositioned the resident unto his side and told him it was going to be alright, then left the room. Resident #1 continued to struggle to breath, panic and push his call light. At 4:46 a.m. LPN MM returned to Resident #1's room and said Stop pushing the call light, what is wrong now? Resident #1 responded My Heart . LPN MM then responded to Resident #1 Let me get my stethoscope, turned the call light off and left the room. At 4:58 a.m. LPN MM could be heard telling Resident #1 There is nothing wrong your heart, blood pressure not elevated, nothing wrong with your heart. You're having anxiety, that's all, and you just need to calm down. Resident #1 audibly moaned. Resident #1 continued to call out Help me, Help me. He was moaning, groaning and pushing his call light. At 5:23 a.m., CNA 11 entered Resident #1's room and asked What do you want? CNA 11 changed the resident's brief and at 5:27 a.m. she removed the oxygen nasal cannula from the resident. Resident #1 appeared disoriented. At 5:28 a.m., Resident #1 was unresponsive. At 5:30 a.m. LPN MM entered Resident #1's room and asked CNA 11, What happened? CNA 11 threw her hands into the air and said, I came in, he died ! At 5:30 a.m. both CNA 11 and LPN MM left the room. No CPR was administered. The first chest compressions did not occur until 6:34 a.m. LPN MM admitted telling Resident #1 to stop pressing his call light and there was nothing wrong with his heart during an interview on [DATE] at 10:27 a.m. LPN MM also stated that Resident #1 was just Needy and was acting no differently than he has acted in the past. Interview with the facility Administrator on [DATE] at 1:32 p.m. revealed that when he became aware of the allegations of abuse/neglect due to the [DATE] incident involving Resident #1 he contacted the corporate legal department. The compliance team met with the individuals named in the complaint. The facility implemented the following actions to remove the Immediate Jeopardy: 1. All residents had the potential to be affected. All resident records were audited (139 of 139) by the Director of Nursing and Unit Managers on [DATE] to determine that the resident had the right to formulate an advanced directive and the code status was clearly documented and consistently located in the resident's medical record for Cardiopulmonary Resuscitation (CPR) or Do Not Initiate Cardiopulmonary Resuscitation (CPR) as per the resident, responsible person (s) or Medical Power of Attorney (POA) wishes. No concerns were identified. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents ' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. 3. Education was provided for all staff on two separate occasions, defined in the following timeline: On [DATE] at 8:00 a.m. the Administrator held Town Hall meetings with all staff that were scheduled to work. Seventy-seven staff members attended the [DATE] in-service. On [DATE] a second Town Hall meeting was held and thirty-seven staff members were re-educated. All staff that were unavailable for re-education will be provided re-education prior to initiating work assignment and new staff will be educated during his/her orientation process. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 4. On [DATE] additional educational in services were conducted for all staff members. A total of one hundred and fourteen staff members were trained. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. 6. On [DATE] a second audit of all residents' Advance Directives. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. 8. The Director of Nursing, Unit Managers, Staff Development Coordinator will perform random audits weekly of five (5) residents for how long 8 weeks then monthly for two (2) months, then frequency determined by the QAPI recommendations: - Change of Condition -Advance Directives -Oxygen Verification. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. 10. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. 11. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. The State survey agency validated the implementation of the facility's Credible Allegation of Jeopardy Removal (CAJR) as follows: 1. Review of an audit log dated [DATE] revealed the Social Service Director and Unit Managers reviewed all resident's records related to Advanced Directives to ensure clear documentation related to Advanced Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE] by survey team. All health records clearly indicated resident Code Status. 2. All resident Care Plans (139 of 139) were audited by a licensed nurse or Social Service director (SSD) on [DATE] to determine that resident code status was on the residents' plan of care. Care Plans were updated by a licensed nurse upon discovery if corrective action was required. Interviews with the Interim DON on [DATE] at 3:22 p.m. revealed that the facility performed a 100% chart audit of resident Care Plans related to Advanced Directives. 3 & 4. Education was provided for all staff on two separate occasions. Education included the following topics: -Call Light Response -How to report Abuse and Neglect -Cardiopulmonary Resuscitation -Advance Directives Policy -Changes in Resident Condition Policy -Code Blue Status -Stop and Watch. The documentation for the Staff Education Meetings that were held on [DATE], [DATE], [DATE], [DATE] and [DATE], and [DATE] that were submitted by the interim DON were reviewed by the State Agency. 5. On [DATE] Random Call light audits were conducted by the Interim Director of Nursing and the Social Services Director. State Survey Agency observed the random call lights audits in progress on [DATE] and reviewed the facility's Audit Log. 6. On [DATE] a second audit of all residents' Advance Directives. State Survey Agency conducted a 100% audit of all resident health records for Advance Directive Code Status performed on [DATE]. All health records clearly indicated resident Code Status. 7. On [DATE] Social Worker conducted fifteen resident interviews regarding resident care with no concerns voiced by the residents. Interview with the Facility Administrator on [DATE] at 5:00 p.m. confirmed that the resident interviews were conducted as indicated with no additional concerns voiced by residents. 8. The Director of Nursing, Unit Managers and Staff Development Coordinator will perform random audits weekly of five residents then monthly for two months then frequency dependent upon QAPI recommendation. - Change of Condition -Advance Directives -Oxygen Verification. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random audits would be reported to the QAPI committee each month. 9. The Social Services Directors, Unit Managers, Staff Development Coordinator will perform random resident interviews utilizing Abacus Tool weekly. Interview with the Interim DON on [DATE] at 3:22 p.m. confirmed that the results of the random resident interviews would be reported during the weekly at risk meetings. That information is then brought to the QAPI committee each month. 10. and 11. The Administrator will review the Change of Condition, Advance Directives, Oxygen Verification, Resident Abuse and Neglect, as well as the Resident Interviews audit tools weekly for four weeks then monthly for two months to determine compliance. The Administrator will report and discuss the audit results monthly in the monthly Quality Assurance Performance Improvement (QAPI) meetings. Interview with the facility Administrator on [DATE] at 5 p.m. confirmed that he would review the audit tools and report to the QAPI committee each month.

Based on record review, hospital ED Admission Report Form review, hospital History and Physical report review, hospital X-ray report review, Interdisciplinary Post Fall Review report review, Resident Care Cardex Worksheet review, and staff interview, the facility failed to ensure that all nurse aides demonstrated competency during the provision of care, regarding the transfer of one (1) resident ("Q"), of four (4) sampled residents reviewed for falls, on the total survey sample of thirty-five (35) residents. Rather, Resident Care Specialist "DD" transferred Resident "Q" by herself and without the use of a mechanical lift, instead of ensuring the presence of two (2) staff and the use of a mechanical lift as specified by the resident's assessed need. During this transfer, Resident "Q" fell , complained of right leg pain, and was diagnosed with [REDACTED]. Findings include: Resident "Q"'s 10/13/2014 Admission Minimum Data Set assessment documented [DIAGNOSES REDACTED]. Section G-Functional Status documented that Resident "Q" required the extensive assistance of two (2) - plus persons with transfer. In a 10/21/2014, 11:15 a.m. Nurse's Notes entry, Licensed Practical Nurse (LPN) "AA" documented that on 10/20/2014, he received a call from Resident "Q"'s responsible party asking about a fall. LPN "AA" documented that he talked with Resident "Q" and was told that about an hour earlier, a staff member was transferring him and dropped him. LPN "AA" noted swelling of Resident "Q"'s right leg and an order for [REDACTED]. Resident "Q"'s 10/20/2014 hospital ED Admission Report Form documented hospital transfer due to a fall, and the hospital History and Physical documented a right femur fracture likely secondary to a fall. A 10/20/2014, 9:38 p.m. hospital X-ray revealed an angulated comminuted distal right femoral fracture. A facility Interdisciplinary Post Fall Review form for Resident "Q" documented that on 10/20/2014, the resident was being transferred by only one (1) person, rather than two (2) persons as required. During a 10/21/14, 3:00 p.m. interview, LPN "AA" stated that upon learning of Resident "Q"'s fall, the LPN asked the resident's assigned Resident Care Specialist (RCS) "DD" about the fall, and RCS "DD" acknowledged Resident "Q"'s fall during transfer on 10/20/14. During interview on 10/21/2014 at 3:10 p.m., the Director of Nursing (DON) acknowledged Resident "Q"'s fall of 10/20/2014 while being transferred by only one (1) RCS (RCS "DD"). The DON further stated that RCS staff were taught from the very start of orientation that they were to use two (2) persons to assist with the transfer of all residents except totally independent residents, that residents were to be lifted via mechanical lift, and that this information was listed on each resident's Resident Care Cardex Worksheet. Review of Resident "Q"'s Resident Care Cardex Worksheet revealed the Worksheet specified that Resident "Q" required the assistance of two (2) persons for transfer and instructed staff to use a Hoyer lift for transfers. However, during interview on 10/22/2014 at 9:55 a.m., RCS "DD" acknowledged Resident "Q" fell on [DATE] while she was manually transferring the resident from bed to wheelchair (rather than utilizing a mechanical lift), with no second staff member present. RCS "DD" denied having received training on resident transfer procedures, and denied having been trained regarding the use of the Resident Care Cardex Worksheet. However, despite RCS "DD"'s assertion, per the 10/22/2014, 9:55 a.m. interview referenced above, that she had received no training regarding resident transfer procedures and no training regarding the use of the Resident Care Cardex, review of facility inservice training records revealed a Skills Check-Off for Mechanical Lifts dated 06/30/2014 which documented, by her signature, that RCS "DD" had been trained during orientation regarding mechanical lift use, and also documented that the RCS had been observed and checked-off as being proficient in mechanical lift use. In addition, an in-service signature sheet dated 09/09/2014, which included RCS "DD"'s signature, documented that this RCS had received training on that date which included resident bed mobility and transfers. Review of the facility's Safe Transfer Student Program Guide revealed that RCS staff were instructed on topics which included the key principles of good body mechanics and helping to ensure a resident's safety during transfer. Procedures listed in this Safe Transfer Guide included handling procedures for a resident, resident instruction during transfer, and the process of determination for the need of a mechanical lift during transfer. During an interview with LPN "JJ" conducted on 10/22/2014 at 2:22 p.m., LPN "JJ" stated that she had been involving in providing staff in-service training regarding resident transfers during the year of 2014. She indicated that direct care staff in-service training related to resident transfer procedures had been conducted in June of 2014 and also on 09/09/2014 (as referenced above), and that the Safe Transfer Student Program Guide had been covered. LPN "JJ" stated that RCS staff had been taught procedures to ensure a resident's safety during transfers, and stated that the use of mechanical lifts was discussed. LPN "JJ" also stated that she discussed the Resident Care Cardex Worksheet, which contained resident transfer information, as part of a walking tour performed during new staff orientation. LPN "JJ" further stated that she specifically remembered showing RCS "DD" the Resident Care Cardex Worksheet, and discussing what was contained within the Worksheet document, including resident transfer information. During an interview conducted on 10/21/2014 at 3:20 p.m., RCSs "EE" and "FF" acknowledged they had been taught to determine resident care needs by looking at the Resident Care Cardex kept at the nurse's station, and that they had been taught to use two (2) staff for all resident transfers. Based on the above, Resident "Q" was nonambulatory and had been assessed to require the assistance of two (2) staff persons and a Hoyer lift during transfer, and the resident's Resident Care Cardex Worksheet reflected these transfer requirements. However, despite RCS "DD" having received training regarding the requirement of utilizing two (2) staff during transfers and regarding the use of the Resident Care Cardex Worksheet to determine the specific transfer requirements for each resident, RCS "DD" attempted to transfer Resident "Q" from the bed to the wheelchair by herself and without the use of a Hoyer lift. During this transfer, Resident "Q" fell to the floor, complained of right leg pain, and was diagnosed with [REDACTED]. Cross refer to F323 for more information regarding Resident "Q".

Based on record review, family interview, hospital ED Admission Report Form review, hospital History and Physical form review, hospital X-ray report review, facility Incident/Accident Report review, Interdisciplinary Post Fall Review report review, Resident Care Cardex Worksheet review, Physical Therapist interview, and staff interview, the facility failed to provide safe transfer by failing to ensure the presence of two (2) staff persons and the use of a Hoyer lift as required to transfer one (1) resident ("Q"), of four (4) sampled residents reviewed for falls, on the total survey sample of thirty-five (35) residents. This failure resulted in harm for Resident "Q", who subsequently fell during transfer, by only one (1) staff person and without the use of a mechanical lift, from the bed to the wheelchair, complained of right leg pain, and was diagnosed with [REDACTED]. Findings include: Record review for Resident "Q" revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 10/13/2014 which documented the resident's facility admission Entry Date of 10/06/2014. Section G - Cognitive Patterns of this MDS documented that Resident "Q" had a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating that the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. A Fall Risk Evaluation form of 10/13/2014 for Resident "Q" assessed the resident to have a Total Score of 20, listing any Total Score of 10 or greater representing a high risk for falls. During an interview with family members of Resident "Q" conducted on 10/21/2014 at 1:30 p.m., a family member stated that the resident was admitted to the facility to receive rehabilitation to make him stronger, as he did not have leg strength. The family member stated that he had received a call from Resident "Q" the day before at around 11:10 a.m., and the resident stated he had been dropped and his leg hurt. The family member stated he then called the facility and talked to the resident's nurse, but the nurse stated he was unaware of the fall. The family member stated he was later called back by the nurse and notified that an X-ray was to be performed on Resident "Q"'s leg, and that the resident had been transferred to the hospital due to a fracture which would require surgical repair. Record review for Resident "Q" revealed a Nurse's Notes entry 10/21/2014, timed at 11:15 a.m. and written by Licensed Practical Nurse (LPN) "AA", in which LPN "AA" documented that on 10/20/2014 at 11:15 a.m., he had received a call from the resident's responsible party asking about a fall involving the resident earlier that morning. LPN "AA" documented that he was not aware of a fall involving Resident "Q", but was informed by the responsible party that the resident had stated he was dropped while being transferred from the bed to the wheelchair. LPN "AA" documented that review of Resident "Q"s record revealed no documented fall, so the nurse proceeded to the resident's room to investigate. The LPN asked Resident "Q" about the fall, and the resident stated that about one (1) hour prior, a staff member was transferring him and dropped him, and that two (2) staff members had then pulled him from the floor. LPN "AA" documented Resident "Q" complained of pain in the right leg and the nurse noticed swelling of the right leg; thus, the physician was called and an order was obtained for an X-ray of the right lower extremity. The LPN documented that at approximately 3:15 p.m. on 10/20/2014, the X-ray results were received indicating a fracture of Resident "Q"'s right femur, and when informed, the physician ordered to send the resident to the hospital emergency room . The LPN further documented that at 6:30 p.m. on 11/20/2014, Resident "Q" was transported to the hospital. During an interview with LPN "AA" conducted on 10/21/14 at 3:00 p.m., he stated that at around 11:00 a.m. on the previous day of 10/20/14, he had received a telephone call from a family member of Resident "Q" who told him the resident called the family and said he had fallen. LPN "AA" stated he was not aware of Resident "Q" having experienced a fall, and therefore went to the resident's room to talk with the resident. LPN "AA" stated that upon entering Resident "Q"'s room, he observed the resident sitting up in a wheelchair. Resident "Q" stated to LPN "AA" that an aide had attempted to transfer him about an hour prior and had dropped him. The LPN stated Resident "Q" also told him that after the fall, another staff member was brought to the room, and the two (2) staff members assisted him up to the wheelchair. LPN "AA" stated he assessed Resident "Q" and noted the right leg to be swollen, and stated that the resident was complaining of leg pain. LPN "AA" stated he called the physician who ordered a STAT X-ray which revealed a fracture, and the resident was then sent to the Emergency Department (ED). The ED Admission Report Form of 10/20/2014 for Resident "Q" documented that the resident had been transported to the hospital due to having sustained a fall earlier that morning in the nursing facility while facility staff were transferring him from the bed to the wheelchair. This Report Form further documented that Resident "Q" complained of pain of the right leg. A hospital History and Physical form of 10/21/2014 for Resident "Q" noted in the Assessment/Plan section that the resident had a femur fracture on the right that was documented to likely be secondary to a traumatic fall. A hospital X-ray of 10/20/2014, timed at 9:38 p.m., of Resident "Q"'s right femur documented an angulated comminuted distal femoral fracture. An facility Incident/Accident (I/A) Report of 10/20/2014, completed by the facility regarding Resident "Q"'s fall of that date, documented the time of the fall as 10:50 a.m. This I/A Report further documented the Resident "Q" stated he was being transferred by nursing staff, fell to the floor, and was pulled up by two (2) nursing staff. An Interdisciplinary Post Fall Review (IPFR) form for Resident "Q" was completed by the facility as part of the facility's review and investigation into the resident's fall of 10/20/2014. This IPFR form documented, in the Summary of Interdisciplinary Team section, that when Resident "Q" experienced the fall of 10/20/2014, he was being transferred in his room by only one (1) person, but that the resident actually required the assistance of two (2) persons for transfer. During the 10/21/2014, 3:00 p.m. interview with LPN "AA" referenced above, LPN "AA" stated that after learning of Resident "Q"'s fall of 10/20/2014 and being told by the resident that he had fallen while being transferred by his aide, the LPN approached Resident Care Specialist (RCS) "DD", who was the RCS assigned to Resident "Q" on the morning of the fall. LPN "AA" stated that he asked RCS "DD" what had happened, and that initially, RCS "DD" denied that the resident had fallen, but then stated to the nurse that she had lowered Resident "Q" to the floor during the transfer and later asked RCS "GG" to assist in getting the resident off the floor. During an interview with RCS "DD" conducted on 10/22/2014 at 9:55 a.m., RCS "DD" stated that at around 10:30 a.m. on 10/20/2014, she heard Resident "Q" requesting to get out of bed. RCS "DD" stated that after getting Resident "Q" dressed she got a wheelchair, but when transferring the resident from the bed to the wheelchair, his leg got caught behind the wheel and she saw they were falling, so she put the resident's buttocks on her leg to allow her to lower the resident to the floor. RCS "DD" stated Resident "Q"'s right leg was bent behind him and behind the wheel of the wheelchair and that the resident complained of pain, further stating that the resident had not complained of pain prior to this incident. RCS "DD" stated she went into another resident's room to ask RCS "GG" to help her get Resident "Q" up to the wheelchair, but then got distracted by another resident and did not inform the nurse of the fall. During interview with the Director of Nurses (DON) conducted on 10/21/2014 at 3:10 p.m., the DON acknowledged RCS "DD" had admitted during interview that she had slid Resident "Q" down her leg to the floor when the resident's foot got caught under the wheelchair during the 10/20/2014 transfer from the bed to the wheelchair. The DON further stated that staff were to use two (2) person assistance for transfers of all residents unless they were totally independent, and that no resident was to be lifted unless it was with a mechanical lift. The DON stated that resident transfer information was written on each resident's Resident Care Cardex Worksheet which was kept at the Nurse's Station. During interview with RCS "GG" conducted on 10/22/2014 at 12:41 p.m., RCS "GG" acknowledged that on 10/20/2014, RCS "DD" had come to ask her to help get Resident "Q" off the floor, and that she and RCS "DD" picked the resident up and put him in the wheelchair. RCS "GG" stated that in the past, she had used a Hoyer lift to transfer Resident "Q" from the wheelchair to a stretcher when the resident was going to dialysis, and that she knew when residents were to be transferred using a lift because it would be listed on the Resident Care Cardex. Review of Resident "Q"'s Resident Care Cardex Worksheet revealed this Worksheet indicated that Resident "Q" required the assistance of two (2) persons for transfer, and also instructed staff to use a Hoyer lift for transfers. During interview with Unit Manager "CC" conducted on 10/21/2014 at 3:25 p.m., Unit Manager "CC" verified, upon review of Resident "Q's" Resident Care Cardex Worksheet (to be used by RCS staff) at that time, that the transfer information regarding Resident "Q" needing two (2) person transfer assistance and a Hoyer lift was in place prior to the resident's fall on 10/20/2014. During interview with Physical Therapist (PT) "HH" conducted on 10/22/2014 at 10:58 a.m., PT "HH" stated that she had been working with Resident "Q" since 10/07/2014 for strengthening and balance, including transfers. PT "HH" stated that Resident "Q" had a transmetatarsal amputation on one foot, that transfers were difficult for him, and that the resident had not been able to ambulate for several years. PT "HH" stated that she assessed Resident "Q" at the time of facility admission as being totally dependent for transfers which meant that the resident was unable to stand, could not be transferred by standing and pivoting, and therefore a Hoyer lift was the only appropriate transfer method to be used by nursing staff to transfer this resident. PT "HH" further stated that from the time of Resident "Q's" facility admission, she had told nursing staff that the resident needed to use a Hoyer lift for transfers. During interview with Unit Manager "CC" conducted on 10/22/2014 at 11:21 a.m., Unit Manager "CC" acknowledged that PT "HH" told her the day after Resident "Q" was admitted to the facility that the resident required two (2) person assistance for transfers using a Hoyer lift. Based on the above, Resident "Q" was nonambulatory and had been assessed to require the assistance of two (2) staff persons and a Hoyer lift during transfer. However, on 10/20/2014, only one (1) RCS attempted to transfer Resident "Q" from the bed to the wheelchair without the use of a Hoyer lift, the resident fell to the floor, complained of pain to the right leg, and was subsequently diagnosed with [REDACTED].

Based on record review, hospital History and Physical form review, hospital X-ray report review, Interdisciplinary Post Fall Review report review, Physical Therapist interview, and staff interview, the facility failed to ensure that the comprehensive Care Plan developed to address the fall potential and transfer requirements of one (1) resident ("Q") reflected the required number of staff and the required use of a mechanical lift for Resident ("Q"), who was nonambulatory, had a history of [REDACTED]. A total of four (4) sampled residents were reviewed for falls, and the total survey sample was thirty-five (35) residents. Resident "Q" subsequently sustained actual harm when the resident fell during transfer from the bed to the wheelchair by only one (1) staff, with no mechanical lift utilized during the transfer, and was diagnosed with [REDACTED]. Findings include: Resident "Q"'s Admission Minimum Data (MDS) Set assessment of 10/13/2014 documented the resident's facility admission on 10/06/2014. Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident "Q" had required the extensive assistance of staff with all Activities of Daily Living (ADL) care during the look-back period, including the assistance of two (2) - plus persons with transfers. Section J - Health Conditions documented that Resident "Q" had experienced a fall in the month prior to facility admission, and Section O - Special Treatment Programs documented that the resident received Skilled Physical Therapy during the look-back period. Review of the comprehensive Care Plan for Falls for Resident "Q" revealed a Rap/Problem/Need dated 10/17/2014 which identified the resident's risk for falls due to reasons including, but not limited to, a history of falls. Resident "Q"'s Care Plan for Falls also contained multiple Approaches including, but not limited to, encouraging the resident to ask for help, keeping the call bell within reach, and assisting the resident with toileting. However, further review of Resident "Q"'s Care Plan for Falls revealed no reference to the need for two (2) plus staff persons to assist with transfers, as assessed in the resident's 10/13/2014 Admission MDS assessment referenced above. Resident "Q"'s comprehensive Care Plan for ADL Care identified a Rap/Problem/Need dated 10/17/2014 which did identify the resident's dependence on staff for ADL care, including assistance with transfers. However, the Approach related to transfers referenced in the Care Plan for ADL Care indicated that either one (1) or two (2) staff could assist Resident "Q" with transfers, rather than two (2) staff assisting with transfers, per the 10/13/2014 MDS assessment referenced above. Additionally, during a 10/22/2014, 10:58 a.m. interview, Physical Therapist (PT) "HH" stated Resident "Q" had received therapy since 10/07/2014 (as indicated in the 10/13/2014 MDS referenced above which identified the resident's receipt of Skilled Physical Therapy). PT "HH" stated she assessed Resident "Q" upon admission as totally dependent for transfers and as requiring the assistance of two (2) staff persons, and a Hoyer lift, for transfer of the resident. PT "HH" stated facility staff had been instructed to use a Hoyer lift for the transfer of Resident "Q" since his facility admission. However, even though Resident "Q"'s 10/13/2014 MDS referenced above identified the resident's receipt of Skilled Physical Therapy at the time of assessment, and even though the Physical Therapist had both assessed the resident from the time of facility admission to require the use of a mechanical lift for safe transfers and had informed facility staff of the required need for mechanical lift transfer, further review of Resident "Q"'s 10/17/2014 comprehensive Care Plan for Falls and comprehensive Care Plan for ADL care referenced above revealed no Care Plan reference to the need for staff to utilize a mechanical lift during transfer of the resident. Further record review for Resident "Q" revealed a 10/21/2014, 11:15 a.m. Nurse's Notes entry by Licensed Practical Nurse (LPN) "AA" which documented a 10/20/2014 call from Resident "Q"'s responsible party asking about a fall of which LPN "AA" was unaware. LPN "AA" questioned Resident "Q" who stated that a staff member had dropped him during transfer earlier in the morning of 10/20/2014. LPN "AA" documented that Resident "Q" complained of right leg pain and right leg swelling was noted. LPN "AA" documented an X-ray of Resident "Q"'s right leg revealed a right femur fracture, and an order was obtained for hospital transfer. Resident "Q"'s 10/20/2014 hospital History and Physical noted a femur fracture on the right that was documented to likely be secondary to a fall, and a hospital X-ray report documented an angulated comminuted distal right femoral fracture. A facility Interdisciplinary Post Fall Review form documented that Resident "Q" had fallen on 10/20/2014 during transfer by only one (1) person, rather than two (2) persons as required. In a written statement provided by Resident Care Specialist (RCS) "DD" as part of the facility's investigation, RCS "DD" indicated she was the RCS who transferred Resident "Q" on 10/20/14 when he fell . RCS "DD" further indicated that she transferred Resident "Q" herself (rather than utilizing a mechanical lift), and documented that it was only after the fall that she called for the assistance of a second co-worker to assist with lifting the resident from the floor. During an interview conducted on 10/22/2014 at 1:25 p.m., MDS Registered Nurse (RN) "II" was questioned about Resident "Q"'s Care Plan and the process of Care Plan development. MDS RN "II" acknowledged that the resident's Care Plan should include the number of staff needed for safe transfer. She stated that when resident comprehensive Care Plans were developed, she did not include things like the type of equipment needed for transfers on the resident's Care Plan. She further stated that it would be up to the nurses on the units to include the use of equipment like mechanical lifts on resident Care Plans. However, even though Unit Manager "CC" stated during a 10/22/2014, 11:21 a.m. interview that PT "HH" had told her the day after Resident "Q"'s admission to the facility that the resident required transfer using a Hoyer lift, Unit Manager "CC" stated during a subsequent interview on 10/23/14 at 10:15 a.m. that she did not know she was to include this information on the resident's Care Plan. Cross refer to F323 for more information regarding Resident "Q".