Every finding on record at Signature Healthcare of Hartford Rehab & Wellness

Based on observation, interview, record review, and review of facility policies, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident, to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two of 22 sampled Resident (R) 83 and R59. The findings include: 1.Review of facility policy, Comprehensive Care Plans', reviewed on 01/31/2025, revealed the facility would develop and implement a comprehensive person- centered care plan for each resident that included measurable objectives, the time frames to meet a residents’ medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Continued review revealed the licensed nurse and or the interdisciplinary team (IDT) would develop and maintain a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. Each resident's comprehensive care plan was designed to incorporate identified problem areas and incorporate risk factors associated with identified problems. The comprehensive care plan would be person-centered for each resident. Review of facility policy Psychotropic Medications Policy, dated 05/07/2024, revealed psychotropic medications would be used appropriately for residents with mental illness and or related disorders. Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs. It was important for the interdisciplinary team (IDT) to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility supported the goal of determining the underlying cause of residents having difficulty sleeping, so the appropriate treatment of environmental or medical interventions can be utilized prior to psychotropic medication use. Review of Resident Face Sheet revealed the facility admitted Resident 83 (R83) to the facility on [DATE] with diagnoses that included multiple sclerosis, unspecified dementia, mild, with other behavioral disturbance, insomnia, and psychoactive substance abuse, uncomplicated. Review of the admission Minimum Data Set with an assessment reference date (ARD) of 05/29/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating R83 was cognitively intact. Review of MDS, section E, Behavior, revealed R83 had not exhibited any behaviors. Review of physician order dated 05/27/2025, revealed R83 admitted to the facility with an order Seroquel (an antipsychotic) 100 milligrams (mg) daily at bedtime. The indication (diagnosis) for the medication was insomnia and dementia with mood disorder. Review of physician order dated 05/30/2025, revealed an order that read, 'Target Behavior: 'restlessness, inability to concentrate, impulsiveness, and lack of interest. Documentation directions read, at the end of each shift, mark frequency-how often behavior occurred, and intensity-how resident responded to redirection. Intensity code: 0=did not occur, 1=easily altered; 2=difficult to redirect. Review of R83's Comprehensive Care Plan (CCP), dated 05/27/2025, revealed the care plan did not include a focus problem for any type of behavior monitoring as indicated by the physician's order. Additionally, there was no evidence that a care plan had been developed for R83's diagnosis of insomnia. Review of CCP focus problem, Health Related Complications, dated 05/27/2025, revealed Patient was at risk for substance abuse due to substance use disorder. Interventions dated 05/27/2025 included offer behavioral health services as indicated for substance use disorder, be alert for bizarre behaviors with visiting friends and family members. Review of Psych Services Consent to Treat, not signed by R83 or his representative, revealed, R83 declined services on 07/03/2025. During an interview with the Minimum Data Set (MDS) nurse and the Regional Clinical Reimbursement Specialist (CRS) on 07/03/2025 at 3:31 PM, the MDS nurse stated she had been the MDS nurse since February and was still in training. The MDS nurse stated, the purpose of the care plan was to plan care for the resident to guide staff. She stated it was important for the care plan to be accurate so that staff know what care a resident needed. The MDS nurse stated R83 did not have a behavior care plan because he did not have behaviors. She stated that the Seroquel was for insomnia. During an interview with the Assistant Director of Nursing (ADON) on 07/03/2025 at 3:58 PM, she stated R83 really doesn't have any behaviors. She stated he had a diagnosis of insomnia, dementia with mood disorder, and substance abuse. She stated she would not expect R83 to have a behavior care plan if he did not have behaviors. During an interview with the Director of Nursing on 07/03/2025 at 4:07 PM, she stated she expected care plans to reflect the needs of the residents. She stated R83 should have had a care plan for insomnia. The DON stated that if behavior monitoring was being done on a resident, then the resident should have a behavior care plan. The DON stated that nonpharmacological interventions vary and should be specific to the residents. During an interview 07/03/2025 with R83 at 4:56 PM, he stated he was offered psych services today, just a few minutes ago. He stated he had not been provided with psych services previously. R83 stated he had seen a therapist in another county last year, and when he requested something to help him sleep, Seroquel was prescribed. He stated he had been taking the medication for about a year. During an interview with the Administrator on 07/03/2025 at 5:01 PM, he stated he expected the Pharmacy Consult to follow guidelines and policies when doing the monthly medication reviews. He stated if the Nurse Practitioner referred a resident for a psychiatric consult, that information would be communicated to the Social Services Director, who would reach out to the provider. He stated he was not sure if R 83 had been offered or refused psych services since admission to the facility. 2. Review of the facility's policy titled, Falls, last revised on 01/31/2025, revealed care plan goals and interventions would be revised as applicable, and a comprehensive care plan would be implemented with interventions specific to each resident to attempt to reduce the risk of avoidable falls. Review of R59' Face Sheet revealed the facility admitted the resident on 05/26/2022 with diagnoses that included unspecified displaced fracture of surgical neck of left humerus, subsequent encounter for fracture with routine healing, and chronic obstructive pulmonary disease. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/202 revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating R59 is cognitively intact. Review of a Progress Note dated 06/04/2025 at 8:38 AM revealed R59 experienced a fall during a self-transfer to the recliner when the recliner moved causing R59 to fall without injury. Review of the Fall Event report dated 06/04/2025 at 8:59 AM revealed the Interdisciplinary Team (IDT) discussed the root cause of the fall and determined placing dycem under the legs of the recliner would address the root cause of the recliner sliding when weight was applied during a transfer. Review of the care plan in the category Falls identified an intervention with an approach start date of 06/04/2025 that stated dycem to legs under recliner. Observation on 06/30/2025 at 12:36 PM, 06/30/2025 at 4:15 PM, and 07/03/2025 at 5:02 PM, revealed there was no dycem was present under the legs of the recliner. In an interview with Certified Nursing Assistant (CNA) 4 (CNA4) on 07/03/2025 at 5:01 PM, CNA4 stated she was assigned to R56 on 07/03/2025. CNA4 stated she used the CNA paper as a guide to care. Upon viewing the CNA paper care guide, it was dated 05/27/2025 with no update regarding dycem related to the fall intervention placed for R59 on 06/04/2025. In an interview with Housekeeper (HK) 13 (HK13) on 07/03/2025 at 5:07 PM, HK13 stated she cleaned R59's room today but didn't recall seeing the dycem under R59's recliner. She added that she cleans on several of the halls and can't recall if she has seen the dycem in R59's room or not but knows what dycem was. In an interview with the Staff Scheduler / Ambassador (SS/A) on 07/03/25 at 5:29 PM, the SS/A stated she has been the Ambassador for R59 since around November [2024]. She stated she knew what dycem was and it normally sets under the metal frame of the recliner. The SS/A stated she doesn't know why it wasn't there. In an interview with the Director of Nursing (DON) on 07/03/2025 at 5:19 PM, the DON stated when a fall occurs, staff create an event in the electronic medical record (EMR) then call her or the on-call staff to notify of the fall and the immediate intervention. The DON stated events were reviewed as part of their clinical meetings and following the meeting, one staff will go and ensure the intervention is in place. The DON added that Ambassador Rounds were done daily to ensure interventions stay in place. She stated the CNA Care guide was updated daily and printed a couple of times a week then taken to the respective nursing desk to be placed in the binder but, added that CNAs can also see the plan of care in the EMR. She stated the interventions were in place to ensure the safety of the resident. In an interview with the Administrator on 07/03/2025 at 5:12 PM, he stated that if the IDT reviews an event and determines an intervention based on the root cause and reviews the intervention in place and may add to or change the intervention to ensure the resident was safe. He stated an intervention should be put in place, given a fair amount of time to place the intervention. He stated that from 06/04/2025 to 07/03/2025 would be a fair amount of time to place dycem under the resident's recliner. The Administrator further stated the IDT keeps the CNA care guide up to date and no one person was responsible to change out the updated versions. He stated the CNA could utilize the EMR to view the residents one at a time but, the care guide allowed more than one resident's information for ease of access.

Based on interview, record review, and review of facility policy, the facility failed to ensure that each resident was free from chemical restraints imposed for purposes of discipline or convenience and that were not required to treat the resident's medical symptoms. Additionally, the facility failed to ensure that residents who use psychotropic drugs have behavior monitoring, non-pharmacological, and behavioral interventions for one of three sampled residents, Resident (R) 83.The findings include: Review of the facility's policy titled, Psychotropic Medications Policy, dated 05/07/2024, revealed psychotropic medications would be used appropriately for residents with mental illness and or related disorders. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: anti-psychotics, antidepressants, antianxiety, and hypnotics. Continued review revealed the facility would make every effort to comply with state and federal regulations related to the use of psychotropic medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risk, and/or benefits. Each resident's entire drug medication regimen is managed and monitored to promote or maintain the resident's highest practical mental, physical and psychosocial well-being. As part of the residents' medication management, it is important for the interdisciplinary team to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility supports the goal of determining the underlying cause of residents having difficulty sleeping, so the appropriate treatment of environmental or medical interventions can be utilized prior to psychotropic medication use. Review of R83's Resident Face Sheet revealed the facility admitted the resident on 05/27/2025 with diagnoses that included multiple sclerosis, unspecified dementia, mild, with other behavioral disturbance, insomnia, and psychoactive substance abuse, uncomplicated.Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating R83 was cognitively intact. Continued review of the MDS assessment revealed R83 had not exhibited any behaviors and active diagnosis included, non-Alzheimer's Dementia, and no psychiatric or mood disorders were documented on the admission MDS. Additional review of the MDS assessment revealed R83 received antipsychotic medication with an indication noted. Further review revealed that question N2001, drug regimen review, was not answered and was left blank.Review of the Hospital Discharge summary dated [DATE] revealed R83 discharge diagnoses included self-care deficit, multiple sclerosis, decubitus ulcer of sacrum stage 3, mild dementia with mood disturbance, history of drug abuse and chronic pain.Review of Event Report, Pharmacy Recommendation, dated 05/29/2025, revealed the pharmacy consultant completed a medication regimen review but gave no recommendations related to psychotropic medications and or diagnosis.Review of Event Report, Pharmacy Recommendations dated 06/16/2025, revealed the Medication Regimen Review (MRR) was completed and no recommendations were made.Review of physician order dated 05/27/2025, revealed R83 admitted to the facility with an order Seroquel (an antipsychotic) 100 milligrams (mg) daily at bedtime. The indication (diagnosis) for the medication was insomnia and dementia with mood disorder.Review of physician order dated 05/30/2025, revealed an order that read, 'Target Behavior: restlessness, inability to concentrate, impulsiveness, and lack of interest. Documentation directions read, at the end of each shift mark frequency-how often behavior occurred and intensity-how resident responded to redirection. Intensity code: 0=did not occur, 1=easily altered; 2= difficult to redirect.In an interview with the Pharmacy Consultant on 07/03/2025 at 10:36 AM, she stated she does medication reviews on admission and monthly. She stated insomnia was not an adequate diagnosis for the use of Seroquel. She stated R83 had a history of drug abuse which can cause mental and psychological issues. She stated Seroquel was a mood stabilizer and could be beneficial. She stated when reading the admission note that the NP provided, she saw a diagnosis of neurocognitive disorder and did not address the insomnia diagnosis listed as the indication for use. She further stated she does not typically ask for a dose reduction on psychotropic medications until the residents have settled in at the facility.In an interview with the interim Nurse Practitioner on 07/03/2025 at 11:03 AM, she stated she was just filling in and was not the routine provider for the facility. The NP stated using Seroquel for a diagnosis of insomnia would be dependent on the resident. She stated she gave no new diagnosis to R83, and she read he had a diagnosis of neurocognitive disorder in the hospital records. She stated she would expect behavior monitoring and care plan to be in place for a resident receiving psychotropic, specifically antipsychotic medications. In an interview with the Minimum Data Set (MDS) nurse and the Regional Clinical Reimbursement Specialist (CRS) on 07/03/2025 at 3:31 PM, the MDS nurse stated she had been the MDS nurse since February and was still in training. She stated Seroquel was an antipsychotic and was typically given for bipolar disorder, schizophrenia or mood disorder. The MDS nurse stated psychoactive substance abuse would be an indication for an antipsychotic medication. She stated she coded an indication because insomnia and dementia were listed in the physician's order.In an interview with the Assistant Director of Nursing (ADON) on 07/03/2025 at 3:58 PM, she stated Seroquel could be given for insomnia as an off label use. She stated R83 admitted to the facility on the medication, and she would have expected the pharmacy consultant to have noted any discrepancies or errors. She further stated it was the responsibility of the pharmacy consult to notify the provider. She stated she was aware the NP referred R83 for psych consult and that he was offered services and had refused. In an interview with the Director of Nursing on 07/03/2025 at 4:07 PM, she stated new admissions were reviewed in clinical meetings to ensure orders and diagnosis were in place. She stated R83 had mood disorder and that was an indication for Seroquel and was listed in the order. On 07/03/2025 at 4:45 PM the Assistant Director of Nursing brought a declination of psych services that was dated 07/03/2025.In an interview with R83 at on 07/03/2025 at 4:56 PM, he stated he was offered psych services today, just a few minutes ago and not prior to this date. R83 stated he had seen a therapist in another county last year and when he requested something to help him sleep, Seroquel was what she gave him. He stated he had been receiving the medication for about a year.In an interview with the Administrator on 07/03/2025 at 5:01 PM, he stated he expected the Pharmacy Consult to follow guidelines and policies when doing the monthly medication reviews. He stated if the Nurse Practitioner referred a resident for a psychiatric consult that information would be communicated to the Social Services Director who would reach out to the provider. He stated he was not sure if R83 had been offered or refused psych services since admission to the facility.

Based on interview, record review, and review of facility policy, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug without an adequate indication for its use. This affected one of three of 22 sampled residents Resident (R) 83. Review of record revealed R 83 was receiving an antipsychotic medication (seroquel) for an indication of insomnia and dementia. Review of the facility's policy titled, Psychotropic Medications Policy, dated 05/07/2024, revealed psychotropic medications would be used appropriately for residents with 's mental illness and or related disorders. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Continued review revealed the facility would make every effort to comply with state and federal regulations related to the use of psychotropic medications in the long-term care facility, to include regular review for continued need, appropriate dosage, side effects, including psychosocial, and risk and or benefits. Residents who use psychotropic drugs received gradual dose reductions and behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs. Each resident's entire drug medication regimen is managed and monitored to promote or maintain the resident's highest practical mental, physical, and psychosocial well-being. As part of the resident's medication management, it was important for the interdisciplinary team (IDT) to implement non-pharmacological approaches designed to meet the individual needs of each resident. The facility supported the goal of determining the underlying cause of residents having difficulty sleeping, so the appropriate treatment of environmental or medical interventions can be utilized prior to psychotropic medication use. Review of R83's Resident Face Sheet revealed the facility admitted the resident on 05/27/2025 with diagnoses that included multiple sclerosis, unspecified dementia, mild, with other behavioral disturbance, insomnia, and psychoactive substance abuse, uncomplicated.Review of the admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/29/2025, revealed a Brief Interview for Mental Status (BIMS) score of 14 of 15, indicating R83 was cognitively intact. Review of MDS, section E, Behavior, revealed R83 had not exhibited any behaviors.Review of MDS assessment revealed R83 was coded as having non-Alzheimer's Dementia, and no psychiatric or mood disorders were documented on the MDS. Further review revealed R83 received an antipsychotic medication with an indication noted. Continued review revealed that question N2001, drug regimen review, was not answered and was left blank.Review of physician order dated 05/27/2025, revealed R83 admitted to the facility with an order Seroquel (an antipsychotic) 100 milligrams (mg) daily at bedtime. The indication (diagnosis) for the medication was insomnia and dementia with mood disorder.Review of physician order dated 05/30/2025, revealed an order that read, 'Target Behavior: restlessness, inability to concentrate, impulsiveness, and lack of interest. Documentation directions read, at the end of each shift, mark frequency-how often behavior occurred, and intensity-how the resident responded to redirection. Intensity code: 0=did not occur, 1=easily altered; 2=difficult to redirect.Review of Event Report, Pharmacy Recommendation', dated 05/29/2025, revealed the pharmacy consultant completed a medication regimen review but gave no recommendations related to psychotropic medications and or diagnosis.Review of Event Report, Pharmacy Recommendations dated 06/16/2025, revealed the MRR was completed, and no recommendations were made Interview with the Pharmacy Consultant on 07/03/2025 at 10:36 AM, she stated she does medication reviews on admission and monthly. She stated insomnia was not an adequate diagnosis for the use of Seroquel. She stated R83 had a history of drug abuse, which can cause mental and psychological issues. She stated Seroquel was a mood stabilizer and could be beneficial. She stated that when reading the admission note that the Nurse Practitioner (NP) provided, she saw a diagnosis of neurocognitive disorder and did not address the insomnia diagnosis listed as the indication for use. She further stated she does not typically ask for a dose reduction on psychotropic medications until the residents have settled in at the facility.Interview with the interim Nurse Practitioner on 07/03/2025 at 11:03 AM, she stated she was just filling in and was not the routine provider for the facility. The NP stated that using Seroquel for a diagnosis of insomnia would be dependent on the resident. She stated she gave no new diagnosis to R 83, and she read he had a diagnosis of neurocognitive disorder in the hospital records. She stated she would expect behavior monitoring and a care plan to be in place for a resident receiving psychotropic medications, specifically antipsychotic medications. Interview with the Minimum Data Set (MDS) nurse and the Regional Clinical Reimbursement Specialist (CRS) on 07/03/2025 at 3:31 PM, the MDS nurse stated she had been the MDS nurse since February and was still in training. She stated Seroquel was an antipsychotic and was typically given for bipolar disorder, schizophrenia, or mood disorder. She stated that the R83 had a diagnosis of psychoactive substance abuse, and that would be an indication for the use of an antipsychotic. The MDS nurse stated she could not speak to whether Seroquel was an adequate diagnosis for insomnia. She stated R83 was receiving the antipsychotic medication for insomnia, as that was what was on the order.Interview with the Assistant Director of Nursing (ADON) on 07/03/2025 at 3:58 PM, she stated Seroquel could be given for insomnia as an off-label use, and it was not an unnecessary medication, as he took it for insomnia. She stated R83 was admitted to the facility on medication and has a diagnosis of dementia with mood disorder and substance abuse. She stated R83 did not have any behaviors that she was aware of. She stated she was aware that the NP had referred R83 for psych services and that he was offered services and had refused.Interview with the Director of Nursing on 07/03/2025 at 4:07 PM, she stated new admissions were reviewed in clinical meetings to ensure orders and diagnoses care plans were in place. She stated R83 had mood disorder and insomnia, and those were indications for Seroquel. She stated R83 did not have behaviors Interview with the Administrator on 07/03/2025 at 5:01 PM, he stated he expected staff to follow policies and procedures of the facility. He stated if the Nurse Practitioner referred a resident for a psychiatric consult that information would be communicated to the Social Services Director, who would reach out to the provider.

Based on interview, record review and facility policy review, it was determined the facility failed to revise the Comprehensive Care Plan for one (1) of three (3) sampled residents (Resident #1). Resident #1 had a significant change in condition on 02/28/19 and was assessed to require extensive assistance of two (2) staff for bed mobility, transfers, walking in room and in corridor. In addition, the resident was unsteady with balance during transitions and walking; and required staff assistance to stabilize balance when moving from seated to standing position, and walking (with assistive device if used), turning around and facing opposite direction while walking. The facility also assessed the resident would not call for assistance to transfer and ambulate. However, the facility failed to revise the care plan to address the resident's assessed need for extensive assistance of two staff for transfers and ambulation, assistance of staff for stabilization of balance during transfers and ambulation, and the resident's continuing to get up without assistance. Resident #1 fell on [DATE], 03/07/19, and 03/08/19 when he/she attempted to ambulate without assistance. The resident sustained [REDACTED]. The findings include: Review of the facility policy titled, Comprehensive Care Plans dated 07/19/18 revealed a person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, mental and psychological needs is developed for each resident. Each resident's Comprehensive Care Plan is designed to incorporate identified problem areas, and incorporate risk factors associated with identified problems. The Minimum Data Set (MDS) will be used to assess the resident's clinical condition, cognitive and functional status and use of services. Care Plans are ongoing and revised as information about the resident and the residents condition change and the nurse and Interdisciplinary Team (IDT) is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes in the resident's status,: when there has been a significant change in the resident's condition, change in goals, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly. Record review revealed the facility admitted Resident #1 on 08/10/18 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 10/28/18 and the Significant Change MDS assessment dated [DATE] revealed the facility assessed Resident #1's cognition was moderately impaired with a Brief Interview of Mental Status (BIMS) score of ten (10 and nine (9) respectively, which indicated the resident was interviewable. Further review of the MDS assessments revealed the facility assessed the resident declined from requiring extensive assist of one (1) person to two (2) persons for bed mobility, transfers, and ambulation in room and corridor. In addition, the facility assessed the resident was unsteady during transitions and walking, and declined from being able to stabilize without staff assistance to needing staff assistance to stabilize when moving from seated to standing position, walking (with assistive device if used), turning around and facing opposite direction while walking, moving on and off toilet, and transfer from bed and chair or wheelchair {w/c}). However, review of the Comprehensive Care Plan for Activities of Daily Living (ADL) Deficit and for Risk for Falls initiated on 01/23/19 revealed no interventions to address the resident's decline in these areas and increased need of staff's assistance for transfers and ambulation. Review of the facility fall investigations, revealed Resident #1 had unwitnessed falls on 02/27/19 at 3:00 AM which caused a quarter sized bump to the back of the crown of head with a pin size abrasion and a silver dollar sized skin tear to the right upper forearm; on 03/07/19 at 5:15 AM which caused an abrasion to base of scalp, posterior scalp hematoma, abrasion to the upper back measuring three (3) by five (5) centimeters (cm.), abrasion to the mid back measuring one (1) cm. by two and half (2.5) cm. and bruising to the right buttocks; and on 03/08/19 at 8:30 PM which caused a bleeding laceration to the right cheek requiring ice pack and pressure to control the bleeding and transfer to the emergency room for eight sutures. Further review of the investigations revealed in each instance the resident was ambulating without staff's assistance and knowledge. Post fall interventions initiated were bed in low position, assistive device (walker), environment safe, encourage rest periods, proper lighting, re-educate to use call light system when needing to ambulate anywhere or for other assist, toilet resident between the hours of 5:00 PM and 5:30 PM, fall mat next to bed, and appropriate foot wear. However, further review of the Comprehensive Care Plan for Activities of Daily Living (ADL) Deficit and for Risk for Falls initiated on 01/23/19 revealed there was no intervention to address the resident's increased need of supervision or the resident continuing to get up without assistance until the intervention for every fifteen minute checks after the 03/08/19 fall. In addition, review of the (MONTH) 2019 Certified Nursing Assistant (CNA) Care Plan revealed Resident #1 was one (1) assist with walker even though the facility had assessed the resident required extensive assist of two (2) staff for ambulation. Interview with MDS Coordinator on 03/25/19 at 9:50 AM revealed the residents are assessed, and interviews are conducted with family and staff to determine the resident's status related to completing the MDS assessments. The MDS Coordinator stated the clinical team updated the care plan daily in morning meeting and she was part of the clinical team. Interview with Staffing Development Coordinator (SDC) on 04/24//19 at 8:50 AM revealed the staff go over fall interventions daily in meetings, and new interventions are put in place after each fall, depending on the root cause of the fall. Interview with the Director of Nursing (DON) on 04/25/19 at 12:38 PM revealed Resident #1's Activities of Daily Living (ADL'S) fluctuate and that was why two assist was not on Care Plan. The DON stated she expected nursing staff and MDS staff to update the care plan as changes in the resident occur. Interview with the DON on 04/25/19 at 12:46 PM revealed she expected the charge nurse to come up with interventions to prevent falls. Interview with the Administrator on 04/25/19 at 9:00 AM revealed he did not know what else the facility staff could have done to keep the resident safe.

Based on interview, record review, and facility policy review, it was determined the facility failed to provide adequate supervision and assistive devices to prevent accidents for one (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 required extensive assistance of two (2) staff for bed mobility, transfers, walking in room and in corridor, was unsteady with balance during transitions and walking, and required staff assistance to stabilize balance when moving from seated to standing position, and walking (with assistive device if used), turning around and facing opposite direction while walking. In addition. the facility assessed the resident would not call for assistance to transfer and ambulate. However, the facility failed to provide increased supervision or assistive devices to prevent accidents. Resident #1 fell on [DATE], 03/07/19, and 03/08/19 when he/she attempted to ambulate without assistance. The resident sustained [REDACTED]. The findings include: Review of the facility policy titled, Falls, last revised 08/16/18 revealed all residents will have a Comprehensive fall risk assessment on admission/readmission, quarterly, annually and with significant change of condition. If a fall occurs, assess resident to include neurological checks, pain, range of motion, skin, joints, extremities, and vital signs. Assess the resident for seventy-two (72) hours. Interdisciplinary Team (IDT) to determine root cause of fall, if possible. Review of a facility policy titled Safety and Supervision of Resident, dated 05/31/18 revealed staff shall make routine checks to help maintain resident safety and well-being. Resident safety, supervision and assistance, to prevent accidents are facility-wide priorities. Record review revealed the facility admitted Resident #1 on 08/10/18 with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment, dated 10/28/18 revealed the facility assessed Resident #1's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of nine (9) which indicated the resident was interviewable, Further review of the MDS assessment revealed the facility assessed the resident now required extensive assist of one person for bed mobility, transfers, dressing, toilet use, and was totally dependent on one (1) person for bathing, frequently incontinent of urine and always continent of bowel. In addition, the facility assessed the resident was not steady but, able to stabilize without staff assistance for moving from seated to standing position, walking (with assistive device if used), turning around and facing opposite direction while walking, moving on and off toilet, and transfer from bed and chair or wheelchair {w/c}). Review of a Falls Risk Evaluation for 02/18/19 revealed Resident #1 had a score of twenty-two (22), with a score of ten (10) or greater indicating a high risk for falls. Review of a Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of ten (10) which indicated the resident was interviewable. Further review of the MDS assessment revealed the resident had declined in Activities of Daily Living, as he/she now required extensive assist of two (2) staff (instead of one) for transfers, bed mobility, dressing, bathing toilet use, walking in room and corridor; and, was occasionally incontinent of bowel and bladder. In addition, the resident was assessed as unsteady with balance during transitions and walking, and had declined from being able to stabilize self to being able to stabilize with staff assistance for moving from seated to standing position, walking (with assistive device if used), turning around and facing opposite direction while walking, and surface to surface transfer (transfer between bed and chair or w/c. Review of a Comprehensive Care Plan for Activities of Daily Living (ADL) Deficit requiring assistance in transferring, and ambulation initiated 01/23/19 revealed interventions to provide and maintain any equipment used for transfer and ambulation, use of walker, and staff to assist with transfer and ambulation. Further review revealed Resident #1 was also care planned for risk for falls related to injury from previous fall, initiated on 01/23/19 with interventions dated 02/18/19 to provide call light in reach, provide adequate lighting, keep area free of clutter, monitor for appropriate foot wear, provide/monitor use of adaptive devices, and give cues as needed:walker. However, further review revealed there were no interventions to address Resident #1's increased need of assistance (now two instead of one staff) for transfers, bed mobility, toilet use, and walking in room and corridor; and, needing staff assistance to stabilize balance when moving from seated to standing position, walking (with assistive device if used), turning around and facing opposite direction while walking, and surface to surface transfer (transfer between bed and chair or wheelchair {w/c}). Review of the facility fall investigation dated 02/27/19 revealed Resident #1 had an unwitnessed fall on 02/27/19 at 3:00 AM with minor injury of a quarter sized bump to the back of the crown of head with a pin size abrasion and a silver dollar sized skin tear to the right upper forearm. The resident was ambulating without assistance to the bathroom and was found on the floor facing the hallway in front of the bath room. The resident stated he/she was trying to get back in bed, lost footing and fell . Contributing factors to fall were listed as history of falls, lower extremity weakness, forgot to ask for help, poor balance, impaired balance during transitions, poor safety awareness, unsteady gait. Post fall interventions were for bed in low position, assistive device (walker), monitor pain and pain relief, environment safe, encourage rest periods, and proper lighting. Other post fall interventions listed were re-educate to use call light system when needing to ambulate anywhere or for other assist. The resident stated he/she forgot and will try, in response to this post intervention. However, there was no intervention to address the resident's need of increased supervision or assistive devices due to the resident now needing extensive assistance of two staff for ambulation, decline in ability to balance self, and not asking for assistance prior to standing, transfer, or ambulating. Review of a facility fall investigation dated 03/07/19 revealed Resident #1 had an unwitnessed fall on 03/07/19 at 5:15 PM while coming out of the bath room with walker unassisted by staff. The resident was found on the floor with back up against the wall close to the bathroom. Contributing factors to fall were listed as history of falls, recent cognitive decline, forgot to ask for help, noncompliant with safety interventions, poor mobility, dizziness, confused, anxiety, poor safety awareness, narcotic [MEDICATION NAME], unsteady gait. This fall resulted in an abrasion to base of scalp, posterior scalp hematoma, abrasion to the upper back measuring three (3) by five (5) centimeters (cm.), abrasion to the mid back measuring one (1) cm. by two and half (2.5) cm. and bruising to the right buttocks. Post fall interventions were to toilet resident between the hours of 5:00 PM and 5:30 PM, and active and passive range of motion. The summary of findings and conclusion of this fall revealed the resident took self to bathroom without assist, lost balance, and fell . The resident is on Hospice and has had increased weakness. However, there was still no intervention to address the resident's need of increased supervision or assistive devices due to the resident now needing extensive assistance of two staff for ambulation, decline in ability to balance self, and not asking for assistance prior to standing, transfer, or ambulating. Further review of the Fall Risk Care Plan revealed the care plan was revised on 03/07/19 with an intervention for staff to assist resident to bathroom between 5:00 PM and 5:30 PM, Review of the facility fall investigation dated 03/08/19 revealed Resident #1 had an unwitnessed fall on 03/08/19 at 8:30 PM. This fall resulted in a bleeding laceration to the right cheek requiring ice pack and pressure to control the bleeding and transfer to the emergency room for eight sutures. Contributing factors to the fall were history of falls, forgot to ask for help, confused, and frequent pain medications given as ordered for pain control. Post fall interventions were a fall mat next to bed, bed in low position, every fifteen minute monitoring, appropriate foot wear, education, monitor pain and pain relief. Further review of the Fall Risk Care Plan revealed on 03/08/19 an intervention was added for fall mat to left side of bed for safety. However, there was still no ongoing intervention to address the resident's need of increased supervision or assistive devices due to the resident now needing extensive assistance of two staff for ambulation, decline in ability to balance self, and not asking for assistance prior to standing, transfer, or ambulating. Review of the (MONTH) 2019 Certified Nursing Assistant (CNA) Care Plan revealed Resident #1 was one (1) assist with walker even though the facility had assessed the resident required extensive assist of two (2) staff for ambulation, toilet between 5:00 PM and 5:30 PM, and fall mat to left side of bed. Interview with CNA #4 on 04/24/19 at 3:34 PM revealed Resident #1 would try to get up by self and was getting weaker. Interview with CNA #1 on 04/23/19 at 4:20 PM revealed on 03/08/19, he had just been in Resident # 1's room about two minutes prior passing snacks. CNA #1 revealed before he left the room, Resident #1 was sitting on the side of the bed, feet on the floor, had on non- kid socks, and shoes close to the bed. CNA #1 stated after leaving the room, he heard a noise, went to the resident's room, and found the resident lying on right side, over bed table had moved from where it had been, and the resident was bleeding from the face and near right eye. CNA #1 stated he called for the nurse and she came and assessed the resident. CNA #1 stated he thought the resident tried to get up and fell as his/her feet were crossed over each other when he/she was sitting on the side of the bed. CNA #1 further stated the resident had the call light in reach but, the resident usually will not use the call light and the aides check on the resident every two (2) hours. Interview with Licensed Practical Nurse (LPN) #1 on 04/23/19 at 2:28 PM revealed CNA #1 called for her to come to Resident# 1's room on 03/08/19. LPN #1 stated when she entered the resident's room, the bedside table was close to the resident, overbed table was near heating/cooling unit, and bed was against wall and long ways. LPN #1 revealed the resident had been getting weaker, would try to get up without help, and had call, light but often would not use it for assistance. LPN #1 further stated she assessed the resident and the resident was bleeding from the face and had a scrape on the forehead. She stated CNA's checked on the resident every two (2) hours as the resident was incontinent and had not been in earlier months. Interview with LPN #1 on 04/24/19 at 1:58 PM revealed Resident #1 was ambulatory with walker, was getting weaker, and last time the resident came back from hospital in (MONTH) or February, the resident was not ambulatory, would try to walk but could not. LPN #1 stated staff would always answer the call light when the resident put the call light on. Interview with Registered Nurse (RN) #1 on 04/24/19 at 8:57 AM revealed she and LPN #1 were getting report on 03/08/19 when Resident #1 fell . RN #1 stated she and LPN #1 went to the room after a CNA called them and found the resident on the floor on his/her right side, non skid socks on, blood on the floor, over bed table was to the side and it looked as if the resident stood up and fell . Interview with Staffing Development Coordinator (SDC) on 04/24//19 at 8:50 AM revealed the staff go over fall interventions daily in meetings, and new interventions are put in place after each fall, depending on the root cause of the fall. Interview with the Medical Director on 04/24/19 at 3:25 PM revealed there is only so much a facility can do to prevent falls without restraining a resident. Interview with the DON on 04/25/19 at 12:46 PM revealed Resident #1's ADL's fluctuated, and she would expect the charge nurse to come up with interventions to prevent falls. The DON stated the facility policy was to increase supervision, sometimes like one-on-one but it was not considered for Resident #1. She revealed it depends on the resident and what was going on at the time of the fall. Interview with the Administrator on 04/25/19 at 9:00 AM revealed he did not know what else the facility staff could have done to keep the resident safe.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure it must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, for two (2) of twenty-two (22) sampled residents (Residents #72 and #88). Observations on 02/13/19 and 02/14/19 revealed a staff entered Resident #72's and #88's rooms without knocking on the door prior to entering. The findings include: Review of the facility policy titled, Resident Rights, dated 06/01/15 and last revised 08/16/18, revealed all residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self determination and communication with and access to persons and services inside and outside the facility. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to privacy and confidentiality. The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity. 1. Record review revealed the facility admitted Resident #72 on 01/15/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 01/22/19 revealed the Brief Interview of Mental Status (BIMS) score was coded at ninety-nine (99) which indicated the resident was unable to complete the interview. Observation on 02/13/19 at 9:25 AM revealed Registered Nurse (RN) #1 walked into Resident' #72's room to provide wound care without knocking on the door and asking permission to enter. This surveyor knocked on the door prior to entering. An attempt to interview Resident #72 on 02/14/19 at 1:56 PM was unsuccessful due to severe cognitive impairment. 2. Record review revealed the facility admitted Resident #88 on 01/16/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 01/23/19 revealed the BIMS was coded as ninety-nine (99) due to the resident being hardly/never understood. Observation on 02/14/19 at 1:58 PM revealed RN #1 walked into Resident #88's room to provide Gastrostomy tube care without knocking on the door. Further observation revealed the Certified Nurse Aide (CNA) behind the nurse tried to knock on the door but she had her hands full of linen. The nurse then turned around after entering the room, went back and knocked on the door. Interview with RN #1 on 02/14/19 at 2:18 PM revealed she was not aware she had not knocked on the residents' doors. She stated she usually knocked on the residents' doors before entering and was aware the residents had a right to privacy and the facility was their home. She further stated she was forgetful. Interview on 02/14/19 at 3:44 PM with the Director of Nursing (DON) revealed it was not proper for RN#1 to enter resident' rooms without knocking. She stated she expected all staff to knock on the door prior to going into the room and staff should be invited into the room by the resident, if able.

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to establish and maintain 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 for three (3) of twenty-two (22) sampled residents (Residents #72, #76 and #88). Observations revealed staff failed to establish a clean field prior to dressing changes;, and, to wash hands and change gloves when moving from dirty to clean area, and before contact with items in the room when providing treatments or dressing changes for Residents #76, #72 and #88. The findings include: Review of the facility policy titled, Infection Control' last revised (MONTH) (YEAR), revealed the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. The objectives of the infection control policies and practices are to prevent, detect, investigate, and control infections in the facility; and, maintain a safe sanitary, and comfortable environment for personnel, residents, visitors, and the general public. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission Based Precautions. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. Review of the Non-Sterile Dressing Change Competency dated 06/01/15 revealed preparation included assembling equipment and explaining the procedure to the resident, provide privacy, and ask if any pain. Steps include: 1. Wash and dry hands thoroughly 2. Position to expose area for treatment 3. Put on non-sterile gloves 4. Remove soiled dressing and discard in appropriate receptacle 5. Remove gloves and discard them. Wash and dry hands. 6. Establish a clean field, date dressing or label tape. 7. Put on non-sterile gloves 8 Cleanse wound per Physicians's orders. Assess Wound. 9. Remove gloves and discard. Wash and dry hands. 10. Put on non-sterile gloves. 11. Apply dressings and secure per physician's order. 12. Remove and discard gloves 13. Wash and dry hands thoroughly 1. Record review revealed the facility admitted Resident #72 on 01/15/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment, dated 01/22/19 revealed the Brief Interview of Mental Status (BIMS) score was coded at ninety-nine (99) which indicated the resident was not interviewable. Observation of Resident #72's pressure ulcer care to right heel, on 02/13/19 at 9:25 AM revealed a 3.3 centimeter (cm) by 4.0 cm unstagable pressure ulcer with eschar. Registered Nurse #1 placed a bath basin with the dressings inside on the resident's bed, instead of using a barrier on the overbed table at the resident's bed side to establish a clean field per facility policy. Interview with RN #1, on 02/14/19 at 9:15 AM revealed she used the bath basin to keep her supplies in and should have used the bedside table with a barrier instead of the resident's bed. She stated she was not sure what the facility's policy said. 2. Record review revealed the facility readmitted Resident #76 on 09/22/18 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 01/21/19, revealed the facility assessed Resident 76's cognition as moderately impaired with a BIMS score of ten (10) which indicated the resident was interviewable. Observation of skin assessment on 02/14/19 at 8:50 AM for Resident# 76 revealed the Director of Nursing (DON) washed her hands and donned Personal Protective Equipment (PPE) prior to going into the resident's room due to the resident being on contact precautions. The DON brought [MEDICATION NAME] cream (cream for Shingles treatment) into the room. The Certified Nurse Aide (CNA) helped turn the resident on his/her side and removed the resident's shirt. The DON then applied the [MEDICATION NAME] cream to the shingles which were over the entire left side of resident's back and down toward buttocks. The resident then complained about itching to the buttock and down upper thigh and the CNA stated she had been using a barrier cream on the buttocks. The DON then reached into the resident's bed side table with her soiled gloves, pulled out the barrier cream, applied the cream to her soiled glove, and then applied the cream to the resident's buttocks with the gloved hands she had used to place the [MEDICATION NAME] cream on the resident's shingles. She then put the resident's brief back on with the dirty gloves, straightened the bed covers on the resident, and moved the privacy curtain from around the resident's bed, still with the dirty gloves on that had touched the shingles. She removed her gloves, washed her hands and went out of the room. Interview with the DON on 02/14/19 at 9:15 AM, revealed she should not have reached into the resident's bed side table without removing the gloves and washing her hands. She stated she should not have touched the resident's personal property, curtain and supplies without removing her gloves and washing her hands. 3. Record review revealed the facility admitted Resident #88 on 01/16/19 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 01/23/19 revealed the BIMS was coded as ninety-nine (99) due to the resident being hardly/never understood which indicated the resident was not interviewable. Observation of Resident #88's gastrostomy-tube site dressing change on 02/14/19 at 9:58 AM revealed RN #1 gathered her supplies in a bath basin, washed her hands in the room, then picked up the basin with the supplies in it and placed it on the resident's bed without a barrier to establish a clean field. RN #1 did not open any of her supplies prior to starting procedure, and each time she needed a gauze pad, she had to reach into the basin, pick up the package, peel the sticker off the package, then open the package and get the gauze out of the package. She also picked up her new bottle of normal saline, opened it, and placed the cap on the bed, then handed the bottle to the CNA that was assisting her. Further observation revealed after the procedure was completed, she was tying up her trash bag she had placed on the resident's bed, and the CNA asked if she wanted her bottle of saline. RN #1 said yes, picked up the cap and replaced it and carried it out of the room. As she was leaving the room she removed her gloves, washed her hands, then picked up the soiled trash with her bare hands and left the room. Interview with RN #1 at 10:15 AM on 02/14/19 revealed she always used a basin for her supplies and brings it into the room for care. She stated the basin was clean since she removed it from the supply room prior to going into the room. She revealed she should have washed her hands between removing the soiled dressing and cleaning the area around the tube site. She stated she also should have put on gloves to carry the soiled trash out of the room and not put it on the resident's bed. Interview with Staff Development Coordinator/Infection Control Nurse on 02/14/19 at 9:59 AM regarding infection control policy and education regarding hand washing, dressing changes and the use of PPE with a Contact Isolation resident revealed employees are educated on hire, annually, and as needed. She stated Resident #76 has shingles and that was why the resident was on contact isolation and required the use of PPE. She further stated staff should follow facility policies and procedures as written. Interview with the DON on 02/14/19 at 3:38 PM revealed RN #1 should have used a barrier like a towel used under residents for dressing changes. She stated she was not sure why RN #1 placed the supplies in a bath basin and then placed the basin on the bed. She revealed she expected the nurses to use a barrier and open the supplies needed on to the barrier. She further stated all staff should follow the policy and procedures for wound care, isolation, and hand washing as written.

Based on interview, record review, and review of the facility Abuse, Neglect and Misappropriation of Property policy and procedures, it was determined the facility failed to implement the policy and procedures by removing an employee from resident care areas immediately when an allegation of physical abuse was reported for one (1) of three (3) sampled residents (Resident #1). In addition, facility staff failed to report the allegation immediately to the Administrator. On 09/19/18 at approximately 3:00 AM, Certified Nurse Aide (CNA) #2 reported CNA #1 grabbed and rolled over roughly Resident #1 while providing incontinent care. CNA #2 reported the allegation of abuse to the facility Charge Nurse, Registered Nurse (RN) #1 at approximately 3:30 AM; however, RN #1 failed to remove CNA #1 from resident care immediately per the facility's policy. In addition, Licensed Practical Nurse (LPN) #1 notified the Director of Nursing (DON) of the allegation on 09/19/18 at 5:00 AM (one and a half {1.5} hours later, instead of immediately per facility policy. The findings include: Review of the facility's policy and procedures titled, Abuse, Neglect, and Misappropriation of Property, not dated, revealed it is the facility's policy to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property and to ensure the allegations are investigated, and reported immediately to the facility Administrator, the State Survey Agency, and other appropriate State and local agencies in accordance with Federal and State law. If the suspected perpetrator is a Stakeholder, the charge nurse immediately will remove that Stakeholder from resident care areas and suspend him/her while the matter is investigated. Record review revealed the facility readmitted Resident #1 on 08/31/18 with [DIAGNOSES REDACTED]. Interview with CNA #2, on 10/04/18 at 3:14 PM, revealed she reported CNA #1 grabbed Resident #1 and pulled the resident towards her (CNA #1) after Resident #1 hit CNA #1 in the face. CNA #2 stated, it happened really quick, it was forceful and firm. CNA #2 further stated she reported the incident to the facility charge nurse, (RN #1) at approximately 3:30 AM and the charge nurse removed CNA #1 off West Hall to South Hall. Interview with CNA #1, on 10/04/18 at 2:00 PM, revealed RN #1 informed her it was alleged she was aggressive while providing care to Resident #1. CNA #1 stated, I was removed from West Hall and sent to work on North and South Hall. She stated the DON came in, and she had to write a statement, and was suspended for the allegation to be investigated. She stated she did not clock out until 5:46 AM. Interview with RN #1, on 10/04/18 at 3:20 PM, revealed she was the facility's charge nurse on 09/19/18 from 6:00 PM to 6:00 AM. RN #1 stated CNA #2 reported Resident #1 hit CNA #1 in the face during incontinent care and CNA #1 was rough while providing Resident #1's care afterward. RN #1 further revealed she removed CNA #1 from West hall and assigned her to South Hall but did not suspend CNA #1 immediately after the allegation of abuse was reported per facility policy. Interview with the DON, on 10/05/18 at 9:20 AM, revealed LPN #1 reported there was an allegation of abuse of Resident #1 on 09/19/18 at 5:00 AM (one and a half {1.5} hours after initial allegation) instead of immediately per the facility policy. The DON stated she arrived at the facility at approximately 5:15 AM and upon her arrival she had CNA #1 escorted to her office. She revealed she obtained CNA #1's statement, explained to her the suspension process, and had her sign the Stakeholder Suspension Form. She revealed she then walked her to the time clock, and out of the facility. She stated she expected the Charge Nurse, (RN #1), to have removed CNA #1 from resident care areas and notify her of the allegation of abuse; immediately per facility policy.

Based on interview, record review, and facility policy review it was determined the facility failed to ensure one (1) of three (3) sampled residents had the right to make choices related to when to go to bed (Resident #1). On 06/12/18, Certified Nurse Aide (CNA) #1 under the direction of Licensed Practical Nurse (LPN) #1 directed Resident #1 to go to bed multiple times even thought Resident #1 did not want to and refused to. Resident #1 became upset and started hollering out and making allegations against CNA #1. The findings include: Review of the facility's policy titled, Resident Rights, dated 06/30/17, revealed all residents have the right to be treated with respect and dignity. Further review revealed when providing care and services the stakeholders will respect the resident's individuality and value their input. Record review revealed the facility admitted Resident #1 on 09/26/17 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 06/14/18 revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated the resident was not interviewable. Interview with Resident #1 on 6/25/18 at 12:32 PM, revealed CNA #1 told him/her she needed to lay down. She stated around midnight one night, CNA #1 pulled his/her bed covers down and told him/her it was time for bed. Resident #1 stated he/she then pulled the covers back up and CNA #1 again pulled the bed covers down and told him/her it was time to lay down. Resident #1 revealed he/she again made the bed up and CNA #1 once again pulled the covers down and told him/her it was time to lay down. Resident #1 stated he/she told CNA #1 no again and then CNA #1 got mad and punched him/her in the chin and that is when he/she started yelling for help. Interview with CNA #1 on 6/25/18 at 2:06 PM, revealed he had been working at the facility for about three (3) months and less than a year ago he had worked at the facility for about a year. He stated LPN #1 asked him to redirect the resident back to his/her room and tell him/her the play was rescheduled so Resident #1 could be redirected back to his/her room due to the time of night it was and the resident was confused. He revealed LPN #1 told him that it was late and to try and get Resident #1 to go to bed. He stated he walked Resident #1 back to his/her room, pulled Resident #1's covers down on his/her bed for him/her, and encouraged him/her to lay down and get some rest. He revealed he attempted to encourage Resident #1 to lay down a few times and after the last time of attempting to get Resident #1 to lay down in bed, Resident #1 started hollering out about something and saying he/she was going to report him for hitting him/her like he did the last time when he supposedly hit him/her. CNA #1 stated he had never hit Resident #1 ever. CNA #1 further revealed when Resident #1 started hollering and accusing him of hitting him/her, he immediately stepped backwards out of the room and CNA #2 was right there. He stated LPN #1 also came immediately and he informed LPN #1 of what happened and they called the Director of Nursing (DON). He revealed the DON came to the facility and she took his statement and suspended him pending the investigation. Interview with CNA #2 on 6/25/18 at 5:07 PM, revealed she was on duty when the incident and allegation of abuse occurred related to Resident #1 and CNA #1. She stated both herself and LPN #1 heard some screaming coming from the area of Resident #1's room and when she approached the area it was coming from Resident #1's room. She revealed she asked CNA #1 what happened and he said Resident #1 started screaming at him and when she asked Resident #1 what happened he/she stated Resident #1 had hit him/her. She stated she immediately told CNA #1 to go back up to the lobby and wait. She revealed LPN #1 had come to the room and assessed Resident #1 and then asked Registered Nurse (RN) #1 to also check Resident #1 out. She stated RN #1 assessed Resident #1 and then called the DON to report the incident and allegation. She further stated she had been present when LPN #1 directed CNA #1 to get Resident #1 to bed because Resident #1 had been pacing a lot from the room to the lobby and back and forth. She stated Resident #1 had been pacing some, but was fine without any behaviors until CNA #1 tried to get Resident #1 to lay down. She further stated she knew that they are supposed to ensure the facility is a person centered environment and staff can't force residents to do things like go to bed when they do not want to. Interview with LPN #1 on 6/25/18 at 5:25 PM, revealed she was the charge nurse on duty on Resident #1's side on 06/12/18; and, herself, CNA #1, and CNA #2 were working together. She stated she told CNA #1 to try and get Resident #1 to see if he/she would lay down since it was late and she told CNA #1 to take the resident to his/her room and see if he/she would want to lay down. She revealed she did not give any directive for CNA #1 to make Resident #1 go to bed. She stated a resident has the choice to not go to bed if they want and the incident could of been avoidable by not having CNA #1 encourage Resident #1 to go to bed. Interview with RN #1 on 6/25/18 at 5:38 PM, revealed she was on duty at the facility when the incident with Resident #1 and CNA #2 occurred on 6/12/18. She stated she would not give a CNA a directive to get or have a resident lay down due to the time of night it is and that the residents have the choice to be up late if they wish. Interview with Social Services Director on 06/26/18 at 1:20 PM, revealed she feels like the facility needs to honor the residents' rights for all residents and a resident who wants to be up at any time of the day or night has the right to do so and this is their home and if it is not allowed she would want to know about it so she could investigate it. Interview with DON, on 04/25/18 at 4:39 PM, revealed facility residents have a right to be up at whatever times they want to be and we have to ensure the residents' rights are followed at all times. Interview with the Administrator on 06/25/18 at 2:35 PM, revealed staff have to make sure they honor the residents' choices and ensure they allow them to have choices and feel like they are in a homelike environment. Further interview with the Administrator on 06/26/18 at 10:26 AM revealed a resident can be up if they want at any time in the facility as long as they are safe and not a danger to others. He stated they should respect the residents' rights if they refuse something whether it be care or treatment.

Based on observation, interview, and review of facility protocol, it was determined the facility failed to ensure food was stored, prepared and served in accordance with professional standards, by properly checking expiration dates for thirty-one (31) of two-hundred and seventy-five (275) cartons of two percent 2% milk, which were not date stamped or dated in any way. Review of the Census and Condition, dated 02/06/18, revealed eighty-five (85) of eighty-eight (88) residents received their food from the kitchen. The findings include: Review of the facility Protocol for Receiving and Storage of Food and Drinks, not dated, revealed all food items must have a use by or expiration date and if the product does not have a use by or expiration date, it must be discarded. Observation of the refrigerated milk storage units in the kitchen, on 02/07/18 at 9:49 AM, revealed a milk crate of two percent (2%) milks with no available expiration dates marked on the cartons. Interview on 02/07/18 at 10:00 AM with the Dietary Manager (DM) and the Registered Dietician (RD,) revealed 31 out of 275 cartons of milk had no date stamp. The DM sated she would have to start monitoring what the milk delivery person brought into the facility and stated she never had an issue with this. There was no assignment sheet that required the staff to check the dates prior to accepting the delivery or routinely check the dates in the milk cooler and no documented evidence this was being completed. Interview with the RDLD on 02/08/18 at 11:03 AM, revealed she had spoken with the milk distributor, regarding the missing dates for the 31 cartons and the other dates of milks, in the same milk crate. The RDLD stated the facility kitchen staff were to have been responsible to have checked the expiration dates, prior to having accepted the delivery and prior to serving the milk with meals. The RDLD revealed there was no way to know how many had been distributed to the residents at this time and there was no documented evidence they were checked. The RDLD further stated the DM never had any issues with this and stated she was unsure how many had been served to residents. Interview with the Administrator on 02/08/18 at 3:24 PM, revealed she would have expected the dietary staff to have checked the expiration dates, prior to having accepted the milk delivery and periodically prior to having served the milk to the residents.

Based on observation, interview and facility policy review, it was determined the facility failed to ensure acceptable standard of quality was provided for two (2) of twenty-eight (28) sampled residents ( Resident #61 and Resident #340). Observation revealed a Licensed Nurse failed to date and initial Resident #61's gastrostomy tube dressing. In addition, Licensed Staff failed to follow professional standards of practice for wound care when she failed to wash hands after removing dirty dressing, cleanse wound after removing dressing, and after wound care was completed. The findings include: 1. Review of the facility policy titled Perry Potter Clinical Nursing Skills & Techniques 8th edition, dated 2014, revealed once dressing is secured on resident then place date, time, and initials on new dressing. Record review revealed the facility admitted Resident #61 on 12/21/11 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 01/09/18 revealed the facility assessed Resident #61's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) indicating the resident was not interviewable. In addition, the resident was assessed as requiring total care with activities of daily living (ADLs). Review of a Physician Order, dated 12/13/16 revealed to apply [MEDICATION NAME] 0 Units/Gram powder ([MEDICATION NAME]) topically to redness under ostomy site every shift and as needed until healed. Observation on 02/07/18 at 11:20 AM with Registered Nurse (RN) #1 revealed Resident #61's [DEVICE] dressing was not initialed or dated per the facility's standards of practice/policy. Interview on 02/07/18 at 11:20 AM with RN #1 revealed she had changed the dressing to Resident #61's [DEVICE] cite prior to surveyor's observation and had failed to date and initial the dressing. RN #1 stated she did not know what the policy stated about dressing changes. Interview on 02/08/18 at 9:53 AM with the Director of Nursing (DON) revealed she expected the dressing to be dated/initialed, per facility policy. Interview on 02/08/18 at 4:10 PM with Administrator revealed she expected dressing to be completed per facility policy. 2. Review of Clinical Nursing Skills & Techniques 8th Edition of Perry Potter Ostendorf, revised 2014, Chapter 39; Dressings, Bandages, and Binders.revealed: Implementation of wound care: 3. Position patient comfortably and drape to expose only wound site. 4. Place disposable waterproof bag within reach of work area. Fold top of bag to make cuff. Perform hand hygiene and apply clean gloves. 5. Gently remove tape, bandages, or ties; use nondominant hand to support dressing and, with your dominant hand, pull tape parallel to skin and toward dressing. 6. With gloved hand remove dressing one layer at a time, observing appearance and drainage of dressing. Carefully remove outer secondary dressing first; then remove inner primary dressing that is in contact with wound bed. 7. Inspect wound and periwound for appearance, color, size, drainage, [MEDICAL CONDITION], and presence of granulation tissue, or odor. Measure wound. 8. Fold dressing with drainage contaminated inside and remove gloves inside out. With small dressings remove gloves inside out over dressing. Dispose of gloves and soiled dressing according to agency policy. Cover wound lightly with sterile gauze pad and perform hand hygiene. 10. Create sterile field with sterile dressing, tray or individually wrapped sterile supplies on over-bed table. Pour any prescribed solution into sterile basin. 11. Cleanse wound. a. Perform hand hygiene and apply clean gloves. b. clean from least to most contaminated area. 12. Use sterile dry gauze to blot to dry wound. 14. Apply dressing 15. Secure dressing. 16. Dispose of all dressing supplies. Remove cover gown and goggles and remove gloves inside out; dispose of them according to agency policy. 17. Label tape over dressing with your initials and date dressing is change. 19. Perform hand hygiene. Record review revealed the facility admitted Resident #340 on 01/31/18 with [DIAGNOSES REDACTED]. Observation of dressing change on 02/08/18 at 1:33 PM by Registered Nurse (RN) #2 revealed the nurse provided wound care to Resident #340 left lower posterior leg while resident was sitting in a recliner. RN #2 put on gloves and did not wash hands prior to removing old dressing. and after removing the dressing. RN #2 then noted she did not have a trash can close by per facility policy and proceeded to fold the dressing and toss the soiled dressing over the resident's shoulder into the trash can behind the resident. Further observation revealed an approximate 1/2 dollar size wound to the posterior lower leg. RN #2 removed the dirty gloves and picked up scissors that were not clean and cut tape off. RN #2 proceeded to open clean dressings and place them on the over the bed table without cleaning the table or placing a barrier on the table. RN #2 then donned a pair of clean gloves without washing hands, placed a Vaseline gauze to wound without cleansing the wound, then a [MEDICATION NAME] with tape placed on top. RN #2 dropped tape on floor and picked it up and leaned onto the over the bed table and put dirty tape in trash. RN #2 then cut another piece of tape and put over dressing without washing hands or changing gloves. The RN then proceed to the right leg. RN #2 did not wash hands, and removed shoe and sock. RN #2 then cut [MEDICATION NAME] with dirty scissors to place between the resident's toes. RN #2 went to closet and opened closet door to put sock into bag without taking off dirty gloves and then removed the dirty gloves and opened [MEDICATION NAME] and started wrapping right foot without washing hands or donning clean gloves. She replaced the resident's shoe and then removed the left sock and placed old dirty foam on over the bed table. She then used the dirty scissors and placed new foam between toes. The RN completed the dressing and walked out of room without washing hands. Observation revealed The RN did not wash her hands at any time in the room and did not use hand sanitizer. Interview with RN #2 on 02/08/18 at 2:00 PM revealed when asked if she would do anything different, she stated she would use sterile technique. She stated she did not expect the wound that she found. She revealed she did not wash her hands while in the room but she washed her hands prior to coming into room. She stated she should have washed her hands after removing the dressing and donned clean gloves, and after gloves became soiled. She also revealed she should have washed her hands and changed her gloves when going to another wound and placing foam between toes. She stated she should have washed hands after completing the dressing and before touching resident's bed, curtains, etc. She revealed she should have cleaned her scissors, and over the bed table and used a barrier. Interview with the Director of Nursing (DON) and Administrator on 02/08/18 at 2:32 PM revealed they expected the staff to follow Professional Standards of Practice.

Based on interview, record review, and facility policy review, it was determined the facility failed to develop a Comprehensive Care Plan related to care for behaviors for one (1) of twenty-eight (28) sampled residents (Resident #53). Resident #53 was receiving routine antipsychotic medication, and having behaviors of yelling out and episodes of crying; and was receiving Risperidal (antipsychotic) two (2) times a day for behaviors; however, there was no care plan developed to address the resident's behaviors. The findings include: Review of facility policy titled, Care Plans-Comprehensive last reviewed 09/21/16 revealed a person-centered comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs, goals and preferences. Care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The interventions will reflect action, treatment, or procedure to meet the objectives toward achieving the resident goals. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (Minimum Data Set {MDS}/Care Area Assessments {CAA}). The care plan should reflect the current status of the resident and be updated with changes. Record review revealed the facility admitted Resident #53 on 10/09/18 with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE], and Quarterly MDS assessment dated [DATE] revealed Resident #53 had no behaviors, delusions or hallucinations during each look back period and received antipsychotic medication for seven (7) days of the seven-day look back period. Further review of the Quarterly MDS assessment revealed the facility assessed Resident #53's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) which indicated the resident was not interviewable. Review of the Behavior Monitoring Record for November and December 2017; and January 2018, revealed Resident #53 was being monitored for increased yelling out. There were six (6) documented episodes of yelling out during the three (3) month period for which redirection, fluids and one-on-one interventions were effective. Further review revealed on 12/23/17 additional monitoring was initiated for crying episodes. Documentation indicated Resident had two (2) episodes of crying for which redirection and one-on-one were effective interventions. However, review of the Comprehensive Care Plan, initiated 10/29/17 and last reviewed 01/17/19, revealed there was no documented evidence a behavior care plan had been initiated. Interview with Licensed Practical Nurse (LPN) #2 on 02/08/18 at 12:40 PM, revealed everyone, nurses, and the Assistant Director of Nursing (ADON) had been updating the care plans. LPN #2 stated no one in particular is responsible to do this. Interview with MDS Coordinator on 02/08/18 at 1:19 AM revealed each discipline is responsible for their own care plans. She stated Social Services would be responsible for initiating a care plan for a resident with behaviors and on antipsychotic medications. The MDS Coordinator stated Social Services typically does the care plans for advanced directives and documented behaviors. Interview with Social Services Director (SSD) on 02/08/18 at 2:12 PM revealed Social Services Department is responsible for initiating and updating care plans related to behaviors. The SSD stated comprehensive care plans are initiated after the resident has been in the facility for seven (7) days, and if there was documented behaviors, a care plan would have been initiated. Interview with Director of Nursing (DON), on 02/08/18 at 12:45 PM revealed Social Sevices, the MDS Coordinator, and nurses on the units are responsible for updating the care plans as needed. The DON stated she would expect a care plan to be initiated for a resident having behaviors.

Based on observation, interview, and review of the facility's policy, it was determined the facility failed to ensure one (1) of twenty-eight (28) sampled residents had a clean, safe and comfortable environment. Observations on 02/07/18 and 02/08/17 revealed there were bath basins stored on a couch stacked inside one another, and dried food on a Resident #57's floor. The findings include: Review of facility policy titled, Cleaning and Disinfecting Non-Critical Resident Care Items, dated 01/01/00, revealed bedpans as non-critical care items and non-critical care items are to be placed in the resident's bedside cabinet after use. Review of facility policy titled, Housekeeping In-Service 5-Step Daily Patient Room Cleaning, dated June 2016 revealed the most important area of a resident's room to disinfect is the floor. This is where most air-borne bacteria will settle and so it needs to be sanitized daily. Observation on 02/07/18 at 9:32 AM, 12:37 PM and 3:20 PM and on 02//08/18 at 1:30 PM of Resident #57's room revealed two (2) bath basins stacked inside one another placed on couch, and dried food particles on floor. Interview on 02/07/18 at 9:23 AM with Resident #57 revealed the rooms are cleaned every day. Interview on 02/08/18 at 1:40 PM with Certified Nursing Aide (CNA) #1 revealed staff are supposed to put bath basins/bedpans in plastic bags on the shelf, and food is not expected to be on the floor. Interview on 02/07/18 at 3:38 PM with Registered Nurse (RN) #1 revealed bath basins should be in their own separate bag and not stacked in one another with no covering plastic bag and there should not be dried food on the floor. Interview on 02/08/18 at 1:50 PM with Housekeeping Aide #1 revealed she sweeps and mops every day and missed the food dried on the floor in Resident # 57's room. She stated she would not expect dried food on the floor. Interview on 02/08/18 at 11:00 AM with the Supervisor of Housekeeping/Laundry revealed there should not be dried food on a residents' floor, and bath basins should not be on a couch uncovered. He stated it is his responsibility to ensure it is not there and to his knowledge the bath basins are usually not stored stacked that way. Interview on 02/08/18 at 12:55 PM with District Manager of Housekeeping revealed there should not be dried food on the floor of a residents' room. Interview on 02/07/18 at 3:58 PM with Assistant Director of Nursing (ADON) revealed bath basins should not be stacked in one another with no plastic bag covering them. She stated the bath basins should not be stacked on the couch in Resident #57's room but did not think the bath basins were being used. Interview on 02/08/18 at 9:53 AM with Director of Nursing (DON) revealed she did not expect dried food to be on the floor. Interview on 02/08/18 at 4:10 PM with the Administrator revealed the facility did not have a policy or standards of practice to address how bath basins were supposed to be stored. The Administrator stated she expected the bedpans to be bagged and the floors should be swept and mopped daily when needed.

Based on observation, interview, record review, review of Nursing Drug Handbook by Lipponcott, and facility policy review it was determined the facility failed to ensure one (1) of twenty-eight (28) sampled residents was not administered a [MEDICAL CONDITION] medication without an appropriate diagnosis (Resident #53). Resident #53 was being administered [MEDICATION NAME] (antipsychotic) with a [DIAGNOSES REDACTED]. The findings included: Review of the facility policy titled, [MEDICAL CONDITION] Medications, last revised 05/09/17, revealed the term [MEDICAL CONDITION] medication is defined as any drug that affects brain activities associated with mental processes and behavior, anti-anxiety agents, antidepressants, hypnotics, antypsychotics and other drugs that affect behavior. The use of [MEDICAL CONDITION] medications will be in accordance with all federal and state regulations. Further review of the policy revealed for residents who are admitted on [MEDICAL CONDITION] medications, the physician will review the medical record, medical history, and related factors for the appropriate [DIAGNOSES REDACTED]. If appropriate [DIAGNOSES REDACTED]. Review of a Nursing Drug Handbook by Lipponcott, dated 2014, revealed [MEDICATION NAME] was used for the following: [MEDICAL CONDITION], Aggression, irritability, temper tantrums, self-injury associated with Autism, and [MEDICAL CONDITION]. Review of the Black Box Warning revealed fatal Cardiovascular or Infectious adverse events may occur in elderly patients with dementia and is not safe or effective in these patients. Record review revealed the facility admitted Resident #53 on 10/09/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and Quarterly MDS assessment dated [DATE], revealed the resident had no behaviors, delusions or hallucinations during each look back period. Further review of the Quarterly MDS assessment revealed the facility assessed Resident #53's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of three (3) indicating the resident was not interviewable. Observation of Resident #53 on 02/06/18 at 4:40 PM and 02/07/18 at 3:30 PM revealed the resident was in bed, sleeping. Further observation on 02/08/18 at 8:28 AM revealed the resident was up in wheelchair in commons area awake, pleasant and talkative. Review of the Comprehensive Care Plan for Risk for Side Effects of [MEDICAL CONDITION] medications last reviewed 01/17/18 revealed interventions to administer medication as prescribed by the physician and monitor for effectiveness; observe for any signs and symptoms of drug related [MEDICAL CONDITION], gait disturbance, cognitive impairment, behavioral impairment, Activities of Daily Living (ADL) decline, decline in appetite; and report to physician any negative outcomes associated with use of drug. Review of the Physicians Orders dated January 2018, revealed orders for [MEDICATION NAME] 1 milligram (mg) by mouth in the AM and [MEDICATION NAME] 1 mg (give one and half tabs to equal 1.5 mg) by mouth every PM for Alzheimer's Dementia with behaviors, initiated on 10/21/17. Review of the Behavior Monitoring Record for November 2017, December 2017, and January 2018, revealed the resident was being monitored for increased yelling out. There were six (6) documented episodes of yelling out during the three (3) month period for which redirection, fluids and one-on-one interventions were effective. Further review revealed on 12/23/17 additional monitoring was initiated for crying episodes. Documentation indicated the resident had two (2) episodes of crying for which redirection and one-on-one were effective interventions. Review of the PharMerica Medication Regimen Review revealed Resident #53 was receiving [MEDICATION NAME] 1 mg in AM and 1.5 mg in PM. Further review revealed there were no documented recommendations per the pharmacist. Further review revealed on 11/20/17, 12/12/17 and 01/17/18, the pharmacist reviewed the resident's medication regimen and marked a X over a box indicating no new suggestions. Interview with the Advance Practice Registered Nurse (APRN) for Resident #53 on 02/08/18 at 10:27 AM revealed she was aware Dementia with Behaviors or without Behaviors was not an appropriate [DIAGNOSES REDACTED]. She stated the resident was crying all the time when she made rounds and the Physician (Physician #1) was the one that made the recommendation to use the [MEDICATION NAME]. Staff attempts to contact Resident #53's Physician for interview on 02/08/18 were unsuccessful because the Physician was out of state and did not return phone calls. Interview with the Assistant Director of Nursing (ADON) on 02/08/18 at 10:59 AM; and Registered Nurse (RN) #1 on 02/08/18 at 8:20 AM revealed neither was aware [MEDICATION NAME] was not to be given to a resident with a [DIAGNOSES REDACTED].

Based on observation, interview, record review and facility policy review, it was determined the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, for one (1) of twenty-eight (28) sampled residents (Resident #340). Observation on 02/08/18 revealed the Licensed Nurse failed to wash hands per facility policy while conducting wound care/dressing changes for Resident #1. In addition, she failed to cleanse the wound, clean the over the bed table/and place barrier prior to placing clean dressings on table, ensure scissors were clean prior to use, and ensure trash can available for use per facility policy/standards of practice. The findings as follows: Review of Handwashing/Hand Hygiene policy from Infection Control Policy and Procedure Manual, last revised August 2015, revealed the facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: d. Before performing any non-surgical invasive procedures; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with a resident's intact skin' k. After handling used dressing, contaminated equipment, etc.; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; m. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. Review of Clinical Nursing Skills and Techniques 8th Edition of Perry Potter Ostendorf, revised 2014, revealed on page 946 Chapter 39; Dressings, Bandages, and Binders. that a wound is a break in skin integrity that increases a patient's risk for infection. Use the appropriate type of gloves when changing a dressing and wash hands thoroughly before and after a dressing change. Implementation of wound care: 3. Position patient comfortably and drape to expose only wound site. 4. Place disposable waterproof bag within reach of work area. Fold top of bag to make cuff. Perform hand hygiene and apply clean gloves. 5. Gently remove tape, bandages, or ties; use nondominant hand to support dressing and, with your dominant hand, pull tape parallel to skin and toward dressing. 6. With gloved hand remove dressing one layer at a time, observing appearance and drainage of dressing. Carefully remove outer secondary dressing first; then remove inner primary dressing that is in contact with wound bed. 7. Inspect wound and periwound for appearance, color, size, drainage, [MEDICAL CONDITION], and presence of granulation tissue, or odor. Measure wound. 8. Fold dressing with drainage contaminated inside and remove gloves inside out. With small dressings remove gloves inside out over dressing. Dispose of gloves and soiled dressing according to agency policy. Cover wound lightly with sterile gauze pad and perform hand hygiene. 10. Create sterile field with sterile dressing, tray or individually wrapped sterile supplies on over-bed table. Pour any prescribed solution into sterile basin. 11. Cleanse wound. a. Perform hand hygiene and apply clean gloves. b. clean from least to most contaminated area. 12. Use sterile dry gauze to blot to dry wound. 14. Apply dressing 15. Secure dressing. 16. Dispose of all dressing supplies. Remove cover gown and goggles and remove gloves inside out; dispose of them according to agency policy. 17. Label tape over dressing with your initials and date dressing is change. 19. Perform hand hygiene. Record review revealed the facility admitted Resident #340 from the hospital on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital Culture of wound/lesion, dated 01/22/18 revealed the left lower leg wound was positive for Pseudomonas Aeruginosa. Review of the initial Wound assessment dated [DATE] at 7:42 PM revealed an open lesion other than an ulcer to left calf. No measurements were noted to the assessment. Review of Baseline Admission Care Plan dated 02/02/18 revealed Resident has an Infection Wound to Left lower extremity with a goal of the resident will be free from signs and symptoms of [MEDICAL CONDITION]. Further review revealed interventions to administer medications as per physician's orders [REDACTED]. Review of a Physician order [REDACTED]. Observation of dressing change on 02/08/18 at 1:33 PM by Registered Nurse (RN) #2 revealed the nurse provided wound care to Resident #340 left lower posterior leg while resident was sitting in a recliner. RN #2 put on gloves and did not wash hands prior to removing old dressing. After removing the dressing, RN #2 noted she did not have a trash can close by per facility policy and proceeded to fold the dressing and toss the soiled dressing over the resident's shoulder into the trash can behind the resident. Further observation revealed an approximate 1/2 dollar size wound to the posterior lower leg. RN #2 removed the dirty gloves and picked up scissors that were not clean and cut tape off. RN #2 proceeded to open clean dressings and place them on the over the bed table without cleaning the table or placing a barrier on the table. RN #2 then donned a pair of clean gloves without washing hands, placed a Vaseline gauze to wound without cleansing the wound, then a [MEDICATION NAME] with tape placed on top. RN #2 dropped tape on floor and picked it up and leaned onto the over the bed table and put dirty tape in trash. RN #2 then cut another piece of tape and put over dressing without washing hands or changing gloves. The RN then proceed to the right leg. RN #2 did not wash hands, and removed shoe and sock. RN #2 then cut [MEDICATION NAME] with dirty scissors to place between the resident's toes. RN #2 went to closet and opened closet door to put sock into bag without taking off dirty gloves and then removed the dirty gloves and opened [MEDICATION NAME] and started wrapping right foot without washing hands or donning clean gloves. She replaced the resident's shoe and then removed the left sock and placed old dirty foam on over the bed table. She then used the dirty scissors and placed new foam between toes. The RN completed the dressing and walked out of room without washing hands. Interview with RN #2 on 02/08/18 at 2:00 PM revealed when asked if she would do anything different, she stated she would use sterile technique. She stated she did not expect the wound that she found. She revealed she did not wash her hands while in the room but she washed her hands prior to coming into room. She stated she should have washed her hands after removing the dressing and donned clean gloves, and after gloves became soiled. She also revealed she should have washed her hands and changed her gloves when going to another wound and placing foam between toes. She stated she should have washed hands; after completing the dressing and before touching resident's bed, curtains, etc. She revealed she should have cleaned her scissors, and over the bed table and used a barrier. Interview with the Director of Nursing (DON) and Administrator on 02/08/18 at 2:32 PM revealed they expected staff to follow care plans, hand washing policy as written, and follow instructions specific to MD orders. They stated they expected hand washing to be completed before, during and after care especially going from dirty to clean.

Based on interview, record review, and review of the Resident Instrument Assessment (RAI) Manual 3.0, it was determined the facility failed to implement the care plan for one (1) of one (1) sampled residents (Resident #1). The facility care planned for staff to monitor Resident #1 for tailgating visitors while they were in the building and to use an audible monitoring system to alert staff of exit seeking behaviors. However, on 11/13/17, Resident #1 exited the building behind a visitor without staff's knowledge and without the alarm system sounding. The facility's failure to implement the care plan related to monitoring the resident for tail gaiting and to provide adequate supervision to include a functioning audible monitoring system to alert staff has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/11/17 and determined to exist on 11/13/17. The facility was notified of the Immediate Jeopardy on 12/11/17. An acceptable Allegation of Compliance (AoC) was received on 12/14/17, alleging the removal of Immediate Jeopardy on 11/23/17. The State Survey Agency (SSA) determined the facility had not fully implemented the AoC and the Immediate Jeopardy could not be removed. The facility was notified Immediate Jeopardy was still present and ongoing at the time of exit on 12/15/17. The findings include: Interview with the Director of Nursing (DON) on 11/21/17 at 1:39 PM, revealed the facility follows the RAI Manual for implementing/following the care plan. Review of the RAI Manual 3.0, dated October 2016, revealed care planning crafts the how of resident care. Furthermore, implementation is putting that course of action (specific interventions derived through interdisciplinary individualized care planning) into motion by staff knowledgeable about the resident's care goals and approaches; carrying out the how and when of resident care. Record review revealed the facility admitted Resident #1 on 09/01/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Sets (MDS) assessment, dated 09/07/17, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable Review of Resident #1's Comprehensive Care Plan for Risk for Elopement, dated 09/08/17, revealed interventions to monitor the resident for tailgating when visitors were in the building and to use an audible monitoring system to alert staff of exit seeking behavior. However, review of a Nursing Assessment Report, dated 11/13/17 at 2:18 PM, revealed Resident #1 followed a family member outside of the North Lobby Entrance to the porch without staff's knowledge and without the alarm sounding. Interview with Certified Nurse Aide (CNA) #3 on 11/21/17 at 10:15 AM revealed the door did not alarm when Resident #1 exited the building because she did not hear the alarm and staff did not see the resident exit the building. Interview with Licensed Practical Nurse (LPN) #1 on 11/21/17 at 9:33 AM revealed she brought the resident back into the building after a family member alerted her the resident was outside. LPN #1 stated on the day the resident eloped from the building the alarm did not sound nor did the door lock down. She stated staff did not see the resident exit the building with a visitor. Interview with the Director of Nursing (DON) on 11/20/17 at 1:55 PM revealed the resident was assessed on admission as being an elopement risk and had a transmitter placed on his/her leg. She stated on 11/13/17 a visitor pressed the code and the resident followed the visitor out the door. She stated the door did not alarm nor lock down. The DON stated the visitor tried to shut the door but the resident followed her out. Further interview revealed the visitor did not tell anyone because she saw another person outside whom she thought was an employee with the facility's dog. She stated the resident proceeded to talk with the visitor on the porch and another visitor saw the resident outside and alerted LPN #1. The DON stated the alarm did not sound when the resident exited the building and staff did not see the resident exit the building. Interview on 11/21/17 at 1:39 PM revealed she expected the staff to provide adequate supervision as well as follow the plan of care. Interview with the Administrator on 11/21/17 at 1:50 PM revealed he expected staff to follow the care plan for care provided. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was placed on one (1) to one (1) monitoring immediately, assessed head to toe, reassessed for elopement risk on 11/13/17, responsible party and physician were notified, and care plan and CNA care plan were updated by the Assistant Director of Nursing (ADON) on 11/13/17. 2 All residents residing in the facility on 11/13/17 were reassessed for elopement risk by the ADON starting on 11/13/17 and completed on 11/14/17 and one (1) resident was identified as being an elopement risk. Upon identification through the assessment, the physician and family were notified, a wander guard was applied, the care plan and Certified Nurse Aide (CNA) care plan were updated, and elopement books were updated. 3. All residents identified as an elopement risk (12 residents), based on the assessments, had their wander guard bracelets checked for appropriated placement along with proper functioning of the wander guard bracelets by the Maintenance Director on 11/13/17. No concerns were noted. 4. All elopement books were reviewed to ensure accuracy and current resident information by the ADONs starting on 11/13/17 and completed by 11/14/17 with no concerns noted. 5. All care plans and CNA care plans for residents assessed at risk for elopement were audited and reviewed to ensure accuracy, appropriate interventions, and the plan of care was appropriate and individualized by the ADON and Minimum Data Set (MDS) Nurses starting on 11/13/17 and completed by 11/14/17, with no concerns noted. 6. All exit doors were assessed by the Maintenance Director along with the remote assistance of the company to ensure proper functioning on 11/13/17 and completed by 11/14/17 with no concerns noted. The wander guard system was adjusted by the Maintenance Director with assistance from the remote monitoring company on 11/13/17 to ensure if a resident with a wander guard in place, approached the door while it was open, the alarm would sound. 7. All accidents/incidents along with nurses notes and social services notes for the past thirty (30) days were reviewed for any exit seeking behaviors by the DON starting on 11/13/17 and completed by 11/14/17, with no concerns identified. 8. All door codes were changed by the Maintenance Director on 11/13/17 and signs posted at each door by maintenance on 11/13/17 to educate visitors that staff must allow them entrance/exit to and from the facility. 9. The DON was educated by the Regional Nurse Consultant (RNC) on 11/13/17 on policies and procedures to include residents with behaviors of wandering (identification, care plan, and monitoring), processes (placement, function test, EZMAR documentation, monitoring), competencies (wander guard to activate alarm when the door is open, no visitors to have to code, staff will allow visitors to enter/exit the facility) and tools. 10. The DON then trained the ADONs, Social Services which is a Licensed Practical Nurse (LPN), Medical Records (LPN), MDS Coordinators, and Nursing Supervisors on 11/13/17 on the policies and procedures. 11 Staff working on 11/13/17 were educated on elopement and missing resident policy and procedure, wander guard placement and function checks, documentation of wander guard placement and function in the EZMAR system and ensuring no visitors would be allowed to have knowledge of the codes by the Director of Nursing and Nurse Supervisor on 11/13/17. Once the Nursing Supervisor was educated on the policies and procedures and process she was then assigned to re-educate the staff starting 11/13/17 and completed on 11/22/17. The education was also included for all newly hired staff members. 12. Department Managers were educated on how to check the alarm system for correct code alert function at every exit in the facility by the Maintenance Director on 11/22/17. 13. An Ad Hoc Quality Assurance (QA) meeting was completed on 11/13/17 with the Medical Director via phone, the Administrator, and DON to review the incident and current plan. 14. The DON, ADONs, MDS Coordinators, Nurse Supervisor, and Social Services will audit/review all nurse's notes, social service notes, accident/incidents and twenty-four (24) hour report audits to encompass all shift daily to include Saturday and Sunday for eight (8) weeks to ensure any exit seeking behavior noted had appropriate intervention(s) implemented and updated on the care plans. 15. Findings of daily audits will be reviewed by the DON daily during the morning meeting and discussed in QA during every two (2) week QA meetings for six (6) weeks, then monthly. 16. The Maintenance Director or Weekend Manager will check/monitor all facility entrance/exit doors to ensure proper alarming and functioning daily, on alternating shift, to include Saturday and Sunday for eight (8) week, then daily on alternating shifts, Monday through Friday for eight (8) weeks starting on 11/14/17. Findings of daily checks will be reviewed with the Administrator daily and brought to QA. 17. Door codes will be changed by the Maintenance Director monthly to decrease the risk of visitors becoming aware of the door codes. 18. All audits will be reviewed by the Administrator every day during morning meeting and discussed with the QA team during QA meetings every two (2) weeks for eight (8) weeks then monthly for a minimum of six (6) months. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of a skin assessment revealed a head to toe assessment was completed for Resident #1 on 11/13/17 by LPN #1. A hand written note by the DON revealed the physician and family were notified on 11/13/17 of the elopement of Resident #1. Review of Resident #1's care plan and Nurse's Notes revealed the resident was placed on one (1) to one (1) supervision and the resident's wander guard was in place and functioning. Review of the Elopement Risk Evaluation dated 11/13/17 revealed the resident was reassessed to be at risk for elopement. Review of a resident census list revealed on 11/13/17, Resident #1's care plan and CNA care plan were reviewed and updated by the two (2) MDS staff. However, review of Resident #1's care plan revealed the care plan did not address checking the resident's wander guard for functioning every day. 2. Review of the resident census and all residents Elopement Risk Assessments revealed all residents but one (1), were reassessed for elopement risk by the ADONs on 11/13/17. Review of the one resident's elopement assessment dated [DATE], revealed he/she was identified at risk for elopement. Review of the resident's Nursing Note dated 11/14/17, revealed a wander guard bracelet was placed and the physician and family were notified. Review of the resident's Comprehensive Care Plan and CNA Care Plan revealed the care plan was updated for elopement risk. Review of the Elopement book revealed the book was updated with this resident's information. In addition, review of two (2) residents readmitted , one (1) admitted on [DATE] and another on 12/06/17 revealed they had exit seeking behaviors. However, these residents' care plans were not updated to include the intervention of checking the functionality daily; and, the orders/EZ MAR did not reflect the need to check the functioning every day. Interview with the DON on 12/15/17 at 10:12 AM revealed the orders should have been checked in the morning meeting. She stated obviously they were not checked to ensure the that the functioning piece was on the order/EZ MAR and the care plan when the residents returned from the hospital. 3. Review of a November 2017 calendar revealed the Maintenance Director checked to ensure all residents identified as being an elopement risk had their wander guard bracelets checked for placement and function. Interview with the Maintenance Director, on 12/14/17 at 2:26 PM revealed he checked the residents with wander guard bracelets to ensure they were in place and functioning on 11/13/17 and continues to check functioning every week. 4. Review of a November 2017 calendar revealed it was signed on 11/13/17 by the ADON indicating all the elopement books were reviewed to ensure accuracy and current resident information. Review of the Elopement Books on 12/14/17 revealed thirteen (13) of thirteen (13) residents identified as at elopement risk with current information. 5. Review of the Resident Census revealed it was signed by the two (2) MDS staff indicating all residents' care plans that were assessed at risk for elopement were accurate, appropriate and individualized. However, surveyor review of the residents' care plans assessed at risk for elopement revealed twelve (12) of thirteen (13) resident care plans did not address checking the function of the resident's wander guards every day. Interview with the two (2) MDS Coordinators on 12/15/17 at 11:45 AM revealed they were responsible to check the care plans to ensure they matched the physician's orders [REDACTED]. They stated if the physician's orders [REDACTED]. 6. Review of the November 2017 calendar dated 11/13/17 and signed by the Maintenance Director revealed the wander guard system was adjusted with assistance from the Code Alert monitoring system to ensure that if a resident with a wander guard in place approached the door while open the alarm would sound. Interview with the Administrator on 12/12/17 at 3:40 PM revealed he was present on the call with Maintenance and the Code Alert Monitoring System on 11/13/17 regarding the adjustment on the doors. 7. Review of all events, Nurse's Notes, and Social Service Notes for the last thirty (30) days revealed the DON had initialed at the bottom of each page to verify she reviewed them on 11/14/17. 8. Review of the November 2017 calendar revealed the Maintenance Director's signature indicating the door codes were changed on 11/13/17. In addition, observation on 12/12/17 revealed there was a note on each exit/entrance door dated 11/13/17, signed by the Administrator educating visitors that staff must let them out and in. Interview with Maintenance Director on 12/14/17 at 2:26 PM revealed he changed the door codes on 11/13/17 with assist from the manufacturing company via phone and the visitors were no longer allowed to have the code. 9. Review of an in-service document conducted by the Nurse Consultant to the DON, dated 11/13/17 revealed the DON was educated on the policies and procedures for elopement, care planning, monitoring, processes for the Physician orders [REDACTED]. The DON was out on leave at time of verification of AoC. 10. Review of Inservice document, dated 11/13/17, revealed the DON educated the Staff Development Coordinator (SDC), ADON's, Social Services (LPN), MDS team, and Nursing Supervisor on the policies and procedures for elopement, care planning, monitoring, processes for the Physician orders [REDACTED]. However, review of the December 2017 Physician order [REDACTED]. not been checked daily for functioning. Interview with the SDC on 12/15/17 at 11:52 AM revealed she was educated by the DON on the policies and procedures for elopement to include care planning, monitoring, processes for the Physician orders [REDACTED]. 11. Review of an Inservice document dated 11/13/17 revealed the SDC educated Nursing staff on the policies and procedures for elopement which included care planning, monitoring, processes for the Physician orders [REDACTED]. Review of the new employee Orientation Packet revealed the same education will be provided to new hires in the orientation process. Review of a new employee personnel file revealed she received the education on 11/14/17. Interview with the SDC on 12/15/17 at 11:52 AM revealed she educated the staff to check placement every shift and function every day and to sign off on the EZMAR. She stated if the nurses did not see an order that matched the inservice they should have changed the order. Interview with LPN #4 on 12/14/17 at 1:56 PM revealed she was educated to do and Elopement Risk Evaluation on admission and if the resident is at risk to apply a code alert bracelet on them. She stated the nurses were responsible to check for placement every shift and sign on the EZ MAR. She stated Maintenance completes the checks for functioning of the bracelets. In addition, she stated no visitors were allowed to know the code and the nurses must push the button at the desk to let visitors in as the staff do not know the code now as it was changed on 12/13/17 due to a visitor finding out the code. Interview on 12/14/17 with CNA #4 at 2:00 PM, and CNA #5 at 2:21 PM revealed they were educated by the SDC to get to the doors in a timely manner if alarming unless providing direct patient care, following the care plan, and not to give the code to any visitors as the code had changed. Interview with LPN #1 on 12/15/17 at 2:21 PM revealed she was not sure who checks the alarms for functioning but she documents on the EZMAR the wander guards were checked for placement and functioning. She stated she did not know how to check the bracelet for functioning. She also stated the order and care plan should match. Interviews on 12/14/17 with LPN #3 at 2:10 PM, LPN #4 at 1:56 PM, and LPN #5 at 4:40 PM revealed the nurses do not check functioning of the bracelet as Maintenance performs that task. They further stated the door code was changed on 12/13/17 because a family member had the code and now staff cannot have the code. Interview with the Administrator on 12/15/17 at 3:17 PM revealed the Maintenance Director checks the Wander Guard bracelets every week but the nurses should check every shift. He stated he had heard a visitor had the door code, therefore the code was changed on 12/13/17 and only he and the Maintenance Director have the code. He stated they did not investigate to determine how the code got out or re-inservice staff. 12. Review of an Inservice Document revealed the Maintenance Director educated the Department Managers on 11/22/17 on how to check the alarm system for correct code alert function at every exit in the facility. Interview with the Admissions/Marketing staff (Department Manager) on 12/14/17 at 3:00 PM revealed she was inserviced by the Maintenance Director on how to check the doors with a bracelet. She further stated they do not check the bracelets for functioning only the doors on the weekend. 13. Review of the AD Hoc QA meeting minutes provided by the facility revealed a plan was developed to address the elopement on 11/13/17. 14. Review of a November and December 2017 calendar revealed initials each day by the Nursing Administration team verifying audit/review of all Nurses' Notes, 24 hour reports, accident/incident reports and Social Services Notes to encompass all shifts to ensure to identify any exit seeking behavior and to ensure care plans/CNA care plans were updated. 15. Review of the facility provided QA book revealed the DON brought the audits that were conducted to the QA meeting conducted on 11/30/17. 16. Review of the November and December 2017 calendars revealed the Maintenance Director or weekend managers initialed they had checked/monitored the entrance/exit doors to ensure proper alarming and functioning every day including weekends on alternating shift through 12/15/17. Observation of entrance/exit doors on 12/14/17 at 11:27 AM revealed the code pushed with a transmitter within range and the door locked and alarmed when the door was pushed open. The door alarm was also tested while the door was open and the transmitter came close to the door and continued through the door and the door alarmed. 17. While the surveyor was in the building on 12/13/17, the Maintenance Director changed the door code. 18. Review of QA Book revealed the audits were reviewed by the Administrator every day during morning meeting and discussed with the QA team during QA meetings on 11/13/17 and 11/30/17. A QA Meeting was scheduled for 12/14/17 and will continue every two weeks for the next four (4) six weeks then monthly for a minimum of six (6) months.

Based on observation, interview, record review, review of the Series 8 and Software User Guide, and facility policy review, it was determined the facility system to ensure one (1) of one (1) sampled resident (Resident #1) received adequate supervision to prevent elopement was ineffective. Resident #1 was assessed and care planned as an elopement risk with interventions to monitor the resident for tailgating when visitors were in the building and to use an audible monitoring system to alert staff of exit seeking behavior. However, Resident #1 was able to follow a visitor out the visitor entrance on 11/13/17 without the alarm system sounding and without staff being aware the resident left the building. The facility's failure to implement the care plan related to monitoring the resident for tail gaiting and to provide adequate supervision to include a functioning audible monitoring system to alert staff has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 12/11/17 and determined to exist on 11/13/17. The facility was notified of the Immediate Jeopardy on 12/11/17. An acceptable Allegation of Compliance (AoC) was received on 12/14/17, alleging the removal of Immediate Jeopardy on 11/23/17. The State Survey Agency (SSA) determined the facility had not fully implemented the AoC. The facility was notified Immediate Jeopardy was still present and ongoing at the time of exit on 12/15/17. The findings include: Review of the facility's Elopement/Wandering policy, not dated, revealed the intent of the facility is to maintain resident safety by identifying residents who are at risk for wandering/elopement behavior. Review of the security system user guide Series 8 Software User Guide, dated 05/13/13, revealed the most reliable method of resident monitoring combines close personal surveillance with correct operation of monitoring equipment. In addition, further review revealed to not rely exclusively on resident generated alarms for resident care and safety. Record review revealed the facility admitted Resident #1 on 09/01/17 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Sets (MDS) assessment, dated 09/07/17, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview of Mental Status (BIMS) score of five (5) which indicated the resident was not interviewable. Further review of the MDS revealed the resident required limited assistance of one (1) with ambulation and supervision with transfers. Review of the Admission Nursing Assessment, dated 09/01/17, revealed the resident was an Elopement Risk. Review of the physician's orders [REDACTED]. Review of the November 2017 Treatment Administration Record (TAR) revealed the wander guard was last checked for placement and function the morning of 11/13/17. Review of the Comprehensive Care Plan for Risk for Elopement, dated 09/08/17, revealed the goal was for the resident not to elope from the facility and to be monitored of his/her whereabouts on an ongoing basis throughout next review date. Further review revealed interventions to monitor the resident for tailgating when visitors are in the building and to use audible monitoring system to alert staff of exit seeking behavior. Review of the most recent Elopement Risk Evaluation, dated 10/04/17, revealed the resident remained an elopement risk. Observation on 11/20/17 at 2:53 PM, revealed Resident #1 sleeping on the couch in the lobby with a transmitter on his/her ankle. Observation on 11/21/17 at 12:54 PM revealed the resident walking around in his/her room with transmitter on ankle. Review of Nurse's Notes, dated 11/11/17 at 1:37 PM, revealed Resident #1 pulled the fire alarm that morning and was placed on fifteen (15) minute checks. Review of a Nursing Assessment Report, dated 11/13/17 at 2:18 PM revealed the resident followed a family member outside of the North lobby entrance to the porch. The resident was last seen on the North Hall lobby. The physician and family were notified and a head to toe assessment was completed with no injuries noted. Interview with Certified Nurse Aide (CNA) #1 on 11/21/17 at 9:47 AM revealed prior to the elopement, the door to the North lobby entrance would not open and the alarm would sound if a resident with a transmitter was near the door while someone was trying to exit with the code. She stated she had worked with Resident #1 the morning before the elopement and the resident was not different than he/she had been. Interview with CNA #3 on 11/21/17 at 10:15 AM revealed prior to the elopement if a resident with a transmitter was by the exit door and someone pressed the code to exit the facility the doors would not open and would alarm. She stated for an employee or visitor to exit the building, the resident with a transmitter must be moved away from the door, for the door to open and the alarm not to sound. CNA #3 revealed the door did not lock nor alarm when Resident #1 exited the building and it should have alarmed. She stated the resident's spouse usually visited in the afternoon. CNA #3 stated the resident would look out the windows waiting for his/her spouse to arrive. Interview with CNA #4 on 11/20/17 at 3:37 PM, revealed prior to the elopement either the resident with a transmitter had to move out of range or the button at the desk had to be pressed to allow a visitor or employee to exit if a resident with a wanderguard was in range of the door. If not, the alarm would sound and the door would lock not allowing exit. She further stated the resident was placed on one to one supervision after the elopement. Interview with CNA #2 on 11/21/17 at 9:59 AM revealed she was also working when the resident exited the building, she was assisting with showers. She stated prior to the elopement when a visitor put in the code to exit the facility and there was a resident with a transmitter, the door would open and no alarm would sound. CNA #2 stated she had taken residents, who had transmitters, to the doctor before; she would walk out with the resident by pressing the code and no alarm would sound and the doors would open. She stated if a resident with a transmitter was behind a visitor and pressed the code to exit the doors the resident could walk on out. Further interview revealed the resident was placed on one to one supervision after the incident. Interview with Licensed Practical Nurse (LPN) #1 on 11/21/17 at 9:33 AM revealed prior to the elopement the door the resident exited would lock and alarm if the code was pressed by someone and a resident with a transmitter was standing near the door. She stated the resident was on fifteen (15) minute checks at the time of the elopement as he/she had pulled the fire alarm a few days prior. LPN #1 stated the resident did not seem to be more anxious or attempt to elope prior to the incident. She further stated on the day the resident eloped from the building the alarm did not sound nor did the door lock down and staff did not see the resident exit the building with the visitor. LPN #1 revealed she brought the resident back into the building after a family member alerted her the resident was outside. She stated she performed a skin assessment with no injuries found and the resident was placed on one to one supervision. Further interview with LPN #1, on 12/15/17 at 2:21 PM revealed on 11/13/17 she did not check Resident #1's bracelet. She stated she would sometimes take the resident to the door to see if the door would alarm but she did not check for functioning for the bracelet routinely. Interview with LPN #2 on 11/20/17 at 3:28 PM revealed prior to the elopement if a resident had a transmitter the door would not open when the code at the door was executed. Therefore, the button behind the desk would need to be held in to unlock the door. If the button was not pressed, the door would alarm and lock. Interview with Registered Nurse (RN) #1 on 12/14/17 at 3:43 PM revealed Resident #1 would follow his/her family to the door and someone would have to catch him/her or he/she would walk right out the door. She stated she was not surprised to hear that he/she had eloped. RN#1 stated she had previously told coworkers to watch him/her closely because the resident was going to get out of the building. Interview with the Tech Support from the transmitter company on 11/21/17 at 11:05 AM revealed by default the alarm system was considered a wander management system. The Tech stated the system was designed to alarm if the transmitter was within three (3) to five (5) feet of the perimeter at the door, and the door was opened before the transmitter reached the three (3) to five (5) feet. In addition, the door should lock and not open if the resident with the transmitter was within the three (3) to five (5) feet and the code was pressed to open the door. He stated to escort a resident out the door a separate code would be used to unlock the door and disable the alarm. He stated if the staff bypass code was the same as the visitor code then the system would not alarm or the door lock depending on how the facility set up the system. Further interview revealed he had spoken with the Maintenance Director on 11/13/17 via phone to troubleshoot the system, but he did not save his notes. He stated the Maintenance Director called him and stated a resident had exited the building and the alarm did not go off. He further stated he determined the system's failure was due to the keypad not detecting the transmitter possibly due to an external source interference, power failure or the antennas did not pick up the transmitter. Further interview revealed the Maintenance Director adjusted the antennas to ensure the area circumference range was three (3) to five (5) feet, as well as reset the system in case there was a power failure which caused the system to fail. He stated even if the system went into wander management mode the door should have alarmed unless the antennas were not within range. He further stated if there was a power failure the antenna gain setting could adjust to a default state and, if the transmitter was on the ankle the transmitter may have not been detected. He stated if the resident had a circular and not a block transmitter the antennae must be adjusted as the circular type which was designed for the wrist did not have a wide range. Interview with the Maintenance Director on 11/20/17 at 2:10 PM revealed he performed transmitter checks weekly to ensure they were functioning properly. He also checked the doors daily to ensure they were functioning properly. He stated the House Supervisor conducts the checks on the weekends. Further interview revealed before the elopement, the doors would alarm but not lock down if a transmitter approached and the code was pressed to exit. He stated the doors were checked the day of 11/13/17, prior to the elopement and the door alarmed. He stated after the resident eloped he could not remember if the doors alarmed or not, but the door did not lock when the code was put in, and a wanderguard was at the door or going through the door. He stated Tech Support revealed it could have been caused by outside interference. He revealed the Tech Support instructed him on how to reset the door. Further interview revealed there had not been any reports to him of the door not alarming prior to the incident. He stated since the doors have been reset, they will now alarm and lock and you must wait for a fifteen (15) second egress before the door will open if the code is pressed and a resident with a transmitter is within range. Further interview on 11/21/17 at 12:37 PM revealed prior to the elopement the door remained locked at all times. If the code was pressed and a resident with a transmitter was within approximately ten (10) feet or closer the door would open and the alarm would sound all over the building. He stated there was not an override code and only one code was used for staff and visitors. He stated when Tech Support was contacted on 11/13/17 the antennas were tested but there were no concerns and it was determined there was a glitch power failure that caused a break in the system. He stated now the doors lock and alarm, and only staff know the code to exit and enter the building. Interview with the Director of Nursing (DON) on 11/20/17 at 1:55 PM, revealed the resident was assessed on admission for an elopement risk and had a transmitter placed on his/her leg. She stated on 11/13/17 a visitor pressed the code and the resident followed out behind her and the door did not alarm nor lock down. She stated the visitor said she tried to shut the door but the resident followed. The DON stated the visitor did not tell anyone because she saw another person outside whom she thought was an employee with the facility's dog. The DON stated the resident proceeded to talk with the visitor on the porch and another visitor saw the resident outside and alerted LPN #1. She stated the alarm did not sound when the resident exited the building and staff were not aware the resident was outside. She stated the resident was currently on fifteen (15) minute checks for pulling the fire alarm a few days prior. The DON stated the system Tech thought there was an issue with the system due to the last code change but was not sure as she did not speak with the Tech. Interview on 11/21/17 at 1:39 PM revealed she expected the staff to provide adequate supervision as well as follow the plan of care plan. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. Resident #1 was placed on one (1) to one (1) monitoring immediately, assessed head to toe, reassessed for elopement risk on 11/13/17, responsible party and physician were notified, and care plan and CNA care plan were updated by the Assistant Director of Nursing (ADON) on 11/13/17. 2 All residents residing in the facility on 11/13/17 were reassessed for elopement risk by the ADON starting on 11/13/17 and completed on 11/14/17 and one (1) resident was identified as being an elopement risk. Upon identification through the assessment, the physician and family were notified, a wander guard was applied, the care plan and Certified Nurse Aide (CNA) care plan were updated, and elopement books were updated. 3. All residents identified as an elopement risk (12 residents), based on the assessments, had their wander guard bracelets checked for appropriated placement along with proper functioning of the wander guard bracelets by the Maintenance Director on 11/13/17. No concerns were noted. 4. All elopement books were reviewed to ensure accuracy and current resident information by the ADONs starting on 11/13/17 and completed by 11/14/17 with no concerns noted. 5. All care plans and CNA care plans for residents assessed at risk for elopement were audited and reviewed to ensure accuracy, appropriate interventions, and the plan of care was appropriate and individualized by the ADON and Minimum Data Set (MDS) Nurses starting on 11/13/17 and completed by 11/14/17, with no concerns noted. 6. All exit doors were assessed by the Maintenance Director along with the remote assistance of the company to ensure proper functioning on 11/13/17 and completed by 11/14/17 with no concerns noted. The wander guard system was adjusted by the Maintenance Director with assistance from the remote monitoring company on 11/13/17 to ensure if a resident with a wander guard in place, approached the door while it was open, the alarm would sound. 7. All accidents/incidents along with nurses notes and social services notes for the past thirty (30) days were reviewed for any exit seeking behaviors by the DON starting on 11/13/17 and completed by 11/14/17, with no concerns identified. 8. All door codes were changed by the Maintenance Director on 11/13/17 and signs posted at each door by maintenance on 11/13/17 to educate visitors that staff must allow them entrance/exit to and from the facility. 9. The DON was educated by the Regional Nurse Consultant (RNC) on 11/13/17 on policies and procedures to include residents with behaviors of wandering (identification, care plan, and monitoring), processes (placement, function test, EZMAR documentation, monitoring), competencies (wander guard to activate alarm when the door is open, no visitors to have to code, staff will allow visitors to enter/exit the facility) and tools. 10. The DON then trained the ADONs, Social Services which is a Licensed Practical Nurse (LPN), Medical Records (LPN), MDS Coordinators, and Nursing Supervisors on 11/13/17 on the policies and procedures. 11 Staff working on 11/13/17 were educated on elopement and missing resident policy and procedure, wander guard placement and function checks, documentation of wander guard placement and function in the EZMAR system and ensuring no visitors would be allowed to have knowledge of the codes by the Director of Nursing and Nurse Supervisor on 11/13/17. Once the Nursing Supervisor was educated on the policies and procedures and process she was then assigned to re-educate the staff starting 11/13/17 and completed on 11/22/17. The education was also included for all newly hired staff members. 12. Department Managers were educated on how to check the alarm system for correct code alert function at every exit in the facility by the Maintenance Director on 11/22/17. 13. An Ad Hoc Quality Assurance (QA) meeting was completed on 11/13/17 with the Medical Director via phone, the Administrator, and DON to review the incident and current plan. 14. The DON, ADONs, MDS Coordinators, Nurse Supervisor, and Social Services will audit/review all nurse's notes, social service notes, accident/incidents and twenty-four (24) hour report audits to encompass all shift daily to include Saturday and Sunday for eight (8) weeks to ensure any exit seeking behavior noted had appropriate intervention(s) implemented and updated on the care plans. 15. Findings of daily audits will be reviewed by the DON daily during the morning meeting and discussed in QA during every two (2) week QA meetings for six (6) weeks, then monthly. 16. The Maintenance Director or Weekend Manager will check/monitor all facility entrance/exit doors to ensure proper alarming and functioning daily, on alternating shift, to include Saturday and Sunday for eight (8) week, then daily on alternating shifts, Monday through Friday for eight (8) weeks starting on 11/14/17. Findings of daily checks will be reviewed with the Administrator daily and brought to QA. 17. Door codes will be changed by the Maintenance Director monthly to decrease the risk of visitors becoming aware of the door codes. 18. All audits will be reviewed by the Administrator every day during morning meeting and discussed with the QA team during QA meetings every two (2) weeks for eight (8) weeks then monthly for a minimum of six (6) months. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Review of a skin assessment revealed a head to toe assessment was completed for Resident #1 on 11/13/17 by LPN #1. A hand written note by the DON revealed the physician and family were notified on 11/13/17 of the elopement of Resident #1. Review of Resident #1's care plan and Nurse's Notes revealed the resident was placed on one (1) to one (1) supervision and the resident's wander guard was in place and functioning. Review of the Elopement Risk Evaluation dated 11/13/17 revealed the resident was reassessed to be at risk for elopement. Review of a resident census list revealed on 11/13/17, Resident #1's care plan and CNA care plan were reviewed and updated by the two (2) MDS staff. However, review of Resident #1's care plan revealed the care plan did not address checking the resident's wander guard for functioning every day. 2. Review of the resident census and all residents Elopement Risk Assessments revealed all residents but one (1), were reassessed for elopement risk by the ADONs on 11/13/17. Review of the one resident's elopement assessment dated [DATE], revealed he/she was identified at risk for elopement. Review of the resident's Nursing Note dated 11/14/17, revealed a wander guard bracelet was placed and the physician and family were notified. Review of the resident's Comprehensive Care Plan and CNA Care Plan revealed the care plan was updated for elopement risk. Review of the Elopement book revealed the book was updated with this resident's information. In addition, review of two (2) residents readmitted , one (1) admitted on [DATE] and another on 12/06/17 revealed they had exit seeking behaviors. However, these residents' care plans were not updated to include the intervention of checking the functionality daily; and, the orders/EZ MAR did not reflect the need to check the functioning every day. Interview with the DON on 12/15/17 at 10:12 AM revealed the orders should have been checked in the morning meeting. She stated obviously they were not checked to ensure the that the functioning piece was on the order/EZ MAR and the care plan when the residents returned from the hospital. 3. Review of a November 2017 calendar revealed the Maintenance Director checked to ensure all residents identified as being an elopement risk had their wander guard bracelets checked for placement and function. Interview with the Maintenance Director, on 12/14/17 at 2:26 PM revealed he checked the residents with wander guard bracelets to ensure they were in place and functioning on 11/13/17 and continues to check functioning every week. 4. Review of a November 2017 calendar revealed it was signed on 11/13/17 by the ADON indicating all the elopement books were reviewed to ensure accuracy and current resident information. Review of the Elopement Books on 12/14/17 revealed thirteen (13) of thirteen (13) residents identified as at elopement risk with current information. 5. Review of the Resident Census revealed it was signed by the two (2) MDS staff indicating all residents' care plans that were assessed at risk for elopement were accurate, appropriate and individualized. However, surveyor review of the residents' care plans assessed at risk for elopement revealed twelve (12) of thirteen (13) resident care plans did not address checking the function of the resident's wander guards every day. Interview with the two (2) MDS Coordinators on 12/15/17 at 11:45 AM revealed they were responsible to check the care plans to ensure they matched the physician's orders [REDACTED]. They stated if the physician's orders [REDACTED]. 6. Review of the November 2017 calendar dated 11/13/17 and signed by the Maintenance Director revealed the wander guard system was adjusted with assistance from the Code Alert monitoring system to ensure that if a resident with a wander guard in place approached the door while open the alarm would sound. Interview with the Administrator on 12/12/17 at 3:40 PM revealed he was present on the call with Maintenance and the Code Alert Monitoring System on 11/13/17 regarding the adjustment on the doors. 7. Review of all events, Nurse's Notes, and Social Service Notes for the last thirty (30) days revealed the DON had initialed at the bottom of each page to verify she reviewed them on 11/14/17. 8. Review of the November 2017 calendar revealed the Maintenance Director's signature indicating the door codes were changed on 11/13/17. In addition, observation on 12/12/17 revealed there was a note on each exit/entrance door dated 11/13/17, signed by the Administrator educating visitors that staff must let them out and in. Interview with Maintenance Director on 12/14/17 at 2:26 PM revealed he changed the door codes on 11/13/17 with assist from the manufacturing company via phone and the visitors were no longer allowed to have the code. 9. Review of an in-service document conducted by the Nurse Consultant to the DON, dated 11/13/17 revealed the DON was educated on the policies and procedures for elopement, care planning, monitoring, processes for the Physician orders [REDACTED]. The DON was out on leave at time of verification of AoC. 10. Review of Inservice document, dated 11/13/17, revealed the DON educated the Staff Development Coordinator (SDC), ADON's, Social Services (LPN), MDS team, and Nursing Supervisor on the policies and procedures for elopement, care planning, monitoring, processes for the Physician orders [REDACTED]. However, review of the December 2017 Physician order [REDACTED]. not been checked daily for functioning. Interview with the SDC on 12/15/17 at 11:52 AM revealed she was educated by the DON on the policies and procedures for elopement to include care planning, monitoring, processes for the Physician orders [REDACTED]. 11. Review of an Inservice document dated 11/13/17 revealed the SDC educated Nursing staff on the policies and procedures for elopement which included care planning, monitoring, processes for the Physician orders [REDACTED]. Review of the new employee Orientation Packet revealed the same education will be provided to new hires in the orientation process. Review of a new employee personnel file revealed she received the education on 11/14/17. Interview with the SDC on 12/15/17 at 11:52 AM revealed she educated the staff to check placement every shift and function every day and to sign off on the EZMAR. She stated if the nurses did not see an order that matched the inservice they should have changed the order. Interview with LPN #4 on 12/14/17 at 1:56 PM revealed she was educated to do and Elopement Risk Evaluation on admission and if the resident is at risk to apply a code alert bracelet on them. She stated the nurses were responsible to check for placement every shift and sign on the EZ MAR. She stated Maintenance completes the checks for functioning of the bracelets. In addition, she stated no visitors were allowed to know the code and the nurses must push the button at the desk to let visitors in as the staff do not know the code now as it was changed on 12/13/17 due to a visitor finding out the code. Interview on 12/14/17 with CNA #4 at 2:00 PM, and CNA #5 at 2:21 PM revealed they were educated by the SDC to get to the doors in a timely manner if alarming unless providing direct patient care, following the care plan, and not to give the code to any visitors as the code had changed. Interview with LPN #1 on 12/15/17 at 2:21 PM revealed she was not sure who checks the alarms for functioning but she documents on the EZMAR the wander guards were checked for placement and functioning. She stated she did not know how to check the bracelet for functioning. She also stated the order and care plan should match. Interviews on 12/14/17 with LPN #3 at 2:10 PM, LPN #4 at 1:56 PM, and LPN #5 at 4:40 PM revealed the nurses do not check functioning of the bracelet as Maintenance performs that task. They further stated the door code was changed on 12/13/17 because a family member had the code and now staff cannot have the code. Interview with the Administrator on 12/15/17 at 3:17 PM revealed the Maintenance Director checks the Wander Guard bracelets every week but the nurses should check every shift. He stated he had heard a visitor had the door code, therefore the code was changed on 12/13/17 and only he and the Maintenance Director have the code. He stated they did not investigate to determine how the code got out or re-inservice staff. 12. Review of an Inservice Document revealed the Maintenance Director educated the Department Managers on 11/22/17 on how to check the alarm system for correct code alert function at every exit in the facility. Interview with the Admissions/Marketing staff (Department Manager) on 12/14/17 at 3:00 PM revealed she was inserviced by the Maintenance Director on how to check the doors with a bracelet. She further stated they do not check the bracelets for functioning only the doors on the weekend. 13. Review of the AD Hoc QA meeting minutes provided by the facility revealed a plan was developed to address the elopement on 11/13/17. 14. Review of a November and December 2017 calendar revealed initials each day by the Nursing Administration team verifying audit/review of all Nurses' Notes, 24 hour reports, accident/incident reports and Social Services Notes to encompass all shifts to ensure to identify any exit seeking behavior and to ensure care plans/CNA care plans were updated. 15. Review of the facility provided QA book revealed the DON brought the audits that were conducted to the QA meeting conducted on 11/30/17. 16. Review of the November and December 2017 calendars revealed the Maintenance Director or weekend managers initialed they had checked/monitored the entrance/exit doors to ensure proper alarming and functioning every day including weekends on alternating shift through 12/15/17. Observation of entrance/exit doors on 12/14/17 at 11:27 AM revealed the code pushed with a transmitter within range and the door locked and alarmed when the door was pushed open. The door alarm was also tested while the door was open and the transmitter came close to the door and continued through the door and the door alarmed. 17. While the surveyor was in the building on 12/13/17, the Maintenance Director changed the door code. 18. Review of QA Book revealed the audits were reviewed by the Administrator every day during morning meeting and discussed with the QA team during QA meetings on 11/13/17 and 11/30/17. A QA Meeting was scheduled for 12/14/17 and will continue every two weeks for the next four (4) six weeks then monthly for a minimum of six (6) months.

Based on interview, record review, facility policy review, and review of hospital records, it was determined the facility failed to ensure their system to prevent new pressure ulcers from developing was effective for one (1) or six (6) sampled residents (Resident #1). Resident #1 was admitted to the facility on [DATE] for therapy after surgery for [REDACTED].#1, when turning and repositioning with pillows was not effective. Resident #1 developed three (3) Stage II pressure ulcers and one (1) week later the resident's wounds became unstageable. The facility determined the resident needed to be turned and repositioned every hour; however, review of records and staff interviews revealed the resident continued to be turned every two (2) hours. In addition, the resident received an order for [REDACTED].#1 was hosptalized on [DATE] and required surgery. The findings include: Review of the facility policy titled, Pressure Ulcer Risk Evaluation, last reviewed 04/24/15, revealed pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. Because a resident at risk can develop a pressure ulcer within two (2) to six (6) hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. In addition, if pressure ulcers are not treated when discovered, they have the potential to become larger, painful and infected. Furthermore, pressure ulcers are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin, decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition. Pressure ulcers are a serious skin condition for the resident. Identifying residents at Risk include [MEDICATION NAME] risk factors for pressure ulcers which includes immobility; extrinsic risk factors include pressure which the resident is not capable of moving without assistance, is confined to bed, and/or requires a regular schedule of turning. When a resident is identified as a high risk proceed to care planning and interventions individualized for the resident and their particular risk factors. Nurses will conduct skin evaluations at least weekly to identify changes. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. If a new skin alteration is noted, complete a pressure risk evaluation. Review of the facility policy titled, Assessment and Evaluations, last reviewed 12/27/16, revealed licensed nurses, nurse designees, or Physical Therapists must complete and document all resident weekly skin assessments in WoundSense. Weekly skin assessments will be conducted and documented in WoundSense. All resident alterations in skin integrity will be tracked weekly in WoundSense. At the time a new alteration in resident skin integrity is identified, the resident's Care Plan should be revised and/or updated. Record review revealed the facility admitted Resident #1 on 07/14/17 with [DIAGNOSES REDACTED]. Review of the Nursing Admission Information Assessment, dated 07/14/17 at 1:30 PM performed by Licensed Practical Nurse (LPN) #5, revealed no skin breakdown or redness to the buttock area or other areas of the body. Further review revealed the resident was assessed as bedfast, completely immobile, skin was often moist, and was considered a problem with friction and shearing. Further review of the assessment revealed the Braden score was a twelve (12) which indicated the resident was at high risk for skin breakdown. Review of the Interim Plan of Care for Alteration in Skin Integrity, dated 07/14/17, revealed interventions for incontinence care as needed, turn and reposition every two (2) hours, pressure reducing mattress, and to consult physical therapy, if indicated. In addition, review of the Interim At risk for Orthopedic Complications Care Plan revealed interventions to observe for [MEDICAL CONDITION], [DEVICE] to left lower extremity, anticoagulant as ordered, and observe for signs and symptoms at surgical sites. Review of July 2017 Certified Nurse Aide (CNA) Care Plan revealed assist with three (3) for positioning and [DEVICE] to right foot/leg with pins, turn and reposition every two (2) hours. However, further review revealed there was no intervention to address the resident pressure when out of bed and in a chair/recliner. Interview with Certified Nurse Aide (CNA) #8, on 09/11/17 at 3:16 PM, revealed she took care of Resident #1 when she first came to the facility and was with Licensed Practical Nurse (LPN) #5 while performing the initial skin assessment. She stated the resident's bottom was clear with no redness or red areas. She stated at times the resident did not want to turn but would turn with assist of three (3) staff. She further stated due to the fixator and the resident's weight, he/she would fall back over on the pillows the staff were using for positioning. She stated she was not aware if anyone told the nurse or administration that the pillows were not working but she did not. She revealed the facility did use wedges for positioning residents but this resident had pillows. Interview with LPN #5, on 09/11/17 at 2:31 PM, revealed she assessed Resident #1 on admission to the facility. She stated the resident did not have any skin breakdown, with only bruises from lab draws and on the back of knees and an [DEVICE] with six (6) pin sites. She further verified she assessed his/her peri area and bottom and there was nothing noted abnormal. She stated the resident was high risk Braden due to immobility, incontinent of stools, and the need to turn and reposition. She further stated the resident was always compliant and never refused to turn and reposition for her. Review of Weekly Skin Assessments, dated 07/15/17 at 4:45 AM, 07/16/17 at 5:57 AM, and 07/17/17 at 1:37 PM revealed reddened intact skin to the coccyx; however, further review of the Interim Care Plan dated 07/14/17, revealed there were no interventions added to address the resident's reddened skin which indicated pressure. Interview with CNA #6, on 09/09/17 at 9:55 AM, revealed she was told in report from the night shift on 07/16/17 the resident had slept in his/her recliner all night. Furthermore, she revealed the resident was compliant with turning and repositioning but it would require three (3) staff members. She stated the resident exhibited no behaviors. Interview with Registered Nurse (RN) #1 on 09/12/17 at 9:00 AM revealed the nurses perform a skin assessment within two (2) hours of admission. She stated if a resident is at high risk for skin breakdown an intervention for repositioning would be in place. She stated the interventions were communicated to staff, but obviously someone did not relieve the pressure from the resident or the wound would not have appeared. She stated she saw the resident sleeping in his/her recliner when she came on shift around 6:30 AM on 07/16/17, and passed on the resident could not sleep in his/her recliner as he/she could not be repositioned. She stated the resident had difficulties with repositioning due to the fixator and did not have a wedge cushion when she cared for the resident. In addition, she stated if interventions are not working then other interventions should be implemented. She stated on 07/17/17 when the buttocks were noted to be red but blanchable the nurse should have implemented other interventions. Interview with LPN #3, on 09/11/17 at 2:48 PM, revealed she took care of Resident #1 on 07/17/17 and the resident had a red bottom but blanchable. She stated due to the fixator and the pins and the resident's size he/she was difficult to reposition and keep off his/her bottom. She stated the staff applied barrier cream and tried to keep the resident off his/her bottom as much as possible and the resident never complained and was very compliant with care and turning. Interview with CNA #11, on 09/14/17 at 10:50 AM, revealed she took care of Resident #1 and positioned the resident with pillows and the resident was compliant. She stated the resident would fall over on the pillows and be back on his/her back after positioning. Review of Weekly skin assessment on 07/24/17 (Monday) at 11:02 AM revealed a Suspected Deep Tissue Injury to the coccyx, and Stage II' pressure ulcers identified to the left buttock measuring 4.6 centimeters (cm) x 5 cm x 0.1 cm, right buttocks ulcer measuring 5.8 cm x 3 cm x 0.1 cm, and coccyx measuring 1.8 cm x 1.2 cm x 0.1 cm. Review of a Nurse's Note, dated 07/24/17 at 4:07 PM by LPN #8 revealed an order was obtained for the wounds and the family notified. Review of Physician's Order on 07/24/17 revealed air mattress with bolsters and to apply [MEDICATION NAME] dressing to open areas on right and left buttocks and on coccyx and change every three (3) days. Review of Acute Skin Care Plan, dated 07/24/17, revealed on 07/24/17 interventions were added for an air mattress with bolsters, a roho cushion to recliner, and nutritional supplements; however, there was no intervention added to address the resident's falling back over the pillows used for positioning due to his/her weight and extender device. Review of Nurse's Note, dated 07/26/17 at 4:54 PM by the Assistant Director of Nursing (ADON) #1 revealed stage II wound measurement to the coccyx was 1.0 centimeters (cm) x 1.4 cm x 0.1 cm, granulation to the wound bed, edges clearly defined, red but blanchable. Improvement from initial assessment on 07/24/17 which was 1.8 cm x 1.2 cm x 0.1 cm. The stage II wound to the right buttock measured 4.7 cm x 3.0 cm x 0.1 cm, granulation to wound bed, surrounding skin red but blanchable, and wound edges visible. Improvement from initial assessment on 07/24/17 which was 5.5 cm x 3.0 cm x 0.1 cm. The stage II wound to the left buttock measured 4.4 cm x 4.5 cm x 0.1 cm, granulation tissue to the wound bed, edges clearly defined, and skin surrounding wound red but blanchable. Improvement from initial assessment on 07/24/17 of 4.6 cm x 5 cm x 0.1 cm. The Deep Tissue Injury to the coccyx and left buttock have resolved. Treatment changed. Review of Physician's Order, dated 07/26/17, revealed to discontinue the Duoderm to coccyx; and, cleanse well with wound cleanser, cover with Double antibiotic ointment (DAO) with Dimethicone ointment, cover with gauze twice a day and as needed when soiled. Further review revealed there was no further assessment of the wounds until 08/02/17. Review of Nurse's Note, dated 08/02/17 at 3:56 PM by ADON #2, revealed unstagable coccyx wound measured 8.0 cm x 2.6 cm x 0.0 cm (prior measurement 1.0 centimeters (cm) x 1.4 cm x 0.1 cm), slough/eschar noted to wound bed, peri-wound red but blanchable. Unstageable ulcer to the right buttock measured 8.4 cm x 4.4 cm x 0.0 cm (prior measurement 4.7 cm x 3.0 cm x 0.1 cm) with slough/eschar to wound bed, peri-wound red but blanchable. Unstageable ulcer to left buttock measured 8.2 cm x 9.2 cm x 0.0 cm (prior measurment 4.4 cm x 4.5 cm x 0.1 cm), slough/eschar noted to wound bed, periwound red but blanchable. Treatment order was changed, no odor or drainage noted. Review of Physician Orders, dated 08/02/17 revealed to discontinue treatment ordered on [DATE]; and, cleanse buttocks and coccyx with warm water, pat dry, apply santyl to slough, cover with gauze three (3) times a day. Interview with LPN #8, on 09/14/17 at 8:30 PM, revealed a CNA told her she was having a difficult time keeping the resident turned with pillows. She stated it took two (2) to three (3) people to turn the resident and the resident was compliant with turning and repositioning. She revealed she assisted a lot of times with repositioning and tried the best she could and also tried to provide the best alignment. She stated she was not in the resident's room every two (2) hours but pretty sure the staff did frequent position changes. Furthermore, she stated she felt the wounds developed from pressure. Interview with LPN #4 on 09/10/17 at 2:25 PM revealed she took care of the resident once the resident received his/her wounds. She stated when she saw the wounds she could not believe how bad they were as they were necrotic and found out he/she received the wounds at the facility. She stated the resident was compliant with turning and repositioning with assist of three (3) CNAs. She further stated the resident ate well. She revealed if the resident would have been turned she would not have developed the wounds as she felt they were avoidable. Interview with CNA #4, on 09/10/17 at 2:11 PM, revealed she took care of the resident once the resident already had developed wounds. She stated the resident was total assist of three (3) staff to turn and reposition. She stated the nurse would tell the staff if a resident was at risk for skin breakdown and they were expected to follow the care plan for care. Further interview with CNA #4, on 09/12/17 at 2:45 PM, revealed when the staff would go back to turn the resident he/she would be on his/her back as he/she would fall over the pillows. She stated she did not use a wedge cushion but had heard staff discussing about the thoughts of using one on the resident. Interview with CNA #7, on 09/09/17 at 5:33 PM, revealed she took care of Resident #1 after she moved halls and had wounds to his/her bottom. She stated the resident was compliant with turning and repositioning with total assist of two (2). Interview with CNA #10, on 09/26/17 at 1:20 PM, revealed the staff are expected to follow the care plan for resident's care. She stated she worked with the resident once wounds were unstageable and was told to turn and reposition every two (2) hours. She stated the resident would be positioned with pillows and fall back over. She stated she never used a foam cushion with positioning the resident. Interview with CNA #3 on 09/09/17 at 9:43 AM revealed she worked with Resident #1 when he/she was first admitted to the facility. She stated the resident developed a spot on his/her bottom and then when she came back to work the resident was moved to another hall. She revealed the resident required two (2) or more assist with turning and repositioning and was compliant with turning and repositioning. Further interview on with CNA #3 on 09/13/17 at 9:24 AM revealed she would place pillows behind the resident when she would turn and reposition the resident but the resident would fall back over on the pillows due to his/her weight and fixator. She stated the CNAs and LPN #1 discussed a wedge cushion for positioning but she was not for sure how far the conversation went. She stated when she came in the next time to care for the resident he/she still had pressure to his/her bottom. She further stated if the resident would have been able to be kept off his/her bottom, he/she would not have probably developed pressure ulcers. Interview with LPN #1, on 09/13/17 at 11:51 AM, revealed Resident #1 was a high risk Braden which means the resident was at high for skin breakdown. She stated when she first worked with the resident he/she did not have skin breakdown. She stated the resident was dependent on staff because of the [DEVICE] and incontinent of bowel. She stated it took three (3) people for turning and repositioning as one (1) staff member had to hold the [DEVICE] while the other staff turned the resident. She stated the resident was a turn and reposition every two (2) hours, then more frequent after the skin breakdown. She further stated the resident was positioned with pillows and sometimes had problems staying over on his/her side. She revealed a CNA did ask about a wedge but told the staff to continue to use the pillows and keep the resident off his/her bottom as one (1) reason there was not a wedge available in the building. In addition, she stated since the resident was not able to turn it would not take long for an area to breakdown. She then stated the resident could roll over. She stated not everyone knows how to position residents with pillows. She revealed she felt the reason the resident develop the wounds was due to pressure, obesity, immobility, and falling back over onto his/her back after positioning due to the fixator and obesity. Furthermore, she stated if interventions are not effective a nurse is responsible to implement a new intervention and update the care plan. She revealed the nurse determines if the interventions are effective by looking at the wound log and if the wound deteriorated then would need to review interventions and change. Review of the Resident Acute Skin Ulcer Care Plan, dated 07/24/17 revealed on 08/02/17 and 08/05/17 an intervention was added to turn the resident every one (1) hour and review of Nurse Aide Care Plan for August 2017 revealed the turning and repositioning schedule was changed to every one (1) hour on 08/02/17. However, there was still no intervention to address the ineffectiveness of positioning the resident with pillows. In addition, review of a Nurse's Note, dated 08/04/17 at 11:37 AM and 08/05/17 at 4:12 PM by LPN #6 revealed turn and reposition resident every two (2) hours and as needed. Review of a Nurse's Note, dated 08/05/17 (Saturday) at 11:15 PM by LPN #9 revealed resident was turned at 8:20 PM and the dressing to buttocks and coccyx was saturated with yellow drainage. Further review of the Nurse's Notes revealed on 08/05/17 at 11:20 PM by LPN #9 revealed the resident was turned and positioned at 10:15 PM (approximately two (2) hours later) and received medications. Review of a Nurse's Note, dated 08/06/17 at 7:10 AM by LPN #4 revealed resident turned and repositioned every two (2) hours per two (2) staff and low air loss mattress in place. Review of a Nurse's Note, dated 08/06/17 at 4:32 PM by LPN #6, revealed resident is being turned every two (2) hours and as needed. Review of a Physician Order, dated 08/05/17 at no time, revealed to utilize foam wedge for positioning in bed with turning; however, review of a Nurse's Note, dated 08/07/17 at 3:06 AM by LPN #1, revealed to turn and reposition every two (2) hours from side to side with use of repositioning pillows. Interview with CNA #5, on 09/09/17 at 7:15 PM, revealed she took care of Resident #1 when he/she already had developed wounds. She stated the wounds had a huge black area. She stated the resident required three (3) staff to turn him/her due to the fixator on his/her leg. Further interview with CNA #5, on 09/26/17 at 7:35 PM, revealed pillows were used for repositioning the resident. She stated the last day she worked with the resident was on 08/03/17 and the resident was being turned and repositioned every two (2) hours. She revealed when she returned to work on 08/08/17 the resident was sent to the hospital but she had heard the resident had been changed to an every hour turn and repositioning. Interview with LPN #6 on 09/26/17 at 1:05 PM revealed nurses are to follow the care plan for care as well as the physician orders. Furthermore, the CNAs are expected to follow the care plan. She stated the staff were in the resident's room constantly. She stated when she documented every two (2) hours and as needed means less than two (2) hours. She further stated she did not remember a wedge cushion for repositioning, but used pillows. Interview on 09/12/17 at 10:00 AM revealed on 08/05/17 the odor was very bad. She stated she called the DON and the DON told her to call the Nurse Practitioner. She stated the Nurse Practitioner stated she was not coming in that she would see the resident on Monday (08/07/17) and would not order an antibiotic but did change the dressing order on 08/05/17 to Dakins solution three (3) times a day to buttocks and coccyx wet to dry and cover with foam. Interview with LPN #9 on 09/26/17 at 7:30 AM revealed she did not use a wedge with repositioning and was resident's nurse on 08/05/17. She stated she follows the care plan and orders for care, but basically goes by the resident's condition. She further stated every resident is turned and repositioned every two (2) hours as well as was Resident #1. Review of a Progress Note written by the Advanced Registered Nurse Practitioner (ARNP) , dated 08/07/17 at no time (Monday), revealed Resident #1's left buttock black eschar Suspected Deep Tissue Injury 4 cm x 5 cm, no drainage with purplish, nonblanchable and firm surrounding tissue; Suspected Deep Tissue Injury to the right buttock with undermining beneath the slough 10 cm x 8 cm x 0 cm with tissue changes undermining 4 cm drainage [MEDICAL CONDITION] moderate amount with moderate odor with surrounding tissue superior purplish, nonblanchable and firm along with odor from dead tissue that was soft and trimmed back; right buttock [DIAGNOSES REDACTED] 3 cm lateral from edge of eschar only on lateral edge. Review of a Late Entry Nurse's Note, dated 08/08/17 at 12:52 PM for 08/07/17 at 12:00 PM by the Director of Nursing (DON), revealed Physician was notified of purulent drainage to the wound and that Nurse Practitioner would not prescribe antibiotic with an order received for Juven, an antibiotic, and a culture of drainage which was obtained at 1:45 PM. Review of the Physician's Order, dated 08/07/17 at no time revealed Juven one (1) packet by mouth twice a day for wound healing and Bactrim DS one (1) by mouth twice a day for ten (10) days, culture purlent fluid. Review of a Nurse's Note, dated 08/07/17 at 4:29 PM revealed LPN #12 requested the nurse practitioner to demonstrate correct positioning and questioned if the pillow should be placed at the buttocks related to the wound. The Nurse Practitioner instructed the resident to be positioned as demonstrated until foam wedge available. Interview with CNA #10, on 09/13/17 at 11:15 AM, revealed she took care of Resident #1 when the resident had areas to his/her bottom. She stated the resident was to be turned and repositioned every two (2) hours with pillows for positioning. She stated right before the resident went to the hospital, the resident went to every hour turn and repositioning. She revealed the resident received a wedge at the end of his/her stay for the top half of his/her body then continued to use pillows for the bottom half. She revealed the wedge assisted the resident to keep him/her off his/her bottom better. She further revealed the resident was compliant with turning and repositioning and would assist anyway he/she could. Interview with CNA #11, on 09/26/17 at 1:25 PM, revealed the staff are to go by the care plan and instructions by the nurse for providing care. She stated she worked with the resident the day before the resident went to the hospital (08/07/17). She stated that LPN #12 talked with the Nurse Practitioner regarding problems of repositioning the resident as the resident would fall over the pillows. The Nurse Practitioner provided education to the CNA's and LPN taking care of the resident on proper positioning. She further stated she found a wedge cushion later in laundry. She stated the resident was turned and repositioned every two (2) hours and then the nurse practitioner told us during education to turn and reposition every hour. Interview with LPN #12/Charge Nurse, on 09/26/17 at 1:39 PM revealed staff are expected to follow the care plan, physician's orders, Treatment Administration Record (TAR), and Medication Administration Record [REDACTED]. She stated the resident did not have a wedge at the time the nurse practitioner educated regarding positioning. She further stated later that day they found a wedge. She revealed the resident became a turn and reposition every hour on 08/07/17 as she had discussed with the Assistant Director of Nursing of need to increase turning and repositioning. She stated she was not sure of the turning schedule prior to 08/07/17. Further interview with LPN #12, on 09/27/17 at 9:00 AM, revealed when a nurse receives an order the nurse is responsible to obtain whatever the order may be. The nurse would then update the care plan with the order and any changes. She further stated the charge nurse is responsible to monitor the CNAs and remind them of certain changes as well as reading their care plans to ensure they are following. The charge nurse is responsible to update the CNAs care plan when the nursing care plan is updated. Review of a Nurse's Note, dated 08/08/17 at 9:38 AM, revealed to direct admit the resident to the hospital per the surgeon. Review of the Hospital History and Physical, dated 08/08/17, revealed the resident was discharged to the nursing home about two (2) weeks ago with a right lower extremity fixator and presented for direct admit after a very significant and worsening decubitus ulcer. The hospital History and Physical skin assessment revealed an extremely large sacral decubitus ulcer with copious eschar, and foul drainage. The Surgeon was consulted and took the resident directly to surgery. He debrided a large amount of eschar. Furthermore, the History and Physical revealed the resident was fairly immobile when discharged to the nursing home. Review of the Hospital Surgeon Consultation, dated 08/09/17 revealed the resident had breakdown of the sacral skin, malodorous smell and oozing material in the last three (3) to four (4) days. The resident had obvious infected and necrotic Stage IV sacral decubitus ulcer. Review of the skin revealed a sacral decubitus ulcer, Stage IV with obvious necrosis and liquefaction of the deeper tissue, it is malodorous with the area measuring 15 cm x 16 cm. Interview with Resident #1's daughter, on 09/12/17 at 3:30 PM, revealed when the resident came to the facility on [DATE] the resident's bottom was clear and the facility requested the family bring a recliner for the resident. She stated on 07/16/17 the facility called and stated they could not wake the resident up and that the resident was in his/her recliner and had been in the recliner all night. She revealed the staff then transferred the resident from the recliner with a lift at approximately 9:30 AM on 07/16/17 and placed the resident in the bed. She stated at that time the resident did not have a cushion to the recliner and after that incident the resident did not get back in the recliner. She revealed they visited the resident once to twice a day and most of the time when visiting the resident was on his/her back. She stated on 08/05/17 the odor was so bad she could not even stay in the resident's room. The daughter stated once the wounds progressed so bad the facility stated on 08/07/17 they would get an appointment with a surgeon for the wound but it would take two (2) weeks. Therefore, the family called a friend physician who was able to direct admit the resident to the hospital the next day on 8/08/17. Once at the hospital the surgeon ordered immediate surgery. She was then transferred to another hospital to care for his/her wounds on 08/16/17 with a wound vac. On 08/24/17 the resident was moved to another hospital for treatment of [REDACTED]. Interview with the Assistant Director of Nursing (ADON) #1 on 09/13/17 at 11:37 AM revealed the resident was a high risk Braden score and interventions for high risk are different for every resident. She stated the standard is to turn and reposition every two (2) hours, pressure reduction mattress, cushion in chair, and position with pillows. She stated if the resident has no skin breakdown the goal is for the resident not to develop skin breakdown during the stay. She further stated the staff never reported to her the interventions were not effective for Resident #1. She stated a nurse told her Resident #1 was reluctant to get into the bed one (1) time but would get into the bed. She revealed she knew on admission the resident had an [DEVICE], but was unsure about weight. She stated if the interventions were not working for the resident the CNA should have followed the interact program and filled out a stop and watch and gave one (1) copy to the nurse and the other to the Director of Nursing (DON) or Administrative nurse so the issue could have been followed up on. She stated she expected the nurses to follow up on issues presented by the CNA. Furthermore, she stated she expected the CNAs to report issues to the nurse and if not followed through by the nurse to report to the DON or ADON. In addition, she stated the interventions for Resident #1 should have been changed since the interventions used were not effective. Interview with ADON #2 on 09/14/17 at 11:10 AM revealed she had not had a nurse come to her about the need for changes in the interventions for Resident #1. She stated the Nurse Practitioner was present when she performed a dressing change when the wounds were unstageable. She stated she would expect the Nurse Practitioner to tell her if the staff were having issues with positioning and needed education by the Staff Development Coordinator. She stated at the end the three (3) wounds blended into one (1) big wound. She stated nursing could have ordered a wedge cushion for the resident as there are two (2) to three (3) in the facility available for use in laundry. She further stated if a resident is a high risk Braden the resident should be repositioned every couple of hours, monitor intake and friction and if a problem noted to address. She revealed nurses are responsible to assess interventions and if not effective to implement new interventions; if no issues then the interventions would be considered effective. She further revealed a new intervention should have been tried if the resident was falling over the pillows and not staying positioned. She stated the goal if a resident does develop a wound is to prevent the wound from worsening. Interview with the Advanced Registered Nurse Practitioner (ARNP) on 09/12/17 at 2:22 PM revealed Resident #1 would be turned if agreeable with turning. She stated the first time she saw the resident at the beginning of the stay he/she was sitting in a chair around breakfast time. She stated the resident did not want to get out of the recliner and was still there at lunch. She revealed if the interventions that are in place for a resident are not effective then other interventions should be implemented. She stated the next time she saw the resident, the resident was laying on pillows on his/her back and had fallen over. She further stated if the staff would have bent his/her leg this would have helped the resident stay over on his/her side. She stated she did provide training with some staff (two {2} staff and one (1) nurse) regarding turning and repositioning the resident but at that time the wounds were unstageable, but no others. In addition, she revealed a limited amount of time on the area when a resident is considered high risk of skin breakdown can cause a pressure ulcer. Interview with the Resident #1's Physician, on 09/11/17 at 2:00 PM, revealed she had the impression from the facility the resident was not wanting to turn. She stated she felt if the resident was not being turned as should have been the wounds were avoidable. She further stated she was scheduled to come to the facility to see the resident on 08/09/17, but was called by the facility on 08/08/17 and was told pus was coming out of wounds. She stated she was not aware of the wounds until then as the Nurse Practitioner had been caring for the wounds. She further stated she should have been aware of the wounds. Interview with the Surgeon, on 09/13 (TRUNCATED)

Based on interview, record review, facility policy review, review of hospital records, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to provide services as outlined by the comprehensive care plan for two (2) of six (6) sampled residents (Residents #1 and #3). Resident #1 was care planned on [DATE] to be turned and repositioned every hour after developing Unstagable Necrotic Wounds on his/her buttocks and coccyx; however, staff failed to turn and reposition the resident every hour. Resident #1 was transferred to the hospital on [DATE] and required immediate surgery on the wounds. Resident #3 was care planned on [DATE] to administer medications as ordered, observe for shortness of breath, reort clinical changes to physician, and breath sounds as needed; however, the staff failed to report Resident #3 had a change in condition on the night of [DATE] into the norning of [DATE] when the resident required four (4) as needed nebulizer treatments in seven (7) hours. In addition, the licensed staff failed to obtain breath sounds after the administration of the nebulizer treatments and failed to administer the medication as ordered when she administered a nebulizer treatment in one (1) hour and fiften (15) minutes instead of two (2) hours as ordered. The findings include: Interview with the Director of Nursing (DON) on [DATE] at 10:33 AM revealed the facility follows the Resident Assessment Instrument (RAI) Version 3.0, dated [DATE] for following the care plan. The RAI Manual revealed putting that course of action (specific interventions derived through interdisciplinary individualized care planning) into motion by staff knowledgeable about the resident's care goals and approaches; carrying out the how and when of resident care. 1. Record review revealed the facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. Review of Nurse's Note, dated [DATE] at 3:56 PM by Assistant Director of Nursing (ADON) #2, revealed the resident had an unstagable ulcer to the coccyx that measured 8.0 cm x 2.6 cm x 0.0 cm, slough/eschar noted to wound bed, peri-wound red but blanchable. An Unstageable ulcer to the right buttock that measured 8.4 cm x 4.4 cm x 0.0 cm with slough/eschar to wound bed, peri-wound red but blanchable. In addition, there was an Unstageable ulcer to left buttock that measured 8.2 cm x 9.2 cm x 0.0 cm, slough/eschar noted to wound bed, periwound red but blanchable. Treatment order was changed, no odor or drainage noted. Review of the Resident Acute Skin Ulcer Care Plan, dated [DATE] and [DATE] Certified Nurse Aide (CNA) Care Plan revealed on [DATE] an intervention was added to turn the resident every one (1) hour. However, review of a Nurse's Note, dated [DATE] at 11:37 AM and [DATE] at 4:12 PM by Licensed Practical Nurse (LPN) #6 revealed turn and reposition resident every two (2) hours and as needed. Review of a Nurse's Note, dated [DATE] (Saturday) at 11:15 PM by LPN #9 revealed resident was turned at 8:20 PM and the dressing to buttocks and coccyx was saturated with yellow drainage. Further review of the Nurse's Notes revealed on [DATE] at 11:20 PM by LPN #9 revealed the resident was turned and positioned at 10:15 PM (approximately two (2) hours later) and received medications. Review of a Nurse's Note, dated [DATE] at 7:10 AM by LPN #4 revealed resident turned and repositioned every two (2) hours per two (2) staff and low air loss mattress in place. Review of a Nurse's Note, dated [DATE] at 4:32 PM by LPN #6, revealed resident is being turned every two (2) hours and as needed. Review of a Progress Note written by the Advanced Registered Nurse Practitioner (ARNP) , dated [DATE] at no time (Monday), revealed Resident #1's wounds had worsened with the left buttock having black eschar Suspected Deep Tissue Injury 4 cm x 5 cm, no drainage with purplish, nonblanchable and firm surrounding tissue; the Suspected Deep Tissue Injury to the right buttock with undermining beneath the slough 10 cm x 8 cm x 0 cm with tissue changes undermining 4 cm drainage [MEDICAL CONDITION] moderate amount with moderate odor with surrounding tissue superior purplish, nonblanchable and firm along with odor from dead tissue that was soft and trimmed back; and the right buttock wound with [DIAGNOSES REDACTED] 3 cm lateral from edge of eschar only on lateral edge. Review of a Late Entry Nurse's Note, dated [DATE] at 12:52 PM for [DATE] at 12:00 PM by the Director of Nursing (DON), revealed Physician was notified of purulent drainage to the wound and an order was received for Juven, an antibiotic, and a culture of drainage which was obtained at 1:45 PM. Review of a Nurse's Note, dated [DATE] at 9:38 AM, revealed to direct admit the resident to the hospital per the surgeon. Interview with CNA #5 on [DATE] at 7:15 PM revealed the last day she worked with the resident was on [DATE] and the resident was turn and reposition every two (2) hours. She stated when she returned to work on [DATE] the resident was sent to the hospital but she had heard the resident had been changed to every hour turning and repositioning. She stated the staff are expected to follow the care plan for care and the nurse's will provide any changes and update the care plan. Interview with CNA #10 on [DATE] at 11:15 AM revealed she took care of Resident #1 when the resident had areas to his/her bottom. She stated the resident was to be turned and repositioned every two (2) hours with pillow. She stated right before the resident went to the hospital she went to every hour turn and repositioning. Interview with CNA #10 on [DATE] at 1:20 PM revealed the staff are expected to follow the care plan for resident's care. She stated she worked with the resident once wounds were unstageable and was told to turn and reposition every two (2) hours. She stated the resident would be positioned with pillows and fall back over. Interview with CNA #11 on [DATE] at 1:25 PM revealed the staff are to go by the care plan and instructions by the nurse for providing care. She stated she worked with the resident the day before the resident went to the hospital ([DATE]). She stated that LPN/Charge Nurse #12 talked with the Nurse Practitoner regarding problems of repositioning the resident as the resident would fall over the pillows. The Nurse Practitioner provided education to the CNAs and LPN taking care of the resident on proper positioning. She further stated she found a wedge cushion later in laundry. She stated the resident was turn and reposition every two (2) hours and then the nurse practitioner told us during education to turn and reposition every hour. Interview with LPN #6 on [DATE] at 1:05 PM revealed nurses are to follow the care plan for care as well as the physician orders. Furthermore, the CNAs are expected to follow the care plan. She stated the staff were in the resident's room constantly. She stated when she documented every two (2) hours and as needed means less than two (2) hours. Interview with LPN #9 on [DATE] at 7:30 AM revealed she follows the care plan and orders for care, but basically goes by the resident's condition. She further stated every resident was turned and repositioned every two (2) hours. Interview with LPN #12 on [DATE] at 1:39 PM revealed staff are expected to follow the care plan. She stated the resident became a turn and reposition every hour on [DATE] as she had discussed with the Assistant Director of Nursing the need to increase the turning and repositioning. However, she stated she was not for sure of the turning schedule prior to [DATE]. She further stated the charge nurse is responsible to monitor the CNAs and remind them of certain changes as well as reading their care plans to ensure they are following. Review of the Hospital History and Physical dated [DATE] revealed the resident was discharged to the nursing home about two (2) weeks ago with a right lower extremity fixator and presented back for direct admit after a very significant and worsening decubitus ulcer. The hospital History and Physical skin assessment revealed an extremely large sacral decubitus ulcer with copious eschar, foul drainage. The surgeon was consulted and took the resident directly to surgery. He debrided a large amount of eschar. 2. Record review revealed the facility admitted Resident #3 on [DATE] with [DIAGNOSES REDACTED]. Review of the Interim Plan of Care for Respiratory Complications related to [MEDICAL CONDITION], dated [DATE], revealed to administer medications as ordered, observe for shortness of breath, changes in sputum/report clinical changes to physician, observe for [MEDICAL CONDITION], and oxygen (O2) as ordered/breath sounds as needed. Review of the admission orders [REDACTED]. In addition the resident orders revealed [MEDICATION NAME] 0.083% Inhalation Solution [MEDICATION NAME] give one (1) vial via nebulizer every two (2) hours as needed for [MEDICAL CONDITION]. Review of the [DATE] MAR and Late Entry Nurse's Notes dated [DATE] at 6:37 AM through [DATE] at 6:42 AM, revealed the resident received as needed nebulizer treatments on [DATE] at 8:49 PM (twenty-four (24) hours after the last as needed dose), on [DATE] at 11:40 PM, on [DATE] at 12:55 AM, and on [DATE] at 3:41 AM due to congested lungs. however, further review of the [DATE] MAR and Late Entry Nurse's Notes dated [DATE] at 6:37 AM through [DATE] at 6:42 AM, revealed there was no documented evidence the staff notified the Physician of the resident's change in clinical status or obtained the resident's breath sounds as needed (after as needed nebulizer treatments were completed) per the care plan. Review of a Late Entry Nurse's Note by Licensed Practical Nurse (LPN) #3 on [DATE] at 10:18 AM for 6:45 AM revealed the resident was lying in bed with eyes closed, with no verbal response or eye contact. Vital signs were obtained and respirations were slightly labored, lung sounds diminished, O2 saturation 93%, with no distress noted at this time, [MEDICATION NAME] was forty-three (43). The physician was notified and an order obtained for [MEDICATION NAME] intramuscularly. At 6:55 AM [MEDICATION NAME] administered and resident unable to arouse. Rechecked [MEDICATION NAME] at 7:10 AM and was forty-six (46). The resident remained unable to arouse. While Charge Nurse was hanging an intravenous antibiotic, the Charge Nurse observed the resident had stopped breathing; a code was called; and. Cardiopulmonary Resuscitation (CPR) was administered at 7:25 AM. The physician was notified at 7:35 AM and was transferred to the hospital with continued CPR. Review of the emergency room Outpatient Encounter Record, dated [DATE] at 7:57 AM revealed the resident arrived at 7:35 AM with CPR in progress. The patient was intubated and hospital's Electrocardiogram (EKG) revealed PEA. Furthermore, a pulse was regained at 7:46 AM and blood pressure was ,[DATE]. At 7:53 AM the resident went into Ventricular Fibrillation (V-Fib) and the resident was deceased at 8:06 AM. Interview with Certified Nurse Aide (CNA) #1 on [DATE] at 10:12 AM she was Resident #3's aide for the night of [DATE] and [DATE]. She stated on the night of [DATE] and into the morning of [DATE], Resident #3 would put on his/her call light and request a nebulizer treatment because he/she could not breath. Interview with LPN #1 on [DATE] at 11:51 AM revealed she administered the treatments because the resident was experiencing difficulty breathing as he had a [DIAGNOSES REDACTED]. She stated respirations, oxygen saturations, heart rate, and lung sounds were supposed to be obtained prior to and after each nebulizer treatment. She revealed the assessment was not available for her to put the information in the computer on the MAR and when that was the case the information would be put in the nurse's notes. She stated she was aware that LPN #2 had administered an as needed nebulizer treatment on [DATE] at 11:40 AM but the resident was having problems breathing and requested another breathing treatment on [DATE] at 12:55 AM, an hour and fifteen minutes later, so she administered another treatment. She revealed she did not determine the resident had a change in condition and the physician should be notified. She stated she conducted neurochecks after the resident fell on [DATE] at 4:45 AM and she noted no changes in the resident and no labored breathing. She stated the resident did not seem to be in respiratory distress when she performed neurological checks after the fall. She revealed the nurses are expected to follow the care plan and this resident's care plan stated to observe for [MEDICAL CONDITION], medications as ordered, monitor for shortness of air and notify the physician if ineffective. Interview with the Minimum Data Set (MDS) Coordinator on [DATE] at 8:49 AM revealed the nurses and CNAs are expected to follow the care plan. The charge nurse is responsible to ensure the care plans are being followed by staff. Interview with Assistant Director of Nursing (ADON) #2 on [DATE] at 11:10 AM revealed the staff are expected to follow the care plan for care. Interview with the DON on [DATE] at 12:45 PM revealed she provides random spot checks to ensure the care plans are being followed. She stated the CNAs sign the back of the care plan every shift indicating they acknowledged the care as written on the care plan. Interview on [DATE] at 9:00 AM revealed she expected staff to follow the plan of care for the resident.

Based on interview, record review, facility policy review, review of hospital records, and review of the Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to review and revise the care plan to prevent avoidable pressure ulcers from developing for one (1) of six (6) sampled residents (Resident #1). Resident #1 was admitted to the facility on [DATE] and assessed to be a high risk for pressure ulcers but no pressure ulcers identified. Resident #1 was care planned to turn and position every two (2) hours; however, staff were unable to keep the resident off his/her back due to his/her weight and the use of an [DEVICE] device on his/her leg. The resident's body would roll over the pillows and the resident would end up back on his/her back; however, the facility failed to revise the care plan and put an intervention in place to address the pillows not working as positioning devices. The resident developed Stage II wounds to the left and right buttock; and coccyx on 07/24/17 which progressed to having slough/eschar noted to wound bed on 08/02/17. On 08/05/17, a physician's orders [REDACTED]. On 08/07/17, the residents wound had worsened with copious eschar and foul drainage noted and the resident was hosptalized on [DATE]. Resident #1 was immediately taken for surgery on the wounds. The findings include: Interview with the Director of Nursing on 09/27/17 at 1:02 PM revealed the facility follows the RAI manual for reviewing and revising the care plan. Review of the RAI Manual, dated October 2015, revealed the results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive plan of care. Review of the facility Pressure Ulcer Risk Evaluation, last reviewed 04/24/15, revealed pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues. Because a resident at risk can develop a pressure ulcer within two (2) to six (6) hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. When a resident is identified as a high risk proceed to care planning and interventions individualized for the resident and their particular risk factors. Record review revealed the facility admitted Resident #1 on 07/14/17 with [DIAGNOSES REDACTED]. Review of the Interim Plan of Care for Alteration in Skin Integrity, dated 07/14/17, revealed incontinence care as needed, turn and reposition every two (2) hours, and physical therapy to consult, if indicated. In addition, an Interim Care Plan for At risk for Orthopedic Complication, dated 07/14/17, revealed to observe for [MEDICAL CONDITION], Device includes [DEVICE] to left lower extremity, anticoagulant as ordered, and observe for signs and symptoms at surgical sites. Review of the July 2017 Certified Nurse Aide (CNA) Care Plan revealed assist with three (3) for positioning and [DEVICE] to right foot/leg with pins, turn and reposition every two (2) hours. Review of the Nursing Admission Information assessment, dated 07/14/17 at 1:30 PM performed by Licensed Practical Nurse (LPN) #5, revealed the resident had no skin breakdown or redness to the buttock area or other areas of the body. Further review of the assessment revealed the resident's Braden score was a twelve (12) which indicated the resident was at high risk for skin breakdown. In addition, the resident was assessed as bedfast, completely immobile, skin was often moist, and there was a problem with friction and shearing. Interviews with Certified Nurse Aide (CNA) #3 on 09/09/17 at 9:43 AM and on 09/13/17 at 9:24 AM , CNA #8 on 09/11/17 at 3:16 PM, CNA #11 on 09/14/17 at 10:50 AM, LPN #1 on 09/13/17 at 11:51 AM, and LPN #3 on 09/11/17 at 2:48 PM revealed the resident was compliant with turning and positioning. They stated they would position the resident on his/her side with the pillows behind the resident but the resident would fall back over on the pillows due to his/her weight and the [DEVICE] device on his/her leg. CNA #3 stated the CNAs and LPN #1 discussed a wedge cushion for positioning but was not for sure how far the conversation went. Review of Weekly Skin Assessment on 07/24/17 (Monday) at 11:02 AM revealed a Suspected Deep Tissue Injury to the coccyx, left buttock, and right buttock with open wounds. Review of Acute Skin Care Plan, dated 07/24/17, revealed on 07/24/17 interventions were added for an air mattress with bolsters, a roho cushion to recliner, treatment, and nutritional supplements; however, there was no intervention added to address the resident's falling back over the pillows used for positioning the resident off his/her buttocks and coccyx. Further review of the Nursing Notes, revealed on 08/02/17 at 3:56 PM, Resident #1's wounds were assessed by ADON #2, and identified the wounds to the coccyx; and, left and right buttock had worsened with slough/eschar noted to wound bed, and peri-wound red but blanchable. Treatment order was changed, no odor or drainage noted. Further review of Acute Skin Care Plan, dated 07/24/17, revealed on 08/02/17 an intervention was added to turn and position Resident #1 every hour, however, there was still no intervention added to address the resident's falling back over the pillows used for positioning the resident off his/her buttocks and coccyx. Review of a Physician Order, dated 08/05/17 at no time, revealed to utilize foam wedge for positioning in bed with turning; however, review of the Interim Care Plans dated 07/12/17; Comprehensive Care Plan, dated 07/24/17, and August 2017 CNA Care Plan revealed the care plan was not revised to include the foam wedge for positioning in bed. Interview with LPN #9 on 09/26/17 at 7:30 AM revealed she did not use a wedge with repositioning and was resident's nurse on 08/05/17. Interview with CNA #11, on 09/26/17 at 1:25 PM, revealed she worked with the resident the day before the resident went to the hospital (08/07/17). She stated LPN #12 talked with the Nurse Practitioner regarding problems of repositioning the resident as the resident would fall over the pillows. The Nurse Practitioner provided education to the CNA's and LPN taking care of the resident on proper positioning. She further stated she found a wedge cushion later in laundry. She stated the resident was turned and repositioned every two (2) hours and then the nurse practitioner told us during education to turn and reposition every hour. Interview with LPN #12/Charge Nurse, on 09/26/17 at 1:39 PM revealed she talked with the nurse practitioner on 08/07/17 at 9:26 AM regarding the pillows used for positioning and the difficulty turning with the air mattress. She stated the resident did not have a wedge at the time the nurse practitioner educated regarding positioning. She further stated later that day they found a wedge. She revealed the charge nurse is responsible to update the CNAs care plan when the nursing care plan is updated. Interview with CNA #10, on 09/13/17 at 11:15 AM, revealed revealed the resident received a wedge at the end of his/her stay for the top half of his/her body then continued to use pillows for the bottom half. She revealed the wedge assisted the resident to keep him/her off his/her bottom better. Review of a Progress Note written by the Advanced Registered Nurse Practitioner (ARNP) , dated 08/07/17 at no time (Monday), revealed Resident #1's left buttock black eschar Suspected Deep Tissue Injury 4 cm x 5 cm, no drainage with purplish, nonblanchable and firm surrounding tissue; Suspected Deep Tissue Injury to the right buttock with undermining beneath the slough 10 cm x 8 cm x 0 cm with tissue changes undermining 4 cm drainage [MEDICAL CONDITION] moderate amount with moderate odor with surrounding tissue superior purplish, nonblanchable and firm along with odor from dead tissue that was soft and trimmed back; right buttock [DIAGNOSES REDACTED] 3 cm lateral from edge of eschar only on lateral edge. Review of a Late Entry Nurse's Note, dated 08/08/17 at 12:52 PM for 08/07/17 at 12:00 PM by the Director of Nursing (DON), revealed Physician was notified of purulent drainage to the wound and that Nurse Practitioner would not prescribe antibiotic with an order received for Juven, an antibiotic, and a culture of drainage which was obtained at 1:45 PM. Review of a Nurse's Note, dated 08/08/17 at 9:38 AM, revealed to direct admit the resident to the hospital per the surgeon. Review of the Hospital History and Physical dated 08/08/17 revealed the resident was discharged to the nursing home about two (2) weeks ago with a right lower extremity fixator and presented back for direct admit after a very significant and worsening decubitus ulcer. The hospital History and Physical skin assessment revealed an extremely large sacral decubitus ulcer with copious eschar, foul drainage. The surgeon was consulted and took the resident directly to surgery. He debrided a large amount of eschar. Interview with LPN #12 on 09/26/17 at 1:39 PM revealed the charge nurse is responsible to update the CNAs care plan when the nursing care plan is updated. Interview with the MDS Coordinator on 09/27/17 at 8:49 AM revealed the charge nurse should revise the care plan when an order is received or for a change in condition. The administrative team reviews the orders Monday-Friday. She stated when an order is received for a device the charge nurse is responsible to obtain the device for the resident. Interview with the Assistant Director of Nursing (ADON) #1 on 09/13/17 at 11:37 AM revealed the resident was a high risk Braden score and interventions for high risk are different for every resident. She stated the standard is to turn and reposition every two (2) hours, pressure reduction mattress, cushion in chair, and position with pillows. She stated if the resident has no skin breakdown the goal is for the resident not to develop skin breakdown during the stay. She further stated the staff never reported to her the interventions were not effective for Resident #1. She stated a nurse told her Resident #1 was reluctant to get into the bed one (1) time but would get into the bed. She revealed she knew on admission the resident had an [DEVICE], but was unsure about weight. She stated if the interventions were not working for the resident the CNA should have followed the interact program and filled out a stop and watch and gave one (1) copy to the nurse and the other to the Director of Nursing (DON) or Administrative nurse so the issue could have been followed up on. She stated she expected the nurses to follow up on issues presented by the CNA. Furthermore, she stated she expected the CNAs to report issues to the nurse and if not followed through by the nurse to report to the DON or ADON. In addition, she stated the interventions for Resident #1 should have been changed since the interventions used were not effective. Interview with ADON #2 on 09/14/17 at 11:10 AM revealed she did not have a nurse come to her about the need for changes in the interventions for Resident #1. She stated the nurses are responsible to assess interventions and if not effective to implement new interventions; if no issues then the interventions would be considered effective. She further revealed a new intervention should have been tried if the resident was falling over the pillows and not staying positioned. She stated the goal if a resident does develop a wound is to prevent the wound from worsening. Interview with the Advanced Registered Nurse Practitioner (ARNP) on 09/12/17 at 2:22 PM revealed if the interventions that are in place for a resident are not effective then other interventions should be implemented. She stated the last time she saw the resident the resident was laying on pillows on his/her back and had fallen over. In addition, she revealed a limited amount of time on the area when a resident is considered high risk of skin breakdown can cause a pressure ulcer. Interview with the Resident's #1's Physician on 09/11/17 at 2:00 PM revealed she had the impression from the facility the resident was not wanting to turn. However, she felt if the resident was not being turned as should have been the wounds were avoidable. In addition, she stated if staff was not turning and repositioning the resident that could have been what caused the wounds. Interview with the Surgeon on 09/13/17 at 2:30 PM revealed off loading of the area would have prevented the wound from occurring as this wound was extensive. He revealed all pressure ulcers are avoidable because there was too much pressure to the area which cause the pressure ulcer. Interview with the Director of Nursing on 09/27/17 at 9:06 AM revealed the charge nurse updates the care plan in between quarterly assessments. She stated she reviews the orders Monday-Friday in clinical standup to ensure the orders are put on the care plan. She further stated the care plan should be updated with changes. Interview on 09/14/17 at 9:00 AM revealed if interventions for the resident are not working then the interventions should be revised. She further stated the CNAs should have provided a stop and watch communication to the nurse as well as to the DON to inform of the interventions not effective.

Based on observation, interview, facility Quality Assurance (QA) process review, and review of the 01/11/16 Recertification Survey Plan of Correction (PoC), and the 06/28/16 Abbreviated Survey PoC, it was determined the facility failed to ensure its PoCs were implemented to correct identified quality deficiencies related to oxygen (O2) therapy. Review of the facility's 01/11/16, Recertification Survey Plan of Correction (PoC) revealed the facility provided education to all nursing staff on 12/23/15 on the protocol of proper placement of O2 tubing and usage of O2 E tanks by the O2 company. In addition, review of the Abbreviated Survey PoC, dated 06/28/16, revealed the facility inserviced nurses on Respiratory Care and O2 therapy and how to determine when to use a portable tank with troubleshooting for portable O2 tanks and O2 concentrators. However, the facility failed to ensure the education was provided to staff per the PoC. Refer to F282 and F328. The facility's failure to ensure its PoCs were implemented to correct identified quality deficiencies related to O2 therapy has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/06/17 and determined to exist on 01/03/17. The facility was notified of the Immediate Jeopardy on 01/06/17. An acceptable Allegation of Compliance (AoC) was received on 01/18/17, alleging the removal of Immediate Jeopardy on 01/10/17. The State Survey Agency validated the Immediate Jeopardy was removed on 01/19/17, 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: Review of the facility's Quality Assurance process, undated, revealed the members meet monthly. The members include the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), Dietary Manager (DM), Admissions, Quality of Life Director, Advanced Registered Nurse Practitioner, Medical Director and Maintenance. The Center reviews falls, pressure ulcers, psychoactive medication, customer satisfaction, safety, education completed, staffing, infections, and any areas of concerns and ways to improve by using huddles. Furthermore, the QA tracks and trends adverse events and develops root cause analysis. Review of the facility's 01/11/16, Recertification Survey PoC revealed the facility's O2 company provided education to all nursing staff on 12/03/15 and 12/08/15 on the proper use of portable oxygen tanks and following the physician's orders [REDACTED]. The Certified Nurse Aides (CNA)/Certified Medication Aides (CMA) were educated on 12/23/15 by the oxygen company on identifying low or empty portable O2 tanks and the reporting protocols. In addition, the charge nurses were responsible for monitoring O2 usage and O2 tubing placement every shift. Review of the Abbreviated Survey Plan of Correction, dated 06/28/16, revealed the Respiratory Therapist, Director of Nursing, or Assistant Director of Nursing inserviced nurses on respiratory care and O2 therapy and how to determine when to use a portable tank with troubleshooting for portable O2 tanks and O2 concentrators. However, observation on 01/03/17 at 3:35 PM, and interview with CNA #1, on 01/03/17 at 3:45 PM, revealed Resident #14 nasal cannula was in the resident's nose but the O2 concentrator was not turned on. Further observation revealed the O2 tubing was dated 11/27/16 (approximately one month prior). Registered Nurse (RN) #1 obtained an O2 saturation (sat) at 3:40 PM which revealed the resident's O2 sat. was 85% to 87% (normal: 93%-98%). CNA #1 stated she forgot to turn the O2 concentrator on whenever she transferred the resident from the wheelchair to the bed at 2:00 PM. Observation and interview with CNA #8, on 01/03/17 at 3:34 PM revealed Resident #13's wheelchair was sitting in the hallway with a portable O2 tank attached to the back of the wheelchair. Further observation revealed CNA #8 was unable to read how much O2 was left in the tank. She stated she did not know anything about the O2 tanks; that the nurse was responsible for the tanks. CNA #8 stated she had never been trained on how to check the O2 in a portable O2 cylinder. Further observation on 01/05/17 at 9:36 AM, revealed Resident #13 eating in the front dining room with a nasal cannula in his/her nose. The resident had a bluish tint to his/her skin and shortness of breath. Observation of the portable O2 tank attached to the back of the resident's wheelchair revealed it was empty. Licensed Practical Nurse (LPN) #1 obtained an O2 saturation per the Surveyor's request which revealed the resident's O2 saturation was 85% to 87% (normal 90%-98%). However, upon the LPN's initial observation of the resident, she did not identify the portable O2 tank was empty or obtain additional O2 for the resident. Review of the education provided to the Licensed Nurses and CNAs from the facility and Respiratory Therapist revealed Licensed Practical Nurse (LPN) #1, LPN #2, LPN #5, CNA #6, CNA #8, and CNA #9, had not received oxygen therapy education as reported in the facility's Recertification and Abbreviated Plan of Correction. Interviews with Licensed Practical Nurse (LPN) #8 on 01/06/17 at 2:28 PM, LPN #5 on 01/06/17 at 2:35 PM, and LPN # 9 on 01/11/17 at 7:32 AM revealed they had not received any training on oxygen therapy from the facility. CNA #9 stated she had one (1) training with the Respiratory Therapist on Oxygen and that was in June 2016 and no further inservices since then. In addition, further review of the Abbreviated Survey Plan of Correction, dated 06/28/16, revealed the Respiratory Therapist will in-service nurses on various oxygen therapy topics quarterly. However, the facility failed to present any documented evidence of quarterly oxygen therapy inservices provided to the nurses for September and December 2016. Interview, with Certified Respiratory Therapist (CRT #1), on 01/12/17 at 10:23 AM, revealed she developed part of an in-service, titled Portable Oxygen Tanks E Cylinders and one for Troubleshooting someone complaining of Shortness of Breath and had faxed these to the facility on [DATE]. She stated she had not conducted any inservices on oxygen to the facility staff prior to 06/14/16 and no quarterly inservice since then. Interview with the Administrator, on 01/06/17 at 5:45 PM, revealed oxygen has been a part of the Quality Assurance Performance Improvement Program (QAPI) beginning the last annual survey Plan of Correction 01/11/16 and repeated again after the POC for 06/28/16. She stated the facility continued to monitor oxygen; however, no concerns had been brought to her attention related to oxygen tanks running low or concentrators not being turned on, prior to the 2017 annual survey. The facility's QA program failed to identify concerns related to the oxygen therapy program and their plans of correction. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/03/17, the Nurse Practitioner saw Resident #14 on 01/03/17 and titrated Resident #14's O2 to 2 liters per minute via nasal cannula. Resident #14 tolerated the titration with no signs and symptoms of Respiratory Distress. On 01/05/17, Resident #13 was observed in the Dining Room with his/her portable O2 tank reading empty. LPN #1 replaced the portable O2 tank. The Nurse Practitioner visited Resident #13 and identified no change in the resident's condition. 2. On 01/03/17, the DON made rounds to check on eight (8) residents that requires O2 Therapy. The DON noted the O2 concentrator indicator light was on and the concentrator was delivering O2. The DON ensured nasal cannulas were in place. No concerns were identified. 3. On 01/04/17, the Administrator assigned audits to check eight (8) residents that required O2 therapy to ensure the O2 concentrator indicator light was on and the concentrator was delivering O2 to the Department Heads, which included the Assistant Directors of Nursing, Quality of Life Director, Admission/Marketing Director, Staff Development Coordinator, Scheduler and MDS. The Department Heads also ensured nasal cannulas were in place. No concerns were identified. 4. On 01/03/17, the (Corporate) Care Consultant (SCC) educated the DON on O2 Administration to ensure professional standards based on facility policy and procedure referencing the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident was receiving O2 therapy as ordered; O2 was applied immediately in a potential emergent situation involving respiratory distress; following the plan of care; the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting a resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting a resident up into the wheelchair, ensure the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the nurse immediately if the portable tank needs to be changed. Only nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON was educated on: Assisting with O2 therapy to ensure professional standards based on CNA Training Manual Mosby third Edition, pages 561-566. This included following the plan of care; the SRNA is to ensure oxygen is switched from the portable tank to the concentrator when assisting resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting the resident up to w/c, ensuring the portable oxygen tank is turned on with nasal cannula or mask is place. Education also included CNAs or Licensed Nurse will observe the amount of oxygen available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed. Only Nurses can change portable tanks, and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, SCC completed a competency on Oxygen Administration with the DON. In addition, the Care Consultant completed an Oxygen Concentrators and Portable Oxygen Tanks competency with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566. 5. On 01/03/17, the DON then educated the SDC on O2 administration to ensure professional standards based on the facility's policy and procedure which includes the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident is receiving O2 therapy as ordered, O2 is applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting the resident to bed, the concentrator is on and the cannula or mask is in place; and, when getting the resident up into the wheelchair, ensuring the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON educated the SDC on: following plan of care, Assisting with oxygen therapy to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566, and included: when assisting a resident the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, the DON then completed a competency with the SDC on Oxygen Administration and Portable Oxygen Tanks and Regulator competencies. In addition, the DON completed a competency with the SDC on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. 6. On 01/03/17, the SDC educated the licensed nurses on O2 administration to ensure professional standards based on facility policy and procedure based on the Lippincott Nursing Procedures Sixth Edition Pages 537-542, which included: ensuring that the resident was receiving O2 therapy as ordered, O2 was applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, when assisting the resident to bed the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator, the concentrator is on and the cannula or mask is in place; and, when getting resident up into the wheelchair, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only nurses can change portable tanks and when the nasal cannula or mask in not in use it is to be placed in a bag. Education continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired Licensed Nurse Staff. Beginning on 01/06/17, the SDC completed competencies with the licensed nurses on oxygen administration with the DON. This competency included: Oxygen Administration and Portable Oxygen Tanks and Regulator Competencies to ensure professional standards based on the facility's policy and procedure which included the Lippincott Nursing Procedures Sixth Edition pages 537-542. Competencies continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated competency will be included in the orientation process of all newly hired Licensed Nurse Staff. 7. On 01/03/17, the SDC then educated the CNAs on following the plan of care and Assisting with Oxygen Therapy to ensure professional standards based on CNA training manual Mosby third Edition, pages 561-566, and included: when assisting a resident to bed, the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. Education continued prior to CNAs working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired CNA's. Beginning on 01/06/17, the SDC completed competencies with CNAs on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. Competencies continued prior to CNAs working and was completed on 01/09/17. The above competency will be included in the orientation process for all newly hired CNAs. 8. On 01/06/17, fifty-three (53) residents at the facility that have a respiratory [DIAGNOSES REDACTED]. This Respiratory Evaluation included: review of the resident's respiratory history of [MEDICAL CONDITION] and apnea, current treatment of [REDACTED]. No concerns were identified. 9. On 01/07/17, eleven (11) residents (as three (3) additional residents received orders for oxygen therapy) that receive oxygen therapy had their charts reviewed by the Director of Clinical Operations Hometown Segment of the Corporation to ensure appropriate action was completed regarding residents with respiratory [DIAGNOSES REDACTED]. Appropriate Actions included: respiratory assessment, notification of Physician/Nurse Practitioner, and following Physician Orders. 10. On 01/07/17, education was conducted by the DON with nine (9) residents with a BIMS of eight (8) or greater. This education included the following: the resident's need for oxygen therapy related to the medical diagnosis, immediately notifying staff when the resident becomes short of breath, notifying staff if oxygen was not operating and the importance of wearing the nasal cannula or mask. 11. On 01/09/17, education was conducted by the DON with two (2) residents (with BIMS less than 8) Responsible Parties. This education included the resident's need for oxygen therapy related to their medical diagnosis, immediately notifying the staff when a resident becomes short of breath, notifying staff if oxygen is not operating and the importance of wearing the nasal cannula or mask. 12. On 01/07/17, the Director of Nursing and the (Corporate) Care Consultant reviewed care plans and nursing assistant care plans of eleven (11) residents receiving O2 therapy to ensure the oxygen administration was included in their plan of care. No concerns were identified. 13. An Ad Hoc QAPI meeting was held on 01/06/17, via phone with the Administrator, Director of Nursing, and Medical Director in regards to Oxygen Therapy Administration, education, interventions, and plans to prevent reoccurrence. A QAPI meeting was held on 01/12/17 by the Administrator, Medical Director, Director of Nursing, and Signature Care Consultant, in regards to Oxygen Therapy Administration, on-going competencies, audits, interventions, and progress on plan to prevent reoccurrence. 14. On 01/09/17, a Resident Council Meeting was held by the Quality of Life Director and Assistant Director of Nursing and Oxygen Therapy related to Medical Diagnosis, immediately notifying staff when the resident becomes short of breath, when not feeling the air flow from the nasal cannula, if oxygen and concentrator is not functioning and the importance of wearing the nasal cannula or mask were among the topics covered. 15. Beginning 01/06/17 and until immediacy is lifted, daily audits (including weekend) will be completed by the Director of Nursing, MDS, Assistant Director of Nursing, Medical Record Coordinator, who is a nurse, Scheduling Coordinator, who is a Nurse, and Staff Development Coordinator each shift for residents receiving oxygen therapy. The audit includes checking the concentrators and portable oxygen tanks, checking to make sure nasal cannula or mask in on, oxygen concentrator is on and has correct setting, portable oxygen tank is on and has correct setting, and checking gauge of portable oxygen tank to check the amount of oxygen in the tank. Once immediacy is lifted, audits will continue daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly as part of QAPI. 16. Beginning 01/07/17 and until immediacy is lifted daily (including weekends) group activity (Quality of Life Group activities, dining room meals, and therapy activities), audits will be completed by the Administrator, Director of Nursing, Rehabilitation Services Manager, Admissions and Marketing Director, Scheduling Coordinator (who is a nurse), Business Office manager, Quality of Life Director, Quality of Life Assistant, Assistant Directors of Nursing, MDS Coordinator, Maintenance Director, Medical Records Coordinator (who is a nurse), Physical Therapist, Physical Therapist Assistant, Occupational Therapist, Occupational Therapist Assistant, or Speech Therapist as these are the times that portable oxygen tanks are utilized rather than oxygen concentrators. These audits include checking to make sure nasal cannula is in place, portable tank is on and has the correct setting, checking the portable tank gauge to ensure oxygen is available for utilization. Documentation of audits will be maintained on an audit tool and will be reviewed daily for completion and appropriate follow up by the Administrator or DON. Once immediacy is lifted these group activity audits will continue daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly as a part of QAPI. 17. Beginning 01/06/17 and until immediacy is lifted, four (4) licensed nurses, and four (4) Certified Nurse Aides per day (including weekends) on various shifts will be given the competency for how to care for a resident on O2 Therapy by the Staff Development Coordinator, Director of Nursing, or Assistant Directors of Nursing. Competency must be achieved by the Licensed Nurse or Certified Nurse Aide. If competency is not achieved by the Licensed Nurse or CNA, then the employee will be re-educated and then given the competency again until competency is achieved. Once immediacy is lifted, competencies will continue at two (2) Licensed Nurses and Certified Nurse Aides per day on various shifts (including weekends) times four (4) weeks then weekly times four (4) weeks, then monthly for six (6) months. 18. Beginning 01/07/17, until immediacy is lifted, five (5) residents will be interviewed daily by the Director of Nursing or Assistant Directors of Nursing and these topics discussed: The resident's need for O2 therapy related to their medical diagnosis, immediately notifying the staff when the resident becomes short of breath, when not feeling the air flow from the nasal cannula, if oxygen and concentrator is not functioning and the importance of wearing the nasal cannula or mask were among the topics covered. Any concerns will be reported to the Administrator or Director of Nursing immediately and follow up will be completed. Once immediacy is lifted, resident interviews will continue to three (3) daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly times six (6) months. 19. Daily Monday through Friday in the morning clinical meeting new orders or changes for O2 Therapy, Care Plans and CNA care plans for those receiving oxygen therapy, and the twenty-four (24) hour report will be reviewed for any change in Respiratory status by the Administrative Nursing Team that consists of the Director of Nursing, Assistant Directors of Nursing, MDS Nurses, Scheduler, and Medical Records Director to ensure interventions were completed. Weekend coverage will be conducted by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, Scheduler (who is a nurse), Medical Records (who is a nurse), or MDS. They will also review new orders or changes for Oxygen Therapy, Care Plans, and CNA care plans for those receiving oxygen therapy, and the twenty-four (24) hour report will be reviewed for any change in Respiratory status. 20. The Administrator or DON will review the oxygen audits, resident interviews, and Licensed Nurses Oxygen Administration and Portable Oxygen Tanks/Regulators Competencies; and, the CNAs Oxygen concentrator and Portable Oxygen Tank Competencies; given daily times four (4) weeks then weekly times four (4) weekly then monthly times six (6) months for any noted concerns. Any concerns will be addressed immediately. 21. QAPI meeting will be held weekly for four (4) weeks then monthly. Results of the resident interviews, daily (Monday thru Friday) review in Clinical AM Meeting, staff competencies, and audits will be reported to the QAPI committee weekly for four (4) weeks and then monthly for six (6) months to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QAPI committee will determine at what frequency the resident interviews, staff competencies and audits will need to continue. Concerns identified will be corrected immediately and reported to the Administrator to ensure appropriate follow up is completed. A nurse from the regional team or corporate office will attend the weekly QAPI meeting providing consultation, oversight and assist in determining the further need of continued education or revision of the plan. 22. The Signature Care Consultant has been on site since 01/03/17 to provide oversight to the facility. The nurse from the regional team or home office has been assisting as needed, performing chart audits and providing oversight and consultation in regards to oxygen audits, Licensed Nurses and CNAs competencies, Resident Interviews, twenty-four (24) hour report reviews, Physician order [REDACTED]. 23. A nurse from the regional team or corporate office will be onsite weekly and available by telephone daily since 01/03/17 and will continue weekly visits and daily review by telephone until immediacy has been lifted, then every other week for four (4) weeks, then monthly. The nurses from the regional team or home office are assisting as needed, performing chart audits and providing oversight and consultation in regards to oxygen audits, Licensed Nurses and CNA competencies, Resident Interviews, twenty-four (24) hour report reviews, Physician order [REDACTED]. 24. Education was provided to the Administrator by the Regional Vice President of Operations on 01/09/17 regarding administration and oversight within the facility to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. Also included in the education was development and oversight for follow through with the plan to correct cited deficient practice. Review was completed of the facility's administration policy. Administration oversight of the facility will be completed by Regional Vice President of Operations, or Regional Controller who is a Licensed Administrator weekly on site and daily by telephone until removal of immediacy beginning 01/09/17, then every other week for four (4) weeks, then monthly. Oversight will be provided by the Regional Vice President of Operations, or Regional Controller, who is a Licensed Administrator, to ensure continuation and follow through with the allegation of compliance plan. Oversight will also include but not limited to daily review of Oxygen audits, Licensed Nurses and CNAs competencies, resident interviews, twenty-four (24) hour report reviews, Physician order [REDACTED]. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/16/17 at 3:29 PM with the APRN, revealed she assessed Resident #13 and #14 with no concerns identified. 2. Interview with the DON, on 01/18/17 at 11:27 AM revealed she rounded on eight (8) residents on 01/03/17 to ensure the indicator light was on and the nasal cannula was in place. No concerns were found. 3. Interview with Assistant Director of Nursing (ADON) #1, on 01/19/17 at 2:00 PM and ADON #2 on 01/19/17 at 2:22 PM, revealed they were assigned random audits during the annual survey after the identification of an oxygen issue on 01/03/17 to ensure concentrators were on and functioning, the correct liter flow was set according to the physician's orders [REDACTED]. They stated no concerns were identified. Review of the documented audits revealed there were no concerns. 4. Review of the education sign-in sheet dated 01/03/17 revealed the DON had been trained by the SCC. Interview with the SCC on 01/19/17 at 1:09 PM revealed she provided the Director of Nursing education based on facility policies and procedures which included the Lippincott Nursing Procedures Sixth Edition, which was the standards of practice used prior to the annual recertification survey. She stated that when the problem with oxygen was identified on 01/03/17 she provided this in-service to the DON which included applying oxygen, assessing the resident, reading the oxygen gauges, following the physician's orders [REDACTED]. She further stated only the Licensed Nurse is allowed to adjust the liter flow for oxygen and change out oxygen tanks. She stated she also provided the Director of Nursing with the Oxygen Administration Competency with return demonstration provided by the Director of Nursing. She also instructed on tubing change every week and as needed, placement of tubing in the nares and over the ears, and tubing placement in a plastic bag when not in use. She further stated she reviewed emergency situations involving respiratory distress. She revealed her education also included when reading the gauge if the tank needed to be changed to change and the CNAs are to notify the nurse immediately if the gauge indicated the tank needed to be changed. She stated she also in-serviced and provided a competency to the Director of Nursing which included reading the oxygen gauge, tubing placement, feeling of the air flow to ensure working, turning the oxygen tank and concentrator on and off, and to report to the nurse if readjustment is required for the liter flow. She further revealed she in-serviced regarding only nurses are allowed to change tanks and adjust the liter flow. Interview with the Care Consultant on 01/19/17 at 1:30 PM, revealed she provided a competency with return demonstration with the Director of Nursing on Oxygen Concentrators and Portable Oxygen Tanks based on the facility policy and procedure which included the Mosby Third Edition. Interview with the DON on 01/18/17 at 11:27 AM, revealed on 01/06/17 the SCC educated her on O2 Administration as well as O2 portable tanks and regulators to included competency check off. 5. Interview with the DON on 01/18/17 at 11:27 AM, revealed she trained the SCD on O2 Administration as well as O2 portable tanks and regulators to included competency check off. Interview with the SDC, on 01/18/17 at 4:00 PM, revealed she had been in-serviced by the DON and competency had been completed. 6. Review of the education and signature sign-in sheets dated 01/03/17 revealed all Licensed staff received O2 inservice. Interview with the SDC, on 01/18/17 at 4:00 PM, revealed she began to in-service all RNs, LPNs, and Full Time Rehab staff (RNs and LPNs) on O2 Administration between the dates of 01/03-09/17 on all shifts and a competency was completed on each by 01/09/16. She stated that some staff were on vacation, LOA or off and they were called in to complete the in-service and competency before allowing to return to work. Competencies were reviewed with no concerns. Interview with Registered Nurse #1 on 01/19/17 at 9:20 AM, and RN #4 at 10:00 AM, revealed they received an in-service by the Staff Development Coordinator as well as return demonstration regarding oxygen administration and assessmen

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure residents received proper care and treatment related to oxygen (O2) administration for two (2) of eighteen (18) sampled residents (Residents #13 and #14). Resident #13 had a physician's orders [REDACTED]. Observation on 01/05/17, revealed Resident #13 sitting in his/her wheelchair in the dining room with an E size O2 cylinder on the back of the wheelchair and a nasal cannula in his/her nose. The O2 tank was observed to be empty. Further observation revealed the resident's lips were a bluish color. The resident complained of shortness of breath. When the resident's O2 saturation rate (oxygen in the blood) was measured, it was noted to be 83% (normal: 90%-99 %). Staff had failed to check the resident's O2 tank since he/she was placed in his/her wheelchair that morning. In addition, Licensed Practical Nurse (LPN) #1 failed to check the resident's O2 tank when it was identified the resident had shortness of breath and an O2 saturation of 83%. Resident #14 had a physician's orders [REDACTED]. However, observation on 01/03/17 revealed staff failed to turn the resident's O2 concentrator on when he/she was assisted to bed and switched from the O2 tank to the O2 concentrator. The resident's O2 saturation rate was 85% to 87% (normal: 93%-98%). The facility's failure to provide the necessary care and services related to oxygen administration has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/06/17 and determined to exist on 01/03/17. The facility was notified of the Immediate Jeopardy on 01/06/17. An acceptable Allegation of Compliance (AoC) was received on 01/18/17, alleging the removal of Immediate Jeopardy on 01/10/17. The State Survey Agency (SSA) validated the Immediate Jeopardy was removed on 01/10/17, 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: Review of the facility's policies titled, Oxygen Administration, not dated; and Oxygen Administration Competency, dated 06/01/15, revealed the purpose of these procedures is to provide guidelines for safe oxygen administration. Oxygen by portable oxygen cylinder or concentrator is to be administered as ordered by the Medical Doctor. Further review revealed staff should observe the resident upon setup of oxygen and periodically thereafter to ensure oxygen is being tolerated; and, an assessment should be conducted for signs and symptoms of cyanosis (i.e. blue tone to the skin and mucous membranes), [MEDICAL CONDITION] (rapid breathing, rapid pulse rate, restlessness or confusion), vital signs and lung sounds. Notify the supervisor if the resident refuses the procedure. Review of the Certified Nurse Aide (CNA) O2 Competency for Concentrators, not dated, revealed a CNA is able to check the gauge on the portable oxygen tank and notify the charge nurse if it needs to be changed. The CNA is NOT permitted to change the portable tank. A CNA can use the O2 key to turn on the portable O2 tank and is able to perform this skill. CNA will note that the regulator is at the correct setting, and report to the nurse if this is incorrect. CNA is NOT permitted to adjust the flow rate. CNA is able to apply O2 device (nasal cannula, mask, etc.) that the nurse has deemed appropriate for resident in addition to checking the tubing to make sure there are no kinks and that the tubing is connected to the portable O2 tank. The CNA can check resident periodically to ensure oxygen device is in place and replace accordingly. The CNA is to notify the charge nurse immediately with any concerns related to portable O2 tank. In addition, the CNA is permitted to turn concentrator on and is able to demonstrate this skill. The CNA is to notify the charge nurse immediately with any concerns related to concentrator, as in alarming, not turning on, etc. 1. Record review revealed the facility admitted Resident #13 on 11/08/16, with [DIAGNOSES REDACTED]. Review of an Admission Minimum Data Set (MDS) assessment, dated 11/15/16, revealed the facility assessed Resident #13's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eleven (11) indicating he/she was interviewable. Further review of the MDS assessment revealed the resident required oxygen prior to admission and while a resident at the facility. Review of the Comprehensive Care Plan, dated 11/08/16, revealed Resident #13 was assessed to have a [MEDICAL CONDITION] condition and diagnosis. The resident had the potential for difficulty breathing related to [MEDICAL CONDITIONS] and Atelectasis. Interventions included to monitor and report to nurse any changes or signs and symptoms of breathing difficulty such as shortness of breath (SOB), cough (productive or non-productive), fever, chills, difficulty speaking, bluish skin color or change in cognition; oxygen saturations (O2 sat.) monitored as needed, and administer oxygen as ordered. Review of Resident #13's Hospital Records revealed Resident #13 was hospitalized from [DATE]-12/22/16 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Resident Acute Care Plan, dated 01/03/17, revealed the resident currently had a respiratory infection and was receiving Cefdiner (antibiotic) 300 milligrams (mg) twice a day for seven (7) days. Observation on 01/05/17 at 9:36 AM revealed Resident #13 sitting in his/her wheelchair in the dining room with an E size O2 cylinder on the back of the wheelchair and a nasal cannula in his/her nose. The resident's lips were observed to be bluish in color and he/she stated he/she was short of breath. Further observation revealed the O2 tank pressure gauge indicated the tank was empty. Upon the SSA's request, LPN #1 came to assess the resident. Licensed Practical Nurse (LPN) #1 obtained an O2 saturation reading of 83%. However, LPN #1 did not immediately check the resident's O2 cylinder, instead she stated she was going to pull up a chair and sit with the resident for a few minutes. After the Surveyor asked the LPN about the resident's O2 cylinder/tank, the LPN assessed the resident's O2 cylinder regulator and noted it was empty. Further observation at 9:42 AM, after the O2 cylinder was changed, revealed the Regional Clinical Consultant reassessed the resident and the resident's O2 saturation was noted to be 96% to 97%, the resident's lips were pink, and his/her shortness of breath had improved. Interview with Resident #13, on 01/05/17 at 9:36 AM, revealed he/she used O2 all the time. The resident stated, he/she had been sick recently, and had been in the hospital with breathing problems. Resident #13 stated he/she had been feeling some increased shortness of breath that morning while eating breakfast. When the O2 saturation level that was obtained earlier was noted to be 83%, the resident stated his/her oxygen saturation was usually between 93%-97%. The resident stated that he/she had other times that his/her O2 tank had run empty in the past. Interview with CNA #5, on 01/19/17 at 2:42 PM, revealed on 01/05/17 at approximately 7:00 AM, she assisted Resident #13 up into the wheelchair and when the CNA hooked the resident up to the O2 tank, the gauge indicated the tank was half full and the rate was set at 3 Liters/Minute. CNA #5 stated the CNAs check the O2 about every hour when the resident was on the portable tank but she did not recall seeing this resident again before breakfast. Interview with LPN #1, on 01/09/17 at 11:05 AM, revealed no one had alerted her that Resident #13's O2 cylinder needed to be changed. She stated staff should check the O2 cylinder upon contact with any resident receiving O2; when O2 was initiated, and every hour thereafter. She stated if staff identified the tank was low they should have alerted a nurse. LPN #1 stated Resident #13's O2 saturation rate was 87% when the tank was noted to be empty and it increased to 93% when the new tank was changed. She stated this resident had a physician's orders [REDACTED]. LPN #1 stated her goals was to assess the resident down on his/her eye level. She stated she identified the tank was empty when she walked up to the resident; however, she needed to complete an assessment first so she pulled up a chair. During further interview, she stated without the supplemental O2, Resident #13 could experience respiratory distress or respiratory compromise and due to this resident's history of [MEDICAL CONDITION] disease he/she could become compromised even faster. LPN #1 stated she was aware Resident #13 had experienced a recent respiratory complication requiring hospitalization . Interviews on 01/06/17 at 2:28 PM with LPN #8; and, at 2:35 PM with LPN #9, revealed if an O2 tank was low, it should be changed. The LPNs stated if a resident's O2 saturation rate was low the first action should be to check the supplemental O2 source such as tank, concentrator, and equipment. The LPNs stated they had never received training on how low the O2 tank should be before changing. Further interview revealed they were not aware it should be changed when it was reached the red zone. LPN #9 stated she knew from working at other facilities that if the O2 cylinder was in the red zone it should be changed. Interview with the facility's Advanced Practice Registered Nurse (APRN), on 01/16/17 at 3:29 PM, revealed she had cared for Resident #13 since admission to the facility and she was very aware of his/her health concerns. She stated she was in the facility on 12/12/16 and asked if the interview was related to a different incident then the hospitalization when this resident Crashed and was sent to the local hospital where he/she was placed on a venturi mask, bi-level positive airway pressure device ([MEDICAL CONDITION]) and later required a ventilator for life support. She stated she had educated both the resident and facility staff as to the importance of the resident using continuous O2. The APRN stated the resident was O2 dependent and the use of O2 was life sustaining for this resident and without the supplemental O2, he/she could die. Further interview with the APRN revealed she had never told the Administrative Nursing Staff it was important to educate all the line staff of the importance of this resident never being without O2 at any time. She stated this resident had experienced hallucinations due to the high Carbon [MEDICATION NAME] (Co2) levels. Interview with the Assistant Director of Nursing (ADON), on 01/06/17 at 2:30 PM, revealed all O2 tanks should be checked frequently but she did not know the policy on when they were to be changed. She stated the equipment should be verified first if the resident's O2 saturation rate was low to ensure it was functioning properly. The ADON stated the first thing to do if a resident was on a tank and the O2 saturation was low would be to ensure there was O2 in the tank and change it immediately if it was empty. She stated the resident's O2 saturation rate should be checked whenever needed to assess the resident, but staff should also monitor the resident for signs and symptoms of respiratory distress. 2. Interview with the Director of Nursing (DON), on 01/06/17 at 1:40 PM, revealed the facility did not have a policy addressing when to change the O2 tubing weekly. The DON stated she expected the O2 tubing to be changed weekly on Wednesdays. She stated it should be on the physician's orders [REDACTED]. Record review revealed the facility admitted Resident #14 on 10/24/16 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data (MDS) Set assessment, dated 11/14/16 revealed the facility assessed Resident #14's cognition as intact with a Brief Interview of Mental Status score of thirteen (13) which indicated the resident was interviewable. Further review of the MDS revealed the resident received oxygen therapy. Review of physician's orders [REDACTED]. However, the order did not include when to change the tubing. Review of the Comprehensive Care Plan for [MEDICAL CONDITION] Condition and potential for difficulty breathing diagnoses, dated 11/07/16, revealed to administer oxygen as ordered. Observation on 01/03/17 at 3:29 PM revealed Resident #14 laying in bed with the door open and call light on. The resident waved at the State Surveyor to come into the room. The resident verbalized he/she needed a bed pan. Observation revealed the resident's nasal cannula was in the resident's nose, but the O2 concentrator was not turned on. Facility staff was notified at 3:35 PM. Registered Nurse (RN) #1 entered the room, turned off the call light, and left the room. After the RN left the room, it was noted the oxygen tubing was dated 11/27/16 (five ({5} weeks ago) and had not been changed weekly. The resident verbalized again that he/she still needed the bed pan. The State Surveyor went to nurses' desk and requested RN #1 to come to the resident's room. RN #1 obtained an O2 sat. at 3:40 PM which revealed the resident's O2 saturation rate was 85% to 87%. RN #1 then proceeded to turn on the concentrator, and the resident asked for a bed pan again. Interview with CNA #1, on 01/03/17 at 3:45 PM, revealed she assisted the resident to bed. CNA #1 stated Resident #14 should be on O2 continuous and she had forgotten to turn the O2 concentrator on when she assisted the resident to bed. She stated she transferred the resident from the wheelchair to the bed at 2:00 PM. CNA #1 stated it was after lunch and she was in a hurry. Interview with RN #1, on 01/03/17 at 3:40 PM, revealed Resident #14 should be on three (3) liters of O2 continuous. She stated the CNA must have laid the resident down from the wheelchair to the bed and switched the tubing from the O2 tank to the concentrator and forgot to turn on the concentrator. She stated she did not realize the resident had already been laid down as she had not been in the resident's room or she would have double checked the concentrator. Further interview with RN #1, on 01/19/17 at 9:20 AM, revealed she did not remember going into Resident #14's room prior to the State Surveyor coming to the desk requesting the nurse to come to the resident's room. Interview with RN #2, on 01/06/17 at 2:07 PM, revealed the O2 tubing should be changed weekly on Wednesday. She stated if the O2 tubing was dated 11/27/16 then the tubing must have not been changed and it should be thrown away related to a risk for infection. Interview with LPN #2, on 01/06/16 at 2:25 PM, revealed O2 tubing will wear out. She stated the tubing could fall down on a resident's face which is a risk for infection and that was the reason for changing the O2 tubing weekly. Interview with Resident #14's Physician, on 01/06/16 at 5:10 PM, revealed if the order stated continuous O2 then he expected the O2 to be on continuous. He stated he expected the resident's O2 saturation to be maintained above 90%. The Physician stated that if staff accidentally failed to turn the oxygen on, this could cause the resident to be in a hypoxic state (condition in which the body or a region of the body is deprived of adequate oxygen supply at the tissue level) and result in a life threatening situation. He further stated leaving the O2 off for approximately an hour and forty-five (45) minutes was not acceptable if the order stated continuous. Interview with the DON, on 01/06/17 at 10:25 AM and 2:40 PM, revealed she expected the CNAs and nurses to ensure residents use their O2 as ordered and to follow the care plan. She stated Resident #14 did not have an order to change the O2 tubing on Wednesday when the humidifying bottles were changed. However, she would have expected the tubing to be changed on Wednesday. Interview with Certified Respiratory Therapist (CRT#1), on 01/12/17 at 10:23 AM, revealed she expected the nurses and CNAs to follow physician's orders [REDACTED]. Further interview revealed she expected the nurses to know that when the O2 gauge was in the red zone, the O2 tank should be changed. The CRT stated an O2 saturation rate of 85% was unacceptable for any resident and it meant the resident was hypoxic (low oxygen level). She stated it would be unacceptable for a nurse to not identify the immediate need to change the oxygen tank and to pull up a chair beside the resident and sit to assess the resident without verifying the tank was functioning properly. She also stated it was company policy for respiratory equipment such as cannulas and nebulizers to be changed weekly to prevent the development of a respiratory infection. Interview with the Administrator, on 01/06/17 at 5:46 PM, revealed she expected staff to follow facility policy, physician's orders [REDACTED]. Interview with the Medical Director, on 01/19/16 at 1:49 PM, revealed she had been the Medical Director since August 2016. She stated she expected the staff to follow orders as written for O2 if ordered and to care for any concerns and then notify the Medical Doctor (MD). The Medical Director stated if a resident was on continuous orders for O2, it should be provided without fail. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/03/17, the Nurse Practitioner saw Resident #14 on 01/03/17 and titrated Resident #14's O2 to 2 liters per minute via nasal cannula. Resident #14 tolerated the titration with no signs and symptoms of Respiratory Distress. On 01/05/17, Resident #13 was observed in the Dining Room with his/her portable O2 tank reading empty. LPN #1 replaced the portable O2 tank. The Nurse Practitioner visited Resident #13 and identified no change in the resident's condition. 2. On 01/03/17, the DON made rounds to check on eight (8) residents that requires O2 Therapy. The DON noted the O2 concentrator indicator light was on and the concentrator was delivering O2. The DON ensured nasal cannulas were in place. No concerns were identified. 3. On 01/04/17, the Administrator assigned audits to check eight (8) residents that required O2 therapy to ensure the O2 concentrator indicator light was on and the concentrator was delivering O2 to the Department Heads, which included the Assistant Directors of Nursing, Quality of Life Director, Admission/Marketing Director, Staff Development Coordinator, Scheduler and MDS. The Department Heads also ensured nasal cannulas were in place. No concerns were identified. 4. On 01/03/17, the (Corporate) Care Consultant (SCC) educated the DON on O2 Administration to ensure professional standards based on facility policy and procedure referencing the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident was receiving O2 therapy as ordered; O2 was applied immediately in a potential emergent situation involving respiratory distress; following the plan of care; the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting a resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting a resident up into the wheelchair, ensure the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the nurse immediately if the portable tank needs to be changed. Only nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON was educated on: Assisting with O2 therapy to ensure professional standards based on CNA Training Manual Mosby third Edition, pages 561-566. This included following the plan of care; the SRNA is to ensure oxygen is switched from the portable tank to the concentrator when assisting resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting the resident up to w/c, ensuring the portable oxygen tank is turned on with nasal cannula or mask is place. Education also included CNAs or Licensed Nurse will observe the amount of oxygen available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed. Only Nurses can change portable tanks, and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, SCC completed a competency on Oxygen Administration with the DON. In addition, the Care Consultant completed an Oxygen Concentrators and Portable Oxygen Tanks competency with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566. 5. On 01/03/17, the DON then educated the SDC on O2 administration to ensure professional standards based on the facility's policy and procedure which includes the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident is receiving O2 therapy as ordered, O2 is applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting the resident to bed, the concentrator is on and the cannula or mask is in place; and, when getting the resident up into the wheelchair, ensuring the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON educated the SDC on: following plan of care, Assisting with oxygen therapy to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566, and included: when assisting a resident the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, the DON then completed a competency with the SDC on Oxygen Administration and Portable Oxygen Tanks and Regulator competencies. In addition, the DON completed a competency with the SDC on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. 6. On 01/03/17, the SDC educated the licensed nurses on O2 administration to ensure professional standards based on facility policy and procedure based on the Lippincott Nursing Procedures Sixth Edition Pages 537-542, which included: ensuring that the resident was receiving O2 therapy as ordered, O2 was applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, when assisting the resident to bed the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator, the concentrator is on and the cannula or mask is in place; and, when getting resident up into the wheelchair, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only nurses can change portable tanks and when the nasal cannula or mask in not in use it is to be placed in a bag. Education continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired Licensed Nurse Staff. Beginning on 01/06/17, the SDC completed competencies with the licensed nurses on oxygen administration with the DON. This competency included: Oxygen Administration and Portable Oxygen Tanks and Regulator Competencies to ensure professional standards based on the facility's policy and procedure which included the Lippincott Nursing Procedures Sixth Edition pages 537-542. Competencies continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated competency will be included in the orientation process of all newly hired Licensed Nurse Staff. 7. On 01/03/17, the SDC then educated the CNAs on following the plan of care and Assisting with Oxygen Therapy to ensure professional standards based on CNA training manual Mosby third Edition, pages 561-566, and included: when assisting a resident to bed, the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. Education continued prior to CNAs working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired CNA's. Beginning on 01/06/17, the SDC completed competencies with CNAs on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. Competencies continued prior to CNAs working and was completed on 01/09/17. The above competency will be included in the orientation process for all newly hired CNAs. 8. On 01/06/17, fifty-three (53) residents at the facility that have a respiratory [DIAGNOSES REDACTED]. This Respiratory Evaluation included: review of the resident's respiratory history of [MEDICAL CONDITION] and apnea, current treatment of [REDACTED]. No concerns were identified. 9. On 01/07/17, eleven (11) residents (as three (3) additional residents received orders for oxygen therapy) that receive oxygen therapy had their charts reviewed by the Director of Clinical Operations Hometown Segment of the Corporation to ensure appropriate action was completed regarding residents with respiratory [DIAGNOSES REDACTED]. Appropriate Actions included: respiratory assessment, notification of Physician/Nurse Practitioner, and following Physician Orders. 10. On 01/07/17, education was conducted by the DON with nine (9) residents with a BIMS of eight (8) or greater. This education included the following: the resident's need for oxygen therapy related to the medical diagnosis, immediately notifying staff when the resident becomes short of breath, notifying staff if oxygen was not operating and the importance of wearing the nasal cannula or mask. 11. On 01/09/17, education was conducted by the DON with two (2) residents (with BIMS less than 8) Responsible Parties. This education included the resident's need for oxygen therapy related to their medical diagnosis, immediately notifying the staff when a resident becomes short of breath, notifying staff if oxygen is not operating and the importance of wearing the nasal cannula or mask. 12. On 01/07/17, the Director of Nursing and the (Corporate) Care Consultant reviewed care plans and nursing assistant care plans of eleven (11) residents receiving O2 therapy to ensure the oxygen administration was included in their plan of care. No concerns were identified. 13. An Ad Hoc QAPI meeting was held on 01/06/17, via phone with the Administrator, Director of Nursing, and Medical Director in regards to Oxygen Therapy Administration, education, interventions, and plans to prevent reoccurrence. A QAPI meeting was held on 01/12/17 by the Administrator, Medical Director, Director of Nursing, and Signature Care Consultant, in regards to Oxygen Therapy Administration, on-going competencies, audits, interventions, and progress on plan to prevent reoccurrence. 14. On 01/09/17, a Resident Council Meeting was held by the Quality of Life Director and Assistant Director of Nursing and Oxygen Therapy related to Medical Diagnosis, immediately notifying staff when the resident becomes short of breath, when not feeling the air flow from the nasal cannula, if oxygen and concentrator is not functioning and the importance of wearing the nasal cannula or mask were among the topics covered. 15. Beginning 01/06/17 and until immediacy is lifted, daily audits (including weekend) will be completed by the Director of Nursing, MDS, Assistant Director of Nursing, Medical Record Coordinator, who is a nurse, Scheduling Coordinator, who is a Nurse, and Staff Development Coordinator each shift for residents receiving oxygen therapy. The audit includes checking the concentrators and portable oxygen tanks, checking to make sure nasal cannula or mask in on, oxygen concentrator is on and has correct setting, portable oxygen tank is on and has correct setting, and checking gauge of portable oxygen tank to check the amount of oxygen in the tank. Once immediacy is lifted, audits will continue daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly as part of QAPI. 16. Beginning 01/07/17 and until immediacy is lifted daily (including weekends) group activity (Quality of Life Group activities, dining room meals, and therapy activities), audits will be completed by the Administrator, Director of Nursing, Rehabilitation Services Manager, Admissions and Marketing Director, Scheduling Coordinator (who is a nurse), Business Office manager, Quality of Life Director, Quality of Life Assistant, Assistant Directors of Nursing, MDS Coordinator, Maintenance Director, Medical Records Coordinator (who is a nurse), Physical Therapist, Physical Therapist Assistant, Occupational Therapist, Occupation

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide services in accordance with each resident's written plan of care five (5) of eighteen (18)sampled residents (Residents #1, #2, #5, #13, and #14). Resident #13 was care planned to receive oxygen (O2) at three (3) liters per minute (LPM), however observation on 01/05/17 revealed the resident's O2 tank was empty and the resident's lips were blue, he/she complained of shortness of breath and the resident's O2 sat was 83% (normal: 90%-99 %). Resident #14 was care planned to receive O2 continuous at three (3) LPM per nasal cannula; however, observation on 01/03/17 revealed Resident #4 had a nasal cannual in his/her nose but the O2 concentrator was turned off, The resident's O2 sat was 85% to 87% (normal: 93% -98%). In addition, the facility failed to follow the care plan related to reporting changes in skin status for Resident #1 and #5 ;and, the facility failed to ensure Resident #2's dressing to wound on his/her coccyx was in place. The facility's failure to provide the necessary care and services related to O2 Administration has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/06/17 and determined to exist on 01/03/17. The facility was notified of the Immediate Jeopardy on 01/06/17. An acceptable Allegation of Compliance (AoC) was received on 01/18/17, alleging the removal of Immediate Jeopardy on 01/10/17. The State Survey Agency validated the Immediate Jeopardy was removed on 01/19/17, 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: Review of the facility's policy titled Care Plans-Comprehensive, last reviewed 09/21/16, revealed the facility develops an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs for each resident. Further review revealed the care plan interventions are implemented after consideration of the resident's problem areas and their causes. Interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. 1. Record review revealed the facility admitted Resident #13 on 11/08/16, with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set assessment, dated 11/15/16, revealed the facility assessed Resident #13's cognition as moderately impaired with a Brief Interview of Mental Status (BIMS) score of eleven (11)indicating he/she was interviewable. Review of the Comprehensive Care Plan, dated 11/08/16, revealed Resident #13 was identified to have a [MEDICAL CONDITION] condition and [DIAGNOSES REDACTED]. Interventions were for staff to monitor oxygen saturations (O2 Sats) as needed, and administer oxygen as ordered. Review of the physician's orders [REDACTED].#13 was sitting in his/her wheelchair in the dining room with an a nasal cannula in his/her nose but the O2 cylinder on the back of the wheelchair was empty, not allowing the resident to receive his/her oxygen per the care plan. The resident's lips were blue and he/she stated he/she was short of breath. The resident's O2 saturation (oxygen in the blood) was 83%. Interview with Certified Nurse Aide (CNA) #5, on 01/19/17 at 2:42 PM, revealed on 01/05/17 at approximately 7:00 AM she assisted Resident #13 up into the wheelchair. When she hooked the resident up to the O2 tank the gauge indicated the tank was half full and was set at 3 Liters/Minute (LPM). CNA #5 stated she did not checked the resident's O2 tank after 7:00 AM (approximately two {2} and a half hours prior to the tank being found empty). Interview with Licensed Practical Nurse (LPN) #1, on 01/09/17 at 11:05 AM, revealed staff should check the O2 cylinder upon contact with any resident receiving O2; when O2 is initiated, and every hour thereafter. LPN #1 stated this resident had a physician's orders [REDACTED]. LPN #1 stated this meant the O2 should be continuous without fail. Interview with the facility's Advanced Practice Registered Nurse (APRN), on 01/16/17 at 3:29 PM, revealed she had educated both the resident and staff as to the importance of him/her using continuous O2. She stated the resident was O2 dependent and the use of O2 was life sustaining for this resident and without the supplemental O2, he/she could die. Interview with the Assistant Director of Nursing (ADON), on 01/06/17 at 2:30 PM, revealed all O2 tanks should be checked frequently, but she did not know the policy on when they were to be changed. 2. Record review revealed the facility admitted Resident #14 on 10/24/16 with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of the Comprehensive Care Plan for [MEDICAL CONDITION] Condition and potential for difficulty breathing diagnoses, dated 11/07/16, revealed to administer oxygen as ordered. Observation on 01/03/17 at 3:29 PM revealed Resident #14 laying in bed with a nasal cannula in his/her nose; however, the oxygen concentrator was not turned on and was not providing oxygen per the resident's care plan. The SSA went to nurses desk and requested RN #1 to come to the resident's room to obtain an oxygen saturation level. The resident's oxygen saturation rate was 85% to 87% (normal: 93% -98%) The nurse then proceeded to turn on the oxygen concentrator. Interview with CNA #1, on 01/03/17 at 3:45 PM, revealed Resident #14 should be on O2 continuous per care plan/physician order. She stated she had forgotten to turn the oxygen concentrator on when she transferred the resident from the wheelchair to the bed at 2:00 PM. Interview with RN #1, on 01/03/17 at 3:40 PM, revealed Resident #14 should be on three (3) liters of O2 continuous. She stated the CNA must have assisted the resident from the wheelchair to the bed and switched the tubing from the oxygen tank to the concentrator and forgot to turn on the oxygen concentrator. Interview with Resident #14's Physician, on 01/06/16 at 5:10 PM, revealed if the order stated continuous oxygen then he expected the oxygen to be on continuous. He stated he expected the resident's oxygen saturation to maintain above ninety percent (90%). He stated if staff accidentally left the oxygen off, the resident could develop major issues including a hypoxic state (condition in which the body is deprived of adequate oxygen supply at the tissue level) and result in a life threatening situation. He further stated leaving the oxygen off for an hour and forty-five (45) minutes was not acceptable if the order stated it ws to be continuous. Interview with the Director of Nursing (DON) on 01/06/17 at 10:25 AM and 2:40 PM, revealed she expected the CNA and nurse to ensure residents received their oxygen per physician's orders [REDACTED]. Interview, with Certified Respiratory Therapist (CRT#1), on 01/12/17 at 10:23 AM, revealed she expected the nurses and CNAs to follow physician orders/care plan for oxygen therapy. Interview with the Administrator, on 01/06/17 at 5:46 PM, revealed she expected staff to follow facility policy, physician's orders [REDACTED]. 3. Record review revealed the facility admitted Resident #1 on 04/30/16 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for risk for developing skin breakdown, dated 05/25/16, revealed to notify the nurse immediately of any new areas of skin breakdown, redness, blisters, discoloration noted during bathing or daily care; and complete weekly skin checks. Review of the Weekly Skin Report, dated 01/03/17 at 12:51 PM revealed the area on Resident #1's coccyx was documented as reddened, intact skin, and blanchable. However, observation of a skin assessment of Resident #1, on 01/04/17 at 10:20 AM, revealed Certified Nurse Aide (CNA) #2 and CNA #9 identified the resident had a large red area with three (3) open areas within the redden areas to the buttocks. Interview with CNA #2 on 01/04/17 at 10:20 AM revealed the open areas were open on the resident's buttock the last day she worked which was three (3) days prior. According to the care plan, the CNA should have reported this to the nurse. However, CNA #2 stated she had not reported the opened areas to the nurse within the last three (3) days. Interview with CNA #11, on 01/04/17 at 3:13 PM, revealed the areas on Resident #1's buttock had been open for the last couple of days. She stated she had told LPN #9 the areas were open. Interview with LPN #9, on 01/11/17 at 7:32 AM, revealed Resident #1's open areas had healed at one (1) time. She stated she expected the CNAs to follow the care plan and let her know if a resident had an open area or if an area had reopened. LPN #9 stated the CNAs could have told her about the pressure sore, but if she was busy she may not have heard them. 4. Record review revealed the facility admitted Resident #5 on 10/26/15 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for skin breakdown, dated 04/11/16, revealed to report changes in skin status including non-healing and new areas to the physician, notify the nurse immediately of any new areas of skin breakdown, redness, blisters, discoloration noted during bathing or daily care; and complete weekly skin checks. Review of the CNA Skin Care Alert Form, dated 12/29/16, 7:00 AM-3:00 PM shift, revealed the resident had redness to the buttock. However, interview with CNA #3, on 01/14/17 at 3:50 PM revealed she saw the open area on 12/30/16 when she gave the resident a shower. She stated she completed a CNA Skin Care Alert Sheet and told Registered Nurse (RN) #1. CNA #3 stated she forgot to fill out a Stop and Watch form to give to the nurse. Observation on 01/04/17 at 3:45 PM of Resident #5's skin assessment with CNA #2 and CNA #3 revealed an open area to the resident's coccyx. Observation of Resident #5's coccyx with the DON, on 01/04/17 at 4:37 PM, revealed the DON assessed the area to the resident's coccyx to be a Stage II. Interview with the Assistant Director of Nursing, on 01/14/17 at 4:04 PM, revealed the CNAs were responsible to tell the nurse if there was an open area. She stated when she made aware of a wound, the wound would be monitored weekly, but she had not been made aware. Interview with Assistant Director of Nursing (ADON) #1, on 01/04/17 at 10:55 AM, revealed she would expect the CNAs to report open areas to the nurse per care plan. Interview with the Director of Nursing (DON), on 01/05/17 at 9:10 AM, revealed she expected the CNAs to follow the care plan and report to the nurse any open areas. 5. Record review revealed the facility admitted Resident #2 on 11/03/16 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for potential for alteration in skin integrity related to fragile skin and frequently incontinent of bowel & bladder, dated 06/10/16, revealed an intervention to follow physician orders [REDACTED]. Review of a physician's orders [REDACTED]. Change dressing every other day and PRN (as needed) if soiled or loose. However, observation on 01/04/17 at 10:15 AM of perineal care provided by Certified Nursing Assistant (CNA) #5 and CNA #8 revealed there was no dressing to Resident #2's wound on the coccyx, per care plan and physician order. Interview with CNA #5 and CNA #8, on 01/04/17 at 10:15 AM, revealed they had provided perinea care around 8:00 AM to Resident #2. Further interview with CNA #5, on 01/04/17 at 11:40 AM, revealed she told Licensed Practical Nurse (LPN ) #1 that there was no dressing to Resident #2's coccyx wound at approximately 8:00 AM. Interview with LPN #1, on 01/04/17 at 10:40 AM, and on 01/12/17 at 2:12 PM, revealed she had been told the dressing was off Resident #2's wound around 8:00 AM. LPN #1 stated she should have placed the dressing on the wound because it was an open area and needed to be covered. She stated any skin issues were care planned and care plans and physician orders [REDACTED]. Interviews on 01/06/17 at 10:03 AM with LPN #4 and at 11:15 AM with LPN #5, revealed the purpose of the care plan was to ensure staff knew how to care for the resident. Interview with the DON, on 01/06/17 at 1:10 PM and 4:10 PM, revealed the dressing should be reapplied as soon as possible, and she expected staff to follow the care plan. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/03/17, the Nurse Practitioner saw Resident #14 on 01/03/17 and titrated Resident #14's O2 to 2 liters per minute via nasal cannula. Resident #14 tolerated the titration with no signs and symptoms of Respiratory Distress. On 01/05/17, Resident #13 was observed in the Dining Room with his/her portable O2 tank reading empty. LPN #1 replaced the portable O2 tank. The Nurse Practitioner visited Resident #13 and identified no change in the resident's condition. 2. On 01/03/17, the DON made rounds to check on eight (8) residents that requires O2 Therapy. The DON noted the O2 concentrator indicator light was on and the concentrator was delivering O2. The DON ensured nasal cannulas were in place. No concerns were identified. 3. On 01/04/17, the Administrator assigned audits to check eight (8) residents that required O2 therapy to ensure the O2 concentrator indicator light was on and the concentrator was delivering O2 to the Department Heads, which included the Assistant Directors of Nursing, Quality of Life Director, Admission/Marketing Director, Staff Development Coordinator, Scheduler and MDS. The Department Heads also ensured nasal cannulas were in place. No concerns were identified. 4. On 01/03/17, the (Corporate) Care Consultant (SCC) educated the DON on O2 Administration to ensure professional standards based on facility policy and procedure referencing the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident was receiving O2 therapy as ordered; O2 was applied immediately in a potential emergent situation involving respiratory distress; following the plan of care; the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting a resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting a resident up into the wheelchair, ensure the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the nurse immediately if the portable tank needs to be changed. Only nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON was educated on: Assisting with O2 therapy to ensure professional standards based on CNA Training Manual Mosby third Edition, pages 561-566. This included following the plan of care; the SRNA is to ensure oxygen is switched from the portable tank to the concentrator when assisting resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting the resident up to w/c, ensuring the portable oxygen tank is turned on with nasal cannula or mask is place. Education also included CNAs or Licensed Nurse will observe the amount of oxygen available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed. Only Nurses can change portable tanks, and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, SCC completed a competency on Oxygen Administration with the DON. In addition, the Care Consultant completed an Oxygen Concentrators and Portable Oxygen Tanks competency with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566. 5. On 01/03/17, the DON then educated the SDC on O2 administration to ensure professional standards based on the facility's policy and procedure which includes the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident is receiving O2 therapy as ordered, O2 is applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting the resident to bed, the concentrator is on and the cannula or mask is in place; and, when getting the resident up into the wheelchair, ensuring the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON educated the SDC on: following plan of care, Assisting with oxygen therapy to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566, and included: when assisting a resident the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, the DON then completed a competency with the SDC on Oxygen Administration and Portable Oxygen Tanks and Regulator competencies. In addition, the DON completed a competency with the SDC on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. 6. On 01/03/17, the SDC educated the licensed nurses on O2 administration to ensure professional standards based on facility policy and procedure based on the Lippincott Nursing Procedures Sixth Edition Pages 537-542, which included: ensuring that the resident was receiving O2 therapy as ordered, O2 was applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, when assisting the resident to bed the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator, the concentrator is on and the cannula or mask is in place; and, when getting resident up into the wheelchair, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only nurses can change portable tanks and when the nasal cannula or mask in not in use it is to be placed in a bag. Education continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired Licensed Nurse Staff. Beginning on 01/06/17, the SDC completed competencies with the licensed nurses on oxygen administration with the DON. This competency included: Oxygen Administration and Portable Oxygen Tanks and Regulator Competencies to ensure professional standards based on the facility's policy and procedure which included the Lippincott Nursing Procedures Sixth Edition pages 537-542. Competencies continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated competency will be included in the orientation process of all newly hired Licensed Nurse Staff. 7. On 01/03/17, the SDC then educated the CNAs on following the plan of care and Assisting with Oxygen Therapy to ensure professional standards based on CNA training manual Mosby third Edition, pages 561-566, and included: when assisting a resident to bed, the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. Education continued prior to CNAs working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired CNA's. Beginning on 01/06/17, the SDC completed competencies with CNAs on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. Competencies continued prior to CNAs working and was completed on 01/09/17. The above competency will be included in the orientation process for all newly hired CNAs. 8. On 01/06/17, fifty-three (53) residents at the facility that have a respiratory [DIAGNOSES REDACTED]. This Respiratory Evaluation included: review of the resident's respiratory history of [MEDICAL CONDITION] and apnea, current treatment of [REDACTED]. No concerns were identified. 9. On 01/07/17, eleven (11) residents (as three (3) additional residents received orders for oxygen therapy) that receive oxygen therapy had their charts reviewed by the Director of Clinical Operations Hometown Segment of the Corporation to ensure appropriate action was completed regarding residents with respiratory [DIAGNOSES REDACTED]. Appropriate Actions included: respiratory assessment, notification of Physician/Nurse Practitioner, and following Physician Orders. 10. On 01/07/17, education was conducted by the DON with nine (9) residents with a BIMS of eight (8) or greater. This education included the following: the resident's need for oxygen therapy related to the medical diagnosis, immediately notifying staff when the resident becomes short of breath, notifying staff if oxygen was not operating and the importance of wearing the nasal cannula or mask. 11. On 01/09/17, education was conducted by the DON with two (2) residents (with BIMS less than 8) Responsible Parties. This education included the resident's need for oxygen therapy related to their medical diagnosis, immediately notifying the staff when a resident becomes short of breath, notifying staff if oxygen is not operating and the importance of wearing the nasal cannula or mask. 12. On 01/07/17, the Director of Nursing and the (Corporate) Care Consultant reviewed care plans and nursing assistant care plans of eleven (11) residents receiving O2 therapy to ensure the oxygen administration was included in their plan of care. No concerns were identified. 13. An Ad Hoc QAPI meeting was held on 01/06/17, via phone with the Administrator, Director of Nursing, and Medical Director in regards to Oxygen Therapy Administration, education, interventions, and plans to prevent reoccurrence. A QAPI meeting was held on 01/12/17 by the Administrator, Medical Director, Director of Nursing, and Signature Care Consultant, in regards to Oxygen Therapy Administration, on-going competencies, audits, interventions, and progress on plan to prevent reoccurrence. 14. On 01/09/17, a Resident Council Meeting was held by the Quality of Life Director and Assistant Director of Nursing and Oxygen Therapy related to Medical Diagnosis, immediately notifying staff when the resident becomes short of breath, when not feeling the air flow from the nasal cannula, if oxygen and concentrator is not functioning and the importance of wearing the nasal cannula or mask were among the topics covered. 15. Beginning 01/06/17 and until immediacy is lifted, daily audits (including weekend) will be completed by the Director of Nursing, MDS, Assistant Director of Nursing, Medical Record Coordinator, who is a nurse, Scheduling Coordinator, who is a Nurse, and Staff Development Coordinator each shift for residents receiving oxygen therapy. The audit includes checking the concentrators and portable oxygen tanks, checking to make sure nasal cannula or mask in on, oxygen concentrator is on and has correct setting, portable oxygen tank is on and has correct setting, and checking gauge of portable oxygen tank to check the amount of oxygen in the tank. Once immediacy is lifted, audits will continue daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly as part of QAPI. 16. Beginning 01/07/17 and until immediacy is lifted daily (including weekends) group activity (Quality of Life Group activities, dining room meals, and therapy activities), audits will be completed by the Administrator, Director of Nursing, Rehabilitation Services Manager, Admissions and Marketing Director, Scheduling Coordinator (who is a nurse), Business Office manager, Quality of Life Director, Quality of Life Assistant, Assistant Directors of Nursing, MDS Coordinator, Maintenance Director, Medical Records Coordinator (who is a nurse), Physical Therapist, Physical Therapist Assistant, Occupational Therapist, Occupational Therapist Assistant, or Speech Therapist as these are the times that portable oxygen tanks are utilized rather than oxygen concentrators. These audits include checking to make sure nasal cannula is in place, portable tank is on and has the correct setting, checking the portable tank gauge to ensure oxygen is available for utilization. Documentation of audits will be maintained on an audit tool and will be reviewed daily for completion and appropriate follow up by the Administrator or DON. Once immediacy is lifted these group activity audits will continue daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly as a part of QAPI. 17. Beginning 01/06/17 and until immediacy is lifted, four (4) licensed nurses, and four (4) Certified Nurse Aides per day (including weekends) on various shifts will be given the competency for how to care for a resident on O2 Therapy by the Staff Development Coordinator, Director of Nursing, or Assistant Directors of Nursing. Competency must be achieved by the Licensed Nurse or Certified Nurse Aide. If competency is not achieved by the Licensed Nurse or CNA, then the employee will be re-educated and then given the competency again until competency is achieved. Once immediacy is lifted, competencies will continue at two (2) Licensed Nurses and Certified Nurse Aides per day on various shifts (including weekends) times four (4) weeks then weekly times four (4) weeks, then monthly for six (6) months. 18. Beginning 01/07/17, until immediacy is lifted, five (5) residents will be interviewed daily by the Director of Nursing or Assistant Directors of Nursing and these topics discussed: The resident's need for O2 therapy related to their medical diagnosis, immediately notifying the staff when the resident becomes short of breath, when not feeling the air flow from the nasal cannula, if oxygen and concentrator is not functioning and the importance of wearing the nasal cannula or mask were among the topics covered. Any concerns will be reported to the Administrator or Director of Nursing immediately and follow up will be completed. Once immediacy is lifted, resident interviews will continue to three (3) daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly times six (6) months. 19. Daily Monday through Friday in the morning clinical meeting new orders or changes for O2 Therapy, Care Plans and CNA care plans for those receiving oxygen therapy, and the twenty-four (24) hour report will be reviewed for any change in Respiratory status by the Administrative Nursing Team that consists of the Director of Nursing, Assistant Directors of Nursing, MDS Nurses, Scheduler, and Medical Records Director to ensure interventions were completed. Weekend coverage will be conducted by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, Scheduler (who is a nurse), Medical Records (who is a nurse), or MDS. They will also review new orders or changes for Oxygen Therapy, Care Plans, and CNA care plans for those receiving oxygen therapy, and the twenty-four (24) hour report will be reviewed for any change in Respiratory status. 20. The Administrator or DON will review the oxygen audits, resident interviews, and Licensed Nurses Oxygen Administration and Portable Oxygen Tanks/Regulators Competencies; and, the CNAs Oxygen concentrator and Portable Oxygen Tank Competencies; given daily times four (4) weeks then weekly times four (4) weekly then monthly times six (6) months for any noted concerns. Any concerns will be addressed immediately. 21. QAPI meeting will be held weekly for four (4) weeks then monthly. Results of the resident interviews, daily (Monday thru Friday) review in Clinical AM Meeting, staff competencies, and audits will be reported to the QAPI committee weekly for four (4) weeks and then monthly for six (6) months to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QAPI committee will determine at what frequency the resident interviews, staff competencies and audits will need to continue. Concerns identified will be corrected immediately and reported to the Administrator to ensure appropriate follow up is completed. A nurse from the regional team or corporate office will attend the weekly QAPI meeting providing consultation, oversight and assist in determining the further need of continued education or revision of the p

Based on interview, review of the Administrator Job Description, and review of the Plan of Correction (POC) for the 01/11/16 and 06/28/16 surveys, it was determined 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. The Administrator failed to ensure the facility's PoC's were implemented related to education to ensure residents received proper care and treatment for [REDACTED].#13 and #14 were not receiving oxygen as ordered by the Physician. Refer to F282, F328, and F520. The facility's failure 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 has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/06/17 and determined to exist on 01/03/17. The facility was notified of the Immediate Jeopardy on 01/06/17. An acceptable Allegation of Compliance (AoC) was received on 01/18/17, alleging the removal of Immediate Jeopardy on 01/10/17. The State Survey Agency validated the Immediate Jeopardy was removed on 01/19/17, 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: Review of the Job Description for the Administrator, last updated December 2011, revealed the Administrator should lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Further review of the Administrator's Job Description revealed the Administrator is responsible for the Quality Assurance program. Interview with the Administrator on 01/06/16 at 5:46 PM revealed the facility had completed audits related to O2 Therapy, monitoring, O2 tubing, use of concentrators and O2 tanks, as per the POCs and had not identified concerns. In addition, the Administrator stated all staff had been retrained and had a competency check with no concerns identified. However, the Administrator failed to ensure the facility's 01/11/16 and 06/28/16 PoCs were implemented related to education to ensure staff provided appropriate care and services related to O2 therapy. Review of the education provided to the Licensed Nurses and Certified Nurse Aides (CNAs) from the facility and Respiratory Therapist revealed Licensed Practical Nurse (LPN) #1, LPN #2, LPN #5, CNA #6, CNA #8, and CNA #9, had not received oxygen therapy education as reported in the facility's Recertification and Abbreviated Plans of Correction. Interviews with Licensed Practical Nurse (LPN) #8 on 01/06/17 at 2:28 PM, LPN #5 on 01/06/17 at 2:35 PM, and LPN # 9 on 01/11/17 at 7:32 AM revealed they had not received any training on oxygen therapy from the facility. CNA #9 stated she had one (1) training with the Respiratory Therapist on Oxygen and that was in June 2016 and no further inservices since then. Observation on 01/05/17 at 9:36 AM, revealed Resident #13 in the front dining room with a nasal cannula in his/her nose. The resident had a bluish tint to his/her skin and shortness of breath. Observation of the portable O2 tank attached to the back of the resident's wheelchair revealed it was empty. However, when Licensed Practical Nurse (LPN) #1 was notified, she did not check the resident's O2 tank, until it was brought to her attention. This resident's O2 saturation was 85% to 87% (normal 90%-98%). Observation on 01/03/17 at 3:35 PM, and interview with CNA #1, on 01/03/17 at 3:45 PM, revealed Resident #14 nasal cannula was in the resident's nose but the O2 concentrator was not turned on. CNA #1 stated she forgot to turn the O2 concentrator on when she transferred the resident from the wheelchair to the bed at 2:00 PM. Interview with CNA #8, on 01/03/17 at 3:34 PM revealed she did not know anything about the O2 tanks; she stated that the nurse was responsible for the tanks. CNA #8 stated she had never been trained on how to check the O2 in a portable O2 cylinder. In addition, further review of the Abbreviated Survey Plan of Correction, dated 06/28/16, revealed the Respiratory Therapist would in-service nurses on various oxygen therapy topics quarterly. However, the facility failed to present any documented evidence of quarterly oxygen therapy inservices provided to the nurses for September and December 2016. Interview, with Certified Respiratory Therapist (CRT #1), on 01/12/17 at 10:23 AM, revealed she developed part of an in-services, titled Portable Oxygen Tanks E Cylinders and one for Troubleshooting someone complaining of Shortness of Breath and had faxed these to the facility on [DATE]. She stated she had not conducted any inservices on oxygen to the facility staff prior to 06/14/16 and no quarterly inservice since then. Interview with the Administrator, on 01/06/17 at 5:45 PM, revealed oxygen has been a part of the Quality Assurance Performance Improvement Program (QAPI) beginning the last annual survey Plan of Correction 01/11/16 and repeated again after the POC for 06/28/16. She stated the facility continued to be monitored; however, there had been no issues brought to her attention related to oxygen tanks running low or concentrators not being turned on, prior to the 2017 annual survey. **The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 01/03/17, the Nurse Practitioner saw Resident #14 on 01/03/17 and titrated Resident #14's O2 to 2 liters per minute via nasal cannula. Resident #14 tolerated the titration with no signs and symptoms of Respiratory Distress. On 01/05/17, Resident #13 was observed in the Dining Room with his/her portable O2 tank reading empty. LPN #1 replaced the portable O2 tank. The Nurse Practitioner visited Resident #13 and identified no change in the resident's condition. 2. On 01/03/17, the DON made rounds to check on eight (8) residents that requires O2 Therapy. The DON noted the O2 concentrator indicator light was on and the concentrator was delivering O2. The DON ensured nasal cannulas were in place. No concerns were identified. 3. On 01/04/17, the Administrator assigned audits to check eight (8) residents that required O2 therapy to ensure the O2 concentrator indicator light was on and the concentrator was delivering O2 to the Department Heads, which included the Assistant Directors of Nursing, Quality of Life Director, Admission/Marketing Director, Staff Development Coordinator, Scheduler and MDS. The Department Heads also ensured nasal cannulas were in place. No concerns were identified. 4. On 01/03/17, the (Corporate) Care Consultant (SCC) educated the DON on O2 Administration to ensure professional standards based on facility policy and procedure referencing the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident was receiving O2 therapy as ordered; O2 was applied immediately in a potential emergent situation involving respiratory distress; following the plan of care; the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting a resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting a resident up into the wheelchair, ensure the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the nurse immediately if the portable tank needs to be changed. Only nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON was educated on: Assisting with O2 therapy to ensure professional standards based on CNA Training Manual Mosby third Edition, pages 561-566. This included following the plan of care; the SRNA is to ensure oxygen is switched from the portable tank to the concentrator when assisting resident to bed; the concentrator is on and the cannula or mask is in place; and, when getting the resident up to w/c, ensuring the portable oxygen tank is turned on with nasal cannula or mask is place. Education also included CNAs or Licensed Nurse will observe the amount of oxygen available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed. Only Nurses can change portable tanks, and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, SCC completed a competency on Oxygen Administration with the DON. In addition, the Care Consultant completed an Oxygen Concentrators and Portable Oxygen Tanks competency with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566. 5. On 01/03/17, the DON then educated the SDC on O2 administration to ensure professional standards based on the facility's policy and procedure which includes the Lippincott Nursing Procedures Sixth Edition Pages 537-542, and included: ensuring that the resident is receiving O2 therapy as ordered, O2 is applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator when assisting the resident to bed, the concentrator is on and the cannula or mask is in place; and, when getting the resident up into the wheelchair, ensuring the portable O2 tank is turned on with the nasal cannula or mask in place. Education also included CNAs or Licensed Nurse will observe the amount of O2 available in the portable tank and they are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks, and when the cannula or mask is not in use it is placed in a bag. In addition, the DON educated the SDC on: following plan of care, Assisting with oxygen therapy to ensure professional standards based on CNA training manual Mosby Third Edition, pages 561-566, and included: when assisting a resident the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. On 01/06/17, the DON then completed a competency with the SDC on Oxygen Administration and Portable Oxygen Tanks and Regulator competencies. In addition, the DON completed a competency with the SDC on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. 6. On 01/03/17, the SDC educated the licensed nurses on O2 administration to ensure professional standards based on facility policy and procedure based on the Lippincott Nursing Procedures Sixth Edition Pages 537-542, which included: ensuring that the resident was receiving O2 therapy as ordered, O2 was applied immediately in a potential emergent situation involving respiratory distress, following the plan of care, when assisting the resident to bed the Licensed Nurse is to ensure O2 is switched from the portable tank to the concentrator, the concentrator is on and the cannula or mask is in place; and, when getting resident up into the wheelchair, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only nurses can change portable tanks and when the nasal cannula or mask in not in use it is to be placed in a bag. Education continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired Licensed Nurse Staff. Beginning on 01/06/17, the SDC completed competencies with the licensed nurses on oxygen administration with the DON. This competency included: Oxygen Administration and Portable Oxygen Tanks and Regulator Competencies to ensure professional standards based on the facility's policy and procedure which included the Lippincott Nursing Procedures Sixth Edition pages 537-542. Competencies continued prior to Licensed Nurses working and was completed on 01/09/17. The above stated competency will be included in the orientation process of all newly hired Licensed Nurse Staff. 7. On 01/03/17, the SDC then educated the CNAs on following the plan of care and Assisting with Oxygen Therapy to ensure professional standards based on CNA training manual Mosby third Edition, pages 561-566, and included: when assisting a resident to bed, the CNA is to ensure Oxygen is switched from the portable tank to the concentrator, the concentrator is on, and the cannula or mask is in place; and, when getting resident up into w/c, ensuring the portable oxygen tank is turned on with the nasal cannula or mask in place. Education also included CNAs are to inform the Nurse immediately if the portable tank needs to be changed, only Nurses can change portable tanks and when nasal cannula or mask is not in use it is to be placed in a bag. Education continued prior to CNAs working and was completed on 01/09/17. The above stated education will be included in the orientation process for all newly hired CNA's. Beginning on 01/06/17, the SDC completed competencies with CNAs on Oxygen Concentrators and Portable Oxygen Tanks with the DON. This competency included: Oxygen Concentrators and Portable Oxygen Tanks and Regulator to ensure professional standards based on CNA training Manual Mosby Third Edition, pages 561-566. Competencies continued prior to CNAs working and was completed on 01/09/17. The above competency will be included in the orientation process for all newly hired CNAs. 8. On 01/06/17, fifty-three (53) residents at the facility that have a respiratory [DIAGNOSES REDACTED]. This Respiratory Evaluation included: review of the resident's respiratory history of [MEDICAL CONDITION] and apnea, current treatment of [REDACTED]. No concerns were identified. 9. On 01/07/17, eleven (11) residents (as three (3) additional residents received orders for oxygen therapy) that receive oxygen therapy had their charts reviewed by the Director of Clinical Operations Hometown Segment of the Corporation to ensure appropriate action was completed regarding residents with respiratory [DIAGNOSES REDACTED]. Appropriate Actions included: respiratory assessment, notification of Physician/Nurse Practitioner, and following Physician Orders. 10. On 01/07/17, education was conducted by the DON with nine (9) residents with a BIMS of eight (8) or greater. This education included the following: the resident's need for oxygen therapy related to the medical diagnosis, immediately notifying staff when the resident becomes short of breath, notifying staff if oxygen was not operating and the importance of wearing the nasal cannula or mask. 11. On 01/09/17, education was conducted by the DON with two (2) residents (with BIMS less than 8) Responsible Parties. This education included the resident's need for oxygen therapy related to their medical diagnosis, immediately notifying the staff when a resident becomes short of breath, notifying staff if oxygen is not operating and the importance of wearing the nasal cannula or mask. 12. On 01/07/17, the Director of Nursing and the (Corporate) Care Consultant reviewed care plans and nursing assistant care plans of eleven (11) residents receiving O2 therapy to ensure the oxygen administration was included in their plan of care. No concerns were identified. 13. An Ad Hoc QAPI meeting was held on 01/06/17, via phone with the Administrator, Director of Nursing, and Medical Director in regards to Oxygen Therapy Administration, education, interventions, and plans to prevent reoccurrence. A QAPI meeting was held on 01/12/17 by the Administrator, Medical Director, Director of Nursing, and Signature Care Consultant, in regards to Oxygen Therapy Administration, on-going competencies, audits, interventions, and progress on plan to prevent reoccurrence. 14. On 01/09/17, a Resident Council Meeting was held by the Quality of Life Director and Assistant Director of Nursing and Oxygen Therapy related to Medical Diagnosis, immediately notifying staff when the resident becomes short of breath, when not feeling the air flow from the nasal cannula, if oxygen and concentrator is not functioning and the importance of wearing the nasal cannula or mask were among the topics covered. 15. Beginning 01/06/17 and until immediacy is lifted, daily audits (including weekend) will be completed by the Director of Nursing, MDS, Assistant Director of Nursing, Medical Record Coordinator, who is a nurse, Scheduling Coordinator, who is a Nurse, and Staff Development Coordinator each shift for residents receiving oxygen therapy. The audit includes checking the concentrators and portable oxygen tanks, checking to make sure nasal cannula or mask in on, oxygen concentrator is on and has correct setting, portable oxygen tank is on and has correct setting, and checking gauge of portable oxygen tank to check the amount of oxygen in the tank. Once immediacy is lifted, audits will continue daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly as part of QAPI. 16. Beginning 01/07/17 and until immediacy is lifted daily (including weekends) group activity (Quality of Life Group activities, dining room meals, and therapy activities), audits will be completed by the Administrator, Director of Nursing, Rehabilitation Services Manager, Admissions and Marketing Director, Scheduling Coordinator (who is a nurse), Business Office manager, Quality of Life Director, Quality of Life Assistant, Assistant Directors of Nursing, MDS Coordinator, Maintenance Director, Medical Records Coordinator (who is a nurse), Physical Therapist, Physical Therapist Assistant, Occupational Therapist, Occupational Therapist Assistant, or Speech Therapist as these are the times that portable oxygen tanks are utilized rather than oxygen concentrators. These audits include checking to make sure nasal cannula is in place, portable tank is on and has the correct setting, checking the portable tank gauge to ensure oxygen is available for utilization. Documentation of audits will be maintained on an audit tool and will be reviewed daily for completion and appropriate follow up by the Administrator or DON. Once immediacy is lifted these group activity audits will continue daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly as a part of QAPI. 17. Beginning 01/06/17 and until immediacy is lifted, four (4) licensed nurses, and four (4) Certified Nurse Aides per day (including weekends) on various shifts will be given the competency for how to care for a resident on O2 Therapy by the Staff Development Coordinator, Director of Nursing, or Assistant Directors of Nursing. Competency must be achieved by the Licensed Nurse or Certified Nurse Aide. If competency is not achieved by the Licensed Nurse or CNA, then the employee will be re-educated and then given the competency again until competency is achieved. Once immediacy is lifted, competencies will continue at two (2) Licensed Nurses and Certified Nurse Aides per day on various shifts (including weekends) times four (4) weeks then weekly times four (4) weeks, then monthly for six (6) months. 18. Beginning 01/07/17, until immediacy is lifted, five (5) residents will be interviewed daily by the Director of Nursing or Assistant Directors of Nursing and these topics discussed: The resident's need for O2 therapy related to their medical diagnosis, immediately notifying the staff when the resident becomes short of breath, when not feeling the air flow from the nasal cannula, if oxygen and concentrator is not functioning and the importance of wearing the nasal cannula or mask were among the topics covered. Any concerns will be reported to the Administrator or Director of Nursing immediately and follow up will be completed. Once immediacy is lifted, resident interviews will continue to three (3) daily (including weekends) times four (4) weeks, then weekly times four (4) weeks, then monthly times six (6) months. 19. Daily Monday through Friday in the morning clinical meeting new orders or changes for O2 Therapy, Care Plans and CNA care plans for those receiving oxygen therapy, and the twenty-four (24) hour report will be reviewed for any change in Respiratory status by the Administrative Nursing Team that consists of the Director of Nursing, Assistant Directors of Nursing, MDS Nurses, Scheduler, and Medical Records Director to ensure interventions were completed. Weekend coverage will be conducted by the Director of Nursing, Assistant Directors of Nursing, Staff Development Coordinator, Scheduler (who is a nurse), Medical Records (who is a nurse), or MDS. They will also review new orders or changes for Oxygen Therapy, Care Plans, and CNA care plans for those receiving oxygen therapy, and the twenty-four (24) hour report will be reviewed for any change in Respiratory status. 20. The Administrator or DON will review the oxygen audits, resident interviews, and Licensed Nurses Oxygen Administration and Portable Oxygen Tanks/Regulators Competencies; and, the CNAs Oxygen concentrator and Portable Oxygen Tank Competencies; given daily times four (4) weeks then weekly times four (4) weekly then monthly times six (6) months for any noted concerns. Any concerns will be addressed immediately. 21. QAPI meeting will be held weekly for four (4) weeks then monthly. Results of the resident interviews, daily (Monday thru Friday) review in Clinical AM Meeting, staff competencies, and audits will be reported to the QAPI committee weekly for four (4) weeks and then monthly for six (6) months to determine the further need of continued education or revision of plan. At that time, based on evaluation, the QAPI committee will determine at what frequency the resident interviews, staff competencies and audits will need to continue. Concerns identified will be corrected immediately and reported to the Administrator to ensure appropriate follow up is completed. A nurse from the regional team or corporate office will attend the weekly QAPI meeting providing consultation, oversight and assist in determining the further need of continued education or revision of the plan. 22. The Signature Care Consultant has been on site since 01/03/17 to provide oversight to the facility. The nurse from the regional team or home office has been assisting as needed, performing chart audits and providing oversight and consultation in regards to oxygen audits, Licensed Nurses and CNAs competencies, Resident Interviews, twenty-four (24) hour report reviews, Physician order [REDACTED]. 23. A nurse from the regional team or corporate office will be onsite weekly and available by telephone daily since 01/03/17 and will continue weekly visits and daily review by telephone until immediacy has been lifted, then every other week for four (4) weeks, then monthly. The nurses from the regional team or home office are assisting as needed, performing chart audits and providing oversight and consultation in regards to oxygen audits, Licensed Nurses and CNA competencies, Resident Interviews, twenty-four (24) hour report reviews, Physician order [REDACTED]. 24. Education was provided to the Administrator by the Regional Vice President of Operations on 01/09/17 regarding administration and oversight within the facility to attain or maintain the highest practicable physical, mental and psychosocial wellbeing of each resident. Also included in the education was development and oversight for follow through with the plan to correct cited deficient practice. Review was completed of the facility's administration policy. Administration oversight of the facility will be completed by Regional Vice President of Operations, or Regional Controller who is a Licensed Administrator weekly on site and daily by telephone until removal of immediacy beginning 01/09/17, then every other week for four (4) weeks, then monthly. Oversight will be provided by the Regional Vice President of Operations, or Regional Controller, who is a Licensed Administrator, to ensure continuation and follow through with the allegation of compliance plan. Oversight will also include but not limited to daily review of Oxygen audits, Licensed Nurses and CNAs competencies, resident interviews, twenty-four (24) hour report reviews, Physician order [REDACTED]. **The State Survey Agency validated the corrective actions taken by the facility as follows: 1. Interview on 01/16/17 at 3:29 PM with the APRN, revealed she assessed Resident #13 and #14 with no concerns identified. 2. Interview with the DON, on 01/18/17 at 11:27 AM revealed she rounded on eight (8) residents on 01/03/17 to ensure the indicator light was on and the nasal cannula was in place. No concerns were found. 3. Interview with Assistant Director of Nursing (ADON) #1, on 01/19/17 at 2:00 PM and ADON #2 on 01/19/17 at 2:22 PM, revealed they were assigned random audits during the annual survey after the identification of an oxygen issue on 01/03/17 to ensure concentrators were on and functioning, the correct liter flow was set according to the physician's orders [REDACTED]. They stated no concerns were identified. Review of the documented audits revealed there were no concerns. 4. Review of the education sign-in sheet dated 01/03/17 revealed the DON had been trained by the SCC. Interview with the SCC on 01/19/17 at 1:09 PM revealed she provided the Director of Nursing education based on facility policies and procedures which included the Lippincott Nursing Procedures Sixth Edition, which was the standards of practice used prior to the annual recertification survey. She stated that when the problem with oxygen was identified on 01/03/17 she provided this in-service to the DON which included applying oxygen, assessing the resident, reading the oxygen gauges, following the physician's orders [REDACTED]. She further stated only the Licensed Nurse is allowed to adjust the liter flow for oxygen and change out oxygen tanks. She stated she also provided the Director of Nursing with the Oxygen Administration Competency with return demonstration provided by the Director of Nursing. She also instructed on tubing change every week and as needed, placement of tubing in the nares and over the ears, and tubing placement in a plastic bag when not in use. She further stated she reviewed emergency situations involving respiratory distress. She revealed her education also included when reading the gauge if the tank needed to be changed to change and the CNAs are to notify the nurse immediately if the gauge indicated the tank needed to be changed. She stated she also in-serviced and provided a competency to the Director of Nursing which included reading the oxygen gauge, tubing placement, feeling of the air flow to ensure working, turning the oxygen tank and concentrator on and off, and to report to the nurse if readjustment is required for the liter flow. She further revealed she in-serviced regarding only nurses are allowed to change tanks and adjust the liter flow. Interview with the Care Consultant on 01/19/17 at 1:30 PM, revealed she provided a competency with return demonstration with the Director of Nursing on Oxygen Concentrators and Portable Oxygen Tanks based on the facility policy and procedure which included the Mosby Third Edition. Interview with the DON on 01/18/17 at 11:27 AM, revealed on 01/06/17 the SCC educated her on O2 Administration as well as O2 portable tanks and regulators to included competency check off. 5. Interview with the DON on 01/18/17 at 11:27 AM, revealed she trained the SCD on O2 Administration as well as O2 portable tanks and regulators to included competency check off. Interview with the SDC, on 01/18/17 at 4:00 PM, revealed she had been in-serviced by the DON and competency had been completed. 6. Review of the education and signature sign-in sheets dated 01/03/17 revealed all Licensed staff received O2 inservice. Interview with the SDC, on 01/18/17 at 4:00 PM, revealed she began to in-service all RNs, LPNs, and Full Time Rehab staff (RNs and LPNs) on O2 Administration between the dates of 01/03-09/17 on all shifts and a competency was completed on each by 01/09/16. She stated that some staff were on vacation, LOA or off and they were called in to complete the in-service and competency before allowing to return to work. Competencies were reviewed with no concerns. Interview with Registered Nurse #1 on 01/19/17 at 9:20 AM, and RN #4 at 10:00 AM, revealed they received an in-service by the Staff Development Coordinator as well as return demonstration regarding oxygen administration and assessment. They both revealed this included following the care plan and physician's orders [REDACTED]. They further revealed they were educated on how to determine how much oxygen is left in the tank according to the gauge and when the gauge reads 1,000 starting at the red zone the tank is to be changed. They stated the CNA is not able to change the oxygen tanks and must let the nurses know when the tank is in the red zone to switch out the tanks. They further stated the CNA can switch the oxygen tubing from the concentrator to the tank and turn the tank and concentrator on and off. They stated when the tubing is not in use it is to be placed in a plastic bag and the tubing is to be changed weekly on Wednesday night and document on the Medication Administration Record [REDACTED]. They further revealed they were in-serviced to check the resident's tank or concentrator every time the nurse makes contact with the resident which should be every hour. Interview with the Speech Therapist (SLP) on 01/19/17 at 11:08 AM revealed she received an inservice on 01/09/17 regarding O2 therapy and reading the oxygen tank gauge to determine the amount of oxygen left in the tank. She further revealed

Based on observation, interview, record review, facility policy review, review of a hospital emergency room Report and Discharge Summary, review of the Hoyer Lift Manual, Sit to Stand Manufacturer's Instruction, and Operator and Maintenance Manual for Patient Slings, review of the facility's Education Documentation, and review of a Material Safety Data Sheet and a hair spray can label, it was determined the facility failed to ensure the residents' environment remained as free of accident hazards as possible; and, failed to ensure adequate supervision was provided to prevent accidents for two (2) of nineteen (19) sampled residents (Residents #1 and #14). In addition, the facility failed to ensure flammable aerosols and cleaning products were not stored in resident rooms. Review of a list provided by the facility, revealed there were a total of fourteen (14) wandering residents in the facility. The facility care planned Resident #1 to be transferred by two (2) staff with the use of a Hoyer (brand) lift. The facility failed to assess the resident for the safe use of the sit to stand lift. On 08/09/15, Resident #1 fell when one (1) staff (Certified Nurse Aide {CNA} #13) transferred him/her with a sit to stand lift instead of with a Hoyer lift with two (2) staff, as care planned. In addition, CNA #13 used a Hoyer lift sling instead of the sit to stand sling with the transfer. Resident #1 sustained a hip fracture requiring surgery. The facility care planned Resident #14 for the use of a Hoyer lift with two (2) staff. On 11/20/15, Resident #14 fell approximately three (3) feet from the Hoyer Lift as staff failed to fully open the supporting legs of the device, causing it to tip over and the resident to fall out of the lift sling. staff. Resident #14 fell sustained a three (3) centimeter laceration to the back of the head that required seven (7) staples to close the wound. In addition, the facility failed to monitor staff training to ensure the staff was qualified in the use of the lifts. The facility provided verbal training during orientation and left it to the other aides to demonstrate the use of the lift on the floor. However, there was no hands on training provided by Administrative staff; and, no follow up to ensure the training was effective. The facility also failed to have the lifts checked to ensure they were working appropriately. The findings include: Review of facility's policy 'Falls Management', dated 01/01/10, revealed the policy is to screen all residents to identify possible risk factors that may place a resident at risk for falls; to evaluate those risks; implement interventions to reduce these risks; and, monitor the interventions and modify when necessary. A Fall's Risk Screen is to be completed upon admission, readmission, quarterly and with a significant change. The facility is to complete an incident report for quality assurance reporting, document the incident in the nursing notes, complete a post fall's investigation tool, review the current plan of care; and, if necessary revise the interventions, initiate a fall's alert for any resident who falls in the facility; and, the fall's tracking is done individually, as well as facility wide to analyze trends for quality assurance reporting. Review of the facility's Hoyer lift Manual, dated 2011, revealed Although the manufacturer recommends that two (2) assistants be used for all lifting preparation and transferring to and from procedures, the equipment will permit operation by one (1) assistant but the use of one (1) assistant is based on the evaluation of the health care professional for each individual case. Further review revealed the legs of the lift must be in the maximum open position and the shifter handle be locked in place for optimum stability and safety. Review of the manufacturer's Sit to Stand Lift Instruction Guide, not dated, revealed individuals that use the sit to stand assist sling must be able to support the majority of their own weight, otherwise injury may occur. Review of the facility's Owner's Operator and Maintenance Manual for Patient Slings, not dated, revealed to use only an approved manufacturer sling that is recommended by the individual's doctor, nurse or medical assistant for the comfort and safety of the individual being lifted. Interview with Director of Nursing (DON), on 12/02/15 at 1:50 PM; and, on 12/03/15 at 4:07 PM, revealed the facility did not have any specific policy in regards to assessing residents for assistive devices to include the use of mechanical lifts. 1. Record review revealed the facility admitted Resident #1 on 01/22/13 with [DIAGNOSES REDACTED]. Review of Resident #1's Fall's Risk Screen, dated 06/08/15, revealed Resident #1 had an inability to walk or stand and required the assistance of two (2) staff with the use of a Hoyer Lift for transfers. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/08/15, revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BIMS) Score of six (6), which indicated this resident was not interviewable. Further review of the MDS assessment revealed the resident required extensive assistance of two (2) staff for transfers. However, there was a note attached to the MDS that indicated the resident should have been coded as total dependence of two (2) staff for transfers because he/she was non weight bearing. Further record review revealed there was no documented evidence Resident #1 was assessed for the safe use of the Hoyer or Sit to Stand lift. Review of Resident #1's Comprehensive Care Plan for Alteration in Physical Mobility, and Risk for Falls, dated 02/04/13 and last revised 10/10/15, revealed to transfer with two (2) assist and the use of a Hoyer Lift. Review of Resident #1's August 2015 Daily Nursing Assistant Care Plan revealed Resident #1 was a two (2) assist for transfers with the use of a Hoyer Lift. Review of a Nursing Note, dated 08/09/15 at 11:15 AM, revealed Registered Nurse (RN) #7 documented Resident #1 was in a sit to stand lift (weight bearing) in the shower room with two (2) assist when the resident's knees began to give and his/her hands let go of the hand grips and the resident began to slip from the lift pad. Staff was unable to get the wheelchair under the resident in time and the resident slipped out of the lift pad landing on the floor on his/her left side but did not hit his/her head. Further review revealed Resident #1 was crying and in severe pain. Staff did not move the resident due to a possible fracture. The Emergency Medical Services (EMS) was called for transport. Staff notified the Advanced Practice Registered Nurse (APRN) of the fall and the clinical situation; an order was received to send the resident to the emergency room (ER) for evaluation and treatment. The Power of Attorney (POA) was notified and a report was called to the ER. EMS arrived and Resident #1 was transferred to a back board and up on the stretcher, where the resident's right leg was noted to be several inches shorter than the left leg. Resident #1 continued to cry in severe pain. Review of Resident #1's Hospital Discharge Summary, dated 08/14/15, revealed the resident was admitted to the hospital on [DATE] and discharged on [DATE]. Further review revealed Resident #1 was diagnosed with [REDACTED]. Review of the Advanced Registered Nurse Practitioner's Note, dated 08/18/15, revealed on 08/14/15, Resident #1 returned from the hospital with orders for physical and occupational therapy to evaluate and treat for rehabilitation after the left femur fracture status [REDACTED]. Interview with Certified Nursing Assistant (CNA) #13, on 12/02/15 at 2:08 PM, revealed he was by himself attempting to transfer Resident #1 to the commode in the shower room with a sit to stand lift when Resident #1 fell on [DATE]. He stated he was unsure if he had looked at the Daily Nursing Assistant Care Plan to see that Resident #1 was to have two (2) staff for transfers, but he had been trained to use the Daily Nursing Assistant Care Plan in orientation. CNA #1 stated in hindsight he should have had another staff to assist him prior to attempting a sit to stand lift transfer for Resident #1. He stated he had used the wrong lift pad as he had used a lift pad that was to be used with the Hoyer lift and not with the sit to stand lift. He stated he did not know there was difference in the slings. CNA #13 stated he did not recall receiving any hands on training related to the use of the lifts during orientation, but he had received verbal training related to the lifts. Interview (Post Survey) with the Mechanical Lift Manufacturer Representative, on 12/11/15 at 9:45 AM, revealed the Hoyer lift sling should not be used with the sit to stand lift because a Hoyer lift sling would not be secure and hold the resident appropriately in a standing position. She stated if a Hoyer lift sling was used with a sit to stand lift the risk for a resident to slip out of the sling and sustain an injury would be very probable. Interview with Registered Nurse (RN) #7, on 12/02/15 at 3:04 PM, revealed she was walking in to the shower room looking for a CNA to assist a resident on the unit when she observed Resident #1 falling to the floor out of the sit to stand lift. She stated CNA #13 was assisting Resident #1 with a transfer using the sit to stand lift by himself without any other staff present and it was not safe or appropriate for one (1) staff to ever use a mechanical lift by themselves for a resident transfer. She further stated any CNA who had been through CNA classes and training should have known that this was an unsafe practice and they should have known it was not safe to do a transfer with use of a mechanical lift alone. During further interview, RN #7 stated if there had been two (2) staff assisting Resident #1 there may not have been an injury or as significant of an injury. RN #7 stated a CNA was responsible for knowing what the Daily Nursing Assistant Care Plan said in regards to the resident's care needs. She stated her Nurse's Note dated 08/09/15 at 11:15 AM, was in error because she charted there were two (2) staff assisting Resident #1 at the time of Resident #1's fall on 08/09/15. RN #7 stated CNA #13 was transferring Resident #1 with the sit to stand lift without the assistance of any other staff. Interview with the Director of Nursing (DON), on 12/02/15 at 1:50 PM, revealed she expected the Interdisciplinary Care Plan and the Daily Nursing Assistant Care Plan to be followed by the nursing staff as both of these care plans called for Resident #1 to have two (2) staff for transfers. She stated she expected all staff to be sure at least two (2) staff was in place for all mechanical lift transfers and it was unacceptable for less than that to be in place for any mechanical lift transfers. She also stated Resident #1 potentially could have not been injured or injured as severely if two (2) staff had been present at the time of Resident #1's fall instead of just one (1) staff. The DON stated the reason CNA #13 transferred Resident #1 with a sit to stand lift instead of the Hoyer lift was because the sit to stand lift was being used on a trial basis to see if this would be helpful for toileting Resident #1. When asked how the staff would have known to use the sit to stand lift without it being on the plan of care, the DON stated staff knew through word of mouth that they were using this on a trial basis. The DON was unable to recall how long the sit to stand lift had been used on a trial basis. She further stated the facility had no process or protocol in place to assess residents for the appropriate and safe use of mechanical lifts. 2. Record review revealed Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Quarterly MDS Assessment, dated 09/30/15, revealed the facility assessed Resident #14's cognition as severely impaired. Further review of the resident's Activity of Daily Living (ADL) Assistance status revealed the resident required total dependence of two (2) plus persons for transfers. Further record review revealed there was no documented evidence an assistive device assessment was completed related to the use of the Hoyer Lift for transfers for Resident #14. Review of Resident #14's Quarterly Fall's Risk Screen, dated 09/30/15, revealed the resident was at risk due to problems with mobility, inability to stand or walk, requires assistance with transfers, poor positioning, leaning, slumping, and sliding. Further review revealed the interventions put in place related to the screen included a Pommel Cushion to his/her reclined geri-chair, Hoyer lift for transfers and when putting the resident to bed, and a mattress with upper and lower roll guards. Review of Resident #14's Comprehensive Care Plan for Self Care Deficit, dated 01/04/12, revealed an intervention for a Hoyer lift and two (2) assist for transfers. Further review revealed a Comprehensive Care Plan for Risk for Falls and Injury with an intervention to use Hoyer lift and two (2) assist for transfers; utilize the large sling with Hoyer lift; and, to follow standards of care. Review of Resident #14's Daily Nursing Assistant Care Plan, dated December 2015, revealed interventions to use a Hoyer (mechanical) lift for transfers with the assist of two (2) persons, staff to use caution when lifting the resident, and ensure proper placement of the resident's arms and legs while utilizing the mechanical lift sling that fits under the resident during transfer. Review of a Nursing Note, dated 11/20/15 at 6:41 PM, revealed when CNA #3 and CNA #12 were attempting to transfer Resident #14 using a Hoyer mechanical lift, the lift tipped causing the resident to slide out of the lift pad onto the floor landing on his/her left hip, then hitting his/her head on the floor. The resident was transferred to a local hospital emergency room for evaluation and treatment related to a fall with a head injury. Review of the emergency room Report, dated 11/20/15, revealed Resident #14 was dropped three (3) feet from a mechanical lift, which resulted in neck and head trauma along with a three (3) centimeter (cm) laceration to the left side of his/her head requiring seven (7) staples to close the wound. Further review of the emergency room Report revealed the resident required Dilaudid (pain medication) one (1) milligram (mg) for pain during the examination. The resident was returned back to the facility with orders for neuro-checks to be completed every two (2) hours for twenty-four (24) hours and wound care. Interview with CNA #12, on 12/03/15 at 3:17 PM, revealed she was transferring Resident #14 from a reclined geri-chair with the Hoyer (mechanical) lift and during the transfer when the resident was in mid air the lift tipped and slid over causing the resident to fall out of the sling. She stated when she started to work in June 2015 she did not receive any formal training in the mechanical lift. She stated she was educated on what type of pad to use with what type of lift and also received hands on training on the use of the sit to stand lift in August 2015. She stated she received hands on training after this incident in November 2015 on the Hoyer lift. She stated the ADON did the training on the sit to stand lift in August 2015; and, the nurses on the floor did the training on the Hoyer lift in November 2015. Interview with CNA #3, on 12/03/15 at 3:15 PM, and on 12/07/15 at 3:11 PM (Post Survey), revealed the ADON completed her orientation and verbally told her about the mechanical lift and described the pads to use; but she did not do any type of demonstration using the lift. She stated when she started working on the units, one (1) of the other CNAs showed her how to use the lift. She stated the ADON only talked to her about each thing on the skills check list during the orientation process and did not demonstrate anything or ask her to complete a return demonstration on any skill. CNA #3 stated she did not know what caused the lift to tilt over. She stated she was at the side of the resident during the transfer and could not see the position of the lift from where she was standing. She stated after the incident, the DON had her and the other CNA demonstrate what they were doing at the time of the fall and CNA #12 did not have the base of the lift spread out completely. She stated after the demonstration, the DON explained the proper use of the lift and thought that could have caused the lift to tip over. Interview with RN #5, on 12/03/15 at 11:22 AM and 11:30 AM, revealed she expected all nursing staff to utilize a minimum of at least two (2) staff for all mechanical lift transfers and it was also the facility's expectations for mechanical lift transfers to have at least two (2) staff present. She stated all nursing staff was responsible for knowing what the residents' care plans state. She revealed one part of her nursing responsibilities was to assess the resident in the restorative program as well as help with the assessment of the assistive devices. She stated the facility did not have a formal process to complete the assessments; they do not involve physical therapy in the assessment process; and, she did not think the facility had a policy related to the assessment for the use of mechanical lifts of any kind. She further revealed each nurse could assess and determine what was best for the resident at the time to determine the type of lift to use, as well as document on the resident's plan of care. She stated if a resident was weight bearing at all, a sit to stand lift could be used, but if a resident was not weight bearing a Hoyer Lift should be used. She stated it was not set in stone what size sling the resident required and the tag on the sling only details the size of the sling, there was nothing documented about weight on the tag. RN #5 further stated the facility should have something documented to use as a guidance related to the appropriate size sling required for each resident but they do not. She revealed she was the RN who completed the post fall investigations and believed the cause for Resident #1's fall on 08/09/15 was due to only one (1) staff being present for the transfer with the use of the mechanical sit to stand lift. She stated during the investigation it was determined CNA #13 used the wrong lift sling, as he had used the lift sling that was to be used for the Hoyer Lift and not the sit to stand lift sling. Further interview revealed it was possible the use of the wrong sling also contributed to the fall. RN #5 stated on 08/09/15 after Resident #1's fall, she took pictures of which slings were to be used with which mechanical lifts and the pictures were attached to each Hoyer Lift and the sit to stand lift, that way staff knew which lift sling went with which mechanical lift. She revealed the facility had not completed the fall's investigation for Resident #14. RN #5 stated they had not decided on the root cause of the fall, but part of the investigation determined that the legs of the lift were not properly spread out and it tipped over. She stated if that happened during the transfer of the resident it could have caused the lift to tip over. Interview with ADON, on 12/02/15 at 12:20 PM and on 12/03/15 at 4:30 PM, revealed the facility did not have any type of assessment that was used for determining what type of mechanical lift was appropriate for what resident. She stated she expected all CNAs to do what they were taught in orientation; which was to review and follow the Daily Nursing Assistant Care Plan during each shift they work as this explained what type of care and assistance the residents required. She stated she was responsible for the CNA training regarding mechanical lifts during their general orientation to the facility. She stated there was nothing during that training that explained how to determine what lift was to be used for what resident. The ADON stated she verbally discussed the use of the mechanical lifts, but there was no hands on training with lifts until the CNAs do their orientation on the floor with other aides. Interview with the DON, on 12/03/15 at 4:10 PM, revealed the Assistant Director of Nursing (ADON) was responsible for the skills check list for all staff during their orientation process. She stated after orientation the CNAs were assigned to work with another employee for a least one (1) week of training and then Administration followed up with them after a few days of working on the floor to see if they had any questions. She revealed after the initial skills check off no one monitored them to ensure they were using the equipment properly. She stated she reviewed Resident #14's incident report and had both the CNAs (CNA #3 and CNA #12) re-enact the exact thing they did during the transfer and noticed CNA #12 did not open the Hoyer lift legs during the transfer demonstration. She stated she explained to both staff members that they have to open the base of the lift legs wide prior to transfer to prevent the lift from tipping over. The DON stated after Resident #1's fall in August 2015 all staff was provided a demonstration of the use of the lifts and were required to perform a return demonstration, but there was no documentation of the training presented at that time. Prior to the exit conference, the DON provided documentation of the training. Review of the documentation revealed sign in sheets, dated 08/09/15 and 08/10/15 that documented staff were educated on the proper use of a Hoyer Lift and a Sit to Stand Lift with a demonstration also provided along with a return demonstration by staff; however, interview with RN #9, on 12/11/15 at 2:51 PM, revealed she provided some of the facility's lift training on 08/09/15 and 08/10/15 in regards to the proper use of a Hoyer lift and the proper use of a sit to stand lift. She stated this training covered how to properly use the Hoyer and sit to stand lifts, what lift slings go with what lift, how to place a sling on someone, how to hook a sling to the lift and that two (2) staff have to be present anytime a lift is being used for a resident. RN #9 stated that not all of the staff performed a return demonstration to show that they knew how to correctly use the lift. She stated, staff that felt like they already knew how to use the lifts did not have to do a return demonstration if they chose not to, as it was not made mandatory for all staff to do a return demonstration to be sure the staff in fact knew how to correctly utilize a mechanical lift. 3. Interview with the DON, on 12/03/15 at 4:03 PM, revealed the facility has no specific policy on the storage of aerosol cans and cleaning products. During Initial Tour on 12/01/15 at 9:37 AM and further observation at 3:25 PM, revealed an aerosol can of Aqua Net hair spray, more than half full, on a counter in the room of Unsampled Resident D. Review of the Aqua Net hair spray label revealed, Danger-flammable, avoid heat, fire, flame or smoking while spraying and until hair is fully dry. Avoid spraying in eyes. Do not ingest. Keep out of reach of children, contents under pressure, do not puncture or incinerate, do not store at temperatures above 120 degrees Farenheit, use only as directed, intentional misuse by deliberately concentrating and inhaling contents can be harmful or fatal. During Initial Tour on 12/01/15 at 9:41 AM and further observation at 3:28 PM, revealed a full spray bottle of Lysol bathroom cleaner in Unsampled Resident E's bathroom, on the side of the tub. Review of the Material Safety Data Sheet for Lysol bathroom cleaner revealed, health injuries are not known or expected under normal use and could be slightly irritating to the skin. Interview with Certified Medication Technician (CMT) #1, on 12/03/15 at 9:18 AM, revealed that there should be no aerosol cans or cleaning products in residents' rooms because they could be flammable and cause injury to the resident. Interview with Registered Nurse (RN) #3, on 12/03/15 at 9:30 AM, revealed there should be no aerosol cans of any kind in resident's rooms because they were flammable and no cleaning products should be in residents' bathrooms because they could be harmful to the residents. Interview with the DON, on 12/03/15 at 4:03 PM, revealed aerosols and cleaners could be flammable and harmful to the residents and should not be kept in residents' rooms.

Based on observation, interview, record review, review of the Hospital emergency room Report and Discharge Summary, and review of the Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to ensure the services provided or arranged were provided by qualified persons and/or in accordance with each resident's written plan of care for three (3) of nineteen (19) sampled residents (Residents #1, Resident #14 and Resident #13). Resident #1 was care planned to be transferred by two (2) staff with the use of a Hoyer (brand of mechanical lift) lift (no weight bearing required). However, on 08/09/15, Resident #1 fell when one (1) staff Certified Nurse Aide {CNA} #13 transferred him/her with a sit to stand lift (weight bearing required) instead of with a Hoyer lift and two (2) staff, as care planned. In addition, CNA #13 used a Hoyer lift sling instead of the sit to stand sling with the transfer because he did not know the difference between the lift slings. Resident #1 sustained a [MEDICAL CONDITION] requiring surgery. Resident #14 was care planned to be transferred by two (2) staff with the use of a Hoyer lift. On 11/20/15, CNA #3 and CNA #12 transferred Resident #14 with the Hoyer lift, but failed to ensure the legs of the lift were spread out during the transfer; the lift tipped over. Resident #14 fell to the floor and sustained a laceration to the head that required seven (7) staples. The facility failed to ensure staff training was effective in ensuring the staff was qualified in operating the lifts. The facility provided verbal training during orientation and left it to other aides to demonstrate the use of the lift on the floor; however, there was no hands on training provided by Administrative staff and no follow up to ensure the training was effective. In addition, Resident #13 was ordered Oxygen (O2) at two (2) liters per minute (LPM) via a nasal cannula to keep oxygen saturations within normal limits (90-100 %). Two (2) observations revealed Resident #13 was sitting in his/her wheelchair with an E cylinder on the back of the wheelchair that was empty. The findings include: Interview with Director of Nursing (DON) on 12/03/15 at 4:07 PM, revealed the facility did not have a specific Care Plan Policy in regards to an Interdisciplinary Care Plan or a Daily Nursing Assistant Care Plan. She stated the facility used the Resident Assessment Instrument (RAI) Manual for a Care Plan Policy. Review of the RAI User Manual Version 3.0 under section 4.7, The RAI and Care Planning, revealed the comprehensive care plan was an interdisciplinary communication tool. It must include measurable interventions and time frames and must describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 1. Record review revealed the facility admitted Resident #1 on 01/22/13 with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment, dated 10/06/15, revealed the facility assessed Resident #1's cognition as severely impaired with a Brief Interview for Mental Status (BIMS) score of five (5), which indicated this resident was not interviewable. Further review of the MDS assessment revealed Resident #1 required two (2) staff for transfers. Review of Resident #1's Comprehensive Care Plan for Alteration in Physical Mobility and At Risk for Falls; and, Resident #1's Daily Nursing Assistant Care Plan, dated August 2015, revealed staff was to transfer the resident with two (2) assist and the use of a Hoyer Lift. Review of Nursing Note, dated 08/09/15 at 11:15 AM, revealed Resident #1 was being transferred by CNA #13 for toileting in the shower room in a sit to stand lift. Resident #1 slipped out of the lift pad landing on the floor on his/her left side. The resident was crying with severe pain and had to be sent to the emergency room . Staff notified the Advanced Practice Registered Nurse (APRN) of the fall and an order was received to send the resident to the emergency room (ER) for evaluation and treatment. Emergency Medical Services (EMS) arrived and Resident #1 was transferred to the ER. Interview with CNA #13, on 12/02/15 at 2:08 PM, revealed he was by himself attempting to transfer Resident #1 to the commode in the shower room with a sit to stand lift when Resident #1 fell on [DATE]. CNA #13 stated he was not sure if he had looked at the Daily Nursing Assistant Care Plan to see that Resident #1 was to have two (2) staff for transfers but he was told to use the sit to stand lift. He stated he had been trained to use the Daily Nursing Assistant Care Plan in orientation. CNA #13 further stated in hindsight he should have had another staff to assist him prior to attempting a sit to stand lift transfer for Resident #1. In addition, CNA #13 revealed he had used a Hoyer lift transfer sling on the Sit to Stand lift when he transferred Resident #1 because he was not aware there was a difference in the slings. He stated he did not recall ever receiving any hands on training on the mechanical lifts prior to Resident #1's fall. Review of Resident #1's Hospital Discharge Summary, dated 08/14/15, revealed the resident was admitted to the hospital on [DATE] and discharged on [DATE]. Further review revealed Resident #1 had a Supracondylar [MEDICAL CONDITION] distal femur (lift [MEDICAL CONDITION]) and received a surgical procedure during the hospital stay of an Open Reduction and Internal Fixation of the Femur. Interview with RN #5, on 12/03/15 at 11:22 AM, revealed she expected all nursing staff to utilize a minimum of at least two (2) staff for all mechanical lift transfers and it was also the facility's expectations for mechanical lift transfers to have at least two (2) staff present. She stated all nursing staff was responsible for knowing what was on the resident's care plan. Interview with the Assistant Director of Nursing (ADON), on 12/02/15 at 12:20 PM, revealed she expected all CNAs to do what they were taught in orientation; which was to review and follow the Daily Nursing Assistant Care Plan during each shift they work as this explains to the CNA what type of care and assistance the residents require. She stated she was responsible for the CNA's training regarding mechanical lifts during the CNA's general orientation to the facility. She stated she verbally discusses the use of the mechanical lifts but there was no hands on training with lifts. The ADON stated the CNAs would see the lifts being used during their orientation working with another CNA on the floor. Interview with Director of Nursing (DON), on 12/02/15 at 1:50 PM, revealed she expected the Interdisciplinary Care Plan and the Daily Nursing Assistant Care Plan to be followed by the nursing staff as both of these care plans call for Resident #1 to have had two (2) staff for transfers. She stated she expected all staff to be sure at least two (2) staff was in place for all mechanical lift transfers and it was unacceptable for less than that to be in place for any mechanical lift transfers. She also stated Resident #1 potentially could have not been injured or injured as severely if two (2) staff were present at the time of Resident #1's fall instead of just one (1) staff. The DON stated the reason for Resident #1's care plan stating he/she was a Hoyer Lift Transfer and, not a sit to stand lift was due to the sit to stand lift was being used on a trial basis to see if this would be helpful for toileting Resident #1. 2. Record review revealed the facility admitted Resident #14 on 12/21/11 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 09/30/15, revealed the facility assessed Resident #14 as unable to complete a BIMS and determined the resident's cognition was severely impaired. Review of the resident's Activity of Daily Living (ADL) Assistance status revealed the resident required total dependence of two (2) plus persons for physical assist with transfers. Review of Resident #14's Comprehensive Care Plan for Self Care Deficit and Risks for Falls, dated 01/04/12, revealed an intervention to transfer with a Hoyer lift and two (2) person assist. It was also noted that staff was to utilize the large sling with the Hoyer lift and follow standards of care. Review of Nursing Note, dated 11/20/15 at 6:41 PM, revealed two (2) CNAs (CNA #3 and #12) were attempting to transfer Resident #14 using a Hoyer lift, when the lift tipped causing the resident to slide out of the lift pad onto the floor landing on his/her left hip, then hitting his/her head on the floor. The resident was sent to local emergency room for treatment of [REDACTED]. Review of the emergency room Report, dated 11/20/15, revealed the resident was dropped three (3) feet from a mechanical lift, which resulted in neck and head trauma along with a three (3) centimeter (cm) laceration to the left side of his/her head requiring seven (7) staples to close the wound. Further review of the emergency room Report revealed the resident required [MEDICATION NAME] (pain medication) one (1) milligram (mg) for pain during the examination. Interview with CNA #3, on 12/03/15 at 3:15 PM; and, on 12/07/15 at 3:11 PM (Post Survey), and with CNA #12 on 12/02/15 at 3:17 PM revealed they went into Resident #14's room to transfer him/her into a reclined shower chair. CNA #12 was operating the lift, and when the lift raised the resident all the way up, the CNA started to swing the resident around, the lift started to tip over and the resident fell out of the sling onto the floor. During interview with CNA #12, she stated she was hired in June 2015 and she did not receive any formal mechanical lift training. She stated she was educated on what type of pad to use with what type of lift. She also received hands on training on the use of the sit to stand lift in August 2015, and after this incident in November 2015 on the Hoyer lift. She stated the ADON did the sit to stand training in August 2015 and the nurses on the floor did the Hoyer training in November 2015. CNA #3 stated she was hired on 09/16/15 (after Resident #1's fall and it was identified staff needed hands on training). She stated one of the other CNAs on the units showed her how to use the lift. CNA #3 stated the ADON only talked to her about each thing on the skills check list, she did not demonstrate anything or ask her to complete a return demonstration on any skill. Interview with the Director of Nursing (DON), on 12/03/15 at 4:10 PM, revealed the Assistant Director of Nursing (ADON) is responsible for the skills check list for all staff during their orientation process. She stated after the orientation they are assigned to work with another employee for a least one (1) week of training and then someone from administration follows up with them after a few days of working on the floor to see if they have any questions. She stated after the initial skills check off no one monitors them to ensure they are using the equipment properly. 3. Record review revealed the facility admitted Resident #13, on 03/17/15 with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 10/30/15, revealed the facility assessed Resident #13's cognition was severely impaired with a BIMS score of 03, indicating he/she was not interviewable. Review of the Comprehensive Care Plan for Alteration in respiratory status related to recent Upper Respiratory Infection, wheezing, and moist lung sounds, dated 05/20/15 and last revised 11/2015, revealed to administer O2 at two (2) LPM via a nasal cannula. Observation during a breakfast meal, on 12/02/15 at 8:00 AM, revealed Resident #13 had an Oxygen E cylinder tank to the back of his/her wheelchair and the tank was empty. Additional observation, on 12/03/15 at 9:30 AM, revealed Resident #13 was sitting in the front lobby with an E tank on the back of the wheelchair and it was empty. In addition, the resident's nasal cannula was off to the side of his/her nose. Licensed Practical Nurse (LPN) #4 obtained Resident #13's O2 saturation at the time of the observation and it was eighty-one percent (81%). Interview (Post Survey) with CNA #16, on 12/10/15 at 9:00 AM, revealed when she got Resident #13 ready for breakfast on 12/02/15, she asked the Charge Nurse if she thought there was enough O2 in the E tank to last throughout the breakfast meal and she was told the tank had enough O2 in it to last. She stated on 12/03/15 when the tank was observed empty again at approximately 9:30 AM, she had gotten the resident up and as before, there was O2 in the tank. She stated if she or anyone else noticed a tank reading empty, they were supposed to notify the Charge Nurse for a new tank. Interviews on 12/03/15 with Certified Nursing Assistant (CNA) #14 at 10:45 AM, LPN #1 at 10:17 AM and LPN #4 at 11:03 AM revealed anyone could check the O2 tanks to ensure they were functioning properly. LPN #1 and LPN #4 stated if a resident was ordered O2 to be on continuous, then it should be on per the physician's orders [REDACTED]. Interview with Registered Nurse (RN) #3, on 12/03/15 at 10:23 AM, revealed the care plan should be followed regarding O2 administration. Interview with the Director of Nursing (DON), on 12/03/15 at 1:30 PM, revealed she expected the care plan to be followed. Post survey interview, on 12/09/15 at 2:40 PM, revealed it was the licensed nurses responsibility to ensure the E tank was functioning properly when placed on the resident.

Based on interview and record review, it was determined the facility failed to have an effective Quality Assurance (QA) Committee that was structured to identify quality issues with the potential for negatively affecting resident care. The facility identified staff was not adequately trained to operate assistive transfer devices, resulting in falls for two (2) residents (Residents #1 and #14.) The QA committee failed to evaluate the root causes of the falls and implement an action plan to ensure resident safety during transfers, and to prevent further falls. Resident #1 fell from a sit-to-stand lift device on 08/09/15, while being transferred in the shower room by one staff member, Certified Nurse Aide (CNA) #13. CNA #13 used the Hoyer lift sling instead of the sit to stand lift sling to conduct the transfer. The resident sustained [REDACTED]. There was no evidence the QA Committee reviewed the incident and ensured all staff was competent to safely operate the assistive devices and failed to implement a plan to monitor the safe use of the devices. Another resident (Resident #14) sustained a fall from a lift device on 11/20/15. The staff failed to ensure the lift legs were spread apart during the transfer and the lift tipped over. Resident #14 sustained a [MEDICAL CONDITION] that required seven (7) staples. Refer to F282 and F323 The findings include: Review of the facility's policy and procedure, titled Quality Assessment and Assurance dated 05/01/08, revealed the purpose of the QA Committee was To establish guidelines regarding the quality assessment and assurance program within each facility. According to the policy, the QA Committee's action plan may be implemented in a variety of ways which may include but was not limited to: · Staff training · Procedure training · Monitoring and feedback mechanisms · Processes to revise plans that are not achieving or sustaining desired outcomes. Interview with the Administrator and Director of Nursing (DON), on 12/03/15 at 4:40 PM, revealed he facilitated the Quality Assurance (QA) meeting to ensure all problem areas were being monitored on an ongoing basis. The QA Committee consisted of the Administrator, Medical Director, DON, Assistant DON, Dietary Manager, Housekeeping/Laundry Supervisor, Activity Director, Social Services Director, and Admission Coordinator. The Administrator stated the Director of Nursing (DON) was responsible for tracking and trending areas which included, but was not limited to, Urinary Tract Infections, Falls, Pressure Ulcers, and any other areas of concern. Further interview with the Administrator and DON, on 12/03/15 at 5:15 PM, revealed there had not been a training on the use of the lifts since 2010 and it was expected the CNAs learned this skill during their CNA training. They stated they had nothing in place to ensure staff were competent with the use of the lifts after their orientation. They revealed there was an inservice of the CNAs, after the first fall on 08/09/15, to ensure all staff was aware of the need to utilize two (2) staff for all transfers with the lift devices, however, repeat demonstrations were not completed by all staff and no process was put in place to monitor to ensure the staff were now using the lifts correctly.

Based on interview, record review, and review of the facility's Administrator Job Description, it was determined the Administration of the facility failed to ensure that the facility's resources were utilized effectively and efficiently to provide the required care and services for two (2) of nineteen (19) sampled residents (Resident #1 and Resident #14). The Administrator failed to develop and implement policies and procedures to assess residents to ensure facility staff provided the necessary supervision and appropriate assistive lift devices to ensure safe transfers. In addition, the Administrator failed to ensure staff was fully trained and competent with the use of the lifts. These failures resulted in Resident #1 sustaining a [MEDICAL CONDITION], requiring hospitalization and surgery, after the use of a sit to stand lift, with the wrong sling, and without the required assistance of two (2) staff members; and, Resident #14 sustaining a [MEDICAL CONDITION] which required seven (7) staples, after staff failed to ensure the Hoyer lift was used correctly during the transfer. There was no documentation either resident was assessed for the use of the lifts. Refer to F282, and F323. The findings include: Review of the Administrator's Job Description, revised 12/2011, revealed the Administrator was responsible to lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Further review revealed under Essential Duties & Responsibilities, the Administrator was responsible for Management duties to include the training and developing of staff; the Quality Assurance (QA) program; and to consult with department managers concerning the operation in their departments to assist in eliminating/correcting problem areas, and/or improvement of services. 1. The facility care planned Resident #1 for the use of a Hoyer lift with two (2)staff assist. However on 08/09/15, Certified Nurse Aide (CNA) #13 transferred Resident #1 with a sit to stand lift and without the assistance of another staff member. In addition, he used a Hoyer lift sling with the sit to stand lift. There was no evidence Resident #1 had been assessed for the use of the sit to stand lift or Hoyer lift and no evidence CNA #13 had received any hands on training on the use of the lifts. Resident #1 fell to the floor and sustained a [MEDICAL CONDITION] which required surgical repair. 2. The facility care planned Resident #14 to be transferred with a Hoyer lift by two (2) staff. On 11/20/15, CNA #3 and CNA #12 transferred Resident #14 using a Hoyer lift and the lift tipped causing the resident to slide out of the lift pad onto the floor landing on his/her left hip, then hitting his/her head on the floor. Resident #14 sustained neck and head trauma along with a three (3) centimeter (cm) laceration to the left side of his/her head requiring seven (7) staples. It was determined the staff failed to ensure the lift legs were opened during the transfer which caused the lift to tip over. There was no evidence Resident #14 had been assessed for the use of the Hoyer lift and no evidence the facility had been monitoring staff to ensure the training with staff in August 2015 was effective. Interview with the Administrator, on 12/03/15 at 5:15 PM, revealed there had not been a formal training on use of the lifts since 2010 and it was expected that the CNAs learned this skill during their CNA training with another CNA on the floor. He stated he had nothing in place to ensure the staff were competent with the use of the lifts after they had completed their orientation. In addition, he stated there was no policy and procedures related to assessing for the use of the lift.

Based on observation, interview, record review, and review of the facility's policy/procedures, it was determined the facility failed to implement written policies and procedures that prohibit abuse for one resident (#2), in the selected sample of seven residents. The facility failed to ensure their staff was trained and knowledgeable regarding their Abuse Prohibition Policy. The facility failed to identify multiple incidents of Resident #2 having aggressive behaviors, both verbal and physical, towards other residents and staff as having the potential to cause harm to residents of the facility. This failure to identify and report prevented the facility from conducting a thorough investigation; ensuring protection of the residents of the facility from Resident #2, the aggressor, from identifying their failure in managing Resident #2's behaviors effectively and ensuring staff knowledge of effective behavior management techniques. The facility failed to implement the facility's Abuse Prohibition policy which prevented them from initiating protective measures to prevent further harm or potential abuse. These failures resulted in physical harm for two residents (#1 and #6). On 11/28/11, the facility's assessment detailed their knowledge that Resident #2 had verbal and behavioral symptoms that were directed towards others and care planned that those behaviors would not cause injury to self or others. On 02/02/12 at 9:45 AM, Resident #2 threatened to beat Resident #7 with the metal extender bar from his/her wheelchair. On 02/05/12 at 2:10 PM, Resident #2 became agitated and threatened Resident #7 and was witnessed by staff chasing Resident #7 down the hallway screaming he/she was going to "get him." On 02/06/12, Resident #2 threatened to hit maintenance staff. On 02/09/12 at 9:05 AM, Resident #2 became agitated and threatened roommate Resident #1 over closing the door to their room. On 02/25/12 at 10:55 AM, Resident #2 struck Resident #1 in the head multiple times with the metal extender bar handle from his/her wheelchair, the same object that this resident threatened Resident #7 with on 02/02/12. The facility transferred Resident #1 to hospital for treatment, requiring sutures to close the four lacerations to his/her head. On 03/06/12 the facility readmitted Resident #2 after determining the resident had physically abused Resident #1; however, failed to implement interventions to ensure protection of the other residents of the facility. On 03/08/12 at 1:20 PM, Resident #2 became agitated and his/her behaviors escalated to the point that he/she physically assaulted Resident #6 by shutting the door on Resident #6's arm. Resident #2 stated he/she would punch Resident #6 in the face if he/she ever came in the room again. Resident #6 had multiple skin tears to left upper arm that required medical intervention and treatment. The facility initiated discharge of Resident #2 on 3/21/12 only to have to readmit this resident on the same evening. Interview with the family on The facility utilized family for supervision, from 7:00 until 11:00 PM; however, made no effort to ensure the family was appropriately trained to ensure the safety of the residents of the facility or to manage the resident's behavior. While the facility was knowledgeable of the escalating aggressive behaviors of Resident #2 and had even identified the incident of 02/25/12 as physical abuse, they continued to fail to identify the behaviors as aggressive and implement their Abuse Prohibition Policy to re-assess this resident and implement behavior management techniques. Furthermore, they had not ensured their staff was educated and instructed on behavior management techniques for residents who exhibit aggressive behaviors in an effort to implement preventive measures and protect residents. Additionally, there was no evidence the facility had identified other residents having aggressive behaviors that had not been re-assessed for appropriate behavior management. The facility Administration, on 03/23/12, detailed that they had not identified any issues with residents having escalating behaviors and had not addressed these concerns. This failure caused or likely caused serious injury, harm, impairment, or death to a resident. Based on observation, interview, record review, it was determined Immediate Jeopardy and Substandard Quality of Care was identified on 03/16/12 and determined to exist on 02/02/12 and is ongoing. (Refer to F250 and F323) Findings include: Review of the facility's policy/procedure, "Abuse Prohibition," revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy defined verbal abuse 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." An example included "threats of harm." The policy defined physical abuse as "includes, but not limited to, humiliation, slapping, pinching and kicking." The policy detailed related to protection of the residents, that staff are to ensure the resident's immediate safety and well being following the initial suspected abuse report and during the following investigation process. The facility's policy detailed that each resident will be assessed and routinely reassessed by the appropriate health care professionals for aggressive behavior, wandering, self-injurious behavior, communication impairments, and heavy nursing care, and/or total dependence on staff. The training through the orientation program and ongoing in-services sessions will include; appropriate interventions to deal with aggressive and/or catastrophic reaction of residents, what constitutes abuse, how to recognize abuse, neglect, involuntary seclusion, misappropriation of funds, and how to report suspected incidents or events potentially of unknown origin. A copy of the residents' rights and resident abuse information will be issued to the employee and the location of the posted resident rights made known to each employee. Employees who have direct care responsibilities will receive specific instructions regarding abuse prohibition practices. All employees will be educated and instructed in behavior management techniques for residents who exhibit aggressive behavior, residents who wander, who have self injurious behavior and who have communication disorders. Under identification of Abuse or Suspected Abuse it detailed any incident of abuse or suspected abuse ...must be reported immediately to the available charge staff person. The policy detailed that occurrences, patterns, or trends that may constitute abuse; witnessed verbal or physically abusive incidents; or any act of mistreatment are events that should be reported and will be investigated. A record review revealed the facility admitted Resident #2 on 11/15/11 with [DIAGNOSES REDACTED]. Interview with the physician, on 03/23/12 at 2:15 PM, revealed due to this resident's TBI he/she " just (reacts) to what (he/she perceives) as a threat to (him/herself). The resident's actions are "not willful intent. " The facility admission Minimum Data Set (MDS) assessment, dated 11/22/11, determined the facility assessed Resident #2 as having no memory deficits; however, had behaviors of threatening others, screaming at others, and cursing at others. The Resident Care Area Assessment (CAA) Summary, dated 11/22/11, revealed Resident #2 had behavioral and verbal symptoms directed toward others with significant disruption of care or living environment as impact, and was noted to wander with significant risk of danger to self. The facility developed an admission care plan, dated 11/28/11, with a goal that he/she would not cause injury to self or others due to behaviors. There were no specific interventions related to supervision of the resident or approaches that detailed how staff would monitor the resident's behaviors or what specific behavioral techniques would be used to manage the resident and his/her behaviors. A review of the nurse's notes, dated 02/02/12 at 9:45 AM, and Social Services notes, dated 02/02/12 at 9:50 AM, revealed Resident #2 got up out of his/her wheelchair and removed the wheelchair extender bar handle and threatened to hit Resident #7 with the handle. Resident #7 was wheelchair bound and had to be removed from the room by staff while Resident #2 was allowed to calm down. The facility initiated a room change to separate the residents. There was no evidence the facility identified the incident as potential abuse or aggressive behaviors requiring re-assessment, initiated an investigation, initiated protection or conducted a re-assessment of Resident #2's behaviors. Review of the care plan revealed no changes had been made to supervision nor had they removed the extender bar from the resident's possession. A review of the nurse's notes, dated 02/05/12 at 2:10 PM, revealed Resident #2 was very agitated and cursing and he/she was anxious and wringing his/her hands. The CNA reported that Resident #2 was in the hallway with his/her walker chasing Resident #7 down the hall saying " I'll get you for making fun of me." Two CNAs attempted to prevent Resident #2 from harming Resident #7 and Resident #2 began hitting and slapping at the two (2) CNAs, who were trying to protect Resident #7. After redirection, Resident #2 ambulated back to his/her room with the CNAs. There was no evidence the facility identified the incident as potential abuse or aggressive behaviors requiring re-assessment, initiated an investigation, initiated protection or conducted a re-assessment of Resident #2's behaviors. Review of Resident #2's care plan revealed no changes had been made related to supervision or behavior management techniques. On 02/06/12 at 3:45 PM, the nurses' notes revealed Resident #2 cursed and threatened to hit maintenance staff. There was no evidence the facility identified the incident as "an occurrence, pattern or trend that may constitute abuse," as per their policy. Furthermore, the facility could provide no evidence they initiated an investigation, initiated protection or conducted a re-assessment of Resident #2's behaviors. Review of Resident #2's care plan revealed no changes had been made related to supervision or behavior management techniques. On 02/09/12 at 9:05 AM, the nurses' notes revealed the Charge Nurse was in the room administering medication to Resident #1, whenever Resident #2 jumped out of the wheelchair and angrily yelled and cursed at Resident #1. The Charge Nurse attempted redirection without success and Resident #1 was assisted up to a wheelchair and out of the room. Review of a Social Services Progress Note, dated 02/09/12 at 9:25 AM, revealed Social Services told Resident #2 that he/she could not yell or threaten Resident #1 in any way. There was no evidence the facility identified the incident as potential abuse or aggressive behaviors requiring re-assessment, initiated an investigation, initiated protection or conducted a re-assessment of Resident #2's aggressive behaviors. However, this same date 02/09/12, the facility completed the Quarterly MDS Assessment, detailing Resident #2 the resident had no mood symptoms or frequency present and detailed the resident had no behaviors exhibited or present. Review of Resident #2's care plan revealed no changes had been made to address the resident's aggressive behaviors or to increase supervision to protect other residents. On 02/25/12 at 10:55 AM, the nurses' notes and an interview with the Dietary Aide (DA), on 03/14/12 at 12:35 PM, revealed the DA was making her rounds, on 02/25/12 at 10:55 AM, when she heard someone yell for help. She observed Resident #2 walking away from Resident #1 carrying a metal object (part of Resident #2's wheelchair), and Resident #1 was covering his/her head trying to protect himself/herself. She stated "I did not see Resident #1 bleeding the first time I walked by; however, I ran and got the CNA and by the time we got back to (the resident's room), Resident #1 was bleeding from his/her head." The Charge Nurse was called to Resident #1's and Resident #2's room. Resident #2 was sitting outside the room in a wheelchair, and was very agitated and combative. Staff attempted to calm Resident #2 and the CNA reported "Resident #2 just beat roommate Resident #1 in the head." Charge Nurse reported that "Resident #1 was bleeding from the head injury and there were multiple staff trying to calm Resident #2, but were unsuccessful. Resident #2 was still trying to get back into the room to hurt Resident #1." Resident #1 was struck multiple times in the head with the metal extender bar handle by Resident #2. Further review of the nurses' notes revealed "Resident #1 had four large lacerations to the head and a purple bruise on his/her sternal notch." Staff had to shut the door to the room with Resident #2 still in the hallway. Resident #2 was agitated and trying to get back into the room and the staff was unable to calm Resident #2 down enough to move him/her to another room until 11:30 AM. The facility moved Resident #2 to a private room, and at that time all metal objects or potential dangerous items were removed from his/her possession. At 11:50 AM, Resident #2 became even more combative, hitting, kicking, and cursing the staff. Later in the evening, on 02/25/12 at 7:20 PM, the facility transferred Resident #2 to a psychiatric hospital for psychiatric services. The facility initiated an investigation of the 02/25/12 incident and concluded Resident #2 physically abused Resident #1; however, record review revealed Resident #2 returned to the facility on [DATE]. On this same date and with the knowledge of Resident #2's recent onset of escalating aggressive behaviors resulting in the facility's determination that Resident #2 physical abused another resident, the facility detailed on the behaviors care plan that they were discontinuing one to one supervision and removal of objects from the resident's environment. There was no evidence the facility had taken measures to provide protection to other residents of the facility upon Resident #2's re-admission or conducted a re-assessment of Resident #2's physically aggressive behaviors which escalated to violence towards another resident. Review of the care plan and medical record revealed no evidence the facility provided supervision of Resident #2 to prevent further potential abuse, as per their investigation determination. On 03/08/12 at 1:20 PM, the nurses' notes revealed "Charge Nurse summoned to room, Resident #2 was shutting the door on Resident #6's arm, saying the next time Resident #6 came into the room he/she would punch Resident #6 in the face." Resident #6's injuries included two skin tears on the left upper dorsal arm which required medical intervention. There was no evidence the facility identified this incident as potential abuse or aggressive behaviors requiring re-assessment, initiated an investigation, initiated protection for other residents, or conducted a re-assessment of Resident #2's behavior, revised the care plan, or initiated supervision to address his/her escalating behaviors to prevent further harm or potential abuse. Observations, during the complaint investigation, revealed the facility had not initiated increased supervision of this resident, who was independently ambulatory, despite having determined through their incident investigation that Resident #2 physically abused another resident on 02/25/12. On 03/14/12 at 9:30 AM, observation revealed Resident #2 sitting on the side of the bed verbalizing "When I came here I could not walk and now I can." There was no facility staff observed supervising Resident #2 and his/her room was the second to last room at the end of a long hall and second to furthermost room from the nurses' station. Observation, on 03/14/12 at 4:39 PM, revealed Resident #2 was lying in bed. No staff was observed supervising Resident #2. Observation, on 03/15/12 at 6:10 PM, revealed Resident #2 was found in his/her room verbalizing he/she could walk anywhere he/she wanted to go. There was no facility staff observed providing supervision to Resident #2. Observation, on 03/16/12 at 4:00 PM, revealed Resident #2 was observed ambulating freely in his/her room without any difficulty and without the assist of a walker or cane. A CNA was posted outside of Resident 2's room; this was the first observation of the facility providing supervision of Resident #2. Observation, on 03/16/12 at 7:06 PM, revealed Resident #2 had two CNAs sitting outside the Resident #2's room. On 03/21/12 at 1:40 PM, record review revealed the facility initiated discharge and transfer to another nursing facility; however, had to readmit this resident the same evening at 7:00 PM, less than six hours later. Upon the facility's readmission of Resident #2, the facility utilized the family to supervise this resident, from 7:00 PM until 11:00 PM; however, the facility was unable to provide documented evidence that they appropriately trained the family on the facility's procedures to ensure the safety of the residents of the facility or to manage the resident's behavior. The facility staff began providing supervision to the resident at 11:00 PM that night. Observation, on 03/23/12 at 8:30 AM, revealed Resident #2 was sitting in his/her room with one to one supervision being provided by a non-facility staff member, employed by the facility to provide Resident #2 one to one supervision. Despite the facility's Abuse Prohibition Policy which stated "all employees would be educated and instructed in behavior management techniques for residents who exhibit aggressive behavior...In-services will be held on a routine and as necessary basis to ensure employees understand Corporate and facility's policies and procedures and possess a good working knowledge of preventive measures to protect each resident. The in-service will include information on....combative residents..."; interviews with facility staff revealed that not all staff had been trained on behavior management techniques for residents exhibiting aggressive behaviors and were not trained to implement preventive measures to protect each resident. An interview with Registered Nurse (RN) #1, Charge Nurse, on 03/15/12 at 11:15 AM, revealed our abuse/neglect policy stated to ensure the safety of the resident first, but ancillary staff, like dietary, were trained to report first and not try to intervene. An interview with RN #2, Charge Nurse, on 03/15/12 at 10:35 AM, revealed the first staff member on the scene was the dietary aide who went and got assistance, and that was what they should do. In our in-services for abuse/neglect, licensed staff was trained to ensure the safety of the residents first, but ancillary staff was trained to report first and not to intervene. The Dietary Aide stated, on 03/14/12 at 12:35 PM, she was in serviced on abuse/neglect and the first thing she was trained to do was report abuse/neglect and not try to intervene. An interview with Housekeeping Staff #1, on 03/15/12 at 9:45 AM, revealed she started June 2011 and was trained if she witnessed abuse, the first thing she would do would be to report to the charge nurse, and then report to her supervisor. An interview with Housekeeping/Laundry Service Staff #2, on 03/15/12 at 10:00 AM, revealed she had been employed at the facility for four years and had an in-service on abuse/neglect in 2011. If she observed a resident to resident altercation, she would inform the Certified Nurse Aide (CNA), then report to the nurse. She revealed she was instructed to inform a CNA or a nurse because housekeeping staff was not allowed to break up altercations. However, interview with the Director of Nursing (DON), on 03/15/12 at 6:20 PM, revealed "I would expect all my staff to go into the resident's room and ensure the safety of the resident first. In all our In-services, I instruct all staff to ensure the safety of the resident first, not to report first. An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed she expected all of the facility staff to ensure the safety of the residents first before reporting, regardless of what level of staff they were, and this was what their facility policy mandated. An interview with the Social Services Director, on 03/23/12 at 11:35 AM, revealed "she was aware Resident #2 used the wheelchair extender bar to threaten Resident #7 but did not follow up to ensure this device was removed, or to ensure the safety of the other residents in the facility." She reported she had no training on how to de-escalate behaviors nor did she attempt to de-escalate residents ' behaviors. On 03/15/12 at 2:15 PM, Social Services revealed she did not initiate re-assessment of Resident #2 related to his/her aggressive behaviors as she had not identified them as aggressive until after the 02/25/12 incident. However, record review revealed no evidence that the facility implemented their Abuse Prohibition Policy related to re-assessment of the resident's aggressive behaviors, revision of the care plan for specific behavior management techniques to address the resident's aggressive behaviors. Continued interview with the DON on 03/15/12 revealed Resident #2's metal wheelchair extender bar handle was not removed from his/her wheelchair, until 02/25/12, after the altercation with Resident #1." Continued interview with the Administrator, on 03/16/12, revealed she was unable to provide evidence that the facility implemented their policy in order to prevent abuse and to protect residents from further harm. Furthermore she revealed that the facility had not provided staff training for management of residents with challenging behaviors. She stated that the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors. While the facility was knowledgeable of the escalating aggressive behaviors of Resident #2 and had even identified the incident of 02/25/12 as physical abuse, they continued to fail to identify the behaviors as aggressive and implement their Abuse Prohibition Policy to re-assess this resident and implement behavior management techniques. Furthermore, they had not ensured their staff was educated and instructed on behavior management techniques for residents who exhibit aggressive behaviors in an effort to implement preventive measures and protect residents. Additionally, there was no evidence the facility had identified other residents having aggressive behaviors that had not been re-assessed for appropriate behavior management. The Administrator, on 03/23/12 at 1:25 PM, revealed she was unaware there was an issue with the wheelchair extender brake handle from the first incident because there was no physical altercation between the two residents." Stating, "there was no paper trail if there was no physical altercation, only when there was a physical altercation, would there be a paper trail." Our failure to thoroughly investigate the first incident, on 02/02/12, where there was no physical altercation that occurred between residents was the reason why we missed removing the wheelchair brake handle," which was later used to hit Resident #1 on 02/25/12. She stated they were unaware of the behavioral issues related to escalating resident behaviors from 02/02/12 through 03/08/12; therefore, we did not address these concerns.

Based on interview, record review and Allegation of Compliance review, it was determined the Immediate Jeopardy (IJ), identified during the abbreviated survey, completed on 03/23/12, had been removed related to development and implementation of the facility's policy and procedure to prevent abuse; however, non-compliance continued to exist at a S/S of a "D," as the facility had not completed the Quality and Assessment and Assurance Committee initiative related to monitoring, analysis of monitoring, and the implementation of the Plan of Correction (PoC) to ensure the facility's policy and procedure was implemented related to abuse. Findings include: Review of the acceptable AoC, dated 03/24/12, and record review revealed a private sitter was placed outside Resident #2's door twenty four hours a day and if the resident came out of the room, the private sitter supervised the resident at all times until the resident's discharge on 03/23/12. The private sitter also redirected wandering residents from the resident's room. The private sitter was educated by the Administrator, Director of Nursing (DON) or Charge Nurse on the Abuse policy and Effective Coping with Challenging Behaviors. A Licensed nurse verified every two hours and signed a document that included time of visual check, staff member/private sitter present and nurse's signature that the private sitter assigned outside of the room or with Resident #2. All available licensed nurses were in-serviced by the DON or Administrator on 03/16/12 or 03/17/12 on the verification process. Unavailable staff was in-serviced prior to returning to work. All available staff was inserviced on 03/16/12 or 03/17/12 on Facility Abuse Policy and Effective Coping with Challenging Behaviors by the DON or Administrator. Licensed Nurses were instructed by the DON to run Group Behavior reports from the Care Tracker system daily to ensure that any behavior noted was reported and if any follow up was needed that the follow up occurred. The Social Service Director was educated on the Care Tracker system including the available reports, how to run the 24 hour group report and how to follow up on behaviors noted on the report, and her responsibility to follow up on any reported behaviors. On 03/17/12, a CareTracker Group Behavior Report was run for the past sixty days to identify all residents with reported behaviors. On that day, Corporate Consultants reviewed the medical records and care plans for any resident on that report to identify any resident considered to be at risk for aggressive behavior toward other residents, and any identified behaviors were referred to facility staff and any identified potential behaviors were referred to the facility staff for review and revision of care plans. On 03/17/12, the DON reviewed all resident that wander for appropriate interventions on care plan to ensure safety needs were identified. Revisions were made as indicated. On 03/17/12, the Minimum Data Set (MDS) Coordinator and Social Services Director reviewed the MDS and Care Plans for all residents listed on the Caretracker Behavior Report who had behaviors in the last 60 days. If the behavior identified met the criteria for a significant change, a significant change assessment was completed. Care plans and interventions were reviewed and revisions were made as indicated. All care plans and nurse aide care plans were updated if indicated. All reported behaviors were reviewed in the morning meetings. The care plan and interventions were reviewed to ensure the effectiveness of the interventions to determine if additional interventions were required. Corporate Nursing Consultant educated the DON and Administrator, on 03/17/12, on assessing and identifying possible risks, implementing interventions to manage behaviors and re-evaluation of interventions for protection of the residents. They were also educated on the proper completion of Incident Report and follow up investigation as indicated. Interview with the Administrator, on 04/12/12 at 2:45 PM, revealed in the future the facility was having staff from a psychiatric service to come in and inservice the staff on behaviors and interventions to address behaviors. She stated the Quality Assessment Committee is going to meet once a month to discuss aggressive behaviors, abuse and resident to resident altercations and follow up. She revealed the Medical Director will be assisting the facility with outside resources to assist the facility in coming up with new intervention.

Based on interview, record review and Allegation of Compliance review, it was determined the Immediate Jeopardy (IJ), identified during the abbreviated survey completed on 03/23/12, had been removed related to supervision to prevent accidents; however, non-compliance continued to exist at a S/S of a "D," as the facility had not completed the Quality and Assessment and Assurance Committee initiative related to monitoring, analysis of monitoring, and the implementation of the Plan of Correction (PoC) to ensure resident supervision is provided to prevent accidents. Findings include: Review of the acceptable AoC, dated 03/24/12, and record review revealed a private sitter was placed outside Resident #'s door twenty four hours a day and if the resident came out of the room, the private sitter supervised the resident at all times up till the resident's discharge on 03/23/12. The private sitter also redirected wandering residents from the resident's room. The private sitter was educated by the Administrator, Director of Nurse (DON) or Charge Nurse on the Abuse policy and Effective Coping with Challenging Behaviors. A Licensed nurse verified every two hours and signed a document that included time of visual check, staff member/private sitter present and nurse's signature that the private sitter assigned outside of the room or with Resident #2. All available licensed nurses were in-serviced by the DON or Administrator on 03/16/12 or 03/17/12 on the verification process. Unavailable staff was in-service prior to returning to work. All available staff was inserviced on 03/16/12 or 03/17/12 on Facility Abuse Policy and Effective Coping with Challenging Behaviors by the DON or Administrator. Licensed Nurses were instructed by the DON to run Group Behavior reports from the Care Tracker system daily to ensure that any behavior noted was reported and if any follow up was needed that the follow up occurred. The Social Service Director was educated on the Care Tracker system including the available reports, how to run the 24 hour group report and how to follow up on behaviors noted on the report, and her responsibility to follow up on any reported behaviors. On 03/17/12, a CareTracker Group Behavior Report was run for the past sixty days to identify all residents with reported behaviors. On that day Corporate Consultants reviewed the medical records and care plans for any resident on that report to identify any resident considered to be at risk for aggressive behavior toward other residents, and any identified behaviors were referred to facility staff and any identified potential behaviors were referred to the facility staff for review and revision of care plans. On 03/17/12, the DON reviewed all resident that wander for appropriate interventions on care plan to ensure safety needs were identified. Revisions were made as indicated. On 03/17/12, the Minimum Data Set (MDS) Coordinator and Social Services Director reviewed the MDS and Care Plans for all residents listed on the Caretracker Behavior Report who had behaviors in the last 60 days. If the behavior identified met the criteria for a significant change, a significant change assessment was completed. Care plans and interventions were reviewed and revisions were made as indicated. All care plans and nurse aide care plans were updated if indicated. All reported behaviors were reviewed in the morning meetings. The care plan and interventions were reviewed to ensure the effectiveness of the interventions to determine if additional interventions were required. Corporate Nursing Consultant educated the DON and Administrator on 03/17/12 on assessing and identifying possible risks, implementing interventions to manage behaviors and re-evaluation of interventions for protection of the residents. They were also educated on the proper completion of Incident Report and follow up investigation as indicated. Interview with the Administrator, on 04/12/12 at 2:45 PM, revealed in the future the facility was having staff from a psychiatric service to come in and inservice the staff on behaviors and interventions to address behaviors. She stated the Quality Assessment Committee was going to meet once a month to discuss aggressive behaviors, abuse and resident to resident altercations and follow up. She revealed the Medical Director will be assisting the facility with outside resources to assist the facility in coming up with new interventions.

Based on interview, record review, and review of the facility's policy/procedure, the facility failed to ensure appropriate, timely and medically related Social Services for one resident (#2), in the selected sample of seven residents. The facility failed to follow their Abuse Prohibition policy related to Prevention Procedures to ensure residents will be re-assessed by appropriate health care professions for aggressive behaviors and will ensure the plan of care will include appropriate direction for team members to meet the individual needs of the resident. The facility failed to ensure the staff responsible for the facility's behavior management program were educated and instructed on behavior management techniques for residents who exhibit aggressive behaviors. This failure prevented the facility from adequately addressing Resident #2's behaviors. On 11/28/11, the facility's assessment detailed their knowledge that Resident #2 had verbal and behavioral symptoms that were directed towards others and care planned that those behaviors would not cause injury to self or others. On 02/02/12 at 9:45 AM, Resident #2 threatened to beat Resident #7 with the metal extender bar from his/her wheelchair. On 02/05/12 at 2:10 PM, Resident #2 became agitated and threatened Resident #7 and was witnessed by staff chasing Resident #7 down the hallway screaming he/she was going to "get him." On 02/06/12, Resident #2 threatened to hit maintenance staff. On 02/09/12 at 9:05 AM, Resident #2 became agitated and threatened roommate Resident #1 over closing the door to their room. On 02/25/12 at 10:55 AM, Resident #2's struck Resident #1 in the head multiple times with the metal extender bar handle from his/her wheelchair, the same object that this resident threatened Resident #7 with on 02/02/12. Resident #1 had to be sent to the emergency room for treatment and required sutures to close the lacerations to his/her head. On 03/06/12 at 10:25 AM, Resident #2 was admitted back to the facility with no behavioral re-assessment or interventions implemented specific to the residents recent history of aggressive behaviors, which the facility had identified as physical abuse related to the 02/25/12 incident. On 03/08/12 at 1:20 PM, Resident #2 became agitated and his/her behaviors escalated to the point that he/she physically assaulted Resident #6 by shutting the door on Resident #6's arm. Resident #2 stated he/she would punch Resident #6 in the face if he/she ever came in the room again. Resident #6 had multiple skin tears to the left upper arm that required intervention and treatment. While the facility was knowledgeable of the escalating aggressive behaviors of Resident #2 and had even identified the incident of 02/25/12 as physical abuse, they continued to fail to identify the behaviors as aggressive and implement their Abuse Prohibition Policy to re-assess this resident and implement behavior management techniques. Furthermore, they had not ensured their staff was educated and instructed on behavior management techniques for residents who exhibit aggressive behaviors in an effort to implement preventive measures and protect residents. Furthermore, there was no evidence the facility had identified other residents having aggressive behaviors that had not been re-assessed for appropriate behavior management. The facility Administration, on 03/23/12, detailed that they had not identified any issues with residents having escalating behaviors and had not addressed these concerns. The facility failed to ensure there was an effective behavior management program implemented as specified in the Abuse Prohibition Policy. The facility failed to ensure that staff identified aggressive behavior as potentially abusive, failed to re-assess the resident in order to meet the individual needs, develop appropriate behavioral management techniques, and ensure protection of the residents. These failures prevented the facility from implementing necessary interventions to address Resident #2's aggressive behaviors and adequate supervision which led to two residents being physically harmed by Resident #2 and the potential for other residents to be harmed. This failure caused or likely caused serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/16/12 and determined to exist on 02/02/12 and is ongoing. (Refer to F323, F280, F226) Findings include: A review of the facility's policy/procedure, "Director of Social Services/Designee," dated 11/04/07, revealed Social Services is responsible for planning, organizing, implementing, evaluating and directing the overall operation of the Social Service Department to provide services that meet the social and/or emotional needs that affect the resident's ability to achieve their highest level of function. Interview with the Social Services Director, on 03/15/12 at 2:15 PM, revealed her "only responsibility was to ensure residents adjust to their new environment" and to review the Behavior Entry data in the Care Tracker System, but only reviewed the behavioral data when the resident's MDS was due." An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed Social Service was the designated person who managed the facility's behavioral program. However, interview with the Director of Nursing (DON), on 03/23/12 at 12:40 PM, revealed, "(the facility had) no policy/procedure for behavioral management, escalating behaviors, or assessments of residents with behaviors." Review of the facility's Abuse Prohibition policy, undated, revealed the facility employees would receive training through the orientation program and ongoing in-service session related to appropriate interventions to deal with aggressive and/or catastrophic reactions of residents. The policy also detailed that all employees would be educated and instructed in behavior management techniques for residents who exhibit aggressive behavior, residents who wander, who have self-injurious behavior and who have communication disorders. It further detailed that in-services will be held on a routine and as necessary basis to ensure employees understand Corporate and facility's policies and procedures and possess a good working knowledge of preventive measures to protect each resident. The policy detailed that the in-service would include information related to combative residents. A record review revealed the facility admitted Resident #2 on 11/15/11 with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 as having no memory deficits; however, had behaviors of threatening, screaming, and cursing at others. The Resident Care Area Assessment (CAA) Summary, dated 11/22/11, revealed the CAA triggered aggressive behavioral data related to behavioral systems. The CAA and the Behavior Report detailed the resident had behavioral and verbal symptoms directed toward others with a significant disruption of care and noted to wander with a significant risk of danger to self. A review of the admission care plan, dated 11/28/11, revealed the facility developed a care plan related to Resident #2's behaviors/agitation that was related to nursing home placement and Dementia. The facility set a goal that the resident would not cause injury to self or others due to his/her behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. There were no specific interventions related to supervision of the resident or approaches that assessed how the resident's behaviors would be monitored. There were no specific interventions to address specific behaviors of threatening, screaming, cursing at others or behavioral and verbal symptoms directed towards others as was detailed in the facility's admission assessment and CAA. On 02/02/12 at 9:45 AM, the nurses' notes revealed Resident #2 got up out of his/her wheelchair, removed the wheelchair extender bar handle and threatened to hit Resident #7 (wheelchair bound) with the handle. The facility staff had to assist Resident #7 from the room while Resident #2 was allowed to calm down. Review of the Social Services Progress Notes, dated 02/02/12 at 9:50 AM, revealed the Charge Nurse had informed the Social Services Director (SSD) and the DON of Resident #2's threat to hit his/her roommate with the metal extender bar handle over the temperature of the room and whether the room door remained open or closed. The note detailed that the SSD, the DON and the Administrator decided to offer Resident #2 a room change. The facility transferred Resident #2 to another room at 10:25 AM at which time he/she began residing with Resident #1. Further review of the Social Services notes and care plan review revealed there was no evidence Social Services addressed the resident's threatening behaviors by conducting an assessment, revising the care plan, ensuring physician notification of the aggressive behaviors, nor did she intervene to remove the extender bar from Resident #2's possession. Rather the facility chose to move Resident #2 into a room with Resident #1, who was a bilateral amputee and without addressing Resident #2's behaviors to ensure a safe environment for all residents. Continued interview with the Social Services Director, on 03/15/12, revealed she did not assess after Resident #2 threatened another resident with the metal extender bar, did not remove the object, or provide one to one supervision related to the resident's threatening behavior. She further stated, on 03/23/12 at 11:35 AM, she did not revise Resident #2's care plan regarding the 02/02/12 incident. She stated, while she was aware Resident #2 used the wheelchair extender bar to threaten Resident #7, she did not follow up to ensure this device was removed, or to ensure the safety of the other residents in the facility." A review of the nurses' notes, dated 02/05/12 at 2:10 PM, revealed the CNA reported Resident #2 was in the hallway without his/her walker chasing Resident #7 down the hall saying "I'll get you for making fun of me." Two CNAs attempted to prevent Resident #2 from harming Resident #7, and Resident #2 began hitting and slapping at the two (2) CNAs, who were trying to protect Resident #7. After redirection from the CNAs, Resident #2 ambulated back to his/her room accompanied by the CNAs. The nurse was called into the room by a Certified Nurse Aide (CNA) because Resident #2 was agitated and cursing. Resident #2 was anxious and wringing his/her hands, and was administered Ativan for anxiety. There was no documented evidence that social services addressed the resident's behaviors related to this incident. There was no evidence social services re-assessed or had appropriate health care professionals re-assess Resident #2 related to his/her aggressive behaviors nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs. Review of the nurses' notes, on 02/06/12 at 3:45 PM, revealed Resident #2 became agitated when maintenance staff entered his/her room. The resident cursed and threatened to hit the staff. There was no documented evidence that social services addressed the resident's behaviors related to this incident. There was no evidence social services re-assessed or had appropriate health care professionals re-assess Resident #2 related to his/her aggressive behaviors nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs. A review of the nurses' notes, dated 02/09/12 at 9:05 AM, revealed the Charge Nurse was in the room administering medications to Resident #1, when Resident #2 jumped out of the wheelchair and angrily yelled and cursed at Resident #1. The Charge Nurse attempted redirection without success and Resident #1 was assisted to a wheelchair and out of the room. The facility administered anxiety medication for Resident #2 at that time. Review of a Social Service Progress note, dated 02/09/12 at 9:25 AM, reported she told Resident #2 that he/she could not be yelling or threatening Resident #1. Per the note, the SSD informed the Administrator of the situation. While the facility notified the resident's family and requested family to consider utilizing a psychiatric consult, there was no evidence social services re-assessed or had appropriate health care professionals re-assess Resident #2 related to his/her aggressive behaviors nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs. Furthermore, this same date 02/09/12, the facility completed the Quarterly MDS Assessment, assessing that Resident #2 had no mood symptoms or frequency present and detailed the resident had no behaviors exhibited or present. Review of Resident #2's care plan revealed no changes had been made to address the resident's aggressive behaviors or to increase supervision to protect other residents; however, detailed the behavior goal had been met and would continue through 05/2012. Review of the Social Service Progress Notes, dated 02/13/12 at 9:30 AM revealed the family spoke with the physician related to the psychiatric consult and the physician stated he would make a recommendation if needed. The SSD informed the family at that time if the resident's behaviors continued then he would need to be seen by psychiatric services and the family agreed. However, review of the medical record revealed neither the social services or the nursing staff had informed Resident #2's physician of the resident's increased aggressive behaviors towards others on 02/02/12, 02/05/12, 02/06/12 and 02/09/12, and furthermore, there was no documented evidence of physician notification or request to the physician for psychiatric referral and assessment. On 02/15/12 at 10:50 AM, review of the Social Services Progress Notes revealed the facility had a care plan meeting with the resident and family in attendance. The note detailed the care plans were reviewed with goals reset for 05/2012. It stated, the "resident noted to have no mood issues noted during this assessment period, but did have behaviors (times one) day noted with no impact on resident or others. No problems reported with roommate by resident, staff, or family. No problems with leaving door open reported since (02/09/12) will continue to follow..." Review of the care plan detailed the facility noted the goal that the "resident will not cause injury to self or others due to behaviors" as "met (and) reset 5/2012". However, during the fourteen day look back period, this resident had three occasions of aggressive behaviors on 02/02/12, 02/05/12 and 02/09/12 where the resident was either threatening, chasing or yelling at another resident, and on 02/06/12 where the resident was cursing and threatening to hit staff with no evidence social services re-assessed or had appropriate health care professionals re-assess Resident #2 related to his/her aggressive behaviors nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs. The SSD and the care plan team could provide no evidence that they identified all the Resident's behaviors during the look back period or that they re-assessed and addressed the resident specifically to his/her aggressive behaviors towards other residents. A review of the nurse's notes, dated 02/25/12 at 10:55 AM, and an interview with the Dietary Aide, on 03/14/12 at 12:35 PM, revealed she was making her rounds, on 02/25/12 at 10:55 AM, when she heard someone yell for help. She observed Resident #2 walking away from Resident #1 carrying a metal object (part of Resident #2's wheelchair), and Resident #1 was covering his/her head trying to protect himself/herself. She did not observe Resident #1 bleeding the first time she walked by; however, she reported she ran and got the CNA, and by the time they got back to Room 7, Resident #1 was bleeding from his/her head. The Charge Nurse was called to the residents' room, and Resident #2 was sitting outside Room 7 in his/her wheelchair. Resident #2 was very agitated and combative. Staff attempted to calm Resident #2, and the CNA reported "Resident #2 just beat roommate Resident #1 in the head." The Charge Nurse reported that "Resident #1 was bleeding from the head injury and there were multiple staff trying to calm Resident #2, but were unsuccessful as Resident #2 was still trying to get back into the room to harm Resident #1." Resident #1 was struck multiple times in the head by Resident #2 with the metal extender bar handle of Resident #2's wheelchair. Further review of the nurse's notes revealed "Resident #1 had four large lacerations on the head and a purple bruise on his/her sternal notch. Resident #1 was on Coumadin Therapy and the staff had to apply pressure to the head wounds to control the bleeding." Staff had to shut the door to Room 7 with Resident #2 in the hallway. Resident #2 was still agitated and trying to get back into Room 7, and staff was unable to calm Resident #2 down enough to move he/she to another room until 11:30 AM. An interview with Registered Nurse (RN) #1, Charge Nurse, on 03/15/12 at 11:15 AM, revealed, on 02/25/12 at 10:55 AM, when she arrived on the scene, and they had already gotten the bar from Resident #2's hand. She stated "My co-workers told me not to go near Resident #2 or he would hit me." Resident #2 had a history of [REDACTED]. Resident #2 did not get along with Resident #7 and social service was involved in that incident. An interview with Certified Nurse Aide (CNA) #1, on 03/15/12 at 11:45 AM, revealed, on 02/25/12 at 10:55 AM, "Resident #2 was thrashing about in the hallway and it was a very intense situation. The CNA was afraid for herself and the other residents." Stating, "I was concerned for the safety of the wandering residents in the facility, that Resident #2 was capable of hurting them, or me." Per the Nurse's Notes, and the care plan, the facility initiated, on 02/25/12, another room transfer moving Resident #2 to a private room, removed the extender bar and all metal objects or potential dangerous items from his/her possession; initiated one to one supervision and detailed family would sit with the resident during periods of agitation. At 11:50 AM, Resident #2 became more combative, hitting, kicking, and cursing at staff. Later in the evening, on 02/25/12 at 7:20 PM, Resident #2 was transported to a psychiatric hospital for psychiatric services. On 03/15/12 at 2:15 PM, interview with the SSD revealed she had not assessed Resident #2 for the metal extender bar, did not remove the object or initiate one to one supervision after he/she threatened another resident with it as she stated she never thought about the resident later using this device as a weapon, and her "only responsibility was to ensure residents adjust to their new environment." Interview, on 03/23/12 at 11:35 AM, revealed she made no revision to Resident #2's care plan prior to 02/25/12 related to his/her aggressive behaviors. The Social Service Director stated, that she was aware of Resident #2's behavior and spoke to the resident about his/her behaviors, but did not identify these behaviors as aggressive behaviors until 02/25/12. Review of the facility's investigation revealed the facility concluded the incident of 02/25/12 was physical abuse. A review of the nurse's notes revealed Resident #2 returned to the facility on [DATE]. Review of the care plan revealed the facility updated it with the revision that Resident #2 was to have a private room and discontinued one to one supervision and removal of dangerous objects. The facility could provide no documented evidence they re-assessed Resident #2 upon return from the psychiatric hospital related to his/her aggressive behaviors nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs and manage his/her behaviors even though the facility's investigation of the incident had identified Resident #2's aggressive behaviors on 02/25/12 as physical abuse. On 03/08/12 at 1:20 PM, nurse's notes revealed the Charge Nurse summoned to room, Resident #2 was shutting the door on Resident #6's arm. Injuries included two skin tears on the left upper dorsal arm which required medical intervention. The facility could provide no documented evidence they re-assessed Resident #2 after this incident related to his/her escalating aggressive behaviors toward another resident nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs and manage his/her behaviors. Care plan review revealed the facility initiated, on 03/13/12, a mesh stop sign which was placed on Resident #2's doorway to keep wandering residents from entering his/her room. However, the facility could provide no documented evidence they re-assessed Resident #2 related to his/her escalating aggressive behaviors toward another resident nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs and manage his/her behaviors. An observation, on 03/14/12 at 9:30 AM, revealed Resident #2 sitting on the side of the bed verbalizing "When I came here I could not walk and now I can." Resident #2 was noted to have no one to one supervision provided by the facility, and his/her room was located at the end of a long hall and was the second to the last room at the end of the hall, and second to furthermost room from the nurses' station. Observation on 03/14/12 at 4:39 PM revealed Resident #2 was lying in bed and was observed to have no one to one supervision provided by the facility. Observation on 03/15/12 at 6:10 PM revealed Resident #2 was found in his/her room verbalizing he/she could walk anywhere he/she wanted to go. Resident #2 was observed to have no one to one supervision provided by the facility. Observation on 03/16/12 at 4:00 PM revealed Resident #2 was observed to be ambulating freely in his/her room without any difficulty and without the assist of a walker or cane. While Resident #2 was not observed having any aggressive behaviors at the time of the observations, the resident was observed independent with ambulation. An interview with the Social Services Director, on 03/23/12 at 11:35 AM, revealed "she was aware Resident #2 used the wheelchair extender bar to threaten Resident #7 but did not follow up to ensure this device was removed, or to ensure the safety of the other residents in the facility." She reported she had no training on how to de-escalate behaviors nor did she attempt to de-escalate Resident #2's behaviors. Interview with the Director of Nursing (DON), on 03/23/12 at 12:40 PM, revealed the facility had not identified a problem with resident behaviors which placed other residents at risk. The DON reported that the problem related to accurate behavioral assessments and a lack of supervision was not identified; therefore, the facility had not addressed it. There was a failure for assessing resident behaviors which would make it difficult to determine quality of care issues or needs of the residents. "We have no policy/procedure for behavioral management, escalating behaviors, or assessments of residents with behaviors." An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed "I do not know who was responsible to look at the Care Tracker System for behaviors, I really do not know"; however, Social Service is the designated person who manages the facility's behavioral program. There has been no staff inservice for management of residents with challenging behaviors. She stated that the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors. Further interview, on 03/23/12 at 1:25 PM, revealed they were unaware of the behavioral issues related to escalating resident behaviors; therefore, we did not address these concerns. The facility could not provide evidence that they had thoroughly re-assessed Resident #2 related to his/her aggressive behaviors and implemented appropriate care plan interventions to provide staff appropriate direction to meet the individuals needs. The care plan the facility had implemented as of 03/23/12 revealed the following goal and interventions: that the resident would not cause injury to self or others due to his/her behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. On 02/25/12, the facility had implemented a room change to reside privately with one to one supervision which was discontinued on 03/06/12; Remove metal clothes hangers, no forks or butter knives on meal trays; remove pants belt from environment which was discontinued on 03/06/12; Family to sit with resident during periods of agitation. On 03/06/12, the facility added the resident was to reside without a roommate and, on 03/13/12, a mesh sign was placed on the doorway to keep wanderers out of the resident's room. There was no evidence of an approach specific to address the resident's aggressive behaviors or appropriate direction provided to the staff in order to manage the resident as per their Abuse Prohibition Policy. The facility had not identified their failure in identifying escalating aggressive behaviors and the need to assess or reassess and to implement medically related interventions. Additionally, the facility had not provided evidence that they had assessed to identify other residents of the facility who had potentially aggressive behaviors that were not being managed. Furthermore the facility had not provided training to the Social Services Director, as of 03/23/12, related to behavior management and how to de-escalate residents with behaviors.

Based on interview, record review and Allegation of Compliance review, it was determined the Immediate Jeopardy (IJ), identified during the abbreviated survey completed on 03/23/12, had been removed related to the provision of medically related Social Services; however, non-compliance continued to exist at a S/S of a "D," as the facility had not completed the Quality Assessment and Assurance Committee initiative related to monitoring, analysis of monitoring, and the implementation of the Plan of Correction (PoC) to ensure medically-related Social Services was provided. Findings include: Review of the acceptable AoC, dated 03/24/12, and record review revealed Licensed Nurses were instructed by the DON to run Group Behavior reports from the Care Tracker system daily to ensure that any behavior noted was reported and if any follow up was needed that the follow up occurred. The Social Service Director was educated on the Care Tracker system including the available reports, how to run the 24 hour group report and how to follow up on behaviors noted on the report, and her responsibility to follow up on any reported behaviors. On 03/17/12, a CareTracker Group Behavior Report was run for the past sixty days to identify all residents with reported behaviors. On that day, Corporate Consultants reviewed the medical records and care plans for any resident on that report to identify any resident considered to be at risk for aggressive behavior toward other residents, and any identified behaviors were referred to facility staff and any identified potential behaviors were referred to the facility staff for review and revision of care plans. On 03/17/12, the DON reviewed all resident that wander for appropriate interventions on care plan to ensure safety needs were identified. Revisions were made as indicated. On 03/17/12, the Minimum Data Set (MDS) Coordinator and Social Services Director reviewed the MDS and Care Plans for all residents listed on the Caretracker Behavior Report who had behaviors in the last 60 days. If the behavior identified met the criteria for a significant change, a significant change assessment was completed. Care plans and interventions were reviewed and revisions were made as indicated. All care plans and nurse aide care plans were updated if indicated. All reported behaviors were reviewed in the morning meetings. The care plan and interventions were reviewed to ensure the effectiveness of the interventions to determine if additional interventions were required. Interview with the Administrator, on 04/12/12 at 2:45 PM, revealed, in the future, the facility was having staff from a psychiatric service to come in and inservice the staff on behaviors and interventions to address behaviors. She stated the Quality Assessment Committee was going to meet once a month to discuss aggressive behaviors, abuse and resident to resident altercations and follow up. She revealed the Medical Director will be assisting the facility with outside resources to assist the facility in coming up with new intervention.

Based on observation, interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure the comprehensive care plan is periodically reviewed and revised by a team of qualified persons after each assessment for one resident, (#2), in the selected sample of seven residents. The facility failed to follow their Abuse Prohibition policy related to Prevention Procedures to ensure residents will be re-assessed by appropriate health care professionals for aggressive behaviors and will ensure the plan of care will include appropriate direction for team members to meet the individual needs of the resident. This failure prevented the facility from adequately addressing Resident #2's behaviors and revising the care plan with appropriate interventions to meet the individual needs of the resident. On 11/28/11, the facility's assessment detailed their knowledge that Resident #2 had verbal and behavioral symptoms that were directed towards others and care planned that those behaviors would not cause injury to self or others. On 02/02/12 at 9:45 AM, Resident #2 threatened to beat Resident #7 with the metal extender bar from his/her wheelchair. On 02/05/12 at 2:10 PM, Resident #2 became agitated and threatened Resident #7 and was witnessed by staff chasing Resident #7 down the hallway screaming he/she was going to "get him." On 02/06/12, Resident #2 threatened to hit maintenance staff. On 02/09/12 at 9:05 AM, Resident #2 became agitated and threatened roommate Resident #1 over closing the door to their room. On 02/25/12 at 10:55 AM, Resident #2 struck Resident #1 in the head four times with the metal extender bar handle from his/her wheelchair, the same object that this resident threatened Resident #7 with on 02/02/12. Resident #1 had to be sent to the emergency room for treatment and required sutures to close the lacerations to his/her head. On 03/06/12 at 10:25 AM, Resident #2 was admitted back to the facility with no behavioral re-assessment or revision of the care plan implemented specific to the resident's recent history of aggressive behaviors, which the facility had identified as physical abuse related to the 02/25/12 incident. On 03/08/12 at 1:20 PM, Resident #2 became agitated and his/her behaviors escalated to the point that he/she physically assaulted Resident #6 by shutting the door on Resident #6's arm. Resident #2 stated he/she would punch Resident #6 in the face if he/she ever came in the room again. Resident #6 had multiple skin tears to left upper arm that required intervention and treatment. While the facility was knowledgeable of the escalating aggressive behaviors of Resident #2 and had even identified the incident of 02/25/12 as physical abuse, they continued to fail to identify the behaviors as aggressive, re-assess this resident and revise the care plan with behavior management techniques and necessary supervision requirements to ensure the safety of the residents of the facility. The facility Administration, on 03/23/12, detailed that they had not identified any issues with residents having escalating behaviors and had not addressed these concerns. The facility failed to revise the comprehensive care plan for Resident #2 in an effort to manage his/her aggressive behaviors, detail necessary interventions of supervision in order to protect residents of the facility from further harm. This failure caused or likely caused serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 03/16/12 and determined to exist on 02/02/12 and is ongoing. (Refer to F323 and F250) Findings include: A review of the facility's policy/procedure, "Director of Social Services/Designee," dated 11/04/07, revealed Social Services is responsible for planning, organizing, implementing, evaluating and directing the overall operation of the Social Service Department to provide services that meet the social and/or emotional needs that affect the resident's ability to achieve their highest level of function. Interview with the Social Services Director, on 03/15/12 at 2:15 PM, revealed her "only responsibility was to ensure residents adjust to their new environment" and to review the Behavior Entry data in the Care Tracker System, but only reviewed the behavioral data when the resident's MDS was due." Further interview revealed the Social Services Director was responsible for the care plan related to behaviors. Review of the facility's policy/procedure, "Abuse Prohibition," revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The facility's policy detailed that each resident will be assessed and routinely reassessed by the appropriate health care professionals for aggressive behavior, wandering, self-injurious behavior, communication impairments, and heavy nursing care, and /or total dependence on staff. The policy stated "the plan of care will include appropriate direction for team members to meet individual needs of the resident." A record review revealed the facility admitted Resident #2 on 11/15/11 with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #2 to have behaviors of threatening, screaming, and cursing at others. The Resident Care Area Assessment (CAA) Summary, dated 11/22/11, revealed the CAA triggered aggressive behavioral data related to behavioral systems. The CAA and the Behavior Report detailed the resident had behavioral and verbal symptoms directed toward others with a significant disruption of care and noted to wander with a significant risk of danger to self. The admission care plan, dated 11/28/11, revealed the facility developed a care plan related to Resident #2's behaviors/agitation that was related to nursing home placement and Dementia. The facility set a goal that the resident would not cause injury to self or others due to his/her behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. There were no specific interventions related to supervision of the resident, no specific interventions to address specific behaviors of threatening, screaming, cursing at others or behavioral and verbal symptoms directed towards others as was detailed in the facility's admission assessment and CAA. Furthermore, the care plan did not address how the facility would monitor the resident's behaviors. On 02/02/12 at 9:45 AM, the nurses' notes revealed Resident #2 got up out of his/her wheelchair, removed the wheelchair extender bar handle and threatened to hit Resident #7 (wheelchair bound) with the handle. The facility staff had to assist Resident #7 from the room while Resident #2 was allowed to calm down. Review of the Social Services Progress Notes, dated 02/02/12 at 9:50 AM, revealed the Charge Nurse had informed the Social Services Director (SSD) and the DON of Resident #2's threat to hit his/her roommate with the metal extender bar handle over the temperature of the room and whether the room door remained open or closed. The note detailed that the SSD, the DON and the Administrator decided to offer Resident #2 a room change. The facility transferred Resident #2 to another room at 10:25 AM, at which time he/she began residing with Resident #1. Further review of the Social Services notes and care plan review revealed there was no evidence Social Services addressed the resident's threatening behaviors through revision of the care plan. Rather the facility chose to move Resident #2 into a room with Resident #1, who was a bilateral [MEDICAL CONDITION] and without addressing Resident #2's behaviors to ensure a safe environment for all residents. Continued interview with the Social Services Director, on 03/23/12 at 11:35 AM, revealed she did not revise the care plan related to the resident's threatening behavior regarding the 02/02/12 incident. She stated, while she was aware Resident #2 used the wheelchair extender bar to threaten Resident #7, she did not follow up to ensure this device was removed, or to ensure the safety of the other residents in the facility." A review of the nurses' notes, dated 02/05/12 at 2:10 PM, the CNA reported Resident #2 was in the hallway without his/her walker chasing Resident #7 down the hall saying "I'll get you for making fun of me." Two CNAs attempted to prevent Resident #2 from harming Resident #7, and Resident #2 began hitting and slapping at the two (2) CNAs, who were trying to protect Resident #7. After redirection from the CNAs, Resident #2 ambulated back to his/her room accompanied by the CNAs. The nurse was called into the room by a Certified Nurse Aide (CNA) because Resident #2 was agitated and cursing. Resident #2 was anxious and wringing his/her hands, and was administered [MEDICATION NAME] for anxiety. There was no documented evidence that social services addressed the resident's behaviors related to this incident. There was no evidence social services revised the care plan to include appropriate direction for staff to meet the resident's individual needs and adequate supervision to protect other residents from his/her aggressive behaviors. Review of the nurses' notes, on 02/06/12 at 3:45 PM, revealed Resident #2 became agitated when maintenance staff entered his/her room. The resident cursed and threatened to hit the staff. There was no documented evidence that social services addressed the resident's behaviors related to this incident through revising the care plan to include appropriate direction for staff to meet the resident's individual needs and to detail necessary supervision. A review of the nurses' notes, dated 02/09/12 at 9:05 AM, revealed the Charge Nurse was in the room administering medications to Resident #1, when Resident #2 jumped out of the wheelchair and angrily yelled and cursed at Resident #1. The Charge Nurse attempted redirection without success and Resident #1 was assisted to a wheelchair and out of the room. The facility administered anxiety medication for Resident #2 at that time. Review of a Social Service Progress note, dated 02/09/12 at 9:25 AM, reported she told Resident #2 that he/she could not be yelling or threatening Resident #1. Per the note, the SSD informed the Administrator of the situation. While the facility notified the resident's family and requested family to consider utilizing a psychiatric consult, there was no evidence social services revised the care plan to include appropriate direction for staff to meet the resident's individual needs and necessary supervision. On 02/15/12 at 10:50 AM, review of the Social Services Progress Notes revealed the facility had a care plan meeting the resident and family were not in attendance. The note detailed the care plans were reviewed with goals reset for 05/2012. It stated, the "resident noted to have no mood issues noted during this assessment period, but did have behaviors (times one) day noted with no impact on resident or others. No problems reported with roommate by resident, staff, or family. No problems with leaving door open reported since (02/09/12) will continue to follow..." Review of the care plan detailed the facility noted the goal that the "resident will not cause injury to self or others due to behaviors" as "met (and) reset 5/2012". However, during the fourteen day look back period, this resident had three occasions of aggressive behaviors on 02/02/12, 02/05/12 and 02/09/12 where the resident was either threatening, chasing or yelling at another resident and on 02/06/12 where the resident was cursing and threatening to hit staff with no evidence social services revised the care plan to include appropriate direction for staff to meet the resident's individual needs. The facility could provide no evidence that they identified all the Resident's behaviors during the look back period or that they re-assessed and addressed the resident specifically to his/her aggressive behaviors towards other residents. A review of the nurses' notes, dated 02/25/12 at 10:55 AM, and an interview with the Dietary Aide, on 03/14/12 at 12:35 PM, revealed she was making her rounds, on 02/25/12 at 10:55 AM, when she heard someone yell for help. She observed Resident #2 walking away from Resident #1 carrying a metal object (part of Resident #2's wheelchair), and Resident #1 was covering his/her head trying to protect himself/herself. She did not observe Resident #1 bleeding the first time she walked by; however, she reported she ran and got the CNA, and by the time they got back to room [ROOM NUMBER], Resident #1 was bleeding from his/her head. The Charge Nurse was called to the residents' room, and Resident #2 was sitting outside room [ROOM NUMBER] in his/her wheelchair. Resident #2 was very agitated and combative. Staff attempted to calm Resident #2, and the CNA reported "Resident #2 just beat roommate Resident #1 in the head." The Charge Nurse reported that "Resident #1 was bleeding from the head injury and there were multiple staff trying to calm Resident #2, but were unsuccessful as Resident #2 was still trying to get back into the room to harm Resident #1." Resident #1 was struck multiple times in the head by Resident #2 with the metal extender bar handle of Resident #2's wheelchair. Further review of the nurse's notes revealed "Resident #1 had four large lacerations on the head and a purple bruise on his/her sternal notch. Resident #1 was on [MEDICATION NAME] Therapy and the staff had to apply pressure to the head wounds to control the bleeding." Staff had to shut the door to room [ROOM NUMBER] with Resident #2 in the hallway. Resident #2 was still agitated and trying to get back into the room, and staff was unable to calm Resident #2 down enough to move he/she to another room until 11:30 AM. An interview with Registered Nurse (RN) #1, Charge Nurse, on 03/15/12 at 11:15 AM, revealed, on 02/25/12 at 10:55 AM, when she arrived on the scene, and they had already gotten the bar from Resident #2's hand. She stated "My co-workers told me not to go near Resident #2 or he would hit me." Resident #2 had a history of [REDACTED]. Resident #2 did not get along with Resident #7 and social service was involved in that incident. Certified Nurse Aide (CNA) #1, on 03/15/12 at 11:45 AM, revealed, on 02/25/12 at 10:55 AM, "Resident #2 was thrashing about in the hallway and it was a very intense situation. The CNA was afraid for herself and the other residents." Stating, "I was concerned for the safety of the wandering residents in the facility, that Resident #2 was capable of hurting them, or me." After the 02/25/12 incident the facility revised the care plan, to include the facility initiated on 02/25/12 another room transfer moving Resident #2 to a private room, removed the extender bar and all metal objects or potential dangerous items from his/her possession; initiated one to one supervision and detailed family would sit with the resident during periods of agitation. On 02/25/12 at 7:20 PM, the facility transferred Resident #2 to a psychiatric hospital for psychiatric services. The SSD, on 03/15/12 at 2:15 PM, during interview revealed she had not assessed Resident #2 for the metal extender bar, did not remove the object or initiate one to one supervision after he/she threatened another resident with it as she stated she never thought about the resident later using this device as a weapon. Interview, on 03/23/12 at 11:35 AM, revealed she made no revision to Resident #2's care plan prior to 02/25/12 related to his/her aggressive behaviors. The Social Service Director stated, that she was aware of Resident #2's behavior and spoke to the resident about his/her behaviors, but did not identify these behaviors as aggressive behaviors until 02/25/12. Review of the facility's investigation revealed the facility concluded the incident of 02/25/12 as physical abuse. A review of the nurses' notes revealed Resident #2 returned to the facility on [DATE]. Review of the care plan revealed the facility updated it with the revision that Resident #2 was to have a private room; however, discontinued one to one supervision and removal of dangerous objects. The facility could provide no documented evidence they re-assessed Resident #2 upon return from the psychiatric hospital related to his/her aggressive behaviors nor was there evidence that the care plan was revised to include appropriate direction for staff to meet the resident's individual needs and manage his/her behaviors even though the facility's investigation of the incident had identified Resident #2's aggressive behaviors on 02/25/12 as physical abuse. On 03/08/12 at 1:20 PM, nurses' notes revealed the Charge Nurse was summoned to room, Resident #2 was shutting the door on Resident #6's arm. Injuries included two skin tears on the left upper dorsal arm which required medical intervention. The facility could provide no documented evidence they revised the care plan to include appropriate direction for staff to meet the resident's individual needs and to ensure adequate supervision to protect residents from harm. Care plan review revealed the facility revised the care plan, on 03/13/12, detailing a mesh stop sign would be placed on Resident #2's doorway to keep wandering residents from entering his/her room. However, the facility could provide no documented evidence they revised the care plan to include appropriate direction for staff to meet the resident's individual needs, manage his/her behaviors and to detail necessary and adequate supervision needs. An observation, on 03/14/12 at 9:30 AM, revealed Resident #2 sitting on the side of the bed verbalizing "When I came here I could not walk and now I can." Resident #2 was noted to have no one to one supervision provided by the facility, and his/her room was located at the end of a long hall and was the second to the last room at the end of the hall, and second to furthermost room from the nurses' station. Observation, on 03/14/12 at 4:39 PM, revealed Resident #2 was lying in bed and was observed to have no one to one supervision provided by the facility. Observation, on 03/15/12 at 6:10 PM, revealed Resident #2 was found in his/her room verbalizing he/she could walk anywhere he/she wanted to go. Resident #2 was observed to have no one to one supervision provided by the facility. Observation, on 03/16/12 at 4:00 PM, revealed Resident #2 was observed to be ambulating freely in his/her room without any difficulty and without the assist of a walker or cane. While Resident #2 was not observed having any aggressive behaviors at the time of the observations, the resident was observed independent with ambulation. An interview with the Social Services Director, on 03/23/12 at 11:35 AM, revealed "she was aware Resident #2 used the wheelchair extender bar to threaten Resident #7 but did not follow up to ensure this device was removed, or to ensure the safety of the other residents in the facility." She reported she had no training on how to de-escalate behaviors nor did she attempt to de-escalate Resident #2's behaviors and had not updated the care plan prior to the 02/25/12 incident as she had not identified the residents behaviors as aggressive. Interview with the Director of Nursing (DON), on 03/23/12 at 12:40 PM, revealed the facility had not identified a problem with resident behaviors which placed other residents at risk. The DON reported that the problem related to accurate behavioral assessments and a lack of supervision was not identified; therefore, the facility had not addressed it. There was a failure for assessing resident behaviors which would make it difficult to determine quality of care issues or needs of the residents. "We have no policy/procedure for behavioral management, escalating behaviors, or assessments of residents with behaviors." The facility could not provide evidence that they had thoroughly re-assessed Resident #2 related to his/her aggressive behaviors and implemented appropriate care plan interventions to provide staff appropriate direction to meet the individuals needs. The care plan the facility had implemented, as of 03/23/12, revealed the following goal and interventions: that the resident would not cause injury to self or others due to his/her behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. On 02/25/12, the facility had implemented a room change to reside privately with one to one supervision which was discontinued on 03/06/12; Remove metal clothes hangers, no forks or butter knives on meal trays; remove pants belt from environment which was discontinued on 03/06/12; Family to sit with resident during periods of agitation. On 03/06/12, the facility added the resident was to reside without a roommate and on 03/13/12 a mesh sign was placed on the doorway to keep wanderers out of the residents room. There was no evidence of an approach specific to address the resident's aggressive behaviors or appropriate direction provided to the staff in order to manage the resident as per their Abuse Prohibition Policy. The facility had not identified their failure in identifying escalating aggressive behaviors and the need to assess or reassess in order to revise the care plan to detail and implement medically related interventions. Additionally, the facility had not provided evidence that they had assessed to identify other residents of the facility who had potentially aggressive behaviors that needed care plan revisions to ensure behavior management. An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed there has been no staff inservice for management of residents with challenging behaviors. She stated that the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors. Further interview, on 03/23/12 at 1:25 PM, revealed they were unaware of the behavioral issues related to escalating resident behaviors; therefore, we did not address these concerns.

Based on interview, record review and Allegation of Compliance review, it was determined the Immediate Jeopardy (IJ), identified during the abbreviated survey completed on 03/23/12, had been removed related to revision of the care plan related to aggressive behaviors; however, non-compliance continued to exist at a S/S of a "D," as the facility had not completed the Quality and Assessment and Assurance Committee initiative related to monitoring, analysis of monitoring, and the implementation of the Plan of Correction (PoC) to ensure care plans were revised. Findings include: Review of the acceptable AoC, dated 03/24/12, and record review revealed Licensed Nurses were instructed by the DON to run Group Behavior reports from the Care Tracker system daily to ensure that any behavior noted was reported and if any follow up was needed that the follow up occurred. The Social Service Director was educated on the Care Tracker system including the available reports, how to run the 24 hour group report and how to follow up on behaviors noted on the report, and her responsibility to follow up on any reported behaviors. On 03/17/12, a CareTracker Group Behavior Report was run for the past sixty days to identify all residents with reported behaviors. On that day Corporate Consultants reviewed the medical records and care plans for any resident on that report to identify any resident considered to be at risk for aggressive behavior toward other residents, and any identified behaviors were referred to facility staff and any identified potential behaviors were referred to the facility staff for review and revision of care plans. On 03/17/12, the DON reviewed all resident that wander for appropriate interventions on care plan to ensure safety needs were identified. Revisions were made as indicated. On 03/17/12, the Minimum Data Set (MDS) Coordinator and Social Services Director reviewed the MDS and Care Plans for all residents listed on the Caretracker Behavior Report who had behaviors in the last 60 days. If the behavior identified met the criteria for a significant change, a significant change assessment was completed. Care plans and interventions were reviewed and revisions were made as indicated. All care plans and nurse aide care plans were updated if indicated. All reported behaviors were reviewed in the morning meetings. The care plan and interventions were reviewed to ensure the effectiveness of the interventions to determine if additional interventions were required. Interview with the Administrator, on 04/12/12 at 2:45 PM, revealed in the future the facility was having staff from a psychiatric service to come in and inservice the staff on behaviors and interventions to address behaviors. She stated the Quality Assessment Committee was going to meet once a month to discuss aggressive behaviors, abuse and resident to resident altercations and follow up. She revealed the Medical Director will be assisting the facility with outside resources to assist the facility in coming up with new intervention.

Based on interview, record review, and review of the facility's policy/procedure, it was determined the facility failed to ensure adequate supervision to prevent accidents was provided for one resident, #2 in the selected sample of seven. The facility failed to follow their Abuse policy/procedure; failing to assess and identify Resident #2 had aggressive and dangerous behaviors that required supervision to prevent the resident from harming others. This failure prevented the facility from taking action and implementing effective interventions and supervision in order to protect three residents (#1, #6 and #7) from harm. The facility assessed Resident #2, on 11/22/11, as having behavioral and verbal symptoms directed towards others; however, detailing no mechanism to monitor the resident's behaviors or need for supervision. The facility was knowledgeable of Resident #2's increased escalation of aggressive behaviors; however, failed to initiate adequate supervision of Resident #2 in order to protect residents of the facility from harm. On 02/02/12 at 9:45 AM, Resident #2 threatened to beat Resident #7 with the metal extender bar from his/her wheelchair. On 02/05/12 at 2:10 PM, staff witness Resident #2 threatening and chasing Resident #7 down the hallway screaming he/she was going to "get (him/her)." On 02/09/12 at 9:05 AM, Resident #2 became agitated and threatened roommate Resident #1 over closing the door to their room. On 02/25/12 at 10:55 AM, Resident #2's behaviors escalated to the point that he/she struck Resident #1 in the head multiple times with the metal extender bar handle from his/her wheelchair that was not removed after the first threatening incident on 02/02/12. The facility transferred Resident #1 to the emergency room for treatment, who required sutures to close the four lacerations to his/her head. After Resident #2 physically assaulted Resident #1, the facility transferred Resident #2 to a private room and provided supervision until the resident could be transferred to a physiatric hospital for inpatient treatment. On 03/06/12 at 10:25 AM, Resident #2 was admitted back to the facility. The facility failed to conduct a behavioral re-assessment or ensure adequate supervision of Resident #2, despite having determined the 02/25/12 incident was physical abuse. On 03/08/12 at 1:20 PM, Resident #2 became agitated and his/her behaviors escalated to the point that he/she physically assaulted Resident #6 by shutting the door on Resident #6's arm. Resident #2 stated he/she would punch Resident #6 in the face if he /she every came in the room again. Resident #6 had multiple skin tears to left upper arm that required intervention and treatment. The facility initiated discharge of Resident #2, on 3/21/12 at 1:40 PM, only to have to readmit this resident on the same evening at 7:00 PM, less than 6 hours later. The facility utilized family for supervision, from 7:00 PM until 11:00 PM; however, made no effort to ensure the family was appropriately trained to ensure the safety of the residents of the facility or to manage the resident's behavior. The facility failed to identify Resident #2's aggressive behaviors as having the potential to cause harm to residents of the facility. The facility's failure to identify the resident's behaviors as aggressive towards other residents prevented them from implementing adequate supervision of Resident #2 in order to provide protection to the residents of the facility and to prevent further harm by Resident #2. The facility continued to fail to provide effective continuous supervision of Resident #2 as he/she was observed unsupervised and ambulatory after his/her readmission on 03/06/12 and after the second physically abusive incident on 03/08/12. Furthermore, the facility failed to ensure all staff was adequately trained on behavior management techniques related combative or aggressive behaviors and could provide no evidence where they had assessed to identify other residents who exhibited aggressive behaviors and implemented necessary interventions to prevent harm to other residents. Furthermore the facility failed to ensure they had trained family, utilized to provide supervision of Resident #2 for four hours on 03/21/12, regarding behavior management techniques and the facility's Abuse Prohibition Policy. Administration, on 03/16/12 and 03/23/12, revealed the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors were unaware of the behavioral issues related to escalating resident behaviors; therefore, they had not addressed these concerns. This failure caused or likely caused serious injury, harm, impairment, or death to a resident. Based on observation, interview, record review, it was determined Immediate Jeopardy and Substandard Quality of Care was identified on 03/16/12 and determined to exist on 02/02/12 and is ongoing. (Refer to F226, F250, and F280) Findings include: Review of the facility's policy/procedure, "Abuse Prohibition," revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy defined verbal abuse 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." An example included "threats of harm." The policy defined physical abuse as "includes, but not limited to, humiliation, slapping, pinching and kicking." The policy detailed related to protection of the residents, that staff are to ensure the resident's immediate safety and well being following the initial suspected abuse report and during the following investigation process. The facility's policy detailed that each resident will be assessed and routinely reassessed by the appropriate health care professionals for aggressive behavior, wandering, self-injurious behavior, communication impairments, and heavy nursing care, and /or total dependence on staff. The training through the orientation program and ongoing in-services sessions will include; appropriate interventions to deal with aggressive and/or catastrophic reaction of residents, what constitutes abuse, how to recognize abuse, neglect, involuntary seclusion, misappropriation of funds, and how to report suspected incidents or events potentially of unknown origin. A copy of the residents' rights and resident abuse information will be issued to the employee and the location of the posted resident rights made known to each employee. Employees who have direct care responsibilities will receive specific instructions regarding abuse prohibition practices. All employees will be educated and instructed in behavior management techniques for residents who exhibit aggressive behavior, residents who wander, who have self injurious behavior and who have communication disorders. Under identification of Abuse or Suspected Abuse it detailed any incident of abuse or suspected abuse ...must be reported immediately to the available charge staff person. The policy detailed that occurrences, patterns, or trends that may constitute abuse; witnessed verbal or physically abusive incidents; or any act of mistreatment are events that should be reported and will be investigated. A record review revealed the facility admitted Resident #2 on 11/15/11 with [DIAGNOSES REDACTED]. Physician interview, on 03/23/12 at 2:15 PM, revealed due to this resident's TBI he/she "just (reacts) to what (he/she perceives) as a threat to (him/herself). The resident's actions are "not willful intent. " The facility admission Minimum Data Set (MDS) assessment, dated 11/22/11, determined the facility assessed Resident #2 as having no memory deficits and identified the resident had behaviors of threatening others, screaming at others, and cursing at others. The Resident Care Area Assessment (CAA) Summary, dated 11/22/11, revealed the CAA triggered aggressive behavioral data related to behavioral systems. The resident had experienced a recent fall at home where he/she sustained a Subdural Hematoma with confusion. A Craniotomy and functional declines were noted. The CAA and behavior report detailed the resident had behavioral symptoms and verbal symptoms directed toward others with significant disruption of care or living environment as impact, and noted to wander with significant risk of danger to self. A review of an admission care plan, dated 11/28/11, revealed the facility identified that Resident #2 had behaviors/agitation related to nursing home placement and Dementia. The goal developed by the facility detailed that Resident #2 would not cause injury to self or others due to behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. There were no specific interventions related to supervision of the resident or approaches that assessed how the resident's behaviors would be monitored. There were no specific interventions to address specific behaviors of threatening, screaming, cursing at others or behavioral and verbal symptoms directed towards others as was detailed in the facility's admission assessment and CAA. Review of social service Progress notes, dated 02/02/12 at 9:50 AM, revealed Resident #2 threatened to hit Resident #7 with the brake handle from his/her wheelchair. A review of the nurses' notes, dated 02/02/12 at 9:45 AM, revealed Resident #2 got up out of his/her wheelchair and removed the wheelchair extender bar handle and threatened to hit Resident #7 with the handle. Resident #7 is wheelchair bound. The facility removed Resident #7 from the room while Resident #2 was allowed to calm down. On 02/02/12 at 10:25 AM, the facility moved Resident #2 to Resident #1's room; however, there was no evidence the facility initiated an investigation to determine a root cause of the resident's behavior. There was no evidence the facility re-assessed Resident #2, revised the care plan, notified the physician, increased supervision, or removed the device from the resident's possession. Further review of the Social Services Progress Notes revealed the facility contacted Resident #2's Power-of-Attorney (POA) for approval to move the resident to another room, with no other interventions attempted. The facility transferred Resident #2 into Resident #1's room, who was a bilateral amputee and with no evidence the facility implemented supervision of Resident #2. A review of the nurses' notes, dated 02/05/12 at 2:10 PM, revealed the nurse was called into the room by a Certified Nurse Aide (CNA). It was reported Resident #2 was very upset, agitated and cursing. Resident #2 was anxious and wringing his/her hands. The CNA reported Resident #2 was in the hallway without his/her walker chasing Resident #7 down the hall saying, "I'll get you for making fun of me." Two CNAs attempted to prevent Resident #2 from harming Resident #7, and Resident #2 began hitting and slapping at the two (2) CNAs, who were trying to protect Resident #7. After redirection, Resident #2 ambulated back to his/her room with the CNA s. Record review revealed there was no evidence of facility action taken related to this incident. There was no documented evidence of a social service progress note, no re-assessment related to the resident's aggressive behaviors, no increased supervision, no care plan revision, no physician notification, and no family notification. Nor was there evidence the facility identified potential for abuse, initiated an investigation, or implemented measures to protect residents from Resident #2's aggressive behaviors. A review of the nurses' notes, dated 02/09/12 at 9:05 AM, revealed the Charge Nurse (CN) was in the room giving medications to Resident #2's roommate, when Resident #2 jumped out of his/her wheelchair and angrily yelled and cursed at the roommate. The CN attempted to redirect Resident #2, without success, and the roommate (Resident #1) was assisted up to a wheelchair and out of the room. The facility administered medication to Resident #2 for anxiety. Review of a Social Services Progress note, dated 02/09/12 at 9:25 AM, revealed she told Resident #2 that he/she should not yell out or threaten Resident #1 in any way; however, there was no evidence the facility conducted a resident re-assessment due to aggressive behaviors, initiated increased supervision, revised the care plan, or notified the physician regarding Resident #2's escalating behaviors. Furthermore, the facility did not identify a trend in Resident #2's escalating aggressive behaviors as creating a potential for harm to other residents. The facility could provide no evidence that they initiated an investigation or implemented measures to protect residents from Resident #2's aggressive behaviors. Additionally, this same date 02/09/12, the facility completed the Quarterly MDS Assessment, detailing Resident #2 had no mood symptoms or frequency present and detailed the resident had no behaviors exhibited or present. Review of Resident #2's care plan revealed the facility noted the resident had met the goal and extended the same goal through 05/2012, making no changes to address the resident's aggressive behaviors or to increase supervision to protect other residents. The nurses' notes, dated 02/25/12 at 10:55 AM, and an interview with the Dietary Aide, on 03/14/12 at 12:35 PM, revealed she was making her rounds, on 02/25/12 at 10:55 AM, when she heard someone yell for help. She observed Resident #2 walking away from Resident #1 carrying a metal object (part of Resident #2's wheelchair), and Resident #1 was covering his/her head trying to protect himself/herself. She did not observe Resident #1 bleeding the first time she walked by; however, she reported she ran and got the CNA, and by the time they got back to the resident's room, Resident #1 was bleeding from his/her head. The Charge Nurse was called to the residents' room, and Resident #2 was sitting outside the room in his/her wheelchair. Resident #2 was very agitated and combative. Staff attempted to calm Resident #2, and the CNA reported "Resident #2 just beat roommate Resident #1 in the head." The Charge Nurse reported that "Resident #1 was bleeding from the head injury and there were multiple staff trying to calm Resident #2, but were unsuccessful as Resident #2 was still trying to get back into the room to harm Resident #1." Resident #1 was struck multiple times in the head by Resident #2 with the metal extender bar handle of Resident #2's wheelchair. Further review of the nurses' notes revealed "Resident #1 had four large lacerations on the head and a purple bruise on his/her sternal notch. Resident #1 was on Coumadin Therapy and the staff had to apply pressure to the head wounds to control the bleeding." Staff had to shut the door to resident's room with Resident #2 in the hallway. Resident #2 was still agitated and trying to get back into the room and staff was unable to calm Resident #2 down enough to move he/she to another room until 11:30 AM. Registered Nurse (RN) #1, Charge Nurse, on 03/15/12 at 11:15 AM, revealed, on 02/25/12 at 10:55 AM, when she arrived on the scene, they had already gotten the bar from Resident #2's hand. She stated "My co-workers told me not to go near Resident #2 or he would hit me." Resident #2 had a history of [REDACTED]. Resident #2 did not get along with Resident #7 and social service was involved in that incident. An interview with Certified Nurse Aide (CNA) #1, on 03/15/12 at 11:45 AM, revealed, on 02/25/12 at 10:55 AM, "Resident #2 was thrashing about in the hallway and it was a very intense situation. The CNA was afraid for herself and the other residents. Stating, "I was concerned for the safety of the wandering residents in the facility, that Resident #2 was capable of hurting them, or me." An interview with RN #2, Charge Nurse, on 03/15/12 at 10:35 AM, revealed "...(Resident #1) was defenseless in preventing (Resident #2) from hurting (him/her)..." Per the Nurse's Notes and the care plan, the facility initiated, on 02/25/12, another room transfer moving Resident #2 to a private room, removed the extender bar and all metal objects or potential dangerous items from his/her possession; initiated one to one supervision and detailed family would sit with the resident during periods of agitation. At 11:50 AM, Resident #2 became more combative, hitting, kicking, and cursing at staff. Later in the evening, on 02/25/12 at 7:20 PM, the facility transferred Resident #2 to a psychiatric hospital for psychiatric services. On 03/15/12 at 2:15 PM, interview with the SSD revealed she had not assessed Resident #2 for the metal extender bar, did not remove the object or initiate one to one supervision after he/she threatened another resident with it as she stated she never thought about the resident later using this device as a weapon, and her "only responsibility was to ensure residents adjust to their new environment." Interview, on 03/23/12 at 11:35 AM, revealed she made no revision to Resident #2's care plan prior to 02/25/12 related to his/her aggressive behaviors. The Social Service Director stated, that she was aware of Resident #2's behavior and spoke to the resident about his/her behaviors, but did not identify these behaviors as aggressive behaviors until 02/25/12. Review of the facility's investigation revealed the facility concluded the incident of 02/25/12 was physical abuse. Further review of the nurses' notes revealed the facility readmitted Resident #2, on 03/06/12; however, there was no evidence the facility implemented measures of supervision to protect other residents from further harm even though their investigation determined the incident on 02/25/12 was physical abuse. Rather review of the care plan revealed the facility had discontinued one to one supervision and the removal of objects from the residents room. On 03/08/12 at 1:20 PM, a review of the nurse's notes revealed "Charge Nurse summoned to the room, (Resident #2) was shutting the door on (Resident #6's) arm, stating the next time (Resident #6) came into the room, he/she would punch (Resident #6) in the face." Resident #6's injuries included two skin tears to the left upper dorsal arm which required medical intervention. There was no documented evidence that the facility initiated supervision or re-assessment of Resident #2 related to the aggressive behaviors with no care plan revision at that time. However, on 03/13/12 five days after the incident, the facility revised the care plan detailing adding a mesh stop sign on the outside of Resident #2's room door to prevent wandering residents from entering his/her room. Observations, during the complaint investigation, revealed the facility had not initiated any increased supervision for Resident #2 to prevent potential harm until Immediate Jeopardy and Substandard Quality of Care was identified. An observation, on 03/14/12 at 9:30 AM, revealed Resident #2 sitting on the side of the bed verbalizing "When I came here I could not walk and now I can." There ws no facility staff observed supervising Resident #2 at this time. Additionally, it was observed that Resident #2's room was the second to the last room at the end of a long hall, and second to being the furthermost room from the nurses' station. Observation, on 03/14/12 at 4:39 PM, revealed Resident #2 was lying in bed with no facility staff observed supervising the resident. Observation, on 03/15/12 at 6:10 PM, revealed Resident #2 was found in his/her room verbalizing he/she could walk anywhere he/she wanted to go. Resident #2 was observed to have no one to one supervision provided by the facility. Observation, on 03/16/12 at 4:00 PM, revealed Resident #2 was observed to be ambulating freely in his/her room without any difficulty and without the assist of a walker or cane. A CNA was posted outside of Resident 2's room, this was the first observation of facility providing Resident #2 one to one supervision. Observation, on 03/16/12 at 7:06 PM, revealed Resident #2 had two CNAs sitting outside the Resident #2's room. On 03/21/12, record review revealed the facility initiated discharge and transfer to another nursing facility at 1:40 PM; however, less than six hours later. Interview with the family, on 03/23/12 at 8:35 AM, revealed the facility had to readmit this resident as the receiving facility could not meet the resident's needs once she had made them aware of the resident's aggressive behaviors. Administrator interview, on 03/23/12 at 1:25 PM, revealed that upon the facility's readmission of Resident #2, the facility advised the family that they had to supervise this resident, from 7:00 PM until 11:00 PM. Interview with the family, on 03/23/12 at 8:55 AM, revealed upon the resident's return she was told by the facility that she would have to stay with the resident until a private sitter arrived to supervise the resident at 11:00 PM. However, the facility was unable to provide documented evidence that they appropriately trained the family on the facility's procedures to ensure the safety of the residents of the facility or to manage Resident #2's behavior. Observation, on 03/23/12 at 8:30 AM, revealed Resident #2 was sitting in his/her room with one to one supervision being provided by a private sitter who is certified nursing assistant, employed by the facility to provide Resident #2 one to one supervision. Interview with this private sitter, at this time, revealed the facility just gave her a book to read about behaviors and an in-service. She stated she was instructed to meet the needs of the resident and was to provide one to one supervision should the resident leave his/her room. An interview with the Social Services Director, on 03/15/12 at 2:15 PM, revealed Resident #2 had two roommates (Residents #1 and #7) during his/her course of stay at the facility. Resident #2, on 02/02/12 at 9:45 AM, had a verbal disagreement over the room temperature with his/her roommate. Resident #2 got up out of the wheelchair and removed the handle of the wheelchair brake and threatened to hit Resident #7. There was no re-assessment or supervision initiated related to the aggressive incident and stated "I never thought about the resident later using this device as a weapon." On 02/02/12, there was no care plan revision, or MD notification. The only intervention was to change rooms, and Resident #2 was moved into Room 7, which was Resident #1's room. Resident #2 was not on any increased supervision nor assessed to determine the safety of the other residents in the facility. There was no determination as to the root cause of Resident #2's aggressive behaviors, there was no assessment or reassessment to establish a pattern of Resident #2' escalating behaviors. An interview with the Director of Nursing (DON,) on 03/16/12 at 3:04 PM, revealed she was unaware there were five incidents related to Resident #2's aggressive behaviors and that Resident #2's behaviors were escalating with each incident from 02/02/12 until 03/08/12. The DON reported she was aware of the first incident, dated 02/02/12 at 9:45 AM, involving Resident #2 and Resident #7, and after that incident on the same day, the facility moved Resident #2 into Room 7 with Resident #1. She stated she investigated the 02/02/12 incident; however, was unable to provide evidence of this investigation. She further stated, "I did not think (Resident #2) would use the wheelchair brake handle as a weapon, I should have considered this, and (he/she) had no history of behaviors before he was sent to us"; however, the facility assessed, on 11/22/11, that this resident had behavioral and verbal symptoms directed towards others and developed a care plan goal specifying that Resident #2 would not cause injury to self or others due to behaviors. For the first incident, on 02/02/12, when Resident #2 threatened Resident #7 with the metal wheelchair extender bar handle, there was no assessment , supervision, no MD notification, and no care plan revision. "The only thing we did was transfer (Resident #2) to (Resident #1's) room." The wheelchair extender bar handle was not removed from Resident #2's wheelchair. The second incident, on 02/05/12 at 2:10 PM, involved Resident #2 chasing Resident #7 down the hall and Resident #2 was exhibiting threatening behaviors. Resident #2 slapped two CNAs, but they were not injured. Resident #2 was fine the next day and did not recall the event. There was no formal investigation completed related to this event and I was concerned for the safety for (Resident #7) and told (him/her) to take another route in the facility when the resident went out to smoke. There was no assessment or supervision, no care plan revision, and no social service consult for this incident. On 02/09/12 at 9:05 AM, Resident #2 was yelling and cursing his/her roommate and the staff attempted to redirect the resident without success, and the resident was medicated. I was aware of this incident from morning report; however, there was no investigation since there was no physical altercation. There were no interventions put into place because there was no injury or harm. On 02/25/12 at 10:55 AM, Resident #2 hit Resident #1 in the head multiple times with the metal extender bar from Resident #2's wheelchair. Resident #2 hit Resident #1 in the head four times with this object and Resident #1 had four lacerations. This was the same metal object Resident #2 used to threatened Resident #7 on 02/02/12. This time we moved Resident #2 to a private room and took the metal extender bar handle away from the resident. We provided one on one supervision for the resident until (he/she) was transferred out of the facility. I spoke to (Resident #2) about the incident and (he/she) said " (he/she) was not having a good day because (he/she) had gotten into a fight and hit the old guy in the head." On 03/06/12, Resident #2 was readmitted to the facility. Upon the resident's return, there was no supervision or assessment to determine the need for supervision for this resident. On 03/08/12 at 1:20 PM, Resident #6 was injured by Resident #2, who shut the door on Resident #6's arm. On 03/08/12, there was no intervention put in place to ensure the safety of the other residents in the building. " I should have put someone outside (Resident #2's) door to provide one to one supervision and to protect the other residents in the facility." We had placed (Resident #2) back there at he end of the hall in because it was an isolated area, where there was not much traffic. The facility could not provide evidence that they had thoroughly re-assessed Resident #2 related to his/her aggressive behaviors and implemented appropriate care plan interventions to provide staff appropriate direction to meet the individuals needs, or initiated adequate supervision to prevent accidents and potential harm. The care plan the facility implemented, as of 03/23/12, revealed the following goal and interventions: that the resident would not cause injury to self or others due to his/her behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. On 02/25/12, the facility had implemented a room change to reside privately with one to one supervision which was discontinued on 03/06/12; Remove metal clothes hangers, no forks or butter knives on meal trays; remove pants belt from environment which was discontinued on 03/06/12; Family to sit with resident during periods of agitation. On 03/06/12, the facility added the resident was to reside without a roommate and on 03/13/12 a mesh sign was placed on the doorway to keep wanderers out of the residents room. There was no evidence of an approach specific to address the resident's aggressive behaviors, or appropriate direction provided to the staff in order to manage the resident, or supervision detailed to ensure the safety of the residents, as per their Abuse Prohibition Policy. The facility had not identified their failure in identifying escalating aggressive behaviors which required re-assess, to implement medically related interventions and adequate supervision. Additionally, the facility had not provided evidence that they had assessed to identify other residents of the facility who had potentially aggressive behaviors that were not being managed and necessary supervision implemented. Furthermore the facility had not provided training to the Social Services Director as of 03/23/12 related to overseeing the behavior management program, behavior management techniques and how to de-escalate residents with behaviors. Administrator interview, on 03/16/12 at 7:45 PM, revealed there had been no staff in-service for management of residents with challenging behaviors. She stated that the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors. Interview with the Administrator, on 03/23/12 at 1:25 PM, revealed she was unaware there was an issue with the wheelchair extender brake handle from the first incident because there was no physical altercation between the two residents." She stated, "There was no paper trail if there was no physical altercation, only when there was a physical altercation, would there be a paper trail." Our failure to thoroughly investigate the first incident, on 02/02/12, where there was no physical altercation that occurred between residents was the reason why we missed removing the wheelchair brake handle," which was later used to hit Resident #1 on 02/25/12. She further revealed the facility was unaware of the behavioral issues related to escalating resident behaviors which started on 02/02/12 through 03/08/12; therefore, we did not address these concerns.

Based on interview, record review, and review of the facility's policy and procedure, it was determined 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 four residents (#1, #2, #6, and #7), in the selected sample of seven residents. The facility assessed Resident #2, on 11/22/11, as having behavioral and verbal symptoms directed towards others; however, detailing no mechanism to monitor the resident's behaviors or need for supervision. The facility was knowledgeable of Resident #2's increased escalation of aggressive behaviors; however, failed to initiate adequate supervision of Resident #2 in order to protect residents of the facility from Resident #2's aggressive behaviors. On 02/02/12 at 9:45 AM, Resident #2 threatened to beat Resident #7 with the metal extender bar from his/her wheelchair. On 02/05/12 at 2:10 PM, staff witness Resident #2 threatening and chasing Resident #7 down the hallway screaming he/she was going to "get (him/her)." On 02/09/12 at 9:05 AM, Resident #2 became agitated and threatened roommate Resident #1 over closing the door to their room. On 02/25/12 at 10:55 AM, Resident #2's behaviors escalated to the point that he/she struck Resident #1 in the head multiple times with the metal extender bar handle from his/her wheelchair that was not removed after the first threatening incident on 02/02/12. The facility transferred Resident #1 to the emergency room for treatment, who required sutures to close the four lacerations to his/her head. After Resident #2 physically assaulted Resident #1, the facility transferred Resident #2 to a private room and provided supervision until the resident could be transferred to a physiatric hospital for inpatient treatment. On 03/06/12 at 10:25 AM, Resident #2 was admitted back to the facility. The facility failed to conduct a behavioral re-assessment or ensure adequate supervision of Resident #2, despite having determined through their incident investigation that Resident #2 physically abused another resident on 02/25/12. On 03/08/12 at 1:20 PM, Resident #2 became agitated and his/her behaviors escalated to the point that he/she physically assaulted Resident #6 by shutting the door on Resident #6's arm. Resident #2 stated he/she would punch Resident #6 in the face if he /she every came in the room again. Resident #6 had multiple skin tears to left upper arm that required intervention and treatment. The facility initiated discharge of Resident #2, on 3/21/12 at 1:40 PM, only to have to readmit this resident on the same evening at 7:00 PM as the receiving facility could not meet the needs of the resident once they became aware of the aggressive behaviors. The facility utilized family for supervision, from 7:00 PM until 11:00 PM; however, made no effort to ensure the family was appropriately trained to ensure the safety of the residents of the facility or to manage the resident's behavior. The facility failed to identify Resident #2's aggressive behaviors as having the potential to cause harm to residents of the facility. The facility's failure to identify the resident's behaviors as aggressive towards other residents prevented them from implementing adequate supervision of Resident #2 in order to provide protection to the residents of the facility and to prevent further harm by Resident #2. The facility continued to fail to provide effective continuous supervision of Resident #2 as he/she was observed unsupervised and ambulatory after his/her readmission on 03/06/12 and after the second physically abusive incident on 03/08/12. Furthermore, the facility failed to ensure all staff was adequately trained on behavior management techniques related combative or aggressive behaviors and could provide no evidence where they had assessed to identify other residents who exhibited aggressive behaviors and implemented necessary interventions to prevent harm to other residents. Furthermore the facility failed to ensure they had trained family, utilized to provide supervision of Resident #2 for four hours on 03/21/12, regarding behavior management techniques and the facility's Abuse Prohibition Policy. Administration on 03/16/12 and 03/23/12 revealed the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors were unaware of the behavioral issues related to escalating resident behaviors; therefore, they had not addressed these concerns. This failure caused or likely caused serious injury, harm, impairment, or death to a resident. Based on observation, interview, record review, it was determined Immediate Jeopardy and Substandard Quality of Care was identified on 03/16/12 and determined to exist on 02/02/12 and is ongoing. (Refer to F226, F250, F280, F323) Findings include: Review of the facility's policy/procedure, "Abuse Prohibition," revealed the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy defined verbal abuse 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." An example included "threats of harm." The policy defined physical abuse as "includes, but not limited to, humiliation, slapping, pinching and kicking." The policy detailed related to protection of the residents, that staff are to ensure the resident's immediate safety and well being following the initial suspected abuse report and during the following investigation process. The facility's policy detailed that each resident will be assessed and routinely reassessed by the appropriate health care professionals for aggressive behavior, wandering, self-injurious behavior, communication impairments, and heavy nursing care, and/or total dependence on staff. The training through the orientation program and ongoing in-services sessions will include; appropriate interventions to deal with aggressive and/or catastrophic reaction of residents, what constitutes abuse, how to recognize abuse, neglect, involuntary seclusion, misappropriation of funds, and how to report suspected incidents or events potentially of unknown origin. A copy of the residents' rights and resident abuse information will be issued to the employee and the location of the posted resident rights made known to each employee. Employees who have direct care responsibilities will receive specific instructions regarding abuse prohibition practices. All employees will be educated and instructed in behavior management techniques for residents who exhibit aggressive behavior, residents who wander, who have self injurious behavior and who have communication disorders. Under identification of Abuse or Suspected Abuse it detailed any incident of abuse or suspected abuse ...must be reported immediately to the available charge staff person. The policy detailed that occurrences, patterns, or trends that may constitute abuse; witnessed verbal or physically abusive incidents; or any act of mistreatment are events that should be reported and will be investigated. An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed Social Service was the designated person who managed the facility's behavioral program. However, interview with the Director of Nursing (DON), on 03/23/12 at 12:40 PM, revealed, "(the facility had) no policy/procedure for behavioral management, escalating behaviors, or assessments of residents with behaviors." The facility admitted Resident #2 on 11/15/11, per record review with [DIAGNOSES REDACTED]. The facility assessed via the admission Minimum Data Set (MDS), dated [DATE], that Resident #2 to have behaviors of threatening, screaming, and cursing at others. The Resident Care Area Assessment (CAA) Summary, dated 11/22/11, revealed had behavioral and verbal symptoms directed toward others with significant disruption of care and noted to wander with significant risk of being a danger to self. The facility developed the admission care plan, dated 11/28/11, detailing goal that Resident #2 would not cause injury to self or others due to behaviors. An interview with the Director of Nursing (DON,) on 03/16/12 at 3:04 PM, revealed the following: On 02/02/12 at 9:45 AM, Resident #2 threatened and Resident #7 with a metal extender bar from his/her wheelchair. While the DON stated the facility investigated the 02/02/12 incident, there was no documented evidence of the investigation provided. She validated that the facility had not reassessed Resident #2 or initiated supervision, no physician notification, and no care plan revision. "The only thing we did was transfer Resident #2 to Resident #1' s room." The wheelchair extender bar handle was not removed from Resident #2's wheelchair. The second incident, on 02/05/12 at 2:10 PM, involved Resident #2 chasing Resident #7 down the hall and Resident #2 exhibited threatening behaviors. Resident #2 slapped two CNAs, but they were not injured. The DON stated there was no formal investigation completed related to this event. She stated the facility did not complete a re-assessment, initiate supervision, and did not revise the care plan. On 02/09/12 at 9:05 AM, Resident #2 was yelling and cursing his/her roommate and the staff attempted to redirect the resident without success and the resident was then medicated. She stated she was aware of this incident from morning report; however, the facility did not investigate since there was no physical altercation and no assessment or interventions were implement because there was no injury or harm. On 02/25/12 at 10:55 AM, Resident #2 hit Resident #1 in the head multiple times with the metal extender bar from Resident #2's wheelchair. Resident #1 had four lacerations. This was the same metal object Resident #2 used to threaten Resident #7 on 02/02/12. This time Resident #2 was moved to a private room and they took the metal extender bar handle away from the resident. We provided one on one supervision for the resident until he/she was transferred out of the facility. I spoke to Resident #2 about the incident and he/she said, "he/she was not having a good day because he/she had gotten into a fight and hit the old guy in the head." On 03/06/12, Resident #2 was readmitted to the facility; upon the resident's return, there was no supervision or assessment to determine the need for supervision for this resident. On 03/08/12 at 1:20 PM, Resident #6 was injured by Resident #1, who shut the door on the Resident #6's arm. On 03/08/12, there was no intervention put in place to ensure the safety of the other residents in the building. " I should have put someone outside Resident #2's door to provide one to one supervision and to protect the other residents in the facility." We had placed Resident #2 at the end of the hall because it was an isolated area where there was not much traffic. She stated she was unaware there were five incidents related to Resident #2's aggressive behaviors and that Resident #2's behaviors escalated with each incident starting from 02/02/12 through 03/08/12. She further stated, "I did not think Resident #2 would use the wheelchair brake handle as a weapon, I should have considered this. Despite the facility's Abuse Prohibition Policy which stated all employees would be educated and instructed in behavior management techniques for residents who exhibit aggressive behavior; in-services would be held to ensure employees understand Corporate and facility's policies and procedures, and possessing a good working knowledge of preventive measures to protect each resident; interviews with facility staff revealed that not all staff had been trained on behavior management techniques for residents exhibiting aggressive behaviors and were not trained to implement preventive measures to protect each resident. Interviews with Registered Nurse (RN) #1, Charge Nurse, on 03/15/12 at 11:15 AM; RN #2, Charge Nurse, on 03/15/12 at 10:35 A; Dietary Aide, on 03/14/12 at 12:35 PM; Housekeeping Staff #1, on 03/15/12 at 9:45 AM, and Housekeeping/Laundry Service Staff #2, on 03/15/12 at 10:00 AM, revealed our abuse/neglect policy stated to ensure the safety of the resident first, but ancillary staff, like dietary, were trained to report first and not try to intervene. However, Interview with the Director of Nursing (DON), on 03/15/12 at 6:20 PM, revealed "I would expect all my staff to go into the resident's room and ensure the safety of the resident first. In all our In-services, I instruct all staff to ensure the safety of the resident first, not to report first. An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed she expected all of the facility staff to ensure the safety of the residents first before reporting, regardless of what level of staff they were, and this was what their facility policy mandated. Furthermore, interview with the Social Services Director, the staff person responsible for the behavior management program revealed, on 03/23/12 at 11:35 AM, revealed she had no training on how to de-escalate behaviors nor did she attempt to de-escalate Resident #2's behaviors. An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed Social Service was the designated person who managed the facility's behavioral program; however she was unable to detail who was responsible to look at the Care Tracker System which was the facility's system for documenting behaviors. She revealed the facility had not been provided training for management of residents with challenging behaviors. On 03/23/12 at 1:25 PM, she revealed she was unaware there was an issue with the wheelchair extender brake handle from the first incident because there was no physical altercation between the two residents." The Administrator further added, "There was no paper trail if there was no physical altercation, only when there was a physical altercation, would there be a paper trail." Our failure to thoroughly investigate the first incident, on 02/02/12, where there was no physical altercation that occurred between residents was the reason why we missed removing the wheelchair brake handle," which was later used to hit Resident #1 on 02/25/12. The facility could not provide evidence that they had thoroughly re-assessed Resident #2 related to his/her aggressive behaviors and implemented appropriate care plan interventions to provide staff appropriate direction to meet the individuals needs, or initiated adequate supervision to prevent accidents and potential harm to other residents. The care plan the facility had implemented, as of 03/23/12, revealed the following goal and interventions: that the resident would not cause injury to self or others due to his/her behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. On 02/25/12, the facility had implemented a room change to reside privately with one to one supervision which was discontinued on 03/06/12; Remove metal clothes hangers, no forks or butter knives on meal trays; remove pants belt from environment which was discontinued on 03/06/12; Family to sit with resident during periods of agitation. On 03/06/12, the facility added the resident was to reside without a roommate and, on 03/13/12, a mesh sign was placed on the doorway to keep wanderers out of the residents room. There was no evidence of an approach specific to address the resident's aggressive behaviors, or appropriate direction provided to the staff in order to manage the resident, or supervision detailed to ensure the safety of the residents, as per their Abuse Prohobition Policy. The facility had not identified their failure in identifying escalating aggressive behaviors which required re-assessment, to implement medically related interventions and adequate supervision. Additionally, the facility had not provided evidence that they had assessed to identify other residents of the facility who had potentially aggressive behaviors that were not being managed and necessary supervision implemented. Furthermore the facility had not provided training to the Social Services Director, as of 03/23/12, related to overseeing the behavior management program, behavior management techniques and how to de-escalate residents with behaviors. Administrator interview, on 03/16/12 at 7:45 PM, revealed there had been no staff in-service for management of residents with challenging behaviors. She stated that the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors. Interview with the Administrator, on 03/23/12 at 1:25 PM, revealed the facility was unaware of the behavioral issues related to escalating resident behaviors; therefore, we did not address these concerns.

Based on interview, record review and Allegation of Compliance review, it was determined the Immediate Jeopardy (IJ), identified during the abbreviated survey completed on 03/23/12, had been removed related to administering the facility in a manner that it enabled it to use its resources effectively; however, non-compliance continued to exist at a S/S of a "D," as the facility had not completed the Quality and Assessment and Assurance Committee initiative related to monitoring, analysis of monitoring, and the implementation of the Plan of Correction (PoC) to ensure the facility was administered in a manner that it enabled it to use its resources effectively. Findings include: Review of the acceptable AoC, dated 03/24/12, and record review revealed a private sitter was placed outside Resident #2's door twenty four hours a day and if the resident came out of the room, the private sitter supervised the resident at all times until the resident's discharge on 03/23/12. The private sitter also redirected wandering residents from the resident's room. The private sitter was educated by the Administrator, Director of Nurse (DON) or Charge Nurse on the Abuse policy and Effective Coping with Challenging Behaviors. A Licensed nurse verified every two hours and signed a document that included time of visual check, staff member/private sitter present and nurse's signature that the private sitter assigned outside of the room or with Resident #2. All available licensed nurses were in-serviced by the DON or Administrator on 03/16/12 or 03/17/12 on the verification process. Unavailable staff was in-service prior to returning to work. All available staff was inserviced on 03/16/12 or 03/17/12 on Facility Abuse Policy and Effective Coping with Challenging Behaviors by the DON or Administrator. Licensed Nurses were instructed by the DON to run Group Behavior reports from the Care Tracker system daily to ensure that any behavior noted was reported and if any follow up was needed that the follow up occurred. On 03/17/12, the Social Service Director was educated on the Care Tracker system including the available reports, how to run the 24 hour group report and how to follow up on behaviors noted on the report, and her responsibility to follow up on any reported behaviors. On 03/17/12, a CareTracker Group Behavior Report was run for the past sixty days to identify all residents with reported behaviors. On that day Corporate Consultants reviewed the medical records and care plans for any resident on that report to identify any resident considered to be at risk for aggressive behavior toward other residents, and any identified behaviors were referred to facility staff and any identified potential behaviors were referred to the facility staff for review and revision of care plans. On 03/17/12, the DON reviewed all resident that wander for appropriate interventions on care plan to ensure safety needs were identified. Revisions were made as indicated. On 03/17/12, the Minimum Data Set (MDS) Coordinator and Social Services Director reviewed the MDS and Care Plans for all residents listed on the Caretracker Behavior Report who had behaviors in the last 60 days. If the behavior identified met the criteria for a significant change, a significant change assessment was completed. Care plans and interventions were reviewed and revisions were made as indicated. All care plans and nurse aide care plans were updated if indicated. All reported behaviors were reviewed in the morning meetings. The care plan and interventions were reviewed to ensure the effectiveness of the interventions to determine if additional interventions were required. Corporate Nursing Consultant educated the DON and Administrator on 03/17/12 on assessing and identifying possible risks, implementing interventions to manage behaviors and re-evaluation of interventions for protection of the residents. They were also educated on the proper completion of Incident Report and follow up investigation as indicated. Interview with the Administrator, on 04/12/12 at 2:45 PM, revealed in the future the facility was having staff from a psychiatric service to come in and inservice the staff on behaviors and interventions to address behaviors. She stated the Quality Assessment Committee was going to meet once a month to discuss aggressive behaviors, abuse and resident to resident altercations and follow up. She revealed the Medical Director will be assisting the facility with outside resources to assist the facility in coming up with new intervention.

Based on interview, record review, and review of the facility's policy and procedure, it was determined the facility's Quality Assurance Program failed to identify quality of care issues for one Resident #2 in a sample of seven residents. The facility Quality Assurance system failed to identify Resident #2's escalating aggressive behaviors towards other residents as a trend requiring re-assessment and action to protect residents of the facility from harm. The facility failed to investigate, re-assess, and implement interventions and supervision in an effort to protect the residents of the facility. The facility had assessed, care planned and was knowledgeable of Resident #2's behaviors and care planned detailing that the resident would not harm him/herself or others due to behaviors; however, the facility failed to identify multiple incidents of threats, aggressive behaviors such as chasing, slapping, and hitting other residents as aggressive behaviors and did not identify the need to provide adequate supervision to protect the residents of the facility and to identify care needs of Resident #2 to manage his/her behavior. The incidents began on 02/02/12 where Resident #2 threatened Resident #7 with a metal extender wheelchair bar. On 02/05/12, Resident #2 chased Resident #7 down the hall making threats "to get" the resident. On 02/09/12, Resident #2 was verbally aggressive toward his/her roommate. On 02/25/12, Resident #2 used a wheelchair metal extender bar to beat Resident #1 in the head causing Resident #1 to require medical intervention and sutures to four lacerations. The facility readmitted Resident #2 on 03/06/12; however, continued to fail to identify quality concerns and did not implement supervision to protect residents of the facility. On 03/08/12, Resident #2 shut the door on Resident #6's arm, saying the next time Resident #6 came into the room, he/she would punch Resident #6 in the face. The failure to identify this quality issue prevented the facility from addressing Resident #2's behavioral issues and providing adequate supervision to prevent accidents and harm to other residents. The facility failed to identify Resident #2's aggressive behaviors as having the potential to cause harm to residents of the facility. The facility's failure to identify the resident's behaviors as aggressive towards other residents prevented them from implementing adequate supervision of Resident #2 in order to provide protection to the residents of the facility and to prevent further harm by Resident #2. The facility continued to fail to provide effective continuous supervision of Resident #2 as he/she was observed unsupervised and ambulatory after his/her readmission on 03/06/12 and after the second physically abusive incident on 03/08/12. Furthermore, the facility failed to ensure all staff was adequately trained on behavior management techniques related combative or aggressive behaviors and could provide no evidence where they had assessed to identify other residents who exhibited aggressive behaviors and implemented necessary interventions to prevent harm to other residents. Furthermore the facility failed to ensure they had trained family, utilized to provide supervision of Resident #2 for four hours on 03/21/12, regarding behavior management techniques and the facility's Abuse Prohibition Policy. Administration, on 03/16/12 and 03/23/12, revealed the facility had not identified any problems with residents' behaviors or supervision of residents with behaviors were unaware of the behavioral issues related to escalating resident behaviors; therefore, they had not addressed these concerns. This failure caused or likely caused serious injury, harm, impairment, or death to a resident. Immediate Jeopardy and Substandard Quality of Care was identified on 03/16/12 and determined to exist on 02/02/12 and is ongoing. (Refer to F226, F250, F280, F323, F490) Findings include: A review of the facility's policy, "Quality Assessment and Assurance," effective date 05/01/08, revealed the Quality Assessment Committee will identify issues with respect to which quality assessment and assurance activities are necessary and develop and implement appropriate plans of action to correct any identified issues. Its purpose is evaluation of facility systems with objectives of; keeping systems functioning satisfactorily and consistently, preventing deviation from care processes from arising, to the extent possible, discerning issues and concerns with facility systems and determining if issues are identified and correcting inappropriate care processes. A review of the "Abuse Prohibition" policy, dated 01/05/01, Quality Assurance (Reporting/Response) the facility's governing body will analyze any occurrences to determine needed changes, if any, to existing policies and procedures. Include any reports of suspected abuse in the continuous quality improvement process for committee review. Review existing policies and procedures or work situations that may need revision to prevent further occurrences. Implement appropriate revisions of policies or institution of new policies or procedures as determined warranted. Provide education as warranted and indicated after review. Resident #2, who the facility had assessed and care planned for behaviors that could harm him/herself or others since admission. The facility was knowledgeable of the increase in aggressive behaviors towards other residents since 02/02/12 which continued without evidence that the facility identified the behaviors as aggressive with the potential for harm, thus the facility did not investigate, re-assess or implement necessary interventions and adequate supervision to prevent escalation in behaviors and harm of the residents of the facility. Resident #2 continued to escalate his/her behaviors on 02/05/12, 02/09/12, 02/25/12, and 03/08/12. On 02/25/12 the escalation resulted in physical abuse per the determination of the facility's investigation which caused physical harm to Resident #1 being beaten by Resident #2 with the metal extender bar. On 03/08/12, after the facility readmitted Resident #2, they discontinued supervision and failed to protect the residents of the facility. Resident #2 shut the door on Resident #6's arm and threatening to hit the resident in the future. An interview with the Director of Nursing (DON), on 03/23/12 at 12:40 PM, revealed the facility had not identified a problem with resident behaviors which placed other residents at risk. The DON reported that the problem related to accurate behavioral assessments and a lack of supervision was not identified; therefore, it was not addressed by the facility's Quality Assurance Program. There was a failure for assessing resident behaviors which would have made it difficult to determine quality of care issues or needs of the residents. "We have no policy/procedure for behavioral management, escalating behaviors, or assessments of residents with behaviors." An interview with the Administrator, on 03/16/12 at 7:45 PM, revealed "We had not identified, through our Quality Assurance Program, any problems with residents' behaviors or supervision of residents with behaviors. We discussed in our Quality Assurance, actual abuse complaints and if it was reportable or not." Further interview, on 03/23/12 at 1:25 PM, revealed "We were unaware of our lack of investigation issues or behavioral issues related to escalating resident behaviors; therefore, we did not address these concerns in our Quality Assurance Program." The facility could not provide evidence that they had thoroughly re-assessed Resident #2 related to his/her aggressive behaviors and implemented appropriate care plan interventions to provide staff appropriate direction to meet the individuals needs, or initiated adequate supervision to prevent accidents and potential harm. The care plan the facility implemented, as of 03/23/12, revealed the following goal and interventions: that the resident would not cause injury to self or others due to his/her behaviors. The approach for all disciplines detailed staff was to approach the resident in a slow, calm manner; explain the procedure to the resident prior to administering care; explain to the resident inappropriateness of behaviors and encourage to sustain from behaviors; and praise behaviors. On 02/25/12, the facility had implemented a room change to reside privately with one to one supervision which was discontinued on 03/06/12; Remove metal clothes hangers, no forks or butter knives on meal trays; remove pants belt from environment which was discontinued on 03/06/12; Family to sit with resident during periods of agitation. On 03/06/12, the facility added the resident was to reside without a roommate and on 03/13/12 a mesh sign was placed on the doorway to keep wanderers out of the residents room. There was no evidence of an approach specific to address the resident's aggressive behaviors, or appropriate direction provided to the staff in order to manage the resident, or supervision detailed to ensure the safety of the residents, as per their Abuse Prohobition Policy. The facility had not identified their failure in identifying escalating aggressive behaviors which required re-assessment, to implement medically related interventions and adequate supervision. Additionally, the facility had not provided evidence that they had assessed to identify other residents of the facility who had potentially aggressive behaviors that were not being managed and necessary supervision implemented. Furthermore the facility had not provided training to the Social Services Director as of 03/23/12 related to overseeing the behavior management program, behavior management techniques and how to de-escalate residents with behaviors.

Based on interview, record review and Allegation of Compliance review, it was determined the Immediate Jeopardy (IJ), identified during the abbreviated survey completed on 03/23/12, had been removed related to not having an effective quality assessment and assurance committee; however, non-compliance continued to exist at a S/S of a "D," as the facility had not completed the Quality Assessment and Assurance Committee initiative related to monitoring, analysis of monitoring, and the implementation of the Plan of Correction (PoC) to ensure the facility's Quality Assessment and Assurance Committee was effective. Findings include: Review of the acceptable AoC, dated 03/24/12, and record review revealed a private sitter was placed outside Resident #'s door twenty four hours a day and if the resident came out of the room, the private sitter supervised the resident at all times up till the resident's discharge on 03/23/12. The private sitter also redirected wandering residents from the resident's room. The private sitter was educated by the Administrator, Director of Nurse (DON) or Charge Nurse on the Abuse policy and Effective Coping with Challenging Behaviors. A Licensed nurse verified every two hours and signed a document that included time of visual check, staff member/private sitter present and nurse's signature that the private sitter assigned outside of the room or with Resident #2. All available licensed nurses were in-serviced by the DON or Administrator on 03/16/12 or 03/17/12 on the verification process. Unavailable staff was in-service prior to returning to work. All available staff was inserviced on 03/16/12 or 03/17/12 on Facility Abuse Policy and Effective Coping with Challenging Behaviors by the DON or Administrator. Licensed Nurses were instructed by the DON to run Group Behavior reports from the Care Tracker system daily to ensure that any behavior noted was reported and if any follow up was needed that the follow up occurred. The Social Service Director was educated on the Care Tracker system including the available reports, how to run the 24 hour group report and how to follow up on behaviors noted on the report, and her responsibility to follow up on any reported behaviors. On 03/17/12, a CareTracker Group Behavior Report was run for the past sixty days to identify all residents with reported behaviors. On that day Corporate Consultants reviewed the medical records and care plans for any resident on that report to identify any resident considered to be at risk for aggressive behavior toward other residents, and any identified behaviors were referred to facility staff and any identified potential behaviors were referred to the facility staff for review and revision of care plans. On 03/17/12, the DON reviewed all resident that wander for appropriate interventions on care plan to ensure safety needs were identified. Revisions were made as indicated. On 03/17/12, the Minimum Data Set (MDS) Coordinator and Social Services Director reviewed the MDS and Care Plans for all residents listed on the Caretracker Behavior Report who had behaviors in the last 60 days. If the behavior identified met the criteria for a significant change, a significant change assessment was completed. Care plans and interventions were reviewed and revisions were made as indicated. All care plans and nurse aide care plans were updated if indicated. All reported behaviors were reviewed in the morning meetings. The care plan and interventions were reviewed to ensure the effectiveness of the interventions to determine if additional interventions were required. Corporate Nursing Consultant educated the DON and Administrator on 03/17/12 on assessing and identifying possible risks, implementing interventions to manage behaviors and re-evaluation of interventions for protection of the residents. They were also educated on the proper completion of Incident Report and follow up investigation as indicated. Interview with the Administrator, on 04/12/12 at 2:45 PM, revealed in the future the facility was having staff from a psychiatric service to come in and inservice the staff on behaviors and interventions to address behaviors. She stated the Quality Assessment Committee was going to meet once a month to discuss aggressive behaviors, abuse and resident to resident altercations and follow up. She revealed the Medical Director will be assisting the facility with outside resources to assist the facility in coming up with new intervention.