Every finding on record at St Augustine Health and Rehabilitation Center

Based on kitchen and nourishment room observations, staff interviews and a review of the facility's policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the potential outbreak of foodborne illnesses for residents receiving food services from the facility, by failing to ensure food items were properly labeled and dated, and cleanliness of essential kitchen equipment was maintained in sanitary condition. Unsanitary food handling and storage practices have the potential to affect all residents receiving food services from the facility. The findings include:A tour of the kitchen was conducted on 5/18/2026 at 10:05 AM. During the tour, one open bag of thickener powder was observed in the dry storage room, two open boxes of frozen beef patties were observed in the freezer, and one box of pasteurized eggs was observed in the refrigerator with no labels or date markings. One expired carton of fat-free chocolate milk (dated 5/8/26), two expired cartons of whole milk (dated 5/9/26 and 5/12/26), and nine half empty cartons of whole milk were observed sitting in separate crates inside the refrigerator. (Photographic evidence obtained)A follow-up visit to the kitchen on 5/19/2026 at 9:30 AM revealed four whole milk cartons sitting in a tin pan spilled/half full and two expired whole milk cartons (dated 5/13/26) sitting in a separate crate inside the refrigerator. At 11:30 AM, during the second kitchen tour, food residue and debris were observed stuck on and above the safety guard of the mixer, and the microwave hood was filled with dried food splatter and residue. (Photographic evidence obtained) On 5/20/2026 at 10:13 AM, another observation was made of two expired whole milk cartons (dated 5/12/26 and 5/13/26) sitting in a separate crate inside the refrigerator. The same observations of food residue and debris observed on 5/19/2026 at 11:30 AM, were observed stuck on and above the safety guard of the mixer. On 5/20/2026 at 10:24 AM, Dietary Aide (DA) Q stated dietary aides were responsible for receiving and stocking food deliveries. When food items were opened, used, and placed back in the refrigerator, they should be labeled with a start and end date and discarded after three days. Milk found half empty was to be thrown out. Expired milk was saved in the cooler for the delivery truck. All staff in rotation were responsible for cleaning kitchen equipment every shift. Kitchen staff stocked the nourishment room but DA Q was not sure who was responsible for cleaning the nourishment rooms, including the refrigerators and documenting on temperature logs.On 5/20/2026 at 10:31 AM DA I stated morning shift DAs were responsible for receiving and stocking food deliveries. Open and used food items were to be sealed, labeled with an open date and discarded after three days if not used. Expired milk and milk found half empty was to be discarded. When asked who is responsible for cleaning kitchen and food service equipment, DA I stated large items were identified on the cleaning schedule and other items such as microwaves and oven trays were the responsibility of the last staff that used the equipment. Small kitchen items were cleaned daily and larger items were cleaned weekly. Certified Nursing Assistants (CNAs) kept the nourishment rooms clean and completed the temperature logs in those rooms. CNAs and maintenance cleaned the nourishment room refrigerators. Kitchen staff stocked the nourishment rooms. On 5/20/2026 at 10:40 AM, [NAME] H stated the AM kitchen staff were responsible for receiving and stocking food deliveries. Open and used food items were labeled, dated and discarded after three days. Expired milk was discarded. Milk found half empty was pulled and placed in a separate bin and was labeled to return to delivery. When asked who was responsible for cleaning kitchen and food service equipment, [NAME] H stated the equipment was cleaned after each use and deep cleaned weekly. Nursing and housekeeping staff kept the nourishment rooms clean. Housekeeping staff cleaned the nourishment room refrigerators. Kitchen staff stocked the nourishment room refrigerators, checked dates, and removed expired items. [NAME] H was not sure who was responsible for documenting temperatures on the nourishment room logs.On 5/20/2026 at 10:49 AM, Certified Dietary Director (CDM) G stated the morning DA was responsible for receiving and stocking food deliveries. The facility's policy for date marking food items was to cover, add a date, and discard after three days. Expired milk was discarded. Milk that was found half empty was separated, labeled and stored for pick up to receive credit from the company. When asked who was responsible for cleaning kitchen and food service equipment, CDM G replied, Staff follow a weekly cleaning schedule. Kitchen equipment is cleaned after each use. Housekeeping keeps the nourishment rooms clean. Dietary staff stock nourishment rooms three times daily and check for expired food items. Nursing staff document temperatures on the nourishment room logs.A tour of the nourishment rooms on 5/20/2026 between 11:30 AM and 12:00 PM, revealed residue build-up and unclean surfaces inside the refrigerators in two of two nourishment rooms observed. (Photographic evidence obtained)On 5/20/2026 at 1:30 PM, Licensed Practical Nurse (LPN) D stated housekeeping staff were responsible for cleaning the refrigerators in the nourishment rooms, food service equipment should be cleaned after each use, and opened food items should be marked and discarded after three days.Reference: FDA Food Code 2022. https://www.fda.gov/media/184685/download?attachment; (Accessed on 5/21/2026) Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 555. Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of products prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.A review of the facility's policy and procedure titled Food Receipt and Storage (effective date: 8/23/2017), revealed:Purpose: Foods should be received and stored properly to prevent foodborne illness. Standard: Foods should be checked for freshness when received and stored in accordance with FDA Food Code recommendations. Process: .Storage of Foods: .i. refrigerated and frozen items should be checked to be sure the item is still cold or frozen and packages are intact.k. open food items should be covered, labeled, and dated; open dry goods should be kept in tightly sealed containers.A review of the facility's policy and procedure titled Cleaning Schedules (effective date: 8/10/2018), revealed:Purpose: To prevent the spread of bacteria that may cause foodborne illnesses.Process: e. the FNS (Food and Nutritional Services) Manager should supervise adherence to the cleaning schedule and inspect the kitchen weekly for cleanliness.

Based on interviews, record reviews and a review of the facility's policies and procedures, the facility failed to provide a notice of transfer/discharge and a copy of the actual transfer/discharge form to the Long-Term Care (LTC) Ombudsman's Office for four (Residents #3, #55, #29 and #93) of nine residents reviewed for transfer/discharge. Appropriate notification to the LTC Ombudsman's office provides added protection to residents from being inappropriately transferred or discharged . It provides residents with access to an advocate who can inform them of their options and rights, and it ensures that the LTC Ombudsman's office is aware of facility practices and activities related to transfers and discharges. The findings include:1. A review of Resident #3's medical record revealed an admission date of 2/9/2026 with diagnoses including End-Stage Renal Disease (ESRD). She was transferred to an acute-care hospital on 4/1/2026 and returned to the facility on 4/14/2026. The resident's medical record included no evidence of the facility having notified the LTC Ombudsman's office. There was no Nursing Home Transfer and Discharge Notice (CMS Form 3120) in the record.2.A review of Resident #55's medical record revealed an admission date of 5/16/2025 with diagnoses including neurocognitive disorder (condition affecting cognitive abilities like memory, attention, learning, language and problem-solving) . He was transferred to an acute-care hospital on 4/19/2026 and returned to the facility on 4/21/2026. The resident's medical record included no evidence of the facility having notified the LTC Ombudsman's office. There was no Nursing Home Transfer and Discharge Notice (CMS Form 3120) in the record.3.A review of Resident #29's medical record revealed an admission date of 1/20/2021 with diagnoses including squamous cell carcinoma (cancer) of skin on scalp and neck. She was transferred to an acute-care hospital on 4/16/2026 and returned to the facility on 4/23/2026. The resident's medical record included no evidence of the facility having notified the LTC Ombudsman's office. There was no Nursing Home Transfer and Discharge Notice (CMS Form 3120) in the record.4.A review of Resident #93's medical record revealed an admission date of 1/10/2026 with diagnoses including ESRD. He was transferred to an acute-care hospital on 4/13/2026 and returned to the facility on 4/24/2026. The resident's medical record included no evidence of the facility having notified the LTC Ombudsman's office. There was no Nursing Home Transfer and Discharge Notice (CMS Form 3120) in the record.On 5/20/2026 at 9:35 AM, an interview was conducted with the Social Services Director (SSD) who was asked to explain the facility's process for completing transfer/discharge forms and who to notify of transfers/discharges. She stated notification was provided to the resident, the resident's representative, the Primary Care Provider (PCP - resident's physician), the home health agency as needed, and sometimes the Department of Children and Family Services (DCFS) was notified if the discharge was deemed unsafe. She was asked to explain the facility's process for notifying the LTC Ombudsman of transfers and discharges. She stated her process was to send a monthly log to the LTC Ombudsman's office via email. She was asked to provide confirmation that the log was received by the LTC Ombudsman's office. She stated she printed a copy of the email confirmation displaying the date and time that the monthly transfer/discharge log email was sent. The SSD provided the monthly log and the email confirmation sent on 5/12/2026. On 5/21/2026 at 2:40 PM, an interview was conducted with the Administrator who was asked to explain the facility's process for notifying the LTC Ombudsman of resident transfers and discharges. He stated the task was assigned to the SSD. She was expected to send transfer/discharge notification to the LTC Ombudsman at least weekly and daily if needed. He confirmed that she was not processing the notifications appropriately. A review of the facility's policy and procedure titled Resident/Guest Transfer and Discharge (including AMA - Policy #: NM.II-18 (effective date: 5/26/2025, superseded: 6/26/2019), revealed:Process:1.All non-emergency transfers or discharges should be handled by the Social Services Designee.Procedures should include:d) Provide resident/guest with a statement of right to appeal the action to the state agency designated for such appeals, along with name, address, and phone number of the State Long-Term Care Ombudsman. (In Florida, fax a copy of the discharge notice to the local Ombudsman council within 5 business days after signature by the resident/guest/legal representative).

Based on observations, record review, interviews and review of the facility's policies and procedures, the facility failed to ensure that one (Resident #109) of four residents reviewed for impaired skin integrity, received care and treatment in accordance with professional standards of practice. Resident #109's wound dressing was not changed for 24 days. Failure to change a wound dressing for 24 days can result in a bacterial infection, increased pain, additional tissue damage and/or the dressing fusing to healing skin.The findings include:On 5/19/26 at 11:18 a.m., an observation was made of Resident #109 in her room on the Memory Care unit. A dressing was observed on her right lower extremity (RLE) which was dated 4/25/26. Resident #109 was unable to remember what occurred or why she had the dressing on.On 5/20/26 at 11:18 a.m., an observation was made of Resident #109 in her room. The same 4/25/26 dressing was observed on her RLE. (Photographic evidence obtained)A review of the resident's medical record revealed an admission date of 8/19/19 with diagnoses including mild protein calorie malnutrition, anemia and dementia. A physician's order dated 4/25/26 was found in the record which noted a skin tear - Apply antibiotic ointment and cover with dressing if needed to minor cuts or skin tears until healed once a day as needed.A review of the resident's Annual Minimum Data Set (MDS) assessment, dated 3/23/26, revealed a Brief Interview for Mental Status (BIMS) score of 5 out of 15 possible points, indicating severe cognitive impairment. A pressure-reducing device for the bed was noted.A review of a 4/25/26 progress note revealed the resident was walking and struck her leg on her roommate's bed, not realizing she was bleeding. The area was cleansed and a dressing was applied. On 5/20/26 at 2:04 p.m., an interview was conducted with Licensed Practical Nurse (LPN) A who was accompanied to Resident #109's room to observe the RLE dressing. LPN A confirmed that the dressing was dated 4/25/26. She tried to remove the dressing but was unable to. The resident removed the dressing, which was soiled, and handed it to the nurse. (Photographic evidence obtained) The wound was observed with beefy-red tissue exposed. LPN A notified the Unit Manager (UM) of the concern. The UM reviewed the physician's orders and found the as needed order written on 4/25/26. The UM stated there was a communication glitch; the wound should have been reported to the wound care nurse. The UM stated there was a note for the skin tear to the RLE on 4/25/26 and the wound should have been observed daily. Dressings were changed if dislodged, loose or soiled or as ordered. The UM stated the dressing should be replaced weekly. When she was asked how often skin checks were performed and showers were provided, the UM stated Resident #109 received her showers on the 3-11 shift on Tuesdays and Thursdays. Skin checks were performed weekly by the nurse and daily by the assigned certified nursing assistant (CNA) during provision of care.On 5/20/26 at 2:30 p.m., an interview was conducted with CNA E who was asked to describe Resident #109's care needs. CNA E stated the resident required assistance to the bathroom and set up/cueing for dressing. The resident required minimal assistance. CNA E stated she observed the resident's RLE dressing but did not check the date written on it. She stated if a dressing was observed and the date was old, the nurse should be told about it.A review of the May 2026 Medication Administration Record (MAR)/Treatment Administration Record (TAR) revealed that a skin audit was performed on the 7-3 shift on 5/5/26, 5/12/26 and 5/19/26. (Photographic evidence obtained)A review of the facility's policy and procedure titled Dressings - Clean (dated 12/20/16), revealed that physicians' orders should specify the type of wound, frequency of dressing change, and the type of dressing or products to be used.A review of the facility's Protocol for CNA & Licensed Nurse Skin Inspections (revised 10/1/10), revealed:Intent: To identify any skin concerns in residents immediately and implement early interventions.Procedure for CNA Daily Inspections:-CNAs will conduct a body inspection on all assigned residents.-Results of inspection will be documented on the body audit sheet or in Smart Charting bedside appropriate resident's name.-Any skin concern identified by the CNA will be reported to assigned Licensed Nurse immediately.-CNA will document the Nurse it was reported to on the body audit sheet or report changes recorded in Smart Charting.-All body audit sheets will be shared with the assigned Licensed Nurse and Licensed Nurse will submit to the DON (Director of Nursing)/designee. -The body audit sheets will be reviewed by the Treatment Nurse/designee for new skin concerns and findings will be presented at the QA (Quality Assurance) Skin Sub-committee. Treatment Nurse/designee will review for appropriate measures taken and report at morning meetings.Procedure for Licensed Nurse Weekly Inspections:-Designated Licensed Nurse will conduct body inspection on all residents on a weekly basis, per schedule. (DON will ensure that a weekly schedule is developed and implemented.)-Any skin concerns identified by Licensed Nurse will be reported to designated Treatment Nurse immediately for evaluation and treatment orders. If the Treatment Nurse is not available, nurse identifying concern should evaluate wound and notify MD for initial treatment orders.-Any skin concerns identified will be presented at the morning meeting.-Weekly results will be reviewed at the QA Skin Sub-committee meeting.

Based on resident and staff interviews, a review of facility and resident records, and a review of the facility's policy and procedure titled Turning and Positioning the Residents, the facility failed to ensure that residents received adequate supervision and staff assistance to prevent avoidable falls with major injury (hip fracture) for one (Resident #1) of four residents reviewed for Activities of Daily Living (ADL) assistance.On 2/3/2026, Resident #1, who required 2-person assistance for bed mobility, sustained a fall from bed with a subsequent right hip fracture while Certified Nursing Assistant (CNA) A was providing peri-care. The CNA, working alone, turned the resident on his side in bed. The resident's leg slipped off the side of the bed pulling him to the floor. LPN B assessed the resident with no injuries immediately identified. Three staff members assisted the resident back into bed with the use of a Hoyer lift. The resident then complained of right hip pain. The physician was notified, and new orders were received for a STAT x-ray of the right hip. The x-ray results were positive for acute transverse fracture of the right femur (hip fracture), and the resident was sent to the hospital for further evaluation and surgery. Immediate Jeopardy (IJ) at a scope and severity of J (Isolated) was identified at 1:15 PM on March 4, 2026.On February 3, 2026, Immediate Jeopardy began.On March 5, 2026 at 5:30 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on March 5, 2026.The findings include:Cross reference F600.A review of Resident #1's medical record revealed an admission date of 7/29/16 with a re-entry on 2/9/26. His diagnoses included displaced intertrochanteric fracture of the right femur (hip fracture), subsequent encounter for closed fracture with routine healing, peripheral vascular disease (circulation disorder caused by narrowed, blocked, or spasmodic blood vessels, most commonly affecting the legs and feet), myelodysplastic syndrome (blood cancer causing fatigue and shortness of breath among other symptoms), obesity (excessive body fat accumulation), lymphedema (damage in the lymph system causing swelling, usually in the arms and legs that can lead to heaviness, pain and restricted movement), seizures, major depressive disorder, attention-deficit hyperactivity disorder (neurodevelopmental condition characterized by persistent patterns of inattention, hyperactivity, and impulsivity), hereditary and idiopathic neuropathy (nerve disorder causing symptoms like muscle weakness, pain, and numbness in feet/hands), and rheumatoid arthritis with rheumatoid factor (chronic autoimmune disease that produces an antibody that attacks healthy joint tissue, causing inflammation, pain, and stiffness).A review of the resident's active physician's orders revealed:Air mattress - ordered 4/7/25.Venlafaxine (antidepressant) 37.5 mg (milligrams) every day for depression - ordered 1/7/26. Gabapentin (used to treat nerve pain and partial seizures) 300 mg (milligrams) every 8 hours for neuropathy - ordered 2/10/26.Lasix (diuretic) 40 mg two times a day (BID) for fluid retention - ordered 2/10/26.Levetiracetam (Keppra - antiepileptic medication for treating seizures) 500 mg every 12 hours for seizures - ordered 2/10/26.Surgical incision to right hip. Change dressing as needed. Cleanse with normal saline and cover with nonstick island dressing - ordered 2/10/26 upon re-entry after the resident's 2/3/26 fall with hip fracture.Morphine 15 mg every 6 hours for pain - ordered 2/18/26 upon re-entry after the resident's 2/3/26 fall with hip fracture.Transfers with Hoyer lift (mechanical lift for someone who is dependent for transfers) with 2-person assist - ordered 2/19/26, 10 days after Resident #1's re-entry following his 2/3/26 fall with hip fracture and subsequent hospitalization.A review of the resident's active care plan (revised on 12/23/25) revealed that the resident had the potential for falls related to his seizure history, a history of placing himself on the floor once upset and raising his bed to the highest position by himself. Interventions included providing 2-person assistance with bed mobility, floor mats to both sides of the bed, and 2-person assistance for transfers.A review of the annual minimum data set (MDS) assessment with an assessment reference (ARD) of 12/09/25 revealed that the resident had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition.A nursing progress note dated 11/3/25 revealed that Resident #1 had a witnessed fall. As the CNA was providing morning care by herself, she turned the resident on his left side, and he slid out of bed onto the fall mat at bedside. He denied pain or discomfort at the time of the fall, no apparent injuries were noted, no new skin issues were noted, and neuro checks (quick, focused assessments used to monitor a resident's brain function, nervous system and neurological status over time) were within normal limits. The resident was assisted back to bed using a Hoyer lift.A nursing progress note dated 11/4/25 revealed that the interdisciplinary team (IDT) met and reviewed the 11/3/25 fall. [Resident #1] fell out of bed while being cleaned up. Resident to have 2 aides to perform care while in bed.A nursing progress note dated 2/3/26 at 2:15 PM revealed: CNA was in the room providing care to the resident. Resident was rolled to the side of the bed and began having a bowel movement. At that time, he let go of the side rail and began falling off the bed. Resident was hanging onto the bedrail with his bottom half on the floor, ROM (range of motion) performed as tolerated in the current position. Resident was assisted back into bed via Hoyer lift (mechanical lift) and 4 staff members. Once in bed resident C/O (complained of) pain to his right hip. Spoke with NP (nurse practitioner) and X-ray of right hip ordered. DON (Director of Nursing) and RP (responsible party) notified.A nursing progress note dated 2/3/26 at 3:53 PM revealed: X-ray completed and shows a FX (fracture) of the right hip. Spoke with NP who gave new order to send to ER (emergency room) for further eval. (evaluation) Daughter updated.A review of the Imagining Report, dated 2/3/26, revealed right hip 2 view findings:Acute transverse fracture proximal femur. 1 cm (centimeter) medial displacement humeral shaft. Femoral head is anatomically situated within the acetabulum with moderate femoral acetabular joint degenerative changes. Mineralization is decreased. Vascular calcifications. Impression: Acute transverse fracture proximal femur (sudden break in the upper part of the thigh bone, just below the hip joint).A nursing progress note dated 2/9/26 revealed that the resident was re-admitted to the facility from an acute care hospital. He was documented as alert and oriented x4 (able to identify person, place, time and the reason for care). A dressing was noted to the surgical site on the resident's right hip as well as a foam dressing to both of his heels and his sacrum (large, triangular bone located at the base of the spine that connects the spine to the pelvis). He was noted as incontinent of urine and stool. He had gross edema (swelling) to both lower extremities.A nursing progress note dated 2/10/26 revealed that the Interdisciplinary Team (IDT) met to review the resident's 2/3/26 fall from bed with right hip fracture. Resident #1 returned from the hospital following an open reduction and internal fixation (ORIF) of the fracture. Treatment orders were in place. The resident was reviewed for the need of two-person assistance for bed mobility. It was determined that the resident continued to require two-person assistance for bed mobility. His care plan was reviewed and updated.A review of a wound care note dated 2/10/26 revealed: admission skin assessment - Resident re-admitted [DATE] after hospital stay s/p (following) fall from bed and fractured right hip. He has poor bed mobility, and total ADL's, dependent on staff to turn or reposition. Skin assessment to lower extremities and feet with lymphedema (grossly enlarged), heels pink and blanchable, no redness noted to buttocks. Resident on air mattress. Displaced intertrochanteric fracture of right femur, ORIF on 2/4/2026, 17 staples clean and intact, light drainage noted to lower aspect of incision. Incision cleansed with NS (normal saline), skin prepped peri wound and covered with nonstick island dressing.A nursing progress note dated 2/25/26 revealed that the IDT met to review falls. The IDT discussed interventions and bolsters were ordered for Resident #1's air mattress to help with keeping his legs in the bed while turning and repositioning. His care plan was noted as reviewed and updated.In an interview on 3/4/26 at 1:25 PM with CNA A, she stated she had been employed by the facility for seven months. She said she was hired as an Activities Assistant but occasionally assisted on the nursing unit when there was a staffing shortage. When she was asked how she identified residents' needs, she stated she was more familiar with the residents in the Memory Care unit, as she was assigned to provide activities on that unit. She said she would check the residents' care plans and ask the nurse or another CNA who was familiar with the residents. When she was asked if she was familiar with Resident #1, she replied that she did not know him too well. She stated 2/3/26 was the first time she worked with him. On that day, the facility had two staff members who called out, and she was not notified ahead of time that she would be working on the nursing unit until she arrived at the facility at 8:00 AM (Her normal work time was 8:00 AM to 5:00 PM.). When she was figuring out where she was assigned, other staff had already passed the breakfast trays. As she walked to her assignment, she noted that there were three residents on her assignment who required assistance with eating their meals, so she started assisting them. She said, Normally staff review the care plan needs at the beginning of the shift, but on that day, I was already late and the previous staff had already left. I didn't have time to review the care plans. She stated she briefly asked the other CNAs on the unit to provide a rundown of the residents assigned to her. There were two CNAs (She could not recall their names.) who did not mention that Resident #1 required 2-person assistance for bed mobility. At approximately 2:00 PM, she went to the resident's room to provide care. She turned the resident toward the window. Resident #1 was holding onto the siderail and his legs flipped out of bed (he had large legs). His lower body being heavier than his upper body pulled him down and he landed on his buttocks. CNA A called the nurse who conducted an assessment. The resident was then assisted back into bed with a Hoyer lift. While in bed he complained of hip pain and an x- ray was ordered.On 3/4/26 at 1:41 PM, Resident #1 was observed in bed. He stated he always had two staff members assist him with turning/repositioning and bed mobility. He confirmed that on 2/3/26, only one staff member provided the care. He explained that CNA A turned him toward the window too fast and he slid off the bed near the wall. The resident stated he was not provided with any instructions or preparation by CNA A that she was about to turn him. He said, It happened so fast. I remember being turned and the next thing I remember was I was on the floor. A joint interview was conducted with the Director of Nursing (DON) and the Administrator on 3/4/26 at 2:15 PM. They were asked how staff were expected to identify resident needs. The DON stated staff should review the care plan at the beginning of the shift and also get a report from the previous shift staff at the beginning of each shift. When they were asked about Resident #1's 2/3/26 incident, they said that on 2/3/26 at 2:00 pm, CNA A went to the resident's room to provide ADL care. She rolled the resident on the bed toward the window. The resident was holding onto the side rail. At approximately 2:12 PM, as CNA A was providing incontinent care, the resident's feet slid off the bed because he had large legs (lymphedema). The weight of his lower body pulled his upper body out of bed onto the floor. The resident's legs hit the floor first and his upper body was still off floor as he was holding onto the side rail. The CNA notified the nurse who conducted an assessment. Resident #1 complained of hip pain and an x- ray was ordered. The results of the x-ray revealed an acute transverse fracture of the right femur. The resident was sent to the ER for an evaluation. He was admitted to the hospital and surgery was performed. An investigation was initiated immediately. CNA A was given one-to-one education about reviewing the resident's care plan before providing care and was then suspended pending the investigation. When they were asked for the findings of their investigation the DON stated the allegation of neglect could not be substantiated because CNA A was newly assigned to Resident #1 and was not aware of his needs. The DON and the Administrator were given the facility's policy on abuse and neglect so they could review the policy's definition of neglect. The facility's policy reflected the federal abuse and neglect regulation. They stated they would review the policy and get back with the surveyor.In a follow-up interview with the DON and the Administrator on 3/4/26 at 4:31 PM, they stated CNA A was newly assigned to Resident #1 and was not aware of the level of assistance required for the resident's bed mobility. They reiterated that CNA A was unfamiliar with Resident #1 as she did not normally work on that nursing unit. They stated CNA A told them that she received report from staff working on the unit who explained to her that Resident #1 was alert and oriented, and was able to communicate his needs, which was consistent with a resident who required one-person assistance for bed mobility. Therefore, they felt there was no intent to harm the resident, so there was no neglect. The federal abuse/neglect regulation and its definition of neglect, as well as the facility's abuse/neglect policy, were reviewed with the DON and the Administrator. Both voiced understanding of the definition of neglect.In a telephone interview on 3/5/26 at 12:51 PM, Licensed Practical Nurse (LPN) C/Unit Manager stated she had been employed by the facility almost five years. She was asked how she ensured that resident care was provided when there was a staffing shortage. She explained that the facility had a staffing coordinator who was responsible for staffing during the day and an on-call person during off hours. She stated during this time the staff on the nursing unit would be divided and assigned to all residents until additional coverage was found. When she was asked about the staffing on 2/3/26, she stated she was notified that there was a staffing shortage due to call outs. The staffing coordinator notified her that the Activities Assistant would be assisting on the unit. LPN C contacted the Director of Activities and asked her to notify the Activities Assistant when she reported to work that she would be working on the nursing unit. When LPN C was asked about Resident #1's care needs, she stated he required 2-person assistance for bed mobility and that this had been the case for several months. She confirmed that she was on duty on 2/3/26 when Resident #1 fell. She explained that the nurse assigned to Resident #1 (LPN B) notified her that the resident was on the floor after sustaining a fall during care and he complained of hip pain. She went to the resident's room. The resident was already back to bed. She stated she did not interview the resident but asked the assigned CNA (CNA A) what happened. She then notified the Director of Nursing (DON). When she was asked how staff were expected to identify residents' care needs, she replied that they were expected to review the point of care in the electronic medical record at the start of the shift. When she was asked if CNA A was familiar with Resident #1, she said CNA A worked as an Activities Assistant, but she was provided with the training about how to review the care plan before providing care to the residents.On 3/5/26 at 1:10 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) B who stated she had been employed by the facility for two years. She confirmed that she was Resident #1's assigned nurse on 2/3/26. She said the CNA (CNA A) approached her in the hallway and stated she needed assistance because the resident was on the floor. Upon entering the room, the resident was observed on the left side of his bed. He was holding his upper body off the floor by grasping the side rail and his lower body was on the floor in a twisted angle. The assigned CNA (CNA A) stated she was providing incontinent care and when she turned the resident on his side, he rolled out of bed. The CNA was alone while providing care. LPN B stated Resident #1 required two staff members for bed mobility due to his obesity and lymphedema. Resident #1 was assisted onto the floor, an assessment was completed (by LPN B) and no injuries were identified. The resident was then assisted back into bed with the help of three staff members and the use of a Hoyer lift. When the resident was placed back in bed, he complained of right hip pain. LPN B contacted the resident's physician and obtained a STAT (immediate) order for an x-ray. She then notified the Unit Manager and Resident #1's family.A review of the facility's policy and procedure titled Turning and Positioning the Residents (Policy Number: NP. I-88, Effective Date: 10/01/2010), revealed:Process:I. Turning and Repositing Procedurea) Explain the procedure to the resident and ask permission to proceed.b) Use two persons for this procedure as needed.c) If the resident is in bed, turn the resident to the desired position and use pillows or cushions to keep the resident comfortably in place, if needed. A review of the facility's policy and procedure titled Person-Centered Care Plans (Policy Number: NM.III-8, Effective Date: 08/15/2018), revealed:PURPOSE:Person-centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guests) rights.STANDARD:According to federal regulations, the facility develops and implements a baseline plan of care within 48 hours of admission that includes the minimum healthcare information necessary to properly care for the immediate needs of the resident/guest.According to federal regulations, the facility develops a comprehensive person-centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guests) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment and based upon the resident/guests) goals and preferences, potential for future discharge.Process:I. Assessment and Person-Centered Plan of Care Processc) Resident Assessment Instrument (RAI) - within 14 days of admission; quarterly, annually and with a significant change of condition.d) Comprehensive Plan of Care - completed within 7 days of admission RAI assessment and should be reviewed: quarterly and with significant change of condition.f) Upon completion of baseline care plan or comprehensive care plan and when reviewed quarterly/significant change, the MDSC will ensure care plan intervention(s) are entered into Care Guide ADLs/Intervention in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the residents' care needs.

Based on resident and staff interviews, a review of facility and resident records, and a review of the facility's policies and procedures titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and Turning and Positioning the Residents, the facility failed to protect the resident's right to be free from neglect/deprivation of services by Certified Nursing Assistant (CNA) A. The facility failed to ensure sufficient safeguards and supervision to protect the resident's right to be free from neglect by failing to ensure that CNA A was aware of, and implemented, care plan interventions to prevent one resident (#1) from an avoidable fall with major injury (hip fracture), from a total of four residents reviewed for Activities of Daily Living (ADLs) assistance.On February 3, 2026, the facility neglected to ensure adequate supervision to prevent Resident #1, who required two-person assistance with bed mobility, from falling out of bed and sustaining a hip fracture due to CNA A's failure to follow the resident's care plan, and instead, providing care by herself. The resident was rolled onto his side by CNA A while she provided care. The resident's leg slipped over the side of the bed and the weight of it pulled him out of bed onto the floor. He sustained a hip fracture from the fall and had to be admitted to an acute care hospital for further treatment. Immediate Jeopardy (IJ) at a scope and severity of J (Isolated) was identified at 1:15 PM on March 4, 2026.On February 3, 2026 at 2:00 PM, Immediate Jeopardy began.On March 5, 2026 at 5:30 PM, the Administrator was notified of the IJ determination. IJ templates were provided, and Immediate Jeopardy was ongoing as of the survey exit on March 5, 2026.The findings include:Cross reference F689.A review of Resident #1's medical record revealed an admission date of 7/29/16 with a re-entry on 2/9/26. His diagnoses included displaced intertrochanteric fracture of the right femur (hip fracture), subsequent encounter for closed fracture with routine healing, peripheral vascular disease (circulation disorder caused by narrowed, blocked, or spasmodic blood vessels, most commonly affecting the legs and feet), myelodysplastic syndrome (blood cancer causing fatigue and shortness of breath among other symptoms), obesity (excessive body fat accumulation), lymphedema (damage in the lymph system causing swelling, usually in the arms and legs that can lead to heaviness, pain and restricted movement), seizures, major depressive disorder, attention-deficit hyperactivity disorder (neurodevelopmental condition characterized by persistent patterns of inattention, hyperactivity, and impulsivity), hereditary and idiopathic neuropathy (nerve disorder causing symptoms like muscle weakness, pain, and numbness in feet/hands), and rheumatoid arthritis with rheumatoid factor (chronic autoimmune disease that produces an antibody that attacks healthy joint tissue, causing inflammation, pain, and stiffness).A review of the resident's active physician's orders revealed:Air mattress - ordered 4/7/25.Venlafaxine (antidepressant) 37.5 mg (milligrams) every day for depression - ordered 1/7/26. Gabapentin (used to treat nerve pain and partial seizures) 300 mg (milligrams) every 8 hours for neuropathy - ordered 2/10/26.Lasix (diuretic) 40 mg two times a day (BID) for fluid retention - ordered 2/10/26.Levetiracetam (Keppra - antiepileptic medication for treating seizures) 500 mg every 12 hours for seizures - ordered 2/10/26.Surgical incision to right hip. Change dressing as needed. Cleanse with normal saline and cover with nonstick island dressing - ordered 2/10/26 upon re-entry after the resident's 2/3/26 fall with hip fracture.Morphine 15 mg every 6 hours for pain - ordered 2/18/26 upon re-entry after the resident's 2/3/26 fall with hip fracture.Transfers with Hoyer lift (mechanical lift for someone who is dependent for transfers) with 2-person assist - ordered 2/19/26, 10 days after Resident #1's re-entry following his 2/3/26 fall with hip fracture and subsequent hospitalization.A review of the resident's active care plan (revised on 12/23/25) revealed that the resident had the potential for falls related to his seizure history, a history of placing himself on the floor once upset and raising his bed to the highest position by himself. Interventions included providing 2-person assistance with bed mobility, floor mats to both sides of the bed, and 2-person assistance for transfers.A review of the annual minimum data set (MDS) assessment with an assessment reference (ARD) of 12/09/25 revealed that the resident had a brief interview for mental status (BIMS) score of 14 out of 15 possible points, indicating intact cognition.A nursing progress note dated 11/3/25 revealed that Resident #1 had a witnessed fall. As the CNA was providing morning care by herself, she turned the resident on his left side, and he slid out of bed onto the fall mat at bedside. He denied pain or discomfort at the time of the fall, no apparent injuries were noted, no new skin issues were noted, and neuro checks (quick, focused assessments used to monitor a resident's brain function, nervous system and neurological status over time) were within normal limits. The resident was assisted back to bed using a Hoyer lift. A nursing progress note dated 11/4/25 revealed that the interdisciplinary team (IDT) met and reviewed the 11/3/25 fall. [Resident #1] fell out of bed while being cleaned up. Resident to have 2 aides to perform care while in bed.A nursing progress note dated 2/3/26 at 2:15 PM revealed: CNA was in the room providing care to the resident. Resident was rolled to the side of the bed and began having a bowel movement. At that time, he let go of the side rail and began falling off the bed. Resident was hanging onto the bedrail with his bottom half on the floor, ROM (range of motion) performed as tolerated in the current position. Resident was assisted back into bed via Hoyer lift (mechanical lift) and 4 staff members. Once in bed resident C/O (complained of) pain to his right hip. Spoke with NP (nurse practitioner) and X-ray of right hip ordered. DON (Director of Nursing) and RP (responsible party) notified.A nursing progress note dated 2/3/26 at 3:53 PM revealed: X-ray completed and shows a FX (fracture) of the right hip. Spoke with NP who gave new order to send to ER (emergency room) for further eval. (evaluation) Daughter updated.A review of the Imagining Report, dated 2/3/26, revealed right hip 2 view findings:Acute transverse fracture proximal femur. 1 cm (centimeter) medial displacement humeral shaft. Femoral head is anatomically situated within the acetabulum with moderate femoral acetabular joint degenerative changes. Mineralization is decreased. Vascular calcifications. Impression: Acute transverse fracture proximal femur (sudden break in the upper part of the thigh bone, just below the hip joint).In an interview on 3/4/26 at 1:25 PM with CNA A, she stated she had been employed by the facility for seven months. She said she was hired as an Activities Assistant but occasionally assisted on the nursing unit when there was a staffing shortage. When she was asked how she identified residents' needs, she stated she was more familiar with the residents in the Memory Care unit, as she was assigned to provide activities on that unit. She said she would check the residents' care plans and ask the nurse or another CNA who was familiar with the residents. When she was asked if she was familiar with Resident #1, she replied that she did not know him too well. She stated 2/3/26 was the first time she worked with him. On that day, the facility had two staff members who called out, and she was not notified ahead of time that she would be working on the nursing unit until she arrived at the facility at 8:00 AM (Her normal work time was 8:00 AM to 5:00 PM.). When she was figuring out where she was assigned, other staff had already passed the breakfast trays. As she walked to her assignment, she noted that there were three residents on her assignment who required assistance with eating their meals, so she started assisting them. She said, Normally staff review the care plan needs at the beginning of the shift, but on that day, I was already late and the previous staff had already left. I didn't have time to review the care plans. She stated she briefly asked the other CNAs on the unit to provide a rundown of the residents assigned to her. There were two CNAs (She could not recall their names.) who did not mention that Resident #1 required 2-person assistance for bed mobility. At approximately 2:00 PM, she went to the resident's room to provide care. She turned the resident toward the window. Resident #1 was holding onto the siderail and his legs flipped out of bed (he had large legs). His lower body being heavier than his upper body pulled him down and he landed on his buttocks. CNA A called the nurse who conducted an assessment. The resident was then assisted back into bed with a Hoyer lift. While in bed he complained of hip pain and an x- ray was ordered.On 3/4/26 at 1:41 PM, Resident #1 was observed in bed. He stated he always had two staff members assist him with turning/repositioning and bed mobility. He confirmed that on 2/3/26, only one staff member provided the care. He explained that CNA A turned him toward the window too fast and he slid off the bed near the wall. The resident stated he was not provided with any instructions or preparation by CNA A that she was about to turn him. He said, It happened so fast. I remember being turned and the next thing I remember was I was on the floor. A joint interview was conducted with the Director of Nursing (DON) and the Administrator on 3/4/26 at 2:15 PM. They were asked how staff were expected to identify resident needs. The DON stated staff should review the care plan at the beginning of the shift and also get a report from the previous shift staff at the beginning of each shift. When they were asked about Resident #1's 2/3/26 incident, they said that on 2/3/26 at 2:00 pm, CNA A went to the resident's room to provide ADL care. She rolled the resident on the bed toward the window. The resident was holding onto the side rail. At approximately 2:12 PM, as CNA A was providing incontinent care, the resident's feet slid off the bed because he had large legs (lymphedema). The weight of his lower body pulled his upper body out of bed onto the floor. The resident's legs hit the floor first and his upper body was still off floor as he was holding onto the side rail. The CNA notified the nurse who conducted an assessment. Resident #1 complained of hip pain and an x- ray was ordered. The results of the x-ray revealed an acute transverse fracture of the right femur. The resident was sent to the ER for an evaluation. He was admitted to the hospital and surgery was performed. An investigation was initiated immediately. CNA A was given one-to-one education about reviewing the resident's care plan before providing care and was then suspended pending the investigation. When they were asked for the findings of their investigation the DON stated the allegation of neglect could not be substantiated because CNA A was newly assigned to Resident #1 and was not aware of his needs. The DON and the Administrator were given the facility's policy on abuse and neglect so they could review the policy's definition of neglect. The facility's policy reflected the federal abuse and neglect regulation. They stated they would review the policy and get back with the surveyor.In a follow-up interview with the DON and the Administrator on 3/4/26 at 4:31 PM, they stated CNA A was newly assigned to Resident #1 and was not aware of the level of assistance required for the resident's bed mobility. They reiterated that CNA A was unfamiliar with Resident #1 as she did not normally work on that nursing unit. They stated CNA A told them that she received report from staff working on the unit who explained to her that Resident #1 was alert and oriented, and was able to communicate his needs, which was consistent with a resident who required one-person assistance for bed mobility. Therefore, they felt there was no intent to harm the resident, so there was no neglect. The federal abuse/neglect regulation and its definition of neglect, as well as the facility's abuse/neglect policy, were reviewed with the DON and the Administrator. Both voiced understanding of the definition of neglect.On 3/5/26 at 1:10 PM, a telephone interview was conducted with Licensed Practical Nurse (LPN) B who stated she had been employed by the facility for two years. She confirmed that she was Resident #1's assigned nurse on 2/3/26. She said the CNA (CNA A) approached her in the hallway and stated she needed assistance because the resident was on the floor. Upon entering the room, the resident was observed on the left side of his bed. He was holding his upper body off the floor by grasping the side rail and his lower body was on the floor in a twisted angle. The assigned CNA (CNA A) stated she was providing incontinent care and when she turned the resident on his side, he rolled out of bed. The CNA was alone while providing care. LPN B stated Resident #1 required two staff members for bed mobility due to his obesity and lymphedema. Resident #1 was assisted onto the floor, an assessment was completed (by LPN B) and no injuries were identified. The resident was then assisted back into bed with the help of three staff members and the use of a Hoyer lift. When the resident was placed back in bed, he complained of right hip pain. LPN B contacted the resident's physician and obtained a STAT (immediate) order for an x-ray. She then notified the Unit Manager and Resident #1's family.A review of the facility's policy and procedure titled Turning and Positioning the Residents (Policy Number: NP. I-88, Effective Date: 10/01/2010), revealed:Process:I. Turning and Repositing Procedurea) Explain the procedure to the resident and ask permission to proceed.b) Use two persons for this procedure as needed.c) If the resident is in bed, turn the resident to the desired position and use pillows or cushions to keep the resident comfortably in place, if needed. A review of the facility's policy and procedure titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation (Policy Number NM. II-20, Effective Date: 10/15/2022), revealed:Purpose:This policy is concerned with all incidents and accidents involving resident(s)/guest(s). All of our resident(s)/guest(s) have the right to be free from abuse, neglect, exploitation and misappropriation of resident/guest property.Page 4 of 12 - Section B NeglectNeglect is a failure of the facility or its employees or service providers to provide goods and services necessary, to attain or maintain physical, mental, and psychosocial well-being to avoid physical harm, mental anguish, or emotional stress when the facility knew or should have known to provide the goods and/or services but continued to fail to take the actions necessary.Neglect may include, but is not limited to: Leaving residents/guests to sit or lie in urine or feces without appropriately intervening, isolating dependent residents/guests by leaving them in their rooms or other isolated locations (apart from temporary separation occurring in the context of assessment and care planning), deliberate failure to answer call bells to provide needed assistance and performing one-person assistance to transfer a resident/guest when they are care planned for two persons. Failure to implement an effective communication system across all shifts for communicating necessary care and information between staff, practitioners, and resident representatives may result in neglect.Serious Bodily Injury is defined as an injury consisting of extreme physical pain involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation, or an injury resulting from criminal sexual abuse.

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to ensure essential kitchen equipment was in safe operating condition, by failing to maintain the inspection of the kitchen exhaust system to prevent excessive grease build-up. This could potentially endanger staff, residents and any other building occupants due to the risk for fire. The findings include: A kitchen tour was conducted on [DATE] at 11:05 AM. The kitchen hood located above the cook area had an inspection date that was expired. The documented date of inspection should have occurred between ,d+[DATE] and ,d+[DATE]. (Photographic evidence obtained) In an interview with the Certified Dietary Manager (CDM) on [DATE] at 1:53 PM, she reported that the exhaust hood was inspected every three months, and the Maintenance Department was responsible for contacting the vendor. During an interview with the Director of Maintenance on [DATE] at 2:23 PM, he stated he did not notice that the inspection was expired. The vendor came automatically every three months and he was not aware that they had not been to the facility to complete the inspection. On [DATE] at 3:36 PM, the CDM reported that broken equipment was reported to the Maintenance Department. She was not aware that the exhaust hood inspection was due; usually the vendor came automatically. A review of the facility's policy and procedure titled Safety Principles (dated [DATE]) revealed: Purpose: To prevent injury to food service employees through exposure to heat, cold, chemicals and other workplace hazards. (Copy Obtained)

Based on kitchen food service observations, staff interviews, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to seal and date mark open food products in the walk-in refrigerator, and discard food products on or before the expiration date. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: A tour of the kitchen was conducted on [DATE] at 10:14 AM. During the tour, no date markings were observed on one open box of tomatoes, one bin of potatoes, or one open bag of onions in the walk-in refrigerator. The dry storage room had one open bag of wrapped potato chips with no date marking and nine thickened lemon-flavored water containers with expiration dates of [DATE]. On [DATE] at 11:36 AM, the Certified Dietary Manager (CDM) was notified that nine expired thickened lemon-flavored water containers were sitting on the shelf in the dry storage room. (Photographic evidence obtained) On [DATE] at 10:00 AM, nine expired thickened lemon-flavored water containers were observed still sitting on the shelf in the dry storage room. A follow-up tour of the kitchen was conducted on [DATE] at 11:05 AM. No date marking was observed on one open bag of onions or one open box of tomatoes in the walk-in refrigerator. The dry storage room had one thickened lemon-flavored water container with an expiration date of [DATE] sitting on the shelf. During the same tour, three expired thickened lemon-flavored water containers and one bottle of grape juice with no date marking were observed and discarded from the south unit nourishment room refrigerator. (Photographic evidence obtained) An interview was conducted on [DATE] at 1:40 PM with Dietary Aide/Cook A who reported that second shift dietary aides were responsible for stocking the dry storage room. The CDM and the cooks stocked the refrigerator and freezer. When asked to explain the facility's policy regarding date marking food products, Dietary Aide/Cook A stated any food received had to be labeled and dated. When food was opened, used, and placed back in the refrigerator or freezer, the food was placed in a safe container or saran wrapped, labeled with the date made or opened, and discarded after three days. The CDM was notified of any expired food that needed to be discarded. An interview was conducted on [DATE] at 1:45 PM with [NAME] B who reported that dietary aides were responsible for stocking the dry storage room. The morning shift dietary aides were responsible for stocking the refrigerator and freezer. When asked to explain the facility's policy regarding date marking food products, [NAME] B stated food products were labeled with the date delivered. Opened food was dated with the date opened or used. Expired food was discarded. Opened refrigerated food was discarded after three days. An interview was conducted with the CDM on [DATE] at 1:53 PM. She reported that evening staff were responsible for stocking the dry storage room. When asked to explain the facility's policy regarding date marking food products, the CDM confirmed all open food was dated and discarded after three days. When a food item was opened, used, and placed back in the refrigerator or freezer, the food item was wrapped, labeled with the date opened, and discarded after three days. A review of the facility's policy and procedure titled Food Receipt and Storage (dated [DATE]), revealed the Purpose: Foods should be received and stored properly to prevent foodborne illness . e. New items should be placed on the back of shelves with labels in view, with older items pulled to the front of the shelves for use. The First In First Out (FIFO) system should be used to rotate stock routinely. k. Open food items should be covered, labeled, and dated; open dry goods should be kept in tightly sealed containers. (Copy obtained) Reference: FDA Food Code 2022. https://www.fda.gov/media/164194/download (Accessed on [DATE]) Annex 5. Conducting Risk-Based Inspections Annex 5 - C. Intervention Strategies for Achieving Long-term Compliance. 4. Establish First-In-First-Out (FIFO) Procedures. Page 31. https://www.fda.gov/media/164194/download (Accessed on [DATE]): Product rotation is important for both quality and safety reasons. First-In-First Out (FIFO) means that the first batch of product prepared and placed in storage should be the first one sold or used. Date marking foods as required by the Food Code facilitates the use of a FIFO procedure in refrigerated, ready-to-eat, TCS foods. The FIFO concept limits the potential for pathogen growth, encourages product rotation, and documents compliance with time/temperature requirements.

Based on observation, interview, and record review, the facility failed to 1) Label drugs and biologicals in accordance with currently accepted professional principles, and 2) Ensure medications were not used past the expiration date for four (Residents #45, #3, #8, and #90) of 35 residents in the total survey sample. Failure to ensure medications are labeled appropriately and are not expired, pose a risk to resident health due to potentially reduced efficacy and contamination. The findings include: During medication administration observation on 09/10/24 at 10:40 AM, Licensed Professional Nurse (LPN) G was observed preparing a Novolog (insulin) FlexPen (a multi-dose injection pen designed to be used multiple times by the same receiver) for Resident #45. She read the label, placed a new needle on top of the FlexPen, primed the needle, set the correct ordered dose to be administered, and provided it for inspection. Reading the label revealed an opened date of 7/19/24 and an expired date of 8/16/24. When LPN G was asked to look at the expired date, she acknowledged that the FlexPen was past the expiration. She then asked if it was still okay to give. All insulin stored in LPN G's medication cart was reviewed and revealed the following: Two additional single-user, multi-dose prescriptions of insulin were past their expired date for Residents #3 and #8 (expired on 8/27/24 and 8/14/24 respectively). One insulin for Resident #90 had no opened or expired date. (Photographic evidence obtained) A review of the physician's order dated 8/6/23 for Resident #45 revealed Novolog (insulin aspart) per sliding scale before meals. A review of the August and September 2024 medication administration records (MARs) for Resident #45 indicated that the medication was administered daily beyond 8/16/24. A review of the physician's order dated 3/10/24 for Resident #3, revealed Levemir 100 units/milliliters, inject 12 units at bedtime. A review of the August and September 2024 MARs for Resident #3 revealed that the medication was administered daily beyond 8/27/24. A review of the physician's orders for Resident #8 revealed no current orders for Novolog or any other type of insulin. In a 09/11/24 interview with the Director of Nursing (DON) and the Nurse Manager for the unit LPN G was currently working on (LPN J) at 3:08 PM, they confirmed that Resident #8 did not have current orders for Novolog or any other type of insulin, but that he did back in July of 2024. They stated the current procedure for ensuring the removal of discontinued and/or expired medications in the medication carts was to have the nurse in charge of the medication cart at the time the medication is discontinued remove that medication from the cart. Nurses should be looking at the expiration dates and removing medications when they expired. Additionally, the nurse managers checked the medication carts weekly, on the weekend, for medications that had been discontinued and/or expired and removed them from the carts. A review of the facility's policy and procedure titled Storage and Expiration Dating of Medication and Biologicals (revised 08/01/24), revealed the following: General storage procedures: 10. The facility should ensure that medication and biologicals that :1) have an expired dated on the label ;2) have been retained longer than recommended by manufacture or supplier guideline; or 3) have been contaminated or deteriorated , are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 11. Once any medication or biological package is opened, facility should follow manufacturer/supplier guideline with respect to expiration dates for opened medication. Facility staff should record the date opened on the primary medication container ( i.e vial, bottle, inhaler) when the medication has a shortened expiration date once opened or opened 11.1 Facility staff may record the calculated expiration date based on date on the primary medication container. 11.2 mediations with the manufacturer's expiration date expressed in month and year will expire on the last day of the month. 11.3 If a multi-dose vial of the injectable medication has been opened or accessed ( e.g., needle punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different ( shorter or longer) date for that opened vial.

Based on observations and interviews, the facility failed to develop and implement a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This failure directly impacted residents in four (Rooms 108, 120, 121, and 126) of 66 resident rooms with the potential to impact every resident with a personal refrigerator. The findings include: During an initial tour of the facility on [DATE] from 9:30 AM through 12:00 PM, resident areas/rooms were observed: Multiple residents had personal refrigerators in their rooms. There were no temperature logs and expired food was located in the following rooms: Rooms 108, 120, 121, and 126. (Photographic evidence obtained for all) On [DATE] at 11:57 AM, a personal refrigerator was observed in a room occupied by Residents #3 and #59. Both residents were non-verbal. Upon opening the refrigerator, a live roach was observed crawling on the bottom shelf. An interview was conducted on [DATE] at 2:10 PM with Licensed Practical Nurse (LPN) J. She stated the overnight nurses were responsible for checking the residents' refrigerators. She further stated there were temperature log books kept at the nursing station. A tour of the North Wing was conducted with LPN J. The refrigerators in rooms 108, 120, 121, and 126 were observed. LPN J confirmed that there were expired food items in the refrigerators. When asked about the missing thermometers (rooms [ROOM NUMBERS]), she stated she was not sure why they were missing. She was shown the opened, unlabeled and expired items. She stated family members also brought food in without staff knowing. She was asked who should have been monitoring. She again stated it was the responsibility of the overnight nurses. She was asked to read the temperature in the refridgerator in room [ROOM NUMBER]. She stated it read 47 degrees F. She was asked what it should read. She stated she didn't know and she would have to check. She was shown the expired food items. She removed those items and discarded them. She was shown several open and undated/unlabeled items in the refrigerators in rooms [ROOM NUMBERS]. She stated these residents bought food items themselves. Again, she was asked who was responsible for making sure opened items were dated and labeled. She stated it was the responsibility of the overnight nurses. She was asked to provide the temperature logs for the residents' refrigerators. She retrieved a binder labeled N. Wing Temp Log. She stated this wasn't the correct information. At 2:22 PM, she left to find what she said she believed was the correct information. She returned stating she didn't find it. She retrieved another binder from the shelf labeled N. Wing Temp Log. Again, she said this was not the correct information. She stated the information was not current. Both binders were reviewed. The first binder contained information from 2022. The second binder contained information for February 2024. LPN J stated she wasn't able to locate anything more current, and she would have to consult with nursing. On [DATE] at 3:53 PM, the Director of Nursing (DON) was asked to provide a list of residents who had personal refrigerators in their rooms. She stated there was no list. An interview was conducted with the DON on [DATE] at 11:15 AM. She stated the facility did not have a policy for personal resident refrigerators. She stated the upkeep of the refrigerators was generally the responsibility of the nightshift staff. She added that the housekeepers would go in and do any deep cleaning required. She confirmed that LPN J was unable to locate any current temperature logs. She stated it wasn't something the facility had a structure or policy on and confirmed there were no recent logs. She stated they had discussed the concerns and determined there was some room for improvement.

Based on observations and interviews, the facility failed to provide its residents with a safe, clean, comfortable, and homelike environment, directly affecting residents in five (Rooms 118, 121, 124, 126, and 132) of 66 resident rooms. Failure to maintain a safe, clean comfortable environment could result in accidents, the spread of infection, and a negative impact to residents' psychosocial well-being. The findings include: During an initial tour of the facility on 9/9/2024 from 9:30 AM through 12:00 PM, the following environmental concerns in resident areas were observed: Heavily stained privacy curtains and window curtains, holes in window curtains, uncomfortable temperatures, and bug carcasses in the following resident rooms: Rooms 121, 118, 124, 126, and 132. (Photographic evidence obtained for all) During an interview on 9/9/2024 at 11:36 AM with Resident #9, she stated the air conditioning (AC) in her room had been broken for about a month. She further stated she and her roommate had both notified staff of their concerns regarding the AC unit. The roommate interjected during the interview stating she had night sweats and one of the facility's certified nursing assistants (CNAs) had provided her with a personal fan. A small blue fan was observed on the resident's overbed table. The roommate's face was light red in color with small beads of perspiration noted during the interview. Her hair was limp and damp. Resident #9 stated a CNA told her she would also bring her a fan. She stated she also perspired badly during the night. She further stated the CNA had not brought her the fan as of this date. The AC window unit displayed a temperature of 61 degrees Fahrenheit (F); however, the air could not be felt throughout the residents' room. While looking at the AC unit, the window curtains were observed with holes permitting the sun to come through. They were also heavily stained. A black hair clip was holding the curtains together. The residents' privacy curtains were also heavily stained. (Photographic evidence obtained for all) During an interview on 9/9/2024 at 12:54 PM with Resident #82, she stated she had resided in the facility for two years. The resident's bathroom light was flickering. The resident stated she had asked Maintenance to repair it. She further stated they had changed the bulb several times; however, the problem persisted. She said the flickering light bothered her. During an interview on 9/9/2027 at 2:46 PM with Resident #27, he stated he had concerns about pests. He saw them in his room alongside the window and in the bathroom. A dead roach was observed in resident's bath tub, and the resident's room had an overall unkempt appearance. The bedside table was soiled, the floors were dingy, and no personal items were observed. During an interview on 9/10/2024 at 11:22 AM with Resident #20, he stated his toilet had been broken for two days. He further stated he had an order for a laxative and had to go down the hall to use another restroom. The resident's toilet tank cover had been removed from the back of the toilet and was placed across the toilet bowl. Dirty water was observed in the toilet bowl. (Photographic evidence obtained) During another tour of the facility on 9/10/2024 at 11:57 AM, a personal refrigerator was observed in a room occupied by Residents #3 and #59. Both residents were non-verbal. The floor in front of the refrigerator was heavily stained. Upon opening the refrigerator, a live roach was observed crawling on the bottom shelf. At 12:01 PM, Resident #82 again stated she had informed Maintenance that the [electrical] ballast was broken and it wasn't the lightbulb. She stated she also sent the receptionist a text asking her to notify Maintenance about the flickering bathroom light. An interview was conducted with the Housekeeping Supervisor on 9/12/2024 at 11:30 AM. She stated the housekeeping department was responsible for cleaning the privacy curtains and the maintenance department was responsible for the window curtains. She stated the privacy curtains were taken down to be cleaned monthly and as needed. We take down the privacy curtains. She stated the housekeepers were responsible for reporting soiled linens. Every room was cleaned every day. A tour of the facility was conducted with the Housekeeping Supervisor and the Director of Maintenance at this time. The rooms where the environmental concerns were observed were toured. The Housekeeping Supervisor stated the housekeepers were responsible for catching that. She further stated the torn curtains were caused by the handles used to open the windows. They would all be replaced eventually. During this tour, in room [ROOM NUMBER], where a roach had previously been observed crawling in the resident's refrigerator, a roach was now observed crawling on the floor near the refrigerator. The Housekeeping Supervisor stepped on the roach. A second roach was observed crawling on the side of the resident's refridgerator. It was killed. The Housekeeping Supervisor and Director of Maintenance were directed to the small, empty roach eggs that were between the refrigerator and the wall. The Housekeeping Supervisor said she would notify the Administrator of the observation. An interview was conducted with the Director of Maintenance on 9/12/2024 at 12:13 PM. He acknowledged the flickering light in Resident #82's bathroom. He stated he had changed the bulb a couple of times. He observed the light was still flickering on the day of this interview. He stated he believed the [electrical] ballast needed to be replaced again. During an interview with the DON on 9/12/2024 at 11:15 AM, she confirmed that the facility had no established policies and procedures to address the environmental concerns identified during the survey.

Based on observations, interviews, and record reviews, the facility failed to ensure that two residents (#29 and #55) with limited range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. There were three residents reviewed for limited range of motion in a total survey sample of 35 residents. The findings include: 1. During the initial tour on 09/09/24 at 10:00 AM, Resident #29 was observed in her room seated in her wheelchair. She had left-sided weakness. Her left foot was dorsiflexed (upward bending and contracting) and crossed over her right foot. When she was asked if she had any concerns, she used a communication board with alphabet letters on her bedside table and spelled out, It she would like the mess cleaned up. She pointed across the room next to her TV. A splint was located under a heap of belongings there. When asked if she used the splint, she shook her head no. (Photographic evidence obtained) She was asked if anyone assisted her with range of motion and again, she shook her head no. During another observation on 09/09/24 at 11:00 AM, Resident #29 was in her room leaning forward with her head on the bedside table. She did not have a splint on her hand or foot. On 09/11/24 at 12:47 PM, Resident #29 was observed in her room having lunch. The heap of clothing, including the splint, had been removed. The resident did not have a splint on either of her upper or lower extremities. A review of the medical record revealed that Resident #29 was admitted to the facility on [DATE] with diagnoses including hemiplegia - left non-dominant side, cerebral infarction, chronic pain, carpal tunnel syndrome, aphasia, and tarsal tunnel syndrome. A review of the physician's orders, dated 8/23/24, revealed that the resident was an overnight get up with directions provided to wash, dress and get the resident up. Hydrocodone- Acetaminophen 7.5 - 325 milligrams (mg) every 6 hours for chronic pain was ordered on 8/1/24. Diclofenac sodium gel 1%, apply 2 grams topically to left deltoid, was ordered two times a day on 7/16/23. Another order dated 8/5/24, indicated that the resident required a sit-to-stand mechanical lift for transfers. There were no orders for a functional maintenance program or range of motion management. (Copies obtained) A review of the resident's care plan, revised on 9/4/24, revealed that the resident required staff assistance with all activities of daily living (ADLs) related to impaired mobility ( L) hemiplegia, non-ambulatory. The care plan also noted that the resident had a potential for contractures related to impaired mobility, hemiplegia, and muscle spasms. Interventions included following the current functional maintenance program (FMP) if one had been done. A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 6/6/24, revealed that the resident had a brief interview for mental status (BIMS) score of 15 out of 15 possible points, indicating intact cognition. She was documented as not receiving any kind of therapy including restorative therapy. A review of the physical therapy (PT) discharge summary, dated 9/12/23, revealed discharge recommendations for Resident #29 to be discharged to FMP for transfers, and to a certified nursing assistance maintenance program for ankle/foot orthosis (AFO) and sit-to-stand use. ( Copy obtained) 2. On 09/09/24 at 1:55 PM, Resident #55 was observed in bed. She had pillows under her knees. She stated she was getting therapy but ran out of time about two weeks ago. She added that she was notified she would be getting bed exercises at least two to three times a week, but she had not seen anyone yet. A review of the medical record revealed that Resident #55 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, long-term use of anticoagulants, contractures at the right knee, left knee, right ankle, and left ankle, pain in left hip, osteoporosis, fracture of unspecified part of neck of left femur, subsequent encounter for closed fracture with routine healing, and periprosthetic left hip joint subsequent encounter. A review of the physician's order dated 2/19/24, revealed that Hydrocodone-Acetaminophen 7.5 - 325 milligrams (mg) every 6 hours for chronic pain was ordered. On 8/8/24, Xtampza extended release (Oxycodone myristate) 13.5 mg every 12 hours for pain was ordered. There were also orders for a FMP. (Copies obtained) A review of the quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 8/6/24, revealed that the resident had a brief interview for mental status (BIMS) score of 14 out of 15 points, indicating intact cognition. The resident was documented as having received three days of physical therapy totalling 90 minutes during the 7-day look-back period. No restorative nursing or any other therapy was documented. A review of the physical therapy (PT) discharge summary, dated 8/13/24, revealed recommendations for the resident to be discharged to a restorative nursing program for active range of motion (AROM) to both lower extremities (BLE) as well as a splint and brace program. The summary also indicated that the splint and brace program was established for bilateral (both knees) knee extension orthotic for three hours per day for three to five days per week. The goal was to decrease further contractures of the ankle/knees. ( Copy obtained) In an interview on 09/12/24 at 1:22 PM, Certified Nursing Assistant (CNA)/Restorative Aide I stated when a resident was added to the program, the unit manager notifed them. She added that the therapy department also provided a referral with what the restorative aide should be working on and provided education as needed. When asked about Resident #55, CNA I stated the resident was on a FMP for transfers and training the resident on sit-to-stand mechanical lift use; however, the resident was refusing and her legs were buckling so the program was discontinued. When asked about the ankle/foot orthosis (AFO), CNA I stated the resident got up early in the morning and the CNAs assigned to her were responsible for putting on the AFO. She was then asked if Resident #55 was on a FMP program. She replied, As far a I know, she is still in the program for ROM. When asked how often the resident was receiving the exercises, CNA I reviewed the FMP weekly schedule and stated,Mondays, Thursdays and Saturdays. (Copy of schedule obtained) When asked if the sessions were documented, she said the restorative aide should document in the electronic charting system after every session. During an interview on 09/12/24 at 11:23 PM with Licensed Practical Nurse (LPN)/Unit Manager J, she was asked how she was informed of residents' progress on the FMP. She stated the restorative aides should document. She mentioned that when residents had more than a week of refusals, the interdisciplinary team reviewed the reasons for refusal and provided education to the resident. If the resident continued to refuse, the program was discontinued and the therapy department was notified. She was asked to review the FMP for Residents #29 and #55. She confirmed that she could find no documentation verifying that either resident was on the FMP. On 09/12/24 at 3:14 PM, the Director of Rehabilitation (DOR) was asked to explain the discharge recommendations on the PT discharge summaries for Residents #29 and #55. She stated Resident #29 required AFO and the task should be completed by a CNA. She stated the resident was on FMP for transfers and sit-to-stand. She continued to explain that Resident #55 was on a FMP for range of motion. When asked if she had been notified of any refusals, she replied no. She added that normally, if the resident refused the program, nursing should discontinue the program and assess the resident if PT screening was warranted. In a 09/12/24 interview at 3:44 PM, the Director of Nursing (DON) stated Resident #29 was not on a FMP due to refusal, and Resident #55 was on a FMP for ROM. When asked for the documentation for both residents including the documentation of refusals, the DON confirmed there was no documentation and stated she would initiate training right away. A review of the facility's policy and procure titled Restorative Services (Effective October 1, 2010), revealed that the policy's purpose was to ensure that residents received necessary rehabilitative services as determined by comprehensive reviews and care plans, to prevent avoidable physical and mental deterioration, and to assist them in obtaining or maintaining their highest practicable level of functional and psychosocial well-being. The policy further indicated that a comprehensive review should be completed on admission, quarterly, with any MDS (minimum data set assessment) and with a significant change in the residents condition. A comprehensive review included interviews with staff, residents, and family/significant others, along with reviewing and communicating with other members of the interdisciplinary team. Quarterly, significant change and MDS assessment, and restorative reviews should include: A review of the physician orders A review of the FMP to ensure it was still meeting the resident's needs and if not, obtain a physician's order for a therapy evaluation. A review of the the FMP's daily documentation, and Review and update the plan of care as needed.

Based on observations, record reviews, and staff interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections, by failing to perform appropriate hand hygiene during medication administration for two (Residents #13 and #33) of eight residents observed for medication administration from a total survey sample of 35 residents. The findings include: During another observation of medication administration on 9/11/24 at 1:10 PM, LPN H was observed preparing medication for Resident #13 at the nurses' station. LPN H reviewed the physician's orders and obtained two tablets of Buspirone 10 mg (milligrams), Clonazepam 0.5 mg, and Oxycodone-Acetaminophen 10-325 mg. She did not perform hand hygiene before popping medications into a medication cup. She then handed the medication cup with the medication to Resident #13 who was seated on his Rollator walker at the nurses' station. After the resident took the medication, LPN H discarded the cup in the trash but did not perform hand hygiene. She then pushed the medication cart to Resident #33. She reviewed the physician's orders and obtained acetaminophen (Tylenol) 325 mg for pain. She did not perform hand hygiene before popping two tablets into a medication cup and handing the medication to the resident. In an interview in 9/11/24 at 1:30 PM, LPN H was asked about hand hygiene during medication administration. She said, I knew I was forgetting something. A review of the facility's policy and procedure titled General Dose Preparation and Medication Administration (Revised 4/30/24), revealed that prior to preparing or administering medications, authorized and competent facility staff should follow infection control policy. Appropriate hand hygiene should be performed before and after direct resident contact.

Based on record review and an interview with the Business Office Manager, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for two (Resident #42 and Resident #22) of three residents sampled for review of Beneficiary Protection Notifications, from a total sample of 40 residents. The findings include: A review of Resident #42's medical record revealed an admitted [DATE]. His last covered day for Medicare Part A services was 7/19/2022. The resident was discharged from Medicare A and remained in the facility. A review of Resident #22's medical record revealed an admitted d of 7/25/2022. Her last covered day of Medicare Part A services was 8/17/2022. The resident was discharged from Medicare A and remained in the facility. A record review of Beneficiary Protection Notifications for three randomly selected residents, including Residents #42 and #22, who were discharged from a Medicare A covered stay with benefit days remaining in the past 6 months revealed the facility failed to issue Skilled Nursing Facility Advance Beneficiary Notices of Noncoverage (SNF ABN) when required. During an interview with the Business Office Manager (BOM) on 10/13/2022 at 11:37 a.m., she acknowledged that the notifications were not given to Residents #42 or #22. She stated she was new and was told not to give the SNF ABN forms to residents who were flipping to Medicaid. When asked who told her that, she stated she generally spoke with Social Services staff or the Minimum Data Set (MDS) nurse about these things. She further stated there was no documentation about when they spoke with the residents regarding possible liability, and she again stated the facility didn't use the SNF ABN forms. When asked about the break in coverage between Medicare A ending and Medicaid beginning, she stated residents could be liable for that charge. When asked how they would have been informed of that, she stated again that she was told not to use the SNF ABN and that there was no additional documentation. She stated the facility pre-screened residents and pretty much knew which residents would be eligible for Medicaid, but again there was no documentation or communication about possible charges due to a coverage lapse. .

Based on observations, interviews, and record reviews, the facility failed to ensure assessments accurately reflected residents' status for two (Resident #82 and Resident #93) of 40 residents sampled. Failure to accurately assess residents' care needs and medical status could result in a failure to provide needed care and services, resulting in complications and/or functional decline. The findings include: On 10/10/2022 at 2:45 p.m., Resident #82 was observed in his room lying in bed under the covers. He was greeted and he responded with garbled speech. At this time it was determined that the resident was not interviewable. Upon leaving Resident #82's room, Resident #93 was observed being escorted back to her room on a shower bed by two staff members. She was greeted and asked if she would agree to an interview once she returned to her room and got settled. She responded with grunts and giggles, reaching her hand out to make contact, and continuing to grunt, giggle, and motion for the surveyor's hand. At this time it was determined that the resident was not interviewable. During an interview with the Social Services Director (SSD) on 10/13/2022 at 11:38 a.m, she stated she had been employed with the facility since 3/7/2022. She added that she was responsible for completing section C of the Minimum Data Set (MDS) assessment. She stated she conducted the Brief Interview for Mental Status (BIMS) assessment for residents. She explained the process of how she completed the assessment, and stated she went in to see the resident and made an introduction. She asked the resident if they could hear/see her and if she could speak with them. She then asked the resident to repeat the three words and told them to remember the words. She asked the resident to repeat the three words. She stated at times she would give them cues to help them remember the words. She stated she then documented how many words they repeated on the first attempt, then she moved on to the day, year, month, week, then went back to the three words they were previously asked to repeat. She stated the cues were given if the resident couldn't repeat the three words. She was asked how the BIMS score was assessed for nonverbal residents. She stated staff who had worked with and/or were familiar with the resident did the assessment. She stated some of the nonverbal residents could nod, point or make a noise/sound in order to answer assessment questions. She stated the assessment was performed the same way for residents who were cognitively impaired, adding that what they could answer was used to determine their BIMS score. She stated there were times in an assessment that a dash (-) was documented in the answer section, indicating the resident's response was nonsensical or the resident failed to give an answer/response. She stated at times she referred to the MDS staff if she was unsure about an assessment, and there were times when multiple staff members would complete an assessment. When asked how Resident #82 was assessed, she stated he spoke very softly, very minimally, and does more pointing than verbal communication. He has a hard time talking, so I write the 12 months out and he points to the right month; I write the years out and he points to the correct year. She was asked if she could demonstrate this and she agreed. At 12:08 p.m., she went to the resident's room. She re-introduced herself, asked the resident if she could ask him a few questions, and then began the BIMS assessment. The resident responded to all questions asked with moaning and grunting. There were no intelligible words spoken, the resident did not make a pointing motion to communicate, nor did he nod or shake his head in response. The SSD stated she understood the resident's responses. The surveyor advised the SSD that she could not determine what the resident was saying. The SSD continued the assessment. When asked the current month, the resident grunted. The noise he made sounded nothing like a word. The surveyor observed that after each answer the SSD would reply yes, then say the correct answer indicating that the resident got it right. When asked to repeat bed, the resident did not answer. The SSD said to him, It's a piece of furniture. Then the resident pointed to the dresser. The SSD replied, Dresser? No, that's not correct. It was bed. You got that one wrong. The SSD thanked the resident for his time and exited the resident's room. The interview with the SSD continued upon leaving the resident's room. She was shown the previous MDS assessment where the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] .) She stated she understood the resident and maybe the previous SSDs could not. She stated the resident would grunt out words or whisper them softly, but she was able to understand him. During an interview with MDS Coordinator C on 10/3/2022 at 2:03 p.m., he was asked if there was a review for accuracy of the MDS assessments. He stated no. He further stated the MDS Coordinators reviewed each section of the assessment to ensure each section was complete however, they did not go back to determine whether the assessments were accurate. During an interview with MDS Coordinator D on 10/13/2022 at 2:31 p.m., she was asked if the MDS assessments were reviewed for accuracy. She stated she reviewed the assessments, but didn't question anything and assumed the MDS was correct unless there is something major. She stated she knew the residents and could usually determine if something was accurate. She confirmed that she knew Residents #82 and #93. She stated both of the residents were rarely understood and added that she could not determine whether the employee conducting the assessment documented accurately, as she was not in the room when the assessment was done. She was shown and asked about the variance in the BIMS score for both Residents #82 and #93. She stated she could not determine whether the assessment was accurate. She stated she didn't recall having any questions about the assessments, adding that ultimately the MDS Coordinators reviewed the assessments to ensure that they were complete but not necessarily accurate. She stated the MDS Coordinators just have to trust that each section was being completed correctly. During an interview with Licensed Practical Nurse (LPN) E on 10/13/2022 at 3:07 p.m., she stated she had been employed by the facility for seven years, six of which she worked as a Certified Nursing Assistant (CNA). She further stated she was familiar with Residents #82 and #93, and had worked with them extensively as a CNA. She stated neither resident could communicate verbally. She stated both residents were limited to yes or no answers, adding that both residents could also nod or shake their heads when asked yes or no questions. During an interview with CNA F on 10/13/2022 at 3:24 p.m., she stated she had been employed by the facility for approximately six months. She further stated she was familiar with and had worked with both Resident #82 and #93. Both residents required total assistance with their Activities of Daily Living (ADL's), and both residents could say some words, but were rarely understood. She stated the words are grumbled and that she called the nurse when she didn't understand. A review of the 1/26/2022 annual MDS assessment for Resident #82 revealed the resident rarely/never understood, and the BIMS score was not assessed due to the resident being rarely/never understood. A review of the 6/29/2022 quarterly MDS assessment for Resident #82 revealed unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation and scored a 13/15 on the BIMS assessment, indicating intact cognition. A review of the 9/14/2022 quarterly MDS assessment for Resident #82 revealed adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 12/15 on the BIMS assessment, indicating minimally impaired to intact cognition. A review of the most recent Care Plan for Resident #82 included a Focus on: Impaired communication related to [CONDITION(S)] with a Goal to continue to make needs known and Interventions including: Ask simple yes/no questions and give resident time to answer/respond and ask family for alternate means of communication A review of the 4/20/2022 quarterly MDS assessment revealed that Resident #93 had adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 3/15 on the BIMS assessment, indicating severe cognitive impairment. A review of the 7/6/2022 quarterly MDS assessment revealed Resident #93 had adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 3/15 on the BIMS assessment, indicating severed cognitive impairment. A review of the 9/21/2022 quarterly MDS assessment revealed Resident #93 had adequate hearing, unclear speech (slurred or mumbled words), sometimes understands, responds adequately to simple, direct communication only, usually understands, misses some part/intent of message but comprehends most conversation, and scored a 10/15 on the BIMS assessment, indicating moderately impaired cognition. A review of the most recent Care Plan for Resident #93 included a Focus on: Impaired communication related to [CONDITION(S)] secondary to [CONDITION(S)] ([CONDITION(S)]) and [CONDITION(S)] (TBI), uses non-verbal cues with a Goal to continue to make needs known and Interventions including: Ask simple yes/no questions and give resident time to answer or respond, ask family about alternative communication methods, use short simple sentences repeat, rephrase and adjust tones as needed.

Based on observations, interviews, and record review, the facility failed to ensure each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission, and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting appropriate to their needs for one (Resident #67) of 40 sampled residents. The findings include: A review of Resident #67's medical record on 10/10/22 at 2:36 p.m. and on 10/11/22 at 2:00 p.m. revealed no Pre-Admission Screening and Resident Review Process (PASARR) present. On 10/11/22 at 2:50 p.m., the Director of Nursing (DON) stated, I could not find the PASARR. We are going to do a new one now. A record review was conducted for Resident #67 noting an admitted [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment, dated 8/24/22, revealed that the resident entered from hospice and had a Brief Interview for Mental status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. He was expected to remain in the facility. An interview was conducted with the Admissions Coordinator at 11:25 a.m. on 10/13/22. She reported that part of the admission process was to acquire the 3008 transfer form, the PASARR, a face sheet, and the History and Physical upon admission. She reiterated that the PASARR should be received on the day the resident was admitted . She was asked whether a resident could be admitted without a PASARR, and she replied, I don't know. I would say no. An interview was conducted with Social Services Director (SSD) on 10/13/22 at 12:00 p.m. She stated her job was to make sure the PASARRs were in the residents' records. She stated the Director of Nursing (DON) would do the PASARR if facility did not get it on admission. She further stated she thought the PASARR was to be received on the day of admission. A review of the facility's policy titled Pre-Admission Screening for Mental [CONDITION(S)] and Mental Illness (Effective July 15, 2009), revealed under Process Level I Determinations must be signed and dated by a Registered Nurse (RN) at the admitting nursing facility on or before the date of admission. The nursing facility is responsible for ensuring that a Level I screening is completed, submitted and has a Level I Determination and/or a Level II if indicated, on or before nursing home admission and regardless of payment source. The original documents for the Level I and/or Level II determinations will be retained in the medical chart behind the Social Services tab. .

Based on observations, staff interviews, and facility record review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all residents who consumed foods from the facility's kitchen. The facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for food storage and proper sanitation practices in the kitchen. Specific instruction on food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: An initial tour of the kitchen was conducted with Dietary Manager (DM) G on 10/10/2022 at 10:25 a.m. During the tour, the bread cart in the dry storage pantry had three open bundles of bread that were not dated/labeled. The fryer was covered with grease buildup and food debris. The floor underneath the fryer had soiled grease and a buildup of food debris covering the drainage area. During an interview at the time of the observations, DM G stated, The cook or person working in the area is responsible for cleaning the fryer. A weekly cleaning schedule dated 10/8/2022 thru 10/9/2022 was obtained on 10/10/22, indicating the fryer and floor had been cleaned. The same observations previously mentioned were made again on 10/12/2022 at 11:10 a.m. and on 10/13/2022 at 3:30 p.m. (Photographic evidence obtained) Interviews were conducted with Cook I on 10/13/22 at 3:40 p.m. Cook I stated the policy for food storage, including leftovers was to wrap and date food items. She stated each staff member was designated to complete a cleaning task. Dietary Aides 1 and 2 were responsible for cleaning the floor. When asked who monitored the cleaning schedule for the kitchen and food service equipment, Cook I stated, the Dietary Manager. The Dietary Manager (DM), who was also present, stated the policy for food storage, including leftovers was to date the food item and discard it after three days. She stated, The weekly cleaning schedule is posted every Friday, and each position is assigned a cleaning task. The evening aides clean the floor daily and the DM walks through and checks the kitchen daily to ensure tasks are complete. A second copy of the weekly cleaning schedule, with a date that appeared to be marked through to read 10/8/2022 thru 10/14/2022 was obtained on 10/13/22 at 4:00 p.m. A review of the facility's policy and procedure entitled Sanitation Principles (dated 2/1/2022), revealed: Food service areas should be maintained in a clean and sanitary manner. The current USDA Food Code should be utilized as guidelines for the Department. a. Kitchens and dining areas should be kept clean, free from litter and rubbish, and protected from rodents, roaches, flies, and other insects. (Copy obtained) A review of the facility's policy and procedure entitled Safety Principles (dated 8/15/2009) revealed: To prevent injury to food service employees through exposure to heat, cold, chemicals and other workplace hazards. 10. Be sure ovens and stoves are free from grease at all times. Grease is a fire hazard. According to the United States Food and Drug Administration Food Code 2017. 3. Public Health and Consumer Expectations. Clean environment. Page 10. https://www.fda.gov (Accessed 0n 10/18/2022): It is a shared responsibility of the food industry and the government to ensure that food provided to the consumer is safe and does not become a vehicle in a disease outbreak or in the transmission of communicable disease. This shared responsibility extends to ensuring that consumer expectations are met, and that food is unadulterated, prepared in a clean environment, and honestly presented. According to the United States Food and Drug Administration Food Code 2017. 4.602.12. Cooking and Baking Equipment. Page 568. https://www.fda.gov (Accessed 0n 10/18/2022): Food-contact surfaces of cooking equipment must be cleaned to prevent encrustations that may impede heat transfer necessary to adequately cook food. Encrusted equipment may also serve as an insect attractant when not in use. Because of the nature of the equipment, it may not be necessary to clean cooking equipment as frequently as the equipment specified in S 4-602.11.

Based on observations and staff interviews, the facility failed to store dishware, covered or inverted, in a location where it was not exposed to splash, dust and other contamination. The facility failed to maintain two of the three microwaves used for residents, in a safe and sanitary manner. This deficient practice potentially affected all residents in the facility who took their meals from the facility's kitchen and/or obtained any food/beverage items from the North or South Unit nourishment rooms. The findings include: An initial tour of the kitchen was conducted on 3/8/2021 at 9:55 a.m. with the Dietary Manager (DM). During the tour, a plate dispenser was observed with no cover and plates were stored face-up. A second tour of the kitchen and interview with the DM was conducted on 3/11/2021 at 3:40 p.m. The plate dispenser was full of plates and they were not inverted or covered. Food splatter was observed on the rim of the plate dispenser next to the plates. (Photographic evidence obtained) The Dietary Manager acknowledged the potential for splatters and contamination of the eating surface of the plates at the time of the observation. An initial tour of the North Unit Nourishment Room was conducted on 3/10/2021 at 9:44 a.m. with a second visit on 3/11/2021 at 11:20 a.m. The microwave was observed heavily soiled with dark food splatter on the top inside surface, sides and corners during both visits. A tour of the South Unit Nourishment Room was conducted on 3/11/2021 at 12:25 p.m. The microwave was observed with a brown substance resembling coffee splatter on the top inside surface and sides. The counter appeared to have water damage and dark areas behind the sink and along the backsplash that resembled biological growth. (Photographic evidence obtained) An interview was conducted with the Dietary Manager on 3/11/2021 at 3:40 p.m. During the interview, she stated the equipment in the nourishment rooms was to be cleaned daily. A follow-up tour of the North and South Unit nourishment rooms was conducted with the Dietary Manager at the time of this interview. She observed both nourishment rooms and stated she would have them cleaned right away.

Based on observation, interview and record review, the facility failed to provide residents with private space to participate in resident groups and to ensure that staff, visitors or other guests attended resident group or family group meetings only with the respective group's invitation. This involved 10 residents participating in Resident Council on 3/10/2021 (Residents #78, #105, #66, #89, #359, #81, #12, #69, #18 and #59) out of 110 residents residing in the facility at the time of the investigation. The findings include: On 3/9/2021, the Activities Director and Resident Council President scheduled a resident council meeting. The meeting was held on 3/10/2021 at 10:30 a.m. in the facility's dining room. The Activities Director advised all facility staff present in the area where the meeting was to be held to leave, as this was to be a resident-only meeting. The Activities Director provided a copy of the Resident Council Meeting minutes for December 2020, January 2021 and February 2021. The Activities Director placed a sign on the outside of the door which read: Ssshhh RESIDENT COUNCIL MEETING IN SESSION Please do not disturb! There were 10 residents in attendance, including the President and Vice President of the Resident Council. When asked, the residents present in the meeting stated they normally met in the facility's dining room. During the meeting multiple staff were observed entering and exiting the area of the meeting causing the meeting to be paused. The residents in attendance stated that they preferred to meet without staff present, however, staff still came in and out of their meetings without regard to the sign placed on the door. The residents stated that this was a violation of their privacy, and they had made reports to facility staff. The residents voiced concerns with staff obtaining information discussed during their meetings and reporting it to other facility staff possibly resulting in retaliation. A review of the meeting minutes provided by the Activities Director revealed no concerns from the Resident Council during the meetings. When asked about this, the Resident Council President stated that the minutes were not accurate and these were not the minutes that she had taken during the meetings provided. During an interview on 3/10/2021 at 12:14 p.m. with the Administrator and Activities Director, they were advised of the concerns raised during the Resident Council meeting held on 3/10/2021 at 10:30 a.m., and of the concern with the inaccuracy of the meeting minutes provided. They could not explain why staff would continuously come in and out of the meeting, but agreed that this should not have been happening. They acknowledged previous concerns from the council regarding fear of reprisal. The Activities Director stated that the minutes she provided were not taken by the Resident Council President. She provided the survey team with the actual minutes taken by the Resident Council President. A record review revealed inconsistencies between the meeting minutes taken by the Resident Council President and the minutes provided by the Activities Director for meetings held in January 2021 and February 2021. During the meeting held on January 27, 2021, the council documented concerns with being treated with respect and dignity from the staff. This information was not included in the meeting minutes for the same date provided by the Activities Director. During an interview on 3/10/2021 at 1:26 p.m. with the Administrator, she was provided the documentation revealing the discrepancies in the Resident Council Meeting minutes. She stated she was not aware of the concerns raised. When asked how the residents' concerns were reported to her, she stated the Activities Director would obtain the minutes and communicate them to her. During an interview on 3/10/2021 at 2:29 p.m. with the Activities Director in the presence of the Administrator, she was asked why there were separate copies of the meeting minutes and to explain the inconsistencies between the two. She stated she re-wrote the minutes sometimes when the president's writing was not legible. She did not address the inconsistencies of the information, and neither did the Administrator. The Administrator stated again that she was not aware of this issue.

Based on observations, interviews and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for two resident (Residents #22 and #1) of three residents sampled for review of Activities of Daily Living (ADL) from a total of 38 residents in the sample. The findings include: 1. During a tour of the facility on 3/8/21 at 2:17 p.m., Resident #22 was observed lying in bed with dried saliva observed between her lips as she tried to speak. Her hair was unkempt with dandruff visible over her loosely plaited cornrows. Attempts were made to interview the resident on 3/8/21 at 2:25 p.m. The resident only nodded yes or shook her head no to simple questions. When asked whether the staff were cleaning her, she shook her head no. In a phone interview on 3/9/21 at 2:41 p.m., the resident's mother stated she had concerns about her daughter's care. She stated when she visited her daughter about two weeks ago, her hair and teeth were not clean. She added that the facility was supposed withdraw money from her daughter's personal funds account for hair care and other ADLs as needed, but her monthly statement revealed that no funds had been removed. The resident's mother also stated she had raised these concerns during a care plan meeting. She said before the COVID-19 pandemic, she would visit her daughter and help her with mouth care and she would provide drinks, but she was not sure now whether staff were paying attention to her daughter. She couldn;t verify whether they were, because she was unable to visit frequently. A review of the clinical record indicated that Resident #22 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set (MDS) assessment, dated 1/13/21, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5 out of a possible 15 points, indicating severe cognitive impairment. Resident #22 was also assessed to be totally dependent on staff for bed mobility, transfers, toileting and eating. Her current ADL care plan revealed the following interventions: Resident is unable to make choices at this time related to severe cognitive impairment, observe for inability to perform care, make bathing process pleasant by ensuring non-hurried atmosphere, give assistance as needed, assist with hair, assist with brushing teeth/oral care, bath per schedule. A review of the shower schedule revealed that the resident's shower days were Tuesdays, Thursdays and Saturdays. On 3/10/21 at 1:50 p.m., Employee A, Certified Nursing Assistant (CNA), stated residents were provided with showers/bed baths per the schedule and as needed (PRN). She further stated showers were documented in the electronic medical record software whe showers were provided or refused. If showers were refused, the nurses were notified. A review of the CNA task documentation revealed that Resident #22 had not received a shower or bed bath from 2/11/21 through 3/10/21. During an interview with Employee I, Registered Nurse (RN)/Unit Manager, on 3/11/21 at 10:30 a.m., she stated residents should receive showers/bed baths on their scheduled days and PRN. When asked whether she had conducted audits of the showers provided, she replied no. In an interview on 3/11/21 at 4:15 p.m. with the Director of nursing (DON), she was asked about the facility's provision of salon services. She stated during the pandemic salon services were not offered. Residents were receiving in-room services. She also stated residents were to receive hair care during their scheduled shower days. When asked if Resident #22 received hair care services, she confirmed that there was no documentation available to verify that she had. A review of the policy and procedure titled, Maintaining ADL skills NM.I.30, effective November 10, 2014, revealed: Purpose The facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychological well-being of the resident, in accordance with the comprehensive assessment and plan of care. 2. An observation of Resident #1, conducted on 3/8/21 at 11:12 a.m., found his fingernails on both hands unfiled and with jagged edges. Several nails were long, especially on the left hand, which was observed to be contracted (permanently shortened muscles or joints). The pointer finger on his right hand had a build-up of an unidentified dark substance under the nail. When asked if staff assisted him with nail care to his satisfaction, he looked at his nails but did not answer. In an interview with Employee E, Certified Nursing Assistant (CNA), on 3/10/21 at 9:34 a.m., she stated Resident #1 was alert and orientated and able to communicate using a communication board and finger spelling. He could assist with some activities of daily living (ADLs) using his good hand, the right. He needed assistance with handwashing. CNAs completed his nail care, and this was usually performed as needed and at shower time. An interview was conducted with Employee F, Registered Nurse (RN), on 3/10/21 at 9:59 a.m. She stated Resident #1 partially assisted with ADLs, depending on what you did with him. He had use of his right hand and could assist with handwashing. He didn't really let staff do his nails and he was care planned for that. He might allow it on a good day. Resident #1 was interviewed on 3/11/21 at 11:36 a.m. His fingernails were observed in the same condition during th einterview as they were during the 3/8/21 observation at 11:12 a.m. When asked if he was provided nail care by the aides, he did not respond. When asked if he had refused nail care, he shook his head no. When asked if he wanted his nails cleaned and trimmed, he nodded yes. Employee G, CNA, was interviewed on 3/11/21 at 11:38 a.m. He stated only nurses and someone from the outside did resident nail care. He said Resident #1 did not refuse care. In a second interview on 3/11/21 at 4:32 p.m., Employee G was asked to observe Resident #1's nails. He looked at the resident's nails, which remained in the originally observed state, and only said someone from the outside was supposed to do the residents' nails. In an interview with the Wound Care Nurse on 3/11/21 at 5:55 p.m., she stated CNAs could trim resident's fingernails, but only if the residents were not diabetic. A record review for Resident #1 found a Quarterly Minimum Data Set (MDS) assessment with an assessment reference date of 3/3/21. On this assessment, the resident was assessed with [REDACTED]. He usually understood others. Resident #1 was assessed with [REDACTED]. He was dependent on staff for personal hygiene and bathing. Active [DIAGNOSES REDACTED]. Resident #1 was care planned for behaviors including refusal of oral care. The care plan did not address any refusal of nail care. He was also care planned for total care with ADLs, however, interventions did not address nail care or when it should be performed. A review of nursing progress notes found nothing reflected about the provision or refusal of nail care. .

Based on observations, interviews and record reviews, the facility failed to provide nursing staff with the appropriate competencies and skills sets necessary to care for residents' needs, evidenced by one nurse (Employee A) failed to appropriately disinfect a blood glucose meter before or after its use for one resident (#86) out of a total of 21 residents who required blood glucose monitoring. Observations of the glucometers on all four of the facility's medication carts revealed that three (Both carts on the North Unit and one of two carts on the South Unit) of four carts contained a soiled glucometer. Resident #47, who was diagnosed with [REDACTED]. A 9/12/19 review of the facility's education records revealed that 13 (Employees A, C, D, I, L, M, N, O, P, Q, R, S, and T) of 32 nurses employed by the facility had never received any competency training related to glucometer use, cleaning or disinfection. These failures placed Resident #86 and all diabetic residents requiring blood glucose monitoring at risk for transmission of infectious bloodborne pathogens including [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV) and [MEDICAL CONDITIONS]. On 9/10/19 at 10:23 a.m., the Immediate Jeopardy (IJ) started. On 9/11/19 at 5:30 p.m., the Administrator and Director of Nursing were notified of the IJ determination. On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for licensed staff training/competencies related to glucometers. On 9/12/19 at 6:05 p.m., Immediate Jeopardy was removed after validation of the implementation of the IJ removal plan. The findings include: On 09/10/19 at 10:23 a.m., Employee A, Licensed Practical Nurse (LPN), was observed entering room S-11 to perform blood glucose monitoring for Resident #86. The resident declined to have her blood glucose tested at this time. Employee A returned to the medication cart and placed the glucometer, with the test strip still inserted, on top of the cart. Upon observation of the device, it was noted to be soiled with a red substance. It was also cracked open along one side. Employee A was asked when he would be going back to complete Resident #86's blood glucose testing, and he stated, in an hour. On 9/10/19 at 10:34 a.m., upon return to Employee A's medication cart, the glucometer was not observed. Employee A approached the cart and was asked for the device. He pulled it out of his right pant leg pocket. The glucometer was still cracked and soiled with a red substance as it had been when previously observed at 10:23 a.m. During an interview with the Employee A at this time, he confirmed that this was the same glucometer he took into Resident #86's room for use at 10:23 a.m. When asked how he cleaned and sanitized the glucometers, he stated, I clean them with the Sani-Wipes. I am actually about to get a copy of the policy and procedure to make sure we got it right. He was asked how he cleaned the device yesterday, and he stated, You would clean it with one wipe, wrap for three minutes, then sit it on a barrier to dry for at least another three minutes. When he was asked how many wipes he used, he stated he used one wipe for the entire process. When his attention was brought to the red substance on the device he stated, It could probably be cleaned. Yes, that could be blood. At 10:41 a.m., the Regional Nurse Consultant (RNC) approached Employee A's cart. She was shown the soiled glucometer and she stated, I don't know what that is. It looks old, so I think it is a stain. Let's see if it comes off. She removed a Sani-Wipe and lightly rubbed the glucometer, then stated, See it did not come off. When asked for another wipe and after gently wiping the device again, the red substance came right off. On 9/10/19 at 10:48 a.m., an observation was made of the North Front medication cart with Employee C, LPN. There were two glucometers on her cart. She stated they were both clean and ready to use. When asked how she cleaned the glucometers, she stated she wrapped them in a Sani-Wipe for two minutes, then let them air dry. Observation of both devices revealed that one had a dried, red substance on it. When the nurse was asked about the substance, she stated, That looks like dried blood. At that time, the Unit Manager approached the cart and interrupted her, stating, It is something red. She then told Employee C to make sure that she cleaned the device well, because whoever cleaned it last night did not get in the nooks and crannies. Employee C removed a Sani-Wipe and cleansed the device. The red substance came right off. On 9/10/19 at 11:03 a.m., an observation was made of the North Back medication cart with Employee D, Registered Nurse (RN). There were two glucometers on her cart. One glucometer had a dried, red substance on it. When asked how she cleaned the glucometers, she stated, I wrap them for two minutes, so they can be saturated per the directions. The Director of Nursing (DON) approached the cart and asked what was being discussed. She then took the soiled glucometer, donned gloves, and wrapped the device in a Sani-Wipe for two minutes. She stated, I am saturating it as per the directions for two minutes. She unwrapped the glucometer and the red substance was still observed. The DON asked for another Sani-Wipe and she wiped the device with some pressure applied. The red substance came off. A review of the facility's cleansing/disinfectant wipes (Super Sani-Cloth Germicidal Disposable Wipes) revealed they did not kill [MEDICAL CONDITIONS]. One (Resident #47) of the 21 residents who required blood glucose monitoring was diagnosed with [REDACTED]. The glucometer that was used for this resident was shared with eight other residents on that nursing unit who required blood glucose monitoring, and potentially exposing them to [MEDICAL CONDITION]. On 9/10/19 at 1:50 p.m., an interview was conducted with Employee D, RN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She confirmed that these were the only germicidal wipes used by the facility for cleaning/disinfecting glucometers. When she was asked whether these wipes killed [MEDICAL CONDITION], she replied, Yes they do. On 9/10/19 at 1:53 p.m., an interview was conducted with Employee A, LPN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. When asked whether these were the only wipes used for cleaning and disinfecting the glucometers, he stated that he had only ever seen these wipes in the facility. When he was asked whether they killed [MEDICAL CONDITION], he stated, Yes, as far as I know. On 9/10/19 at 1:55 p.m., an interview was conducted with Employee B, LPN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She verified that these wipes were the only germicidal wipes used by the facility. When she was asked whether they killed [MEDICAL CONDITION], she stated Yes. A review of the facility's Blood Glucose Monitor Cleaning Guidelines and the education records for all thirty-two (32) nurses employed, were reviewed on 9/12/19 and revealed that thirteen nurses had never received any competency training related to glucometer use, cleaning or disinfection. Employee A was one of these thirteen nurses along with Employees C, D, I, L, M, N, O, P, Q, R, S, and T. On 9/11/19 at 9:45 a.m., an interview was conducted with the DON, and she confirmed that the competencies conducted by the facility did not cover using/cleaning glucometers. At 10:10 a.m. on 9/11/19, during an interview ith the DON, she confirmed that the facility had no training at all related to glucometer cleaning prior to identifying the concern yesterday. She further stated that they identified a glucometer utilization/cleansing/disinfection concern in (MONTH) 2019 during a mock survey by Corporate. She stated they had not done any training or audits of nursing practice since identifying the concern in March. The competencies consisted of the following: License Nurse Skills Competency Evaluation Skill Glucometer/CBG Protocol/Emergent Care for Hypo and [MEDICAL CONDITION] Note: There was no competency listed for cleaning and/or disinfecting of the glucometers Blood Glucose Monitor Cleaning Guidelines - Prepare two surfaces (one for clean items and one for contaminated items, paper towels may be used) - Place disinfectant wipe on clean surface - Don (obtain) gloves, Do procedure, Place glucometer on contaminated surface - Remove gloves and put on a second pair - Clean glucometer with disinfectant wipe - Thoroughly wet surface for 2 minutes and allow to air dry - Place contaminated cleaning equipment in garbage bag and remove from room - Wash hands and take glucometer from room The facility had a medication audit report that they conducted as well; however, it did not address blood glucose monitoring. The audit report was as follows: Medication Administration Observation Report Techniques Observed Criteria Met Not Met N/A (not applicable) Med Cart: no missing supplies: clean, always visible or locked. Fluid and adjunctive foods are covered and dated. Resident properly identified before administration. Resident privacy maintained and positioned properly. For meds (medications) with parameters, vital signs are taken prior to administration. Correct medication verified by visual check of med, label and MAR. Liquid med measured accurately, shaken/diluted when appropriate. Proper crushing technique; non-crushable meds have MD (Medical Doctor) order. AC (before meals), PC (after meals), with meals, with food orders administered correctly. Resident observed to ensure medications are swallowed. Medication record is charted consistently/properly. Medications are not left on top of the cart, or at bedside. Refused/withheld medications are properly noted. PRN (as needed) medications administered/documented appropriately. Proper handwashing techniques at appropriate times. Ophthalmics (eye medications) administered properly. [MEDICATION NAME] (through the skin) patches rotated, removed, dated, and initialed properly. Inhalers properly administered/stored; mouthpiece clean. Injections properly prepared, administered and documented. Medication via [DEVICE] (enteral feeding tube) is properly administered. Controlled drugs documented properly at time of administration. All signatures/initials are correct. Medications administered per manufacture's specifications. Medications administered per facility policies and procedures. Facility Policy and Procedure Blood Glucose/PT/INR Machine Cleaning Guidelines 1. Prepare two surfaces, one for clean items and one for contaminated, paper towels may be used. 2. Place disinfectant wipe on clean surface with a pair of clean gloves. 3. Don first pair of gloves, do procedure, place glucometer on contaminated towel/surface. 4. Wash hands and put on second pair of gloves. 5. Clean glucometer with disinfectant wipe, place on clean surface, air dry per manufacture's recommendations. When visibly soiled two wipes will be needed, one for soiling and one for disinfecting afterwards. 6. Place all gloves and contaminated cleaning equipment in bag and remove from room, place lancet in sharps container. 7. Wash hands and take glucometer from room. 8. Disinfectant wipes should be stored in the med cart separate from the medications, i.e. separate basket. Super Sani-Cloth Germicidal Disposable Wipes To Disinfect: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) full minutes. Let air dry. For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting. Assure Platinum Glucometer Page 47 Cleaning and Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and a disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for licensed staff training/competencies related to glucometers, which consisted of the following: - Effective 9/12/19, the facility obtained Clorox Healthcare Bleach Germicidal Wipes, which kill [MEDICAL CONDITION]. - On 9/10/19, all glucometers were replaced with new ones. - On 9/11/19 and 9/12/19, audits were conducted by the Director of Nursing of all glucometers to ensure that they were clean and disinfected. - All licensed nurses would be re-educated prior to being permitted to work, and all training would be complete by 9/17/19. - On 9/12/19, the glucometer checklist used for evaluating nursing practice was updated to include a non-permeable barrier for blood glucose monitoring. - An emergency QAPI (Quality Assurance Improvement Plan) meeting was held on 9/12/19. - The QAPI plan initiated in (MONTH) 2019 for glucometer concerns was reviewed and extended through 9/25/19. As of 9/12/19 at 6:05 p.m., observation of the medication carts revealed the glucometers had been replaced. A review of the training records and audits revealed the facility had re-trained 18 nurses related to glucometer cleaning/disinfection and audits had been completed with no further concerns. The facility provided verification it had obtained the Clorox Bleach Wipes. Glucometer observations were conducted with four nurses working on 9/12/19, and all four performed the task appropriately. The facility's checklist for monitoring nursing practice related to glucometer use/cleansing/disinfection was reviewed with revisions observed. The QAPI plan was presented for review with an extension observed through 9/25/19, and an emergency QAPI meeting was held by all department heads and the Medical Director (via telephone) on 9/12/19.

Based on observations, interviews, record reviews, a review of the Assure Platinum Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, a review of the Super Sani-Cloth Germicidal Disposable Wipes product description and efficacy information, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure blood glucose meters were cleaned and disinfected during resident use to prevent the spread of bloodborne pathogens. During an observation of Blood Glucose Monitoring (BGM) via finger stick testing, one (Employee A) of one licensed practical nurses failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) before or after its use for one (Resident #86) of 21 residents requiring blood glucose monitoring. Observations of the glucometers on all four of the facility's medication carts revealed that three (Both carts on the North Unit and one of two carts on the South Unit) of four carts contained a soiled glucometer. Resident #47, who was diagnosed with [REDACTED]. These failures placed Resident #86 and all diabetic residents requiring blood glucose monitoring at risk for transmission of infectious bloodborne pathogens including [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV) and [MEDICAL CONDITIONS]. On 9/10/19 at 10:23 a.m., the Immediate Jeopardy (IJ) started. On 9/11/19 at 5:30 p.m., the Administrator and Director of Nursing were notified of the IJ determination. On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for the appropriate use, cleansing and disinfection of glucometers. On 9/12/19 at 6:05 p.m., Immediate Jeopardy was removed after validation of the implementation of the IJ removal plan. The findings include: On 09/10/19 at 10:23 a.m., Employee A, Licensed Practical Nurse (LPN), was observed entering room S-11 to perform blood glucose monitoring for Resident #86. The resident declined to have her blood glucose tested at this time. Employee A returned to the medication cart and placed the glucometer, with the test strip still inserted, on top of the cart. Upon observation of the device, it was noted to be soiled with a red substance. It was also cracked open along one side. Employee A was asked when he would be going back to complete Resident #86's blood glucose testing, and he stated, in an hour. On 9/10/19 at 10:34 a.m., upon return to Employee A's medication cart, the glucometer was not observed. Employee A approached the cart and was asked for the device. He pulled it out of his right pant leg pocket. The glucometer was still cracked and soiled with a red substance as it had been when previously observed at 10:23 a.m. During an interview with the Employee A at this time, he confirmed that this was the same glucometer he took into Resident #86's room for use at 10:23 a.m. When asked how he cleaned and sanitized the glucometers, he stated, I clean them with the Sani-Wipes. I am actually about to get a copy of the policy and procedure to make sure we got it right. He was asked how he cleaned the device yesterday, and he stated, You would clean it with one wipe, wrap for three minutes, then sit it on a barrier to dry for at least another three minutes. When he was asked how many wipes he used, he stated he used one wipe for the entire process. When his attention was brought to the red substance on the device he stated, It could probably be cleaned. Yes, that could be blood. At 10:41 a.m., the Regional Nurse Consultant (RNC) approached Employee A's cart. She was shown the soiled glucometer and she stated, I don't know what that is. It looks old, so I think it is a stain. Let's see if it comes off. She removed a Sani-Wipe and lightly rubbed the glucometer, then stated, See it did not come off. When asked for another wipe and after gently wiping the device again, the red substance came right off. On 9/10/19 at 10:48 a.m., an observation was made of the North Front medication cart with Employee C, LPN. There were two glucometers on her cart. She stated they were both clean and ready to use. When asked how she cleaned the glucometers, she stated she wrapped them in a Sani-Wipe for two minutes, then let them air dry. Observation of both devices revealed that one had a dried, red substance on it. When the nurse was asked about the substance, she stated, That looks like dried blood. At that time, the Unit Manager approached the cart and interrupted her, stating, It is something red. She then told Employee C to make sure that she cleaned the device well, because whoever cleaned it last night did not get in the nooks and crannies. Employee C removed a Sani-Wipe and cleansed the device. The red substance came right off. On 9/10/19 at 11:03 a.m., an observation was made of the North Back medication cart with Employee D, Registered Nurse (RN). There were two glucometers on her cart. One glucometer had a dried, red substance on it. When asked how she cleaned the glucometers, she stated, I wrap them for two minutes, so they can be saturated per the directions. The Director of Nursing (DON) approached the cart and asked what was being discussed. She then took the soiled glucometer, donned gloves, and wrapped the device in a Sani-Wipe for two minutes. She stated, I am saturating it as per the directions for two minutes. She unwrapped the glucometer and the red substance was still observed. The DON asked for another Sani-Wipe and she wiped the device with some pressure applied. The red substance came off. A review of the facility's cleansing/disinfectant wipes (Super Sani-Cloth Germicidal Disposable Wipes) revealed they did not kill [MEDICAL CONDITIONS]. One (Resident #47) of the 21 residents who required blood glucose monitoring was diagnosed with [REDACTED]. The glucometer that was used for this resident was shared with eight other residents on that nursing unit who required blood glucose monitoring, and potentially exposing them to [MEDICAL CONDITION]. On 9/10/19 at 1:50 p.m., an interview was conducted with Employee D, RN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She confirmed that these were the only germicidal wipes used by the facility for cleaning/disinfecting glucometers. When she was asked whether these wipes killed [MEDICAL CONDITION], she replied, Yes they do. On 9/10/19 at 1:53 p.m., an interview was conducted with Employee A, LPN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. When asked whether these were the only wipes used for cleaning and disinfecting the glucometers, he stated that he had only ever seen these wipes in the facility. When he was asked whether they killed [MEDICAL CONDITION], he stated, Yes, as far as I know. On 9/10/19 at 1:55 p.m., an interview was conducted with Employee B, LPN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She verified that these wipes were the only germicidal wipes used by the facility. When she was asked whether they killed [MEDICAL CONDITION], she stated Yes. A review of the facility's policy and procedure for Blood Glucose/PT/INR Device Cleaning Guidelines revealed: 1. Prepare two surfaces, one for clean items and one for contaminated, paper towels may be used. 2. Place disinfectant wipe on clean surface with a pair of clean gloves. 3. Don first pair of gloves, do procedure, place glucometer on contaminated towel/surface. 4. Wash hands and put on second pair of gloves. 5. Clean glucometer with disinfectant wipe, place on clean surface, air dry per manufacture's recommendations. When visibly soiled two wipes will be needed, one for soiling and one for disinfecting afterwards. 6. Place all gloves and contaminated cleaning equipment in bag and remove from room, place lancet in sharps container. 7. Wash hands and take glucometer from room. 8. Disinfectant wipes should be stored in the med cart separate from the medications, i.e.:separate basket. A review of the Super Sani-Cloth Germicidal Disposable Wipes revealed: To Disinfect: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) full minutes. Let air dry. For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting. Note: These wipes do not kill [MEDICAL CONDITION] A review of the Assure Platinum Cleaning and Disinfection Guidelines revealed: Page 47 Cleaning and Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and a disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration (6/8/2017) revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for the appropriate use, cleansing and disinfection of glucometers, which included the following: - Effective 9/12/19, the facility obtained Clorox Healthcare Bleach Germicidal Wipes, which kill [MEDICAL CONDITION]. - On 9/10/19, all glucometers were replaced with new ones. - On 9/11/19 and 9/12/19, audits were conducted by the Director of Nursing of all glucometers to ensure that they were clean and disinfected. - All licensed nurses would be re-educated prior to being permitted to work, and all training would be complete by 9/17/19. - On 9/12/19, the glucometer checklist used for evaluating nursing practice was updated to include a non-permeable barrier for blood glucose monitoring. - An emergency QAPI (Quality Assurance Improvement Plan) meeting was held on 9/12/19. - The QAPI plan initiated in (MONTH) 2019 for glucometer concerns was reviewed and extended through 9/25/19. As of 9/12/19 at 6:05 p.m., observation of the medication carts revealed the glucometers had been replaced. A review of the training records and audits revealed the facility had re-trained 18 nurses related to glucometer cleaning/disinfection and audits had been completed with no further concerns. The facility provided verification it had obtained the Clorox Bleach Wipes. Glucometer observations were conducted with four nurses working on 9/12/19, and all four performed the task appropriately. The facility's checklist for monitoring nursing practice related to glucometer use/cleansing/disinfection was reviewed with revisions observed. The QAPI plan was presented for review with an extension observed through 9/25/19, and an emergency QAPI meeting was held by all department heads and the Medical Director (via telephone) on 9/12/19.

Based on observations, record reviews, interviews and the facility's policy and procedure for Quality Assurance Performance Improvement (QAPI), the facility failed to ensure quality assurance monitoring of facility processes related to resident protection from communicable and infectious diseases, and to ensure identification of potential problems related to blood glucose monitoring. This had the potential to affect/harm all twenty-one (21) residents in the facility requiring blood glucose monitoring and could lead to the transmission of potentially infectious bloodborne pathogens including [MEDICAL CONDITIONS], and [MEDICAL CONDITIONS]. On 9/10/19 at 10:23 a.m., the Immediate Jeopardy (IJ) started. On 9/11/19 at 5:30 p.m., the Administrator and Director of Nursing were notified of the IJ determination. On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for consistent, ongoing monitoring of licensed staff's practices as related to glucometers, and follow-up of previously identified concerns through the facility's QAPI process. On 9/12/19 at 6:05 p.m., Immediate Jeopardy was removed after validation of the implementation of the IJ removal plan. The findings include: On 09/10/19 at 10:23 a.m. Employee A, Licensed Practical Nurse (LPN), was observed entering room S-11 to perform blood glucose monitoring for Resident #86. The resident declined to have her blood glucose tested at this time. Employee A returned to the medication cart and placed the glucometer, with the test strip still inserted, on top of the cart. Upon observation of the device, it was noted to be soiled with a red substance. It was also cracked open along one side. Employee A was asked when he would be going back to complete Resident #86's blood glucose testing, and he stated, in an hour. On 9/10/19 at 10:34 a.m., upon return to Employee A's medication cart, the glucometer was not observed. Employee A approached the cart and was asked for the device. He pulled it out of his right pant leg pocket. The glucometer was still cracked and soiled with a red substance as it had been when previously observed at 10:23 a.m. During an interview with the Employee A at this time, he confirmed that this was the same glucometer he took into Resident #86's room for use at 10:23 a.m. When asked how he cleaned and sanitized the glucometers, he stated, I clean them with the Sani-Wipes. I am actually about to get a copy of the policy and procedure to make sure we got it right. He was asked how he cleaned the device yesterday, and he stated, You would clean it with one wipe, wrap for three minutes, then sit it on a barrier to dry, for at least another three minutes. When he was asked how many wipes he used, he stated he used one wipe for the entire process. When his attention was brought to the red substance on the device he stated, It could probably be cleaned. Yes, that could be blood. At 10:41 a.m., the Regional Nurse Consultant (RNC) approached Employee A's cart. She was shown the soiled glucometer and she stated, I don't know what that is. It looks old, so I think it is a stain. Let's see if it comes off. She removed a Sani-Wipe and lightly rubbed the glucometer, then stated, See it did not come off. When asked for another wipe and after gently wiping the device again, the red substance came right off. On 9/10/19 at 10:48 a.m., an observation was made of the North Front medication cart with Employee C, LPN. There were two glucometers on her cart. She stated they were both clean and ready to use. When asked how she cleaned the glucometers, she stated she wrapped them in a Sani-Wipe for two minutes, then let them air dry. Observation of both devices revealed that one had a dried, red substance on it. When the nurse was asked about the substance, she stated, That looks like dried blood. At that time, the Unit Manager approached the cart and interrupted her, stating, It is something red. She then told Employee C to make sure that she cleaned the device well, because whoever cleaned it last night did not get in the nooks and crannies. Employee C removed a Sani-Wipe and cleansed the device. The red substance came right off. On 9/10/19 at 11:03 a.m., an observation was made of the North Back medication cart with Employee D, Registered Nurse (RN). There were two glucometers on her cart. One glucometer had a dried, red substance on it. When asked how she cleaned the glucometers, she stated, I wrap them for two minutes, so they can be saturated per the directions. The Director of Nursing (DON) approached the cart and asked what was being discussed. She then took the soiled glucometer, donned gloves, and wrapped the device in a Sani-Wipe for two minutes. She stated, I am saturating it as per the directions for two minutes. She then unwrapped the glucometer and the red substance was still observed. The DON asked for another Sani-Wipe and she wiped the device with some pressure. The red substance came right off. A review of the facility's cleansing/disinfectant wipes (Super Sani-Cloth Germicidal Disposable Wipes) revealed they did not kill [MEDICAL CONDITIONS]. One (Resident #47) of the 21 residents who required blood glucose monitoring was also diagnosed with [REDACTED]. On 9/10/19 at 1:50 p.m., an interview was conducted with Employee D, RN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She confirmed that these were the only germicidal wipes used by the facility for cleaning/disinfecting glucometers. When she was asked whether these wipes killed [MEDICAL CONDITION], she replied, Yes they do. On 9/10/19 at 1:53 p.m., an interview was conducted with Employee A, LPN regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. When asked whether these were the only wipes used for cleaning and disinfecting the glucometers, he stated that he had only ever seen these wipes in the facility. When he was asked whether they killed [MEDICAL CONDITION], he stated, Yes, as far as I know. On 9/10/19 at 1:55 p.m., an interview was conducted with Employee B, LPN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She verified that these wipes were the only germicidal wipes used by the facility. When she was asked whether they killed [MEDICAL CONDITION], she stated Yes. On 9/10/19 at 5:03 p.m., the Regional Nurse Consultant (RNC) and the Director of Nursing (DON) stated they had already identified the concerns with the soiled glucometers and had addressed them during their (MONTH) 2019 QAPI meeting, but admitted that they had failed to follow up with this QAPI plan. They confirmed that the soiled glucometers had been an ongoing problem, and they had failed to conduct any audits and/or implement any improvement plans. On 9/11/19 at 9:45 a.m., an interview was conducted with the DON, and she confirmed that the competencies conducted by the facility did not cover using/cleaning glucometers. On 9/11/19 at 10:10 a.m. during an interview ith the DON, she confirmed that the facility had no training at all related to glucometer cleaning prior to identifying the concern yesterday. She further stated that they identified a glucometer utilization/cleansing/disinfection concern in (MONTH) 2019 during a mock survey by Corporate. She stated they had not done any training or audits of nursing practice since identifying the concern in March. A review of the facility's Quality Assurance/Quality Assurance Performance Improvement (QAPI) Policy and Procedure effective 11/1/17 revealed: Policy: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting/exceeding the needs, expectations and requirements of the resident/guest cost effectively while maintaining good resident/guest outcomes and perceptions of resident/guest care. QAPI committee will meet quarterly and QAPI Steering Committees will meet at a minimum of monthly. Scope: Our facilities have a Performance Improvement Program which systematically monitors data, analyzes and improves its performance to improve resident/guest outcomes. It recognizes that value in healthcare is the appropriate balance between good measures, excellent care, services and cost. QAPI Plan addresses: a. Clinical Care b. Quality of Life c. Resident/Guest Choices d. Performance Metrics 1. We will use the performance metrics to identify areas of improvement and rank them by factors (such as prevalence, risk, cost, relevance, responsiveness, feasibility, continuity). From this we will determine our Process Improvement Projects (PIP). Our focus will also be on how we can create innovative best practices while making sure resident/guest's autonomy is maintained. 2. Review of past facility measures will be used to benchmark for improvement in all areas. These benchmarks will be reviewed at least monthly and reported to the QAPI committee on a quarterly basis. 1. Governance and Leadership: Administration is accountable for developing, leading, and closely monitoring of QAPI program. a. Input is obtained from facility staff on a monthly basis through the QAPI Steering committees. The committees are responsible for talking to their employees before reporting findings to QAPI. Resident/guests/families have input throughout resident/guest/family council and satisfaction surveys. b. The input given will be acted upon and brings QAPI to life in the facility. Concerns are brought up when a certain department or task is not meeting benchmark. The concern will be discussed and action plans developed. If necessary, a chartered PIP will be established. c. The administrator will be the Quality Management Coordinator and responsible for the (company) QAPI process . IV. Feedback, Data Systems and Monitoring a. QAPI is integrated into the responsibilities and accountabilities of all Regional, Senior Management and Executive Team. b. The following data is monitored through QAPI: i. Input from caregivers, residents/guests, families and others ii. Adverse events iii. Performance indicators . iv. Facility assessments v. Survey findings vi. Complaints c. Process for collecting the above information: i. Gather input from caregivers, residents/guests, families and other meetings ii. Adverse events, incident reports and 24 hour reports . d. The information gathered is analyzed and compared to bench marks that have been set quarterly: i. Current scores are analyzed against bench marks that have been set quarterly ii. Daily IDT (interdisciplinary Team) notes are reviewed including adverse events/complaints and during clinical meetings. We have a mechanism of communicating patterns, trends identified during IDT meetings to the broader QAPI committee . iv. QAPI team will analyze data regularly as part of their project assignments . On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for consistent, ongoing monitoring of licensed staff's practice as related to glucometers, and follow-up of previously identified concerns through the facility's QAPI process, which included the following: - Effective 9/12/19, the facility obtained Clorox Healthcare Bleach Germicidal Wipes, which kill [MEDICAL CONDITION]. - On 9/10/19, all glucometers were replaced with new ones. - On 9/11/19 and 9/12/19, audits were conducted by the Director of Nursing of all glucometers to ensure that they were clean and disinfected. - All licensed nurses would be re-educated prior to being permitted to work, and all training would be complete by 9/17/19. - On 9/12/19, the glucometer checklist used for evaluating nursing practice was updated to include a non-permeable barrier for blood glucose monitoring. - An emergency QAPI (Quality Assurance Improvement Plan) meeting was held on 9/12/19. - The QAPI plan initiated in (MONTH) 2019 for glucometer concerns was reviewed and extended through 9/25/19. As of 9/12/19 at 6:05 p.m., observation of the medication carts revealed the glucometers had been replaced. A review of the training records and audits revealed the facility had re-trained 18 nurses related to glucometer cleaning/disinfection and audits had been completed with no further concerns. The facility provided verification it had obtained the Clorox Bleach Wipes. Glucometer observations were conducted with four nurses working on 9/12/19, and all four performed the task appropriately. The facility's checklist for monitoring nursing practice related to glucometer use/cleansing/disinfection was reviewed with revisions observed. The QAPI plan was presented for review with an extension observed through 9/25/19, and an emergency QAPI meeting was held by all department heads and the Medical Director (via telephone) on 9/12/19. ,

Based on observations, record reviews and interviews, 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 well-being of each resident, by failing to ensure consistent nursing practice and education/training as it related to blood glucose monitoring. During an observation of blood glucose monitoring (BGM), one nurse (Employee A) failed to appropriately disinfect a blood glucose meter before or after its use for one resident (#86) out of a total of 21 residents who required blood glucose monitoring. Observations of the glucometers on all four of the facility's medication carts revealed that three (Both carts on the North Unit and one of two carts on the South Unit) of four carts contained a soiled glucometer. Resident #47, who was diagnosed with [REDACTED]. A 9/12/19 review of the facility's education records revealed that 13 (Employees A, C, D, I, L, M, N, O, P, Q, R, S, and T) of 32 nurses employed by the facility had never received any competency training related to glucometer use, cleaning or disinfection, the facility failed to follow through on a previously identified (March 2019) concern related to glucometer use/cleansing/disinfection, and the facility clinical management was not monitoring the disinfection process of their glucometers. On 9/10/19 at 10:23 a.m., the Immediate Jeopardy (IJ) started. On 9/11/19 at 5:30 p.m., the Administrator and Director of Nursing were notified of the IJ determination. On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for licensed staff training/competencies, a consistent monitoring process, and utilization/cleansing/disinfection of and related to glucometers. On 9/12/19 at 6:05 p.m., Immediate Jeopardy was removed after validation of the implementation of the IJ removal plan. The findings include: On 09/10/19 at 10:23 a.m., Employee A, Licensed Practical Nurse (LPN), was observed entering room S-11 to perform blood glucose monitoring for Resident #86. The resident declined to have her blood glucose tested at this time. Employee A returned to the medication cart and placed the glucometer, with the test strip still inserted, on top of the cart. Upon observation of the device, it was noted to be soiled with a red substance. It was also cracked open along one side. Employee A was asked when he would be going back to complete Resident #86's blood glucose testing, and he stated, in an hour. On 9/10/19 at 10:34 a.m., upon return to Employee A's medication cart, the glucometer was not observed. Employee A approached the cart and was asked for the device. He pulled it out of his right pant leg pocket. The glucometer was still cracked and soiled with a red substance as it had been when previously observed at 10:23 a.m. During an interview with the Employee A at this time, he confirmed that this was the same glucometer he took into Resident #86's room for use at 10:23 a.m. When asked how he cleaned and sanitized the glucometers, he stated, I clean them with the Sani-Wipes. I am actually about to get a copy of the policy and procedure to make sure we got it right. He was asked how he cleaned the device yesterday, and he stated, You would clean it with one wipe, wrap for three minutes, then sit it on a barrier to dry for at least another three minutes. When he was asked how many wipes he used, he stated he used one wipe for the entire process. When his attention was brought to the red substance on the device he stated, It could probably be cleaned. Yes, that could be blood. At 10:41 a.m., the Regional Nurse Consultant (RNC) approached Employee A's cart. She was shown the soiled glucometer and she stated, I don't know what that is. It looks old, so I think it is a stain. Let's see if it comes off. She removed a Sani-Wipe and lightly rubbed the glucometer, then stated, See it did not come off. When asked for another wipe and after gently wiping the device again, the red substance came right off. On 9/10/19 at 10:48 a.m., an observation was made of the North Front medication cart with Employee C, LPN. There were two glucometers on her cart. She stated they were both clean and ready to use. When asked how she cleaned the glucometers, she stated she wrapped them in a Sani-Wipe for two minutes, then let them air dry. Observation of both devices revealed that one had a dried, red substance on it. When the nurse was asked about the substance, she stated, That looks like dried blood. At that time, the Unit Manager approached the cart and interrupted her, stating, It is something red. She then told Employee C to make sure that she cleaned the device well, because whoever cleaned it last night did not get in the nooks and crannies. Employee C removed a Sani-Wipe and cleansed the device. The red substance came right off. On 9/10/19 at 11:03 a.m., an observation was made of the North Back medication cart with Employee D, Registered Nurse (RN). There were two glucometers on her cart. One glucometer had a dried, red substance on it. When asked how she cleaned the glucometers, she stated, I wrap them for two minutes, so they can be saturated per the directions. The Director of Nursing (DON) approached the cart and asked what was being discussed. She then took the soiled glucometer, donned gloves, and wrapped the device in a Sani-Wipe for two minutes. She stated, I am saturating it as per the directions for two minutes. She unwrapped the glucometer and the red substance was still observed. The DON asked for another Sani-Wipe and she wiped the device with some pressure applied. The red substance came off. A review of the facility's cleansing/disinfectant wipes (Super Sani-Cloth Germicidal Disposable Wipes) revealed they did not kill [MEDICAL CONDITIONS]. One (Resident #47) of the 21 residents who required blood glucose monitoring was diagnosed with [REDACTED]. The glucometer that was used for this resident was shared with eight other residents on that nursing unit who required blood glucose monitoring, and potentially exposing them to [MEDICAL CONDITION]. On 9/10/19 at 1:50 p.m., an interview was conducted with Employee D, RN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She confirmed that these were the only germicidal wipes used by the facility for cleaning/disinfecting glucometers. When she was asked whether these wipes killed [MEDICAL CONDITION], she replied, Yes they do. On 9/10/19 at 1:53 p.m., an interview was conducted with Employee A, LPN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. When asked whether these were the only wipes used for cleaning and disinfecting the glucometers, he stated that he had only ever seen these wipes in the facility. When he was asked whether they killed [MEDICAL CONDITION], he stated, Yes, as far as I know. On 9/10/19 at 1:55 p.m., an interview was conducted with Employee B, LPN, regarding the Sani-Wipes (purple top container) used for cleaning and disinfecting the glucometers. She verified that these wipes were the only germicidal wipes used by the facility. When she was asked whether they killed [MEDICAL CONDITION], she stated Yes. A review of the facility's Blood Glucose Monitor Cleaning Guidelines and the education records for all thirty-two (32) nurses employed, were reviewed on 9/12/19 and revealed that thirteen nurses had never received any competency training related to glucometer use, cleaning or disinfection. Employee A was one of these thirteen nurses along with Employees C, D, I, L, M, N, O, P, Q, R, S, and T. On 9/11/19 at 9:45 a.m., an interview was conducted with the DON, and she confirmed that the competencies conducted by the facility did not cover using/cleaning glucometers. At 10:10 a.m. on 9/11/19, during an interview ith the DON, she confirmed that the facility had no training at all related to glucometer cleaning prior to identifying the concern yesterday. She further stated that they identified a glucometer utilization/cleansing/disinfection concern in (MONTH) 2019 during a mock survey by Corporate. She stated they had not done any training or audits of nursing practice since identifying the concern in March. The competencies consisted of the following: License Nurse Skills Competency Evaluation Skill Glucometer/CBG Protocol/Emergent Care for Hypo and [MEDICAL CONDITION] Note: There was no competency listed for cleaning and/or disinfecting of the glucometers Blood Glucose Monitor Cleaning Guidelines - Prepare two surfaces (one for clean items and one for contaminated items, paper towels may be used) - Place disinfectant wipe on clean surface - Don (obtain) gloves, Do procedure, Place glucometer on contaminated surface - Remove gloves and put on a second pair - Clean glucometer with disinfectant wipe - Thoroughly wet surface for 2 minutes and allow to air dry - Place contaminated cleaning equipment in garbage bag and remove from room - Wash hands and take glucometer from room The facility had a medication audit report that they conducted as well; however, it did not address blood glucose monitoring. The audit report was as follows: Medication Administration Observation Report Techniques Observed Criteria Met Not Met N/A (not applicable) Med Cart: no missing supplies: clean, always visible or locked. Fluid and adjunctive foods are covered and dated. Resident properly identified before administration. Resident privacy maintained and positioned properly. For meds (medications) with parameters, vital signs are taken prior to administration. Correct medication verified by visual check of med, label and MAR. Liquid med measured accurately, shaken/diluted when appropriate. Proper crushing technique; non-crushable meds have MD (Medical Doctor) order. AC (before meals), PC (after meals), with meals, with food orders administered correctly. Resident observed to ensure medications are swallowed. Medication record is charted consistently/properly. Medications are not left on top of the cart, or at bedside. Refused/withheld medications are properly noted. PRN (as needed) medications administered/documented appropriately. Proper handwashing techniques at appropriate times. Ophthalmics (eye medications) administered properly. [MEDICATION NAME] (through the skin) patches rotated, removed, dated, and initialed properly. Inhalers properly administered/stored; mouthpiece clean. Injections properly prepared, administered and documented. Medication via [DEVICE] (enteral feeding tube) is properly administered. Controlled drugs documented properly at time of administration. All signatures/initials are correct. Medications administered per manufacture's specifications. Medications administered per facility policies and procedures. Facility Policy and Procedure Blood Glucose/PT/INR Machine Cleaning Guidelines 1. Prepare two surfaces, one for clean items and one for contaminated, paper towels may be used. 2. Place disinfectant wipe on clean surface with a pair of clean gloves. 3. Don first pair of gloves, do procedure, place glucometer on contaminated towel/surface. 4. Wash hands and put on second pair of gloves. 5. Clean glucometer with disinfectant wipe, place on clean surface, air dry per manufacture's recommendations. When visibly soiled two wipes will be needed, one for soiling and one for disinfecting afterwards. 6. Place all gloves and contaminated cleaning equipment in bag and remove from room, place lancet in sharps container. 7. Wash hands and take glucometer from room. 8. Disinfectant wipes should be stored in the med cart separate from the medications, i.e. separate basket. Super Sani-Cloth Germicidal Disposable Wipes To Disinfect: To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for two (2) full minutes. Let air dry. For heavily soiled surfaces, use a wipe to pre-clean prior to disinfecting. Assure Platinum Glucometer Page 47 Cleaning and Disinfecting Guidelines Healthcare professionals should wear gloves when cleaning the Assure Platinum meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Option 1: Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. To use a wipe, remove from container and follow product label instructions to disinfect meter. Take extreme care not to get liquid in the test strip and key code ports of the meter. Many wipes act as both a cleaner and a disinfectant, though if blood is visibly present on the meter, two wipes must be used; use one wipe to clean and a second wipe to disinfect. On 9/10/19 at 5:03 p.m. The Regional Nurse Consultant and the Director of Nursing entered the conference room and stated that they had already identified the concerns with the soiled glucometers, and had addressed it during their (MONTH) 2019 QAPI (Quality Assurance Performance Improvement) Meeting. They then stated that they failed to follow up with the QAPI plan, due to the Immediate Jeapordy (IJ) concern that they were tagged with in (MONTH) 2019. They then confirmed that the soiled glucometers had been an on-going problem, and they still had failed to conduct any audits and/or implement any improvement plans. On 9/12/19 at 5:45 p.m., the facility provided an acceptable, credible IJ removal plan for licensed staff training/competencies related to glucometers, which consisted of the following: - Effective 9/12/19, the facility obtained Clorox Healthcare Bleach Germicidal Wipes, which kill [MEDICAL CONDITION]. - On 9/10/19, all glucometers were replaced with new ones. - On 9/11/19 and 9/12/19, audits were conducted by the Director of Nursing of all glucometers to ensure that they were clean and disinfected. - All licensed nurses would be re-educated prior to being permitted to work, and all training would be complete by 9/17/19. - On 9/12/19, the glucometer checklist used for evaluating nursing practice was updated to include a non-permeable barrier for blood glucose monitoring. - An emergency QAPI (Quality Assurance Improvement Plan) meeting was held on 9/12/19. - The QAPI plan initiated in (MONTH) 2019 for glucometer concerns was reviewed and extended through 9/25/19. As of 9/12/19 at 6:05 p.m., observation of the medication carts revealed the glucometers had been replaced. A review of the training records and audits revealed the facility had re-trained 18 nurses related to glucometer cleaning/disinfection and audits had been completed with no further concerns. The facility provided verification it had obtained the Clorox Bleach Wipes. Glucometer observations were conducted with four nurses working on 9/12/19, and all four performed the task appropriately. The facility's checklist for monitoring nursing practice related to glucometer use/cleansing/disinfection was reviewed with revisions observed. The QAPI plan was presented for review with an extension observed through 9/25/19, and an emergency QAPI meeting was held by all department heads and the Medical Director (via telephone) on 9/12/19.

Based on record reviews and interviews, the facility failed to ensure the provision of care and services in accordance with professional standards of practice for two (Residents #47 and #64) of 44 sampled residents, from a total census of 101 residents. Resident #47 was not provided care and treatment for [REDACTED]. Resident #64 was administered three doses of [MEDICATION NAME] when the facility had documentation verifying that she was allergic to this medication. This resulted in the resident's hospitalization for extreme confusion. The findings include: 1. A record review was conducted for Resident #47 which revealed that she was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed that she had a supra-pubic catheter but had no orders in place for care of the catheter. Documentation revealed that on 9/10/19 she had foul-smelling, yellow-green drainage at the supra-pubic site, and it was red and painful to the touch. The facility notified the physician and he ordered a culture and sensitivity to be completed, as well as Bactrim DS (double strength antibiotic) twice a day, for seven days. The culture was discontinued due to the resident being transferred to a different facility per her request on 9/11/19. She had started the antibiotic therapy (Bactrim DS) for the infection at her supra-pubic catheter site. On 9/12/19 at 3:40 PM, an interview was conducted with the Unit Manager regarding orders for Resident #47's supra-pubic catheter care. She reviewed the electronic medical record and confirmed the resident had no order for supra-pubic catheter care. She stated, Maybe it is something that the CNA's (Certified Nursing Assistants) are doing, we could check their documentation. On 9/12/19 at 3:48 PM, the Director of Nursing (DON) was interviewed regarding her expectations for supra-pubic catheter care. She confirmed that site care should be provided at least daily. 2. A record review was conducted for Resident #64 which revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of her medical record revealed she was allergic to [MEDICATION NAME] (anti-psychotic medication). Her 3008 (admission form) completed by the hospital, and dated 5/17/19, listed her allergy to [MEDICATION NAME]. A review of her electronic Medication Administration Record [REDACTED]. A review of her physician's orders [REDACTED]. On 6/24/19 the medication was increased to 25 mg twice a day by the physician. Further review of her eMAR for (MONTH) 2019 revealed the facility had administered [MEDICATION NAME] 12.5 mg to her on 6/22/19 at 5:00 p.m. and again on 6/23/19 at 9:00 am. The facility then administered an increased third dose of 25 mg on 6/23/19 at 5:00 p.m. On 6/24/19 she was sent to the emergency room for extreme confusion. On 9/12/19 at 1:37 PM, an interview was conducted with the DON regarding administration of [MEDICATION NAME] to Resident #64, despite her allergy. The DON stated, We did not know she had an allergy to [MEDICATION NAME] until she returned from the hospital in June. When she was shown the original 3008, dated 5/17/19, she stated, Yes, I see the allergy right there. A review of the facility's policy and procedure for medication administration revealed the following: Policy Title: 6.0 General Dose Preparation and Medication Administration Application: LTC (Long Term Care) Facilities Receiving Pharmacy Products and Services from Pharmacy Effective Date: 12/01/07 Revision Date: 05/01/10; 01/01/13 Pages 1 of 3 Applicability: This policy 6.0 sets forth the procedures relating to general dose preparation and medication administration. Facility staff should also refer to facility policy regarding medication administration and should comply with applicable law and State Operations Manual when administering medications. Procedure: Page 2 4. Prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: 4.1 Facility staff should: 4.1.4 Check for allergies [REDACTED].>

Based on record reviews and interviews, the facility failed to provide the necessary health care and services to attain or maintain the highest practicable psychosocial well-being, including the treatment of [REDACTED].#1) of three residents reviewed. Resident #1 had a documented months-long history of violent, aggressive behavior that was not addressed by the facility, even though the facility worked with a psychiatric service. The facility's failure to address Resident #1's behaviors placed staff and other residents he encountered at risk for injury. The findings include: A record review for Resident #1 found he was admitted to the facility on [DATE] with a readmission on 11/5/2018. He was discharged on [DATE]. Admission [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. A review of Resident #1's 1/28/2019 quarterly minimum data set (MDS) assessment revealed a brief interview for mental status (BIMS) score of 5 out of a possible 15 points, indicating severe impairment. There were no behaviors, hallucinations or delusions documented. Bed mobility, transfers and walking in the room were documented as requiring limited physical assistance of one person, and toileting was documented as requiring extensive two-person assistance. A review of Resident #1's physician's orders [REDACTED]. On 4/4/2019 an order was obtained for [MEDICATION NAME] (anxiolytic) 2 mg/ml (milligrams per milliliter) vial, administer one mg intramuscularly (IM) every 12 hours as needed for severe agitation. On 4/5/2019 on order was obtained for [MEDICATION NAME] DR (delayed release) 125 mg sprinkles, administer two capsules (250 mg) twice daily for agitation. The resident had been on [MEDICATION NAME] (supplement used to assist with sleep) 5 mg tablets daily at bedtime for [MEDICAL CONDITION] and [MEDICATION NAME] (antidepressant also used as an appetite stimulant) 7.5 mg, 1 tablet daily at bedtime for poor appetite. On 4/9/2019 an order was obtained for a psychiatric consult to Baker Act. Resident on 1:1 supervision until further notice. A review of Resident #1's (MONTH) 2019 Medication Administration Record [REDACTED]. A review of Resident #1's psychiatric notes revealed that he was seen by psychiatric services on 4/9/2019 due to the violent attack on his roommate. The documented concerns .have been happening for months but are worse. Listed [DIAGNOSES REDACTED]. Oriented to person and place. Behavior hostile. Insight/judgement poor. Anxious and irritability increased. Resident was physically aggressive at the time of the visit. The advanced registered nurse practitioner (ARNP) documented the resident was a danger to himself and others. Additional documentation of psychiatric service visits were provided by the facility for 11/7/2018 and 11/14/2018. Per the acting director of nursing (DON) on 4/24/2019 at 2:00 PM, Resident #1 did not see the psychiatrist again because he stabilized. There were no further psychiatric visits until 4/9/2019, though the facility did have a telephone order dated 4/4/2019 for the IM [MEDICATION NAME]. The facility documented that Resident #1 exhibited behaviors on the following dates: On 10/26/2018 at 11:35 PM: When attempting to take to the bathroom, Resident #1 started waving his cane. Going on to roommate's bed. Becoming verbally aggressive. The resident also had chest pains. After contact with his physician, Resident #1 was sent out to the hospital. On 11/6/2018 at 1:53 AM: Resident #1 Took the TV off of the wall and was cursing and trying to hit staff. On 11/6/2018 at 9:33 PM: Resident #1 was swinging clenched fists at staff. He grabbed a coat hanger and broke it and threatened to stab staff. On 11/7/2018 at 10:17 AM: Resident #1 was punching and cursing at staff. 11/7/2018 at 2:28 PM: Resident #1 was combative with staff. 11/7/2018 at 7:18 PM: Resident #1 was physically aggressive. On 11/8/2018 at 3:36 AM, Resident #1 was combative with care, hitting staff, ripping staff clothing, swinging violently from curtains. High risk of hurting others and staff. The nurse wrote in her progress note that the resident was sitting in the room in the chair quiet with dimmed lights. Refused to lie down. Combative with care. Smashing plastic cup with hands. Un-gripped broken cup. Resident grabbed curtain with firm grip and swinging hit body back and forth violently with the curtain. Resident extensive assist of four into Geri chair. Resident very combative. Hitting staff. Ripping clothes off, ripped shirt of writer. Unable to control resident. Resident at high risk of hurting others. The nurse wrote she contacted the resident's physician two times that week, and he refused to give an order for [REDACTED]. The nurse wrote the resident refused on second shift, and no other medication or IM available to this writer to prevent any possible injuries to resident or others. MD would not order anxiety med (medication) or IM. Nursing judgement resident at risk to self and others. Increased agitation and more combative. No safety awareness. On 11/9/2018 at 3:33 AM, Resident #1 was combative with staff. The nurse wrote in her progress note, Resident up in wheelchair until 3:00 AM then complained of being tired. Assisted to bed by the CNA. Easily excitable. Staff attempted to keep voices soft when speaking near resident so as not to over stimulate. Became combative times one (1) when attempting to toilet resident after resident attempted to urinate on floor in day room. Refused snack when offered. Self-propelled in wheelchair in hallways. Intrusive to other resident's space but re-directable. On 11/11/2018 at 2:42 AM, per the nurse's note, Resident #1 was found asleep across his roommate's bed. He was assisted to the correct bed. The nurse wrote he was legally blind. Redirected with verbal cues. No apparent injuries to resident or roommate. On 11/15/2018 at 2:47 PM, the nurse documented, Resident was very agitated this AM as CNA attempted to wake him to assist with bath as he had urinated all over bed, floor, and self. RN (registered nurse) went to room to assist and resident refused. Instructed CNA to wait 5-10 minutes. Reassessed in 30 minutes. More cooperative and took meds. On 11/15/2018 at 11:37 PM, the nurse documented, Resident alert and oriented, verbally and physically combative throughout shift. Refused medications. Redirected from wandering into others' rooms during shift. Urinated in hallway several times during shift after constant redirection, refused food, fluid, and meds. Refused all activities of daily living assistance. Contacted family to speak with resident. Resident became more upset. Administered 0.5 milliliters (ML) of intramuscular (IM) [MEDICATION NAME] and resident tolerated well. On 11/16/2018 at 3:11 AM, per the nurse's note, Resident yelling and aggressive toward staff. IM [MEDICATION NAME] administered, reassurance offered and used a quiet tone. On 11/18/2018 at 1:28 AM, Resident noted to be verbally abusive toward staff, yelling without purpose and also urinating on the floor after refusing assistance with toileting care. Different approaches tried all ineffective. On 11/18/2018 at 2:42 PM, the nurse documented, Yelling and cursing at staff several times throughout shift. Not easily re-directed. On 11/19/2018 at 3:22 AM, the nurse documented, Resident noted to be verbally abusive with staff and attempt to be combative several times this shift and is not easily redirected, multiple approaches tried with little effect. On 11/20/2018 at 11:55 PM, the nurse documented, Per second shift, resident urinated in hallway and on his pants. Resident reluctant to take off wet pants and to be changed. Resident became irate. Resident tore off the side rail to his bed and was swinging it as a weapon. Resident would not let go of side rail. He stated that he would use it to bash in the head of the girl who took his pants. Resident finally fell asleep with side rail under him and it could be retrieved. He was also combative on the day shift. On 11/24/2018 at 10:31 PM, the nurse documented, It was reported to the nurse the resident threw his TV on the ground and knocked over his bedside table. On 11/26/2018 at 10:36 AM, Resident screaming in room. Appeared he had gotten out of bed to find the bathroom. He had moved dresser away from wall and was standing behind it. He had knocked over his roommate's TV from the stand and cracked it. On 11/27/2018 at 2:05 AM, the nurse documented, (Resident #1) urinating in hallway. Wandering in wheelchair. Difficult to direct. Combative to hygiene care. Resident was screaming for his pants that were removed. He was dressed in sleep bottoms. He wanted his shoes I got to get out of this place! Reassured and redirected many times throughout the night. Resident yelling and kicking at staff and stating that he would shoot them. A review of a social services note, dated 1/29/2019 at the quarterly assessment, noted the resident was alert with confusion. Able to communicate most basic needs and wants. Looking for the exit this afternoon. Yelling out for staff to call a cab. Upon asking why resident stated he was going up town. Staff identified resident had personal care needs likely adding to confusion and care for him. There were no documented events of aggressive behavior again until 3/5/2019, when a nursing note revealed that Resident #1 was found on the floor next to the bed with a hematoma and abrasion. He was difficult to redirect. On 3/15/2019 at 10:02 PM the nurse documented, (Resident #1) was having some refusal behaviors, but can often be redirected with a different approach. No new labs or incidents in the last 30 days. On 3/17/2019 at 9:11 PM the nurse documented, At approximately 8:00 PM resident was yelling and screaming for staff to call police because he wanted to be out of the facility. Unable to direct behaviors. Resident was observed by staff for safety and went to bed at 9:10 PM without further episodes. There was a second note that documented at the time of this incident the resident was self-propelling his wheelchair while screaming. On 3/22/2019 at 3:45 AM, the nurse noted at the start of shift the resident was up and in his wheelchair cursing loudly and trying to hit staff who was attempting to get the resident in bed. On 4/4/2019 at 6:45 PM, the nurse documented that at 3:45 PM, the resident was yelling and screaming in hallways, actively exit seeking and asking staff to call the police. Resident's behaviors continued to escalate, at this time resident was at risk to cause harm to self or others, resident was in close observation by staff at this time to keep resident, staff and peers safe. Call placed to psych ARNP and order for IM [MEDICATION NAME] was obtained at 4:29 PM. IM [MEDICATION NAME] was administered in left arm. On 4/9/2019 at 3:45 AM, the nurse documented she was called into Resident #1's room by a CNA who was yelling for help. Resident #1 was standing over Resident #2's bed. He was leaning over the bed. His right hand held a bloody remote for the bed. His other hand was clenched in a fist. Staff separated the residents. Resident #2 was observed to have two closed eyes with [MEDICAL CONDITION], a laceration on his forehead and another on his right cheek. All of the nurses on the third shift came into the room. They applied pressure to stop the bleeding. They applied a pressure dressing to the eyes and forehead. During an interview on 4/24/2019 at 10:19 AM with the South Wing unit manager revealed that for residents with extreme behaviors, they would separate the residents. If the residents were roommates, the facility staff would change resident rooms. They would also notify family and the physician. The administrator and the director of nursing would be notified. The facility would attempt to get the family and everyone involved. The last resort would be medication. The unit manager stated she was not aware of special training for dealing with residents with dementia. She further stated she had worked with Resident #2, and he was very sweet and bedbound. He was only able to move one arm. He was pretty much paralyzed. He was alert with confusion. He required total care, and he could not defend himself. During an interview on 4/24/2019 at 10:37 AM with Licensed Practical Nurse (LPN) A, she stated that a group meeting was held in the AM, and they discussed what was going on with a given resident. Any situation involving behaviors was given in report due to the fact that behaviors changed on a daily basis. If she had a resident with catastrophic behavior, she would ensure the resident was safe. She would place the resident on 1:1 supervision. She would contact the physician to determine what the physician wanted to do about the resident's behavior. She would notify facility management and document in the nurses' notes. The interdisciplinary team (IDT) would work to address resident needs as best they could. When asked about Resident #1, the nurse stated he was alert and oriented to self only. His care was provided by staff due to his visual deficit. He did have some vision, as he knew when you were close to him and entered the room. He had behaviors. He would tell you to call the police because he wanted to leave. She recalled an instance during which Resident #1 was aggressive. She stated on Thursday, 4/4/2019, he was self-propelling down the hallway in his wheelchair. He got to the front hall and wanted to call the police to get out of the facility. He picked up a wet floor sign and started to swing the sign. She immediately went down took the sign and instructed the certified nursing assistant (CNA) to put the resident on 1:1 supervision. She instructed another staff member to contact the physician, and they received an order for [REDACTED]. The nurse stated that she received no report from the previous shift that Resident #1 was aggressive. She further stated that in her opinion, sun-downing behavior was exit seeking behavior, a change in behavior and a change in mood. Resident #1 did not sundown according to her observations of him. She stated she did not know if he even had Alzheimer's or dementia. She said she informed the unit manager and the DON. The information was passed on to the 11PM-7AM nurse, and she documented in the computer. When asked about Resident #2, she stated that he was a sweet man. He required total care, he had use of one arm and he was alert to self. During an interview on 4/24/2019 at 11:15 AM with the Corporate Registered Nurse (RN) and the North Wing LPN unit manager, Resident #1 was admitted on [DATE] from home and had been living by himself prior to that time. He was not admitted with a visual impairment or a dementia diagnosis. Starting on 10/26/2018, behaviors toward staff began. He had a cane when he was first admitted , and when staff would try to provide care, he would try to hit them with the cane. Initially, the facility staff thought the behaviors were adjustment issues. Resident #1 obviously had cognitive impairment at the time he was admitted . They were redirecting him, providing diversional activities and 1:1 supervision. The corporate RN stated Resident #1's family requested a room change in (MONTH) (YEAR). A conversation was had with the family and his response to change was discussed. Due to how difficult a time he was having adjusting to the facility, they decided to leave him in the current room. The North Wing unit manager stated that whenever the family would visit, Resident #1 became angry. New orders were received via telephone from the psychiatric advanced registered nurse practitioner on 4/4/2019, and after Resident #1 was medicated (IM [MEDICATION NAME]), he was fine. He was on scheduled antipsychotic medications, and he had been refusing those intermittently. During an interview on 4/24/2019 at 11:24 AM with the social services director, she stated Resident #2 was admitted to the facility on [DATE]. He was status [REDACTED]. He would repeat himself and yell out for medication, but he was not someone you could hear from down the hallway. He did use his call light, and he would normally have been sleeping at 3:45 AM. During an interview with the psychiatric ARNP on 4/24/2019 at 3:12 PM, she stated she first saw Resident #1 on 11/7/2018. He was blind and did not say very much. She was asked to see him for sleep difficulty. She put him on [MEDICATION NAME] and recommended the nurses approach him in a calm manner, as he would easily become combative and defensive due to his visual impairment. She stated it was a normal behavior, and he was not on any medication for behaviors. She stated she saw Resident #1 again on 11/9/2018 and he was combative with dementia. He had pain issues and [MEDICAL CONDITION]. On 11/7/2018 and 11/9/2018 he was put on [MEDICATION NAME] 1 milligram (mg) as needed every 12 hours for combative behavior, and [MEDICATION NAME] .25 mg at night. She further stated he had dementia and usually behaviors got worse at night. She saw him again on 11/14/2018. The issue was he wanted to do his own activities of daily living (ADL) care. She stated the [MEDICATION NAME] had finished as it was only for 14 days and the [MEDICATION NAME] had continued. Eventually the [MEDICATION NAME] was discontinued and he was put on [MEDICATION NAME] for the Dementia. She stated she was available and visited the facility every Wednesday. She did not see the resident again until she came to the facility on [DATE] to Baker Act him. She had been contacted prior to that via telephone, had increased his [MEDICATION NAME] and gave a new order for IM [MEDICATION NAME]. She confirmed it was on 4/4/2019. She stated she would have seen the resident on her next visit to the facility, which was a Wednesday, but the incident occurred and she was called into the facility to Baker Act him. On 2/26/19 at 12:05 PM, the Administrator was notified of the Immediate Jeopardy determination. Information was shared regarding the facility's failure to protect Resident #2 from Resident #1. The facility's IJ removal plan was received on 2/26/2019 at 5:25 PM. The survey team verified implementation of the plan through a review of facility audits of resident records to ensure appropriate measures were care planned for residents with behavioral issues; a review of staff training on the facility's policies and procedures for abuse prevention, identification, response and reporting, as well as training related to behavior management techniques with a focus on recognizing behaviors, appropriate interventions, and protecting other residents, and the daily clinical meeting process to ensure ongoing appropriate behavior monitoring was in place for residents who required monitoring. The survey team reviewed training that was provided to Admission personnel related to clinical admission criteria, including Department of Children and Families (DCF) screening requirements and admission, as well as training that was provided to clinical staff on the sub-committee process, and behavioral issues that would be reviewed through that process to ensure appropriate interventions were in place and assessment of responses to interventions was completed. Interviews with staff were conducted to determine their knowledge of the expectations going forward. Interviews were conducted with facility management to ensure ongoing oversight for compliance with the removal plan. These activities occurred throughout the day on 2/26/2019 until the IJ was removed at 6:10 PM.

Based on a review of clinical records, interviews with staff, a review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting Five-Day Report; the Sheriff's Office Report/Homicide Ruling; the facility's policy and procedure on Quality Assurance Behavior/[MEDICAL CONDITION] Subcommittee process; the facility's policy and procedure on Distressed Behavior Management Program; the facility's policies and procedures on Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source and Exploitation; the guidelines for the facility's Daily Clinical Meetings, and the facility's policy and procedure for Quality Assurance/Quality Assurance Performance Improvement (QA/QAPI), the facility failed to use its resources effectively and efficiently to attain or maintain the highest psychosocial well-being of one (Resident #1) of three residents reviewed. The facility failed to identify the potential for harm related to Resident #1's aggressive and violent behavior, thereby failing to ensure he was seen/treated by the psychiatric service the facility contracted with. On [DATE] at 3:45 AM, Immediate Jeopardy (IJ) started. On [DATE] at 12:05 PM, the Administrator was notified of the Immediate Jeopardy determination. On [DATE] at 5:25 PM, the facility provided an acceptable credible IJ removal plan for monitoring/care of residents with aggressive behaviors and provision of safety measures for all residents in the facility. On [DATE] at 6:10 PM, the Immediate Jeopardy was removed after validation of the implementation of the plan. The findings include: A review of the facility's AHCA Nursing Homes Federal Reporting Five-Day Report # found that on [DATE] at 3:45 AM, certified nursing assistant (CNA) H entered Resident #1 and #2's room for a routine check, identified a wheelchair that was tipped over and observed Resident #1 leaning over Resident #2's bed. Resident #1 was striking Resident #2 in the face with the bed's remote control device. Due to the bright red drainage on Resident #2's face, he was transferred to an acute care hospital for evaluation. He was subsequently transferred to a trauma center and admitted to a hospice facility where he expired on [DATE]. A review of the Sheriff's Office Report, dated [DATE], revealed an investigation of the death of a [AGE] year-old male who was allegedly battered by an 84-year- old male, both while residents of the facility. The report stated that the Medical Examiner's Office released its preliminary findings in the case this same day, and it ruled the cause of death as [MEDICATION NAME] force trauma and the manner of death as homicide. A record review for Resident #1 found he was admitted to the facility on [DATE] with a readmission on [DATE]. He was discharged to an acute care hospital on [DATE]. His admitting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. A review of the [DATE] quarterly minimum data set (MDS) assessment revealed that Resident #1 had highly impaired vision. He had a brief interview for mental status (BIMS) score of 5 out of a possible 15 points, reflective of severely impaired cognitive skills for daily decision making. There were no behaviors, hallucinations or delusions documented over the assessment lookback period. The resident required limited assistance of one person with bed mobility, transfers and to walk in his room, and extensive, two-person assistance for use of the toilet. Dressing and personal hygiene required extensive assistance from one person. He ate with supervision after set up. Resident #1 was care planned on [DATE] for his visual impairment, with a goal to have no visual deficit that prevented ability to receive communication. He was care planned for exhibiting behavior of striking out at staff and family and striking other residents, yelling out and urinating in inappropriate places. The goal was not to injure himself or others, over the next 90 days, if he had behaviors. Approaches included to place the resident in areas where frequent observation was possible, and talk in a calm voice when behavior was disruptive. Remove from public area when behavior was disruptive and unacceptable. Do not argue with resident, discuss options for appropriate channeling of anger. Approach wandering resident in a positive, calm, and accepting manner. Administer behavior medications ordered by physician, and provide diversional activities. Observe and document target behaviors. When he becomes combative, leave and try to approach later. 1:1 supervision for safety (start date of [DATE]). Resident #1 was care planned for antipsychotic drug use and risk for side effects, with approaches including observe for patterns of target behaviors, medications as ordered, and observe for changes in condition that may warrant increased supervision/assistance and notify the physician. He was care planned for impaired cognition with interventions including observe for episodes of delusions or hallucinations, and choose roommate for compatibility. Observe when restless, hungry, thirsty, needs to use bathroom, pain, and provide care needed. In the resident's care plan for falls, instructions were to remind him to ask staff for assistance with ambulation, assist with one staff member for all ambulation, observe for changes in condition that may warrant increased supervision and assistance and notify the physician. A review of facility records revealed Resident #1 and Resident #2 became roommates on [DATE]. During an interview with the administrator on [DATE] at 12:26 PM, she stated that historically, Resident #1's behavior was against caregivers, the interventions were effective and his roommate was bedbound. She did not feel that his behavior was dangerous in the past. She felt Resident #1's medical management was appropriate. The facility documented that Resident #1 exhibited behaviors on the following dates: On [DATE] at 11:35 PM: When attempting to take to the bathroom, Resident #1 started waving his cane. Going on to roommate's bed. Becoming verbally aggressive. The resident also had chest pains. After contact with his physician, Resident #1 was sent out to the hospital. On [DATE] at 1:53 AM: Resident #1 Took the TV off of the wall in his room and was cursing and trying to hit staff. On [DATE] at 9:33 PM: Resident #1 was swinging clenched fists at staff. He grabbed a coat hanger and broke it and threatened to stab staff. On [DATE] at 10:17 AM: Resident #1 was punching and cursing at staff. [DATE] at 2:28 PM: Resident #1 was combative with staff. [DATE] at 7:18 PM: Resident #1 was physically aggressive. On [DATE] at 3:36 AM, Resident #1 was combative with care, hitting staff, ripping staff clothing, swinging violently from curtains. High risk of hurting others and staff. Refused to lie down. Combative with care. Smashing plastic cup with hands. Un-gripped broken cup. Resident grabbed curtain with firm grip and swinging hit body back and forth violently with the curtain. Resident extensive assist of four into Geri chair. Resident very combative. Hitting staff. Ripping clothes off, ripped shirt of writer. Unable to control resident. Resident at high risk of hurting others. The nurse wrote she contacted the resident's physician two times that week, and he refused to give an order for [REDACTED]. At 3:35 PM, the nurse wrote that the Psychiatric ARNP (advanced resgistered nurse practitioner) gave a new order for [MEDICATION NAME] at bedtime. The nurse wrote the resident refused on second shift, and no other medication or IM available to this writer to prevent any possible injuries to resident or others. MD would not order anxiety med (medication) or IM. Nursing judgement resident at risk to self and others. Increased agitation and more combative. No safety awareness. On [DATE] at 3:33 AM, Resident #1 was combative with staff. The nurse wrote in her progress note, Resident up in wheelchair until 3:00 AM then complained of being tired. Assisted to bed by the CNA. Easily excitable. Staff attempted to keep voices soft when speaking near resident so as not to over stimulate. Became combative times one (1) when attempting to toilet resident after resident attempted to urinate on floor in day room. Refused snack when offered. Self-propelled in wheelchair in hallways. Intrusive to other resident's space but re-directable. On [DATE] at 2:42 AM, per the nurse's note, Resident #1 was found asleep across his roommate's bed. He was assisted to the correct bed. The nurse wrote he was legally blind. Redirected with verbal cues. No apparent injuries to resident or roommate. On [DATE] at 2:47 PM, the nurse documented, Resident was very agitated this AM as CNA attempted to wake him to assist with bath as he had urinated all over bed, floor, and self. RN (registered nurse) went to room to assist and resident refused. Instructed CNA to wait ,[DATE] minutes. Reassessed in 30 minutes. More cooperative and took meds. On [DATE] at 11:37 PM, the nurse documented, Resident alert and oriented, verbally and physically combative throughout shift. Refused medications. Redirected from wandering into others' rooms during shift. Urinated in hallway several times during shift after constant redirection, refused food, fluid, and meds. Refused all activities of daily living assistance. Contacted family to speak with resident. Resident became more upset. Administered 0.5 milliliters (ML) of intramuscular (IM) [MEDICATION NAME] and resident tolerated well. On [DATE] at 3:11 AM, per the nurse's note, Resident yelling and aggressive toward staff. IM [MEDICATION NAME] administered, reassurance offered and used a quiet tone. On [DATE] at 1:28 AM, Resident noted to be verbally abusive toward staff, yelling without purpose and also urinating on the floor after refusing assistance with toileting care. Different approaches tried all ineffective. On [DATE] at 2:42 PM, the nurse documented, Yelling and cursing at staff several times throughout shift. Not easily re-directed. On [DATE] at 3:22 AM, the nurse documented, Resident noted to be verbally abusive with staff and attempt to be combative several times this shift and is not easily redirected, multiple approaches tried with little effect. On [DATE] at 11:55 PM, the nurse documented, Per second shift, resident urinated in hallway and on his pants. Resident reluctant to take off wet pants and to be changed. Resident became irate. Resident tore off the side rail to his bed and was swinging it as a weapon. Resident would not let go of side rail. He stated that he would use it to bash in the head of the girl who took his pants. Resident finally fell asleep with side rail under him and it could be retrieved. He was also combative on the day shift. On [DATE] at 10:31 PM, the nurse documented, It was reported to the nurse the resident threw his TV on the ground and knocked over his bedside table. On [DATE] at 10:36 AM, Resident screaming in room. Appeared he had gotten out of bed to find the bathroom. He had moved dresser away from wall and was standing behind it. He had knocked over his roommate's TV from the stand and cracked it. On [DATE] at 2:05 AM, the nurse documented, (Resident #1) urinating in hallway. Wandering in wheelchair. Difficult to direct. Combative to hygiene care. Resident was screaming for his pants that were removed. He was dressed in sleep bottoms. He wanted his shoes I got to get out of this place! Reassured and redirected many times throughout the night. Resident yelling and kicking at staff and stating that he would shoot them. A review of a social services note, dated [DATE] at the quarterly assessment, noted the resident was alert with confusion. Able to communicate most basic needs and wants. Looking for the exit this afternoon. Yelling out for staff to call a cab. Upon asking why resident stated he was going up town. Staff identified resident had personal care needs likely adding to confusion and care for him. Otherwise staff reports his behaviors have stabilized in general. No problems, concerns or needs identified today. There were no documented events of aggressive behavior again until [DATE], when a nursing note revealed that Resident #1 was found on the floor next to the bed with a hematoma and abrasion. He was difficult to redirect. On [DATE] at 10:02 PM the nurse documented, (Resident #1) was having some refusal behaviors, but can often be redirected with a different approach. No new labs or incidents in the last 30 days. On [DATE] at 9:11 PM the nurse documented, At approximately 8:00 PM resident was yelling and screaming for staff to call police because he wanted to be out of the facility. Unable to direct behaviors. Resident was observed by staff for safety and went to bed at 9:10 PM without further episodes. There was a second note that documented at the time of this incident the resident was self-propelling his wheelchair while screaming. On [DATE] at 3:45 AM, the nurse noted at the start of shift the resident was up and in his wheelchair cursing loudly and trying to hit staff who was attempting to get the resident in bed. On [DATE] at 6:45 PM, the nurse documented that at 3:45 PM, the resident was yelling and screaming in hallways, actively exit seeking and asking staff to call the police. Resident's behaviors continued to escalate, at this time resident was at risk to cause harm to self or others, resident was in close observation by staff at this time to keep resident, staff and peers safe. Call placed to psych ARNP and order for IM [MEDICATION NAME] was obtained at 4:29 PM. IM [MEDICATION NAME] was administered in left arm. On [DATE] at 3:45 AM, the nurse documented she was called into Resident #1's room by a CNA who was yelling for help. Resident #1 was standing over Resident #2's bed. He was leaning over the bed. His right hand held a bloody remote for the bed. His other hand was clenched in a fist. Staff separated the residents. Resident #2 was observed to have two closed eyes with [MEDICAL CONDITION], a laceration on his forehead and another on his right cheek. All of the nurses on the third shift came into the room. They applied pressure to stop the bleeding. They applied a pressure dressing to the eyes and forehead. Resident #1's care plan was updated on [DATE] with an intervention of 1:1 supervision for safety. A review of the (MONTH) 2019 physician's orders [REDACTED]. On [DATE], an order was written for [MEDICATION NAME] (anxiolytic) 2 milligrams/milliliters (mg/ml) vial, administer 1 mg intramuscular (IM) every 12 hours as needed for severe agitation. On [DATE], a new order was written for an increase in [MEDICATION NAME] (anti-convulsant that can be used as a mood stabilizer) DR (delayed release) 125 mg sprinkle capsule, administer 2 capsules (250 mg) twice a day for agitation. The resident had been on [MEDICATION NAME] (a hormone used to help with [MEDICAL CONDITION]/difficulty sleeping) 5 mg tablet at the hour of sleep for [MEDICAL CONDITION] and [MEDICATION NAME] (an anti-depressant that also works to stimulate appetite) 7.5 mg, 1 tablet at the hour of sleep for poor appetite. A review of the (MONTH) 2019 medication administration record (MAR) found the resident received [MEDICATION NAME] 2 mg/ml vial, administer 1 mg IM every 12 hours as needed for a [DIAGNOSES REDACTED]. Further review also found the resident did not have his 5:00 PM dose of [MEDICATION NAME] DR 125 mg for agitation on [DATE], nor did he take his 8:00 PM [MEDICATION NAME] and [MEDICATION NAME] 7.5 mg. The medications were documented on the medication administration record (MAR) as having been refused. The ARNP documented that Resident #1 was seen on [DATE] due to the violent attack on his roommate. The documented concerns were have been happening for months but is worse. Listed were depression, anxiety, agitation, aggression, confusion, and refusing care. Oriented to person and place. Behavior hostile. Insight/judgement poor. Anxious and irritability increased. Resident was physically aggressive at the time of the visit. The ARNP documented the resident was a danger to self and others. During an interview with the acting director of nursing (DON) on [DATE] at 1:32 PM, she was asked for any evidence they notified the doctor that Resident #1 refused his evening medication on [DATE]. She stated the physician had not been notified, as it was something the resident frequently did. During an interview with the acting DON, the nurse consultant and the North Wing unit manager on [DATE] at 4:22 PM, they were asked if they conducted an analysis of what happened. The acting DON, using her notes, stated some of Resident #1's behaviors were normal dementia behaviors, and because his sight was impaired. His behavior was justified sometimes when he would get scared and yell and back away. On [DATE] during an episode at 8:00 PM, he wanted the cops called because he wanted to leave. He was self-propelling his wheelchair and went to bed willingly at 9:10 PM. The next documented behavior was on [DATE] at 3:07 AM. He was up in his wheelchair cursing at staff trying to help him into bed. He was encouraged to go to bed. Verbal and tactile cues were used, as he ddid better with hands-on care. On [DATE] at 3:45 PM he was yelling and screaming in the hallways. Wanting to call police. His behaviors escalated. They contacted the psychiatric nurse and family. They obtained orders for lab work. The unit manager added that when he had visitors he would want to leave with them, and those visits attributed to his behaviors. She stated on [DATE], he had visitors that afternoon and that made his behaviors worse. During an interview with Resident #1's nurse, Licensed Practical Nurse (LPN) A, on [DATE] at 10:40 AM, she stated she worked with Resident #1 for almost five months. He was alert and oriented to self only. He did have some vision as he knew when you were close to him and entered the room. He had behaviors. He would tell you to call the police because he wanted to leave. She recalled an instance when he was aggressive. On Thursday [DATE], he was self-propelling down the hallway. He got to the front hall and wanted to call the police to get out of the facility. He picked up a wet floor sign and started to swing the sign. LPN A immediately went down the hall, took the sign and instructed the certified nursing assistant (CNA) to put one on one staffing in place. She instructed another staff member to contact the physician. They received a physician's orders [REDACTED].#1 allowed LPN A to administer the IM [MEDICATION NAME], and he took the evening medications. LPN A stated the one to one was to be discontinued once the IM med was effective. LPN A stated the day of the incident she had worked a double shift. Resident #1 had no sundowning behaviors according to her observations of him. She stated she did not know if he even had Alzheimer's or dementia. On [DATE] she informed the unit manager and the DON and the information was passed on to the 11:00 PM-7:00 AM nurse. During an interview with the psychiatric ARNP on [DATE] at 3:12 PM, she stated she first saw Resident #1 on [DATE]. He was blind and did not say very much. She was asked to see him for sleep difficulty. She put him on [MEDICATION NAME] and recommended the nurses approach him in a calm manner, as he would easily become combative and defensive due to his visual impairment. She stated it was a normal behavior, and he was not on any medication for behaviors. She stated she saw Resident #1 again on [DATE] and he was combative with dementia. He had pain issues and [MEDICAL CONDITION]. On [DATE] and [DATE] he was put on [MEDICATION NAME] 1 milligram (mg) as needed every 12 hours for combative behavior, and [MEDICATION NAME] .25 mg at night. She further stated he had dementia and usually behaviors got worse at night. She saw him again on [DATE]. The issue was he wanted to do his own activities of daily living (ADL) care. She stated the [MEDICATION NAME] had finished as it was only for 14 days and the [MEDICATION NAME] had continued. Eventually the [MEDICATION NAME] was discontinued and he was put on [MEDICATION NAME] for the Dementia. She stated she was available and visited the facility every Wednesday. She did not see the resident again until she came to the facility on [DATE] to Baker Act him. She had been contacted prior to that via telephone, had increased his [MEDICATION NAME] and gave a new order for IM [MEDICATION NAME]. She confirmed it was on [DATE]. She stated she would have seen the resident on her next visit to the facility, which was a Wednesday, but the incident occurred and she was called into the facility to Baker Act him. During an interview with Resident #1's CNA (B) on [DATE] at 5:27 PM, she stated she worked with Resident #1 often on the 3:00 PM to 11:00 PM shift. He went to bed at varying times. Sometimes he would be up as late as 11:00 PM. The night of the incident he was very agitated. He did not want to go to bed. She got him in bed right before she left at 10:45 PM. She had to beg him. His nurse was aware. He had aggressive behaviors in (MONTH) and (MONTH) and until he was discharged . He would go in other residents' rooms and not come out. He was going up and down the halls in February. This was continual. He would refuse to take medications. During an interview on [DATE] at 10:00 AM with the acting DON and the nurse consultant, the nurse consultant stated they put the resident on behavior monitoring on [DATE], and he continued on the behavior monitoring through [DATE]. She provided the physician's orders [REDACTED]. She provided the monitoring sheets and the approaches used to deal with behaviors. According to the monitoring sheets, the last behaviors were documented on [DATE], [DATE] and [DATE], and they documented all three times that they redirected the resident. The monitoring was for combative behavior toward staff. She stated they did monitor [MEDICAL CONDITION] for a while. She was asked about his behaviors of yelling and exit seeking. She stated he was care planned for those behaviors, but they did not do monitoring sheets, as these would be documented in progress notes. She stated they did not complete a monitoring tool for all the other behaviors. Once the behaviors stopped, the facility did not hold an interdisciplinary team (IDT) meeting. The last IDT note was [DATE] and stated he had improved. During an interview with the administrator on [DATE] at 12:26 PM, she was asked why, in light of Resident #1's behaviors, had they not moved either Resident #1 or Resident #2 out of the room. She replied, Historically his behavior was against caregivers, and the interventions were effective. She would see him in the facility and interact. She did not feel his behavior was dangerous in the past. They felt he was oriented to the left side of the room, A bed. Historically he acted out to caregivers and he had a roommate that was bed bound. If you addressed something and redirected him, he did not go back to the same activity. They felt the medical management was appropriate. He was stable for a long period of time. On [DATE] at 12:28 PM, a telephone interview was conducted with Resident #1's physician. He stated the resident was transferred from the hospital to the facility. He had some behavioral issues at that time. He was stable after a month or so on the medication until recently when this incident occurred. There were no issues, and if so, he would have obtained an opinion from the psychiatrist. He was aware of the resident's refusal of medications at some times, but was unable to provide details. He stated the resident's behaviors were normal for someone with dementia. CNA F was interviewed at 3:32 PM on [DATE], and stated she had seen Resident #1 act out with staff. He was verbally abusive and he would hit. Resident #1 was combative. He was confused and he didn't want the care. We notify the nurse and give him time to calm down. Sometimes it worked and sometimes it didn't. We notify the nurse when they are combative, try to keep them from hurting themselves, and document it in the computer. She confirmed she had training on behaviors, and used redirection and provided activities. Once we get them calm and keep them from hurting themselves, we come in as a team, then we may put them on 1 to 1 watch. LPN [NAME] stated in an interview at 3:46 PM on [DATE], that if a resident went from one status to another then the SBAR (situation, background, assessment, recommendations) form was completed, otherwise it was documented in nurses' notes, and then put in the 24 hour report. It would go to the DON, the unit managers, and upper management was alerted in the morning meetings. LPN F was interviewed at 4:01 PM on [DATE] and said the 24 hour report for behaviors was passed on to everyone in the morning meeting. There was a lot of documentation. He stated they had nurses' meetings where pertinent information was reviewed with the risk manager. RN A was interviewed at 4:10 PM on [DATE]. She stated she was the primary nurse on that unit. When resident behaviors occurred, they let the unit manager know, then the assistant DON and the DON. If none of the nursing management staff were available, then the administrator would be notified. The physician was always called first. It was documented in the shift report, progress notes and the 24 hour report. The 24 hour report was reviewed in the morning meeting. She believed they received all three reports in the morning meeting, but the 24 hour report stayed on for 24 hours. The South Wing unit manager was interviewed at 4:30 PM on [DATE], and reported that Resident #1 had a lot of confusion. If a behaviors occurred, the first thing to do was to get help and notify the nurse immediately. The nurse would assess the resident to see why they were combative. If there were no interventions in place, the psychiatrist, the physician, the charge nurse or the DON would be notified, and it would be documented. We have a 24 hour report sheet that anyone can write on. It specifically asks about behaviors. Each morning it is reviewed. We have morning clinical meetings with all managers and decide as a team what should be done. The DON should already know of the situation, because staff notify her of behaviors and we come to a conclusion as a team. We also have a separate meeting for just the nurses to go over certain topics that might be an issue. The DON was interviewed at 12:04 PM on [DATE]. She was asked to provide the survey team with any and all Quality Assurance/Quality Assurance Performance Improvement (QAPI) information related to the facility's identification of and response to Resident #1's escalating behaviors since his admission. The DON replied that she had already reviewed all of the facility's QAPI notes, and determined there was nothing identified or addressed in relation to Resident #1's conduct. An interview was conducted with LPN C at 2:30 PM on [DATE]. She stated that typically residents with behaviors were kept in a high visibility area like near the nursing station or in the day room. More confused impulsive residents were checked on hourly, and/or each time staff passed by if they were in their room(s). If a violent behavior occurred, staff were to safely remove the patient or other patients in the area. If unable to redirect the behaviors, staff would remain present and provide one to one supervision for the resident. All behaviors were documented on the electronic medication administration record (EMAR) on every shift. Any unusual behavior would be reported to the supervisor. An interview was conducted with LPN D at 4:38 PM on [DATE]. She stated all behaviors were documented on every shift, including staff response and interventions. We would monitor the resident throughout the shift especially if behaviors were observed. We would put interventions in place, we would do something! She stated interventions might include redirecting the resident, offering food, or even providing one to one staff supervision if needed. The policy was to notify the doctor of any behaviors. A review of facility's guidance for Daily Clinical Meetings instructed the following: 1. Review 24 hour shift report from previous day/days. 2. Review all progress notes for all Residents/Guests from previous day/days. 3. Review dashboard for behavior monitoring or new or worsening behaviors . A review of the facility's Quality Assurance Behavior/[MEDICAL CONDITION] Subcommittee process, revised [DATE], found the purpose of the committee was to identify residents/guests at risk related to behavior or new or worsening and use of [MEDICAL CONDITION] drugs. The meetings were scheduled weekly and included a monthly and quarterly review. The weekly functions of the subcommittee included, but were not limited to: -Review new or worsening specific behavior . -Check for behavior monitoring in the electronic medication administration record (EMAR) . -Check resident centered care plans for updates/appropriate care plan interventions . -Review progress notes for supporting documentation . -Review Quality Measures related to any behaviors and any measure that has potential to indicate changes with the resident/guests. -Review resident/guests changes to evaluate for significant change. On a quarterly basis, a monthly report should be presented to the QAA/QAPI Committee that includes: . Review of Quality Measures for behavior/emotional patterns. A review of the facility's Distressed Behavior Management Program (Policy Number NM. I-24 effective (MONTH) 12, (YEAR)) revealed the purpose was to identify residents/guest(s) who currently exhibited some type of distressed behavior symptoms for which additional or new treatment programs may be considered. Standard: Residents/Guest(s) who display mental or psychosocial adjustment difficulty should receive appropriate services in an attempt to correct the problem. Process: 1. Assessment: a. Behaviors should be identified through the RAI (resident assessment instrument) process and through staff interaction. b. Identified behaviors should be evaluated for frequency, duration and intensity for a pattern. c. The plan of care should be developed by the Interdisciplinary Team . e. The plan of care should be reviewed at least quarterly for continued need of behavior management and appropriate interventions. f. Further assessments to identify and manage behavior may be conducted. The Interact Behavior Care Path may be used to assist in identifying causes of distressed behavior symptoms and to determine interventions . A review of the facility's Quality Assurance/ Quality Assurance Performance Improvement (QAPI) Policy and Procedure effective [DATE] section E-1 revealed: Policy: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting/exceeding the needs, expectations and requirements of the resident/guest cost effectively while maintaining food resident/guest outcomes and perceptions of resident/guest care. QAPI committee will meet quarterly and QAPI Steering Committees will meet at a minimum of monthly. Scope: Our facilities have a performance Improvement Program which systematically monitors data, analyzes and improves its performance to improve resident/guest o

Based on a review of clinical records, interviews with staff, a review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting Five-Day Report; the Sheriff's Office Report/Homicide Ruling; the facility's policy and procedure on Quality Assurance Behavior/[MEDICAL CONDITION] Subcommittee process; the facility's policy and procedure on Distressed Behavior Management Program; the facility's policies and procedures on Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source and Exploitation; the guidelines for the facility's Daily Clinical Meetings, and the facility's policy and procedure for Quality Assurance/Quality Assurance Performance Improvement (QA/QAPI), the facility failed to identify risk factors and the potential for harm to a vulnerable resident, thus failing to prevent the physical abuse by Resident #1 of Resident #2, which resulted in the death of Resident #2, one of three residents reviewed for abuse. On [DATE] at 3:45 AM, Immediate Jeopardy (IJ) started. On [DATE] at 12:05 PM, the Administrator was notified of the Immediate Jeopardy determination. On [DATE] at 5:25 PM, the facility provided an acceptable credible IJ removal plan for monitoring/care of residents with aggressive behaviors and provision of safety measures for all residents in the facility. On [DATE] at 6:10 PM, the Immediate Jeopardy was removed after validation of the implementation of the plan. The findings include: 1. A review of the facility's AHCA Nursing Homes Federal Reporting Five-Day Report # found that on [DATE] at 3:45 AM, certified nursing assistant (CNA) H entered Resident #1 and #2's room for a routine check, identified a wheelchair that was tipped over and observed Resident #1 leaning over Resident #2's bed. Resident #1 was striking Resident #2 in the face with the bed's remote control device. Due to the bright red drainage on Resident #2's face, he was transferred to an acute care hospital for evaluation. He was subsequently transferred to a trauma center and admitted to a hospice facility where he expired on [DATE]. A review of the Sheriff's Office Report, dated [DATE], revealed an investigation of the death of a [AGE] year-old male who was allegedly battered by an 84-year- old male, both while residents of the facility. The report stated that the Medical Examiner's Office released its preliminary findings in the case this same day, and it ruled the cause of death as [MEDICATION NAME] force trauma and the manner of death as homicide. A record review for Resident #1 found he was admitted to the facility on [DATE] with a readmission on [DATE]. He was discharged to an acute care hospital on [DATE]. His admitting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. A review of the [DATE] quarterly minimum data set (MDS) assessment revealed that Resident #1 had highly impaired vision. He had a brief interview for mental status (BIMS) score of 5 out of a possible 15 points, reflective of severely impaired cognitive skills for daily decision making. There were no behaviors, hallucinations or delusions documented over the assessment lookback period. The resident required limited assistance of one person with bed mobility, transfers and to walk in his room, and extensive, two-person assistance for use of the toilet. Dressing and personal hygiene required extensive assistance from one person. He ate with supervision after set up. Resident #1 was care planned on [DATE] for his visual impairment, with a goal to have no visual deficit that prevented ability to receive communication. He was care planned for exhibiting behavior of striking out at staff and family and striking other residents, yelling out and urinating in inappropriate places. The goal was not to injure himself or others, over the next 90 days, if he had behaviors. Approaches included to place the resident in areas where frequent observation was possible, and talk in a calm voice when behavior was disruptive. Remove from public area when behavior was disruptive and unacceptable. Do not argue with resident, discuss options for appropriate channeling of anger. Approach wandering resident in a positive, calm, and accepting manner. Administer behavior medications ordered by physician, and provide diversional activities. Observe and document target behaviors. When he becomes combative, leave and try to approach later. 1:1 supervision for safety (start date of [DATE]). Resident #1 was care planned for antipsychotic drug use and risk for side effects, with approaches including observe for patterns of target behaviors, medications as ordered, and observe for changes in condition that may warrant increased supervision/assistance and notify the physician. He was care planned for impaired cognition with interventions including observe for episodes of delusions or hallucinations, and choose roommate for compatibility. Observe when restless, hungry, thirsty, needs to use bathroom, pain, and provide care needed. In the resident's care plan for falls, instructions were to remind him to ask staff for assistance with ambulation, assist with one staff member for all ambulation, observe for changes in condition that may warrant increased supervision and assistance and notify the physician. A review of facility records revealed Resident #1 and Resident #2 became roommates on [DATE]. During an interview with the administrator on [DATE] at 12:26 PM, she stated that historically, Resident #1's behavior was against caregivers, the interventions were effective and his roommate was bedbound. She did not feel that his behavior was dangerous in the past. She felt Resident #1's medical management was appropriate. The facility documented that Resident #1 exhibited behaviors on the following dates: On [DATE] at 11:35 PM: When attempting to take to the bathroom, Resident #1 started waving his cane. Going on to roommate's bed. Becoming verbally aggressive. The resident also had chest pains. After contact with his physician, Resident #1 was sent out to the hospital. On [DATE] at 1:53 AM: Resident #1 Took the TV off of the wall in his room and was cursing and trying to hit staff. On [DATE] at 9:33 PM: Resident #1 was swinging clenched fists at staff. He grabbed a coat hanger and broke it and threatened to stab staff. On [DATE] at 10:17 AM: Resident #1 was punching and cursing at staff. [DATE] at 2:28 PM: Resident #1 was combative with staff. [DATE] at 7:18 PM: Resident #1 was physically aggressive. On [DATE] at 3:36 AM, Resident #1 was combative with care, hitting staff, ripping staff clothing, swinging violently from curtains. High risk of hurting others and staff. Refused to lie down. Combative with care. Smashing plastic cup with hands. Un-gripped broken cup. Resident grabbed curtain with firm grip and swinging hit body back and forth violently with the curtain. Resident extensive assist of four into Geri chair. Resident very combative. Hitting staff. Ripping clothes off, ripped shirt of writer. Unable to control resident. Resident at high risk of hurting others. The nurse wrote she contacted the resident's physician two times that week, and he refused to give an order for [REDACTED]. At 3:35 PM, the nurse wrote that the Psychiatric ARNP (advanced resgistered nurse practitioner) gave a new order for [MEDICATION NAME] at bedtime. The nurse wrote the resident refused on second shift, and no other medication or IM available to this writer to prevent any possible injuries to resident or others. MD would not order anxiety med (medication) or IM. Nursing judgement resident at risk to self and others. Increased agitation and more combative. No safety awareness. On [DATE] at 3:33 AM, Resident #1 was combative with staff. The nurse wrote in her progress note, Resident up in wheelchair until 3:00 AM then complained of being tired. Assisted to bed by the CNA. Easily excitable. Staff attempted to keep voices soft when speaking near resident so as not to over stimulate. Became combative times one (1) when attempting to toilet resident after resident attempted to urinate on floor in day room. Refused snack when offered. Self-propelled in wheelchair in hallways. Intrusive to other resident's space but re-directable. On [DATE] at 2:42 AM, per the nurse's note, Resident #1 was found asleep across his roommate's bed. He was assisted to the correct bed. The nurse wrote he was legally blind. Redirected with verbal cues. No apparent injuries to resident or roommate. On [DATE] at 2:47 PM, the nurse documented, Resident was very agitated this AM as CNA attempted to wake him to assist with bath as he had urinated all over bed, floor, and self. RN (registered nurse) went to room to assist and resident refused. Instructed CNA to wait ,[DATE] minutes. Reassessed in 30 minutes. More cooperative and took meds. On [DATE] at 11:37 PM, the nurse documented, Resident alert and oriented, verbally and physically combative throughout shift. Refused medications. Redirected from wandering into others' rooms during shift. Urinated in hallway several times during shift after constant redirection, refused food, fluid, and meds. Refused all activities of daily living assistance. Contacted family to speak with resident. Resident became more upset. Administered 0.5 milliliters (ML) of intramuscular (IM) [MEDICATION NAME] and resident tolerated well. On [DATE] at 3:11 AM, per the nurse's note, Resident yelling and aggressive toward staff. IM [MEDICATION NAME] administered, reassurance offered and used a quiet tone. On [DATE] at 1:28 AM, Resident noted to be verbally abusive toward staff, yelling without purpose and also urinating on the floor after refusing assistance with toileting care. Different approaches tried all ineffective. On [DATE] at 2:42 PM, the nurse documented, Yelling and cursing at staff several times throughout shift. Not easily re-directed. On [DATE] at 3:22 AM, the nurse documented, Resident noted to be verbally abusive with staff and attempt to be combative several times this shift and is not easily redirected, multiple approaches tried with little effect. On [DATE] at 11:55 PM, the nurse documented, Per second shift, resident urinated in hallway and on his pants. Resident reluctant to take off wet pants and to be changed. Resident became irate. Resident tore off the side rail to his bed and was swinging it as a weapon. Resident would not let go of side rail. He stated that he would use it to bash in the head of the girl who took his pants. Resident finally fell asleep with side rail under him and it could be retrieved. He was also combative on the day shift. On [DATE] at 10:31 PM, the nurse documented, It was reported to the nurse the resident threw his TV on the ground and knocked over his bedside table. On [DATE] at 10:36 AM, Resident screaming in room. Appeared he had gotten out of bed to find the bathroom. He had moved dresser away from wall and was standing behind it. He had knocked over his roommate's TV from the stand and cracked it. On [DATE] at 2:05 AM, the nurse documented, (Resident #1) urinating in hallway. Wandering in wheelchair. Difficult to direct. Combative to hygiene care. Resident was screaming for his pants that were removed. He was dressed in sleep bottoms. He wanted his shoes I got to get out of this place! Reassured and redirected many times throughout the night. Resident yelling and kicking at staff and stating that he would shoot them. A review of a social services note, dated [DATE] at the quarterly assessment, noted the resident was alert with confusion. Able to communicate most basic needs and wants. Looking for the exit this afternoon. Yelling out for staff to call a cab. Upon asking why resident stated he was going up town. Staff identified resident had personal care needs likely adding to confusion and care for him. Otherwise staff reports his behaviors have stabilized in general. No problems, concerns or needs identified today. There were no documented events of aggressive behavior again until [DATE], when a nursing note revealed that Resident #1 was found on the floor next to the bed with a hematoma and abrasion. He was difficult to redirect. On [DATE] at 10:02 PM the nurse documented, (Resident #1) was having some refusal behaviors, but can often be redirected with a different approach. No new labs or incidents in the last 30 days. On [DATE] at 9:11 PM the nurse documented, At approximately 8:00 PM resident was yelling and screaming for staff to call police because he wanted to be out of the facility. Unable to direct behaviors. Resident was observed by staff for safety and went to bed at 9:10 PM without further episodes. There was a second note that documented at the time of this incident the resident was self-propelling his wheelchair while screaming. On [DATE] at 3:45 AM, the nurse noted at the start of shift the resident was up and in his wheelchair cursing loudly and trying to hit staff who was attempting to get the resident in bed. On [DATE] at 6:45 PM, the nurse documented that at 3:45 PM, the resident was yelling and screaming in hallways, actively exit seeking and asking staff to call the police. Resident's behaviors continued to escalate, at this time resident was at risk to cause harm to self or others, resident was in close observation by staff at this time to keep resident, staff and peers safe. Call placed to psych ARNP and order for IM [MEDICATION NAME] was obtained at 4:29 PM. IM [MEDICATION NAME] was administered in left arm. On [DATE] at 3:45 AM, the nurse documented she was called into Resident #1's room by a CNA who was yelling for help. Resident #1 was standing over Resident #2's bed. He was leaning over the bed. His right hand held a bloody remote for the bed. His other hand was clenched in a fist. Staff separated the residents. Resident #2 was observed to have two closed eyes with [MEDICAL CONDITION], a laceration on his forehead and another on his right cheek. All of the nurses on the third shift came into the room. They applied pressure to stop the bleeding. They applied a pressure dressing to the eyes and forehead. Resident #1's care plan was updated on [DATE] with an intervention of 1:1 supervision for safety. A review of the (MONTH) 2019 physician's orders [REDACTED]. On [DATE], an order was written for [MEDICATION NAME] (anxiolytic) 2 milligrams/milliliters (mg/ml) vial, administer 1 mg intramuscular (IM) every 12 hours as needed for severe agitation. On [DATE], a new order was written for an increase in [MEDICATION NAME] (anti-convulsant that can be used as a mood stabilizer) DR (delayed release) 125 mg sprinkle capsule, administer 2 capsules (250 mg) twice a day for agitation. The resident had been on [MEDICATION NAME] (a hormone used to help with [MEDICAL CONDITION]/difficulty sleeping) 5 mg tablet at the hour of sleep for [MEDICAL CONDITION] and [MEDICATION NAME] (an anti-depressant that also works to stimulate appetite) 7.5 mg, 1 tablet at the hour of sleep for poor appetite. A review of the (MONTH) 2019 medication administration record (MAR) found the resident received [MEDICATION NAME] 2 mg/ml vial, administer 1 mg IM every 12 hours as needed for a [DIAGNOSES REDACTED]. Further review also found the resident did not have his 5:00 PM dose of [MEDICATION NAME] DR 125 mg for agitation on [DATE], nor did he take his 8:00 PM [MEDICATION NAME] and [MEDICATION NAME] 7.5 mg. The medications were documented on the medication administration record (MAR) as having been refused. The ARNP documented that Resident #1 was seen on [DATE] due to the violent attack on his roommate. The documented concerns were have been happening for months but is worse. Listed were depression, anxiety, agitation, aggression, confusion, and refusing care. Oriented to person and place. Behavior hostile. Insight/judgement poor. Anxious and irritability increased. Resident was physically aggressive at the time of the visit. The ARNP documented the resident was a danger to self and others. During an interview with the acting director of nursing (DON) on [DATE] at 1:32 PM, she was asked for any evidence they notified the doctor that Resident #1 refused his evening medication on [DATE]. She stated the physician had not been notified, as it was something the resident frequently did. During an interview with the acting DON, the nurse consultant and the North Wing unit manager on [DATE] at 4:22 PM, they were asked if they conducted an analysis of what happened. The acting DON, using her notes, stated some of Resident #1's behaviors were normal dementia behaviors, and because his sight was impaired. His behavior was justified sometimes when he would get scared and yell and back away. On [DATE] during an episode at 8:00 PM, he wanted the cops called because he wanted to leave. He was self-propelling his wheelchair and went to bed willingly at 9:10 PM. The next documented behavior was on [DATE] at 3:07 AM. He was up in his wheelchair cursing at staff trying to help him into bed. He was encouraged to go to bed. Verbal and tactile cues were used, as he ddid better with hands-on care. On [DATE] at 3:45 PM he was yelling and screaming in the hallways. Wanting to call police. His behaviors escalated. They contacted the psychiatric nurse and family. They obtained orders for lab work. The unit manager added that when he had visitors he would want to leave with them, and those visits attributed to his behaviors. She stated on [DATE], he had visitors that afternoon and that made his behaviors worse. During an interview with Resident #1's nurse, Licensed Practical Nurse (LPN) A, on [DATE] at 10:40 AM, she stated she worked with Resident #1 for almost five months. He was alert and oriented to self only. He did have some vision as he knew when you were close to him and entered the room. He had behaviors. He would tell you to call the police because he wanted to leave. She recalled an instance when he was aggressive. On Thursday [DATE], he was self-propelling down the hallway. He got to the front hall and wanted to call the police to get out of the facility. He picked up a wet floor sign and started to swing the sign. LPN A immediately went down the hall, took the sign and instructed the certified nursing assistant (CNA) to put one on one staffing in place. She instructed another staff member to contact the physician. They received a physician's orders [REDACTED].#1 allowed LPN A to administer the IM [MEDICATION NAME], and he took the evening medications. LPN A stated the one to one was to be discontinued once the IM med was effective. LPN A stated the day of the incident she had worked a double shift. Resident #1 had no sundowning behaviors according to her observations of him. She stated she did not know if he even had Alzheimer's or dementia. On [DATE] she informed the unit manager and the DON and the information was passed on to the 11:00 PM-7:00 AM nurse. During an interview with the psychiatric ARNP on [DATE] at 3:12 PM, she stated she first saw Resident #1 on [DATE]. He was blind and did not say very much. She was asked to see him for sleep difficulty. She put him on [MEDICATION NAME] and recommended the nurses approach him in a calm manner, as he would easily become combative and defensive due to his visual impairment. She stated it was a normal behavior, and he was not on any medication for behaviors. She stated she saw Resident #1 again on [DATE] and he was combative with dementia. He had pain issues and [MEDICAL CONDITION]. On [DATE] and [DATE] he was put on [MEDICATION NAME] 1 milligram (mg) as needed every 12 hours for combative behavior, and [MEDICATION NAME] .25 mg at night. She further stated he had dementia and usually behaviors got worse at night. She saw him again on [DATE]. The issue was he wanted to do his own activities of daily living (ADL) care. She stated the [MEDICATION NAME] had finished as it was only for 14 days and the [MEDICATION NAME] had continued. Eventually the [MEDICATION NAME] was discontinued and he was put on [MEDICATION NAME] for the Dementia. She stated she was available and visited the facility every Wednesday. She did not see the resident again until she came to the facility on [DATE] to Baker Act him. She had been contacted prior to that via telephone, had increased his [MEDICATION NAME] and gave a new order for IM [MEDICATION NAME]. She confirmed it was on [DATE]. She stated she would have seen the resident on her next visit to the facility, which was a Wednesday, but the incident occurred and she was called into the facility to Baker Act him. During an interview with LPN A on [DATE] at 5:16 PM, she was asked about Resident #1 refusing his medication on [DATE]. She stated if a resident refused medication and it was a one-time occurrence, it was not an issue. If the refusal occurred for three consecutive days or three consecutive shifts, the nursing staff notified the physician and the family. If it was an alert and oriented resident they had a right to refuse, and nurses would provide education. They made three attempts and then educated. If the resident was not alert and oriented, they would notify the family and physician, then write a note. She stated she would have passed on the information to the next shift that Resident #1 did not take his medication. She further stated that missing his medication was not detrimental to him. She did not see any behaviors that evening. As of 11:00 PM, he was in his bed with his eyes closed, and his roommate was in his bed with his eyes closed. During an interview with Resident #1's CNA (B) on [DATE] at 5:27 PM, she stated she worked with Resident #1 often on the 3:00 PM to 11:00 PM shift. He went to bed at varying times. Sometimes he would be up as late as 11:00 PM. The night of the incident he was very agitated. He did not want to go to bed. She got him in bed right before she left at 10:45 PM. She had to beg him. His nurse was aware. He had aggressive behaviors in (MONTH) and (MONTH) and until he was discharged . He would go in other residents' rooms and not come out. He was going up and down the halls in February. This was continual. He would refuse to take medications. During an interview on [DATE] at 10:00 AM with the acting DON and the nurse consultant, the nurse consultant stated they put the resident on behavior monitoring on [DATE], and he continued on the behavior monitoring through [DATE]. She provided the physician's orders [REDACTED]. She provided the monitoring sheets and the approaches used to deal with behaviors. According to the monitoring sheets, the last behaviors were documented on [DATE], [DATE] and [DATE], and they documented all three times that they redirected the resident. The monitoring was for combative behavior toward staff. She stated they did monitor [MEDICAL CONDITION] for a while. She was asked about his behaviors of yelling and exit seeking. She stated he was care planned for those behaviors, but they did not do monitoring sheets, as these would be documented in progress notes. She stated they did not complete a monitoring tool for all the other behaviors. Once the behaviors stopped, the facility did not hold an interdisciplinary team (IDT) meeting. The last IDT note was [DATE] and stated he had improved. During an interview with the administrator on [DATE] at 12:26 PM, she was asked why, in light of Resident #1's behaviors, had they not moved either Resident #1 or Resident #2 out of the room. She replied, Historically his behavior was against caregivers, and the interventions were effective. She would see him in the facility and interact. She did not feel his behavior was dangerous in the past. They felt he was oriented to the left side of the room, A bed. Historically he acted out to caregivers and he had a roommate that was bed bound. If you addressed something and redirected him, he did not go back to the same activity. They felt the medical management was appropriate. He was stable for a long period of time. On [DATE] at 12:28 PM, a telephone interview was conducted with Resident #1's physician. He stated the resident was transferred from the hospital to the facility. He had some behavioral issues at that time. He was stable after a month or so on the medication until recently when this incident occurred. There were no issues, and if so, he would have obtained an opinion from the psychiatrist. He was aware of the resident's refusal of medications at some times, but was unable to provide details. He stated the resident's behaviors were normal for someone with dementia. CNA [NAME] was interviewed on [DATE] at 3:25 PM. She stated aggressive residents were reported to the nurse(s). The nurses documented the behaviors in their charting. CNA F was interviewed at 3:32 PM on [DATE], and stated she had seen Resident #1 act out with staff. He was verbally abusive and he would hit. Resident #1 was combative. He was confused and he didn't want the care. We notify the nurse and give him time to calm down. Sometimes it worked and sometimes it didn't. We notify the nurse when they are combative, try to keep them from hurting themselves, and document it in the computer. She confirmed she had training on behaviors, and used redirection and provided activities. Once we get them calm and keep them from hurting themselves, we come in as a team, then we may put them on 1 to 1 watch. At 3:40 PM on [DATE], CNA G stated when residents were combative or aggressive, she would move out of their way, report it to the nurse, and document it. LPN [NAME] stated in an interview at 3:46 PM on [DATE], that if a resident went from one status to another then the SBAR (situation, background, assessment, recommendations) form was completed, otherwise it was documented in nurses' notes, and then put in the 24 hour report. It would go to the DON, the unit managers, and upper management was alerted in the morning meetings. LPN F was interviewed at 4:01 PM on [DATE] and said the 24 hour report for behaviors was passed on to everyone in the morning meeting. There was a lot of documentation. He stated they had nurses' meetings where pertinent information was reviewed with the risk manager. RN A was interviewed at 4:10 PM on [DATE]. She stated she was the primary nurse on that unit. When resident behaviors occurred, they let the unit manager know, then the assistant DON and the DON. If none of the nursing management staff were available, then the administrator would be notified. The physician was always called first. It was documented in the shift report, progress notes and the 24 hour report. The 24 hour report was reviewed in the morning meeting. She believed they received all three reports in the morning meeting, but the 24 hour report stayed on for 24 hours. The South Wing unit manager was interviewed at 4:30 PM on [DATE], and reported that Resident #1 had a lot of confusion. If a behaviors occurred, the first thing to do was to get help and notify the nurse immediately. The nurse would assess the resident to see why they were combative. If there were no interventions in place, the psychiatrist, the physician, the charge nurse or the DON would be notified, and it would be documented. We have a 24 hour report sheet that anyone can write on. It specifically asks about behaviors. Each morning it is reviewed. We have morning clinical meetings with all managers and decide as a team what should be done. The DON should already know of the situation, because staff notify her of behaviors and we come to a conclusion as a team. We also have a separate meeting for just the nurses to go over certain topics that might be an issue. The DON was interviewed at 12:04 PM on [DATE]. She was asked to provide the survey team with any and all Quality Assurance/Quality Assurance Performance Improvement (QAPI) information related to the facility's identification of and response to Resident #1's escalating behaviors since his admission. The DON replied that she had already reviewed all of the facility's QAPI notes, and determined there was nothing identified or addressed in relation to Resident #1's conduct. An interview was conducted with CNA C at 2:20 PM on [DATE]. She stated all residents were checked every two hours, and difficult residents might be put on one to one staffing supervision. If she observed a resident with violent behaviors she would report it immediately to a nurse. An interview was conducted with LPN C at 2:30 PM on [DATE]. She stated that typically residents with behaviors were kept in a high visibility area like near the nursing station or in the day room. More confused impulsive residents were checked on hourly, and/or each time staff passed by if they were in their room(s). If a violent behavior occurred, staff were to safely remove the patient or other patients in the area. If unable to redirect the behaviors, staff would remain present and provide one to one supervision for the resident. All behaviors were documented on the electronic medication administration record (EMAR) on every shift. Any unusual behavior would be reported to the supervisor. An interview was conducted with LPN D at 4:38 PM on [DATE]. She stated all behaviors were documented on every shift, including staff response and interventions. We would monitor the resident throughout the shift especially if behaviors were observed. We would put interventions in place, we would do something! She stated interventions might include redirecting the resident, offering food, or even providing one to one staff supervision if needed. The policy was to notify the doctor of any behaviors. An interview with CNA D at 4:50 PM on [DATE] found any escalation in behavior would be reported to the nurse and if needed, one to one staff supervision would be provided. 2. A record review found Resident #2 was admitted to the facility on [DATE] and was discharged [DATE]. The quarterly minimum data set (MDS) assessment with an assessment reference date of [DATE] found Resident #2 had unclear speech, but was usually able to make himself understood. His vision was impaired and he did not wear corrective lenses. He usually understood others. He had a brief interview for mental status (BIMS) score of 8, indicating moderately impaired cognitive ability, and he exhibited no behaviors. His [DIAGNOSES REDACTED]. Resident #2 was care planned on [DATE] for his multiple medical conditions including gout, [MEDICAL CONDITIONS] and pain. He was care planned as at risk for falls related to his dependence on others for transfers, his impaired mobility, and [MEDICAL CONDITION]. Interventions included to assist with him with mobility. Resident #2 was care planned for impaired communication related to a [DIAGNOSES REDACTED]. Resident #2 was care planned for requiring assistance with all activities of daily living (ADLs) related to his bilateral upper extremity contractures. The goal was to maintain self-care for 90 days as evidenced b

Based on a review of clinical records, interviews with staff, a review of the Agency for Health Care Administration (AHCA) Nursing Homes Federal Reporting Five-Day Report; the Sheriff's Office Report/Homicide Ruling; the facility's policy and procedure on Quality Assurance Behavior/[MEDICAL CONDITION] Subcommittee process; the facility's policy and procedure on Distressed Behavior Management Program; the facility's policies and procedures on Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source and Exploitation; the guidelines for the facility's Daily Clinical Meetings, and the facility's policy and procedure for Quality Assurance/Quality Assurance Performance Improvement (QA/QAPI), the facility failed to identify risk factors and the potential for harm to a vulnerable resident, thus failing to prevent the physical abuse by Resident #1 of Resident #2, which resulted in the death of Resident #2, one of three residents reviewed for abuse. On [DATE] at 3:45 AM, Immediate Jeopardy (IJ) started. On [DATE] at 12:05 PM, the Administrator was notified of the Immediate Jeopardy determination. On [DATE] at 5:25 PM, the facility provided an acceptable credible IJ removal plan for monitoring/care of residents with aggressive behaviors and provision of safety measures for all residents in the facility. On [DATE] at 6:10 PM, the Immediate Jeopardy was removed after validation of the implementation of the plan. The findings include: 1. A review of the facility's AHCA Nursing Homes Federal Reporting Five-Day Report # found that on [DATE] at 3:45 AM, certified nursing assistant (CNA) H entered Resident #1 and #2's room for a routine check, identified a wheelchair that was tipped over and observed Resident #1 leaning over Resident #2's bed. Resident #1 was striking Resident #2 in the face with the bed's remote control device. Due to the bright red drainage on Resident #2's face, he was transferred to an acute care hospital for evaluation. He was subsequently transferred to a trauma center and admitted to a hospice facility where he expired on [DATE]. A review of the Sheriff's Office Report, dated [DATE], revealed an investigation of the death of a [AGE] year-old male who was allegedly battered by an 84-year- old male, both while residents of the facility. The report stated that the Medical Examiner's Office released its preliminary findings in the case this same day, and it ruled the cause of death as [MEDICATION NAME] force trauma and the manner of death as homicide. A record review for Resident #1 found he was admitted to the facility on [DATE] with a readmission on [DATE]. He was discharged by Baker Act to an acute care hospital on [DATE]. His admitting [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. A review of the [DATE] quarterly minimum data set (MDS) assessment revealed that Resident #1 had highly impaired vision. He had a brief interview for mental status (BIMS) score of 5 out of a possible 15 points, reflective of severely impaired cognitive skills for daily decision making. There were no behaviors, hallucinations or delusions documented over the assessment lookback period. The resident required limited assistance of one person with bed mobility, transfers and to walk in his room, and extensive, two-person assistance for use of the toilet. Dressing and personal hygiene required extensive assistance from one person. He ate with supervision after set up. Resident #1 was care planned on [DATE] for his visual impairment, with a goal to have no visual deficit that prevented ability to receive communication. He was care planned for exhibiting behavior of striking out at staff and family and striking other residents, yelling out and urinating in inappropriate places. The goal was not to injure himself or others, over the next 90 days, if he had behaviors. Approaches included to place the resident in areas where frequent observation was possible, and talk in a calm voice when behavior was disruptive. Remove from public area when behavior was disruptive and unacceptable. Do not argue with resident, discuss options for appropriate channeling of anger. Approach wandering resident in a positive, calm, and accepting manner. Administer behavior medications ordered by physician, and provide diversional activities. Observe and document target behaviors. When he becomes combative, leave and try to approach later. 1:1 supervision for safety (start date of [DATE]). Resident #1 was care planned for antipsychotic drug use and risk for side effects, with approaches including observe for patterns of target behaviors, medications as ordered, and observe for changes in condition that may warrant increased supervision/assistance and notify the physician. He was care planned for impaired cognition with interventions including observe for episodes of delusions or hallucinations, and choose roommate for compatibility. Observe when restless, hungry, thirsty, needs to use bathroom, pain, and provide care needed. In the resident's care plan for falls, instructions were to remind him to ask staff for assistance with ambulation, assist with one staff member for all ambulation, observe for changes in condition that may warrant increased supervision and assistance and notify the physician. A review of facility records revealed Resident #1 and Resident #2 became roommates on [DATE]. During an interview with the administrator on [DATE] at 12:26 PM, she stated that historically, Resident #1's behavior was against caregivers, the interventions were effective and his roommate was bedbound. She did not feel that his behavior was dangerous in the past. She felt Resident #1's medical management was appropriate. The facility documented that Resident #1 exhibited behaviors on the following dates: On [DATE] at 11:35 PM: When attempting to take to the bathroom, Resident #1 started waving his cane. Going on to roommate's bed. Becoming verbally aggressive. The resident also had chest pains. After contact with his physician, Resident #1 was sent out to the hospital. On [DATE] at 1:53 AM: Resident #1 Took the TV off of the wall in his room and was cursing and trying to hit staff. On [DATE] at 9:33 PM: Resident #1 was swinging clenched fists at staff. He grabbed a coat hanger and broke it and threatened to stab staff. On [DATE] at 10:17 AM: Resident #1 was punching and cursing at staff. [DATE] at 2:28 PM: Resident #1 was combative with staff. [DATE] at 7:18 PM: Resident #1 was physically aggressive. On [DATE] at 3:36 AM, Resident #1 was combative with care, hitting staff, ripping staff clothing, swinging violently from curtains. High risk of hurting others and staff. Refused to lie down. Combative with care. Smashing plastic cup with hands. Un-gripped broken cup. Resident grabbed curtain with firm grip and swinging hit body back and forth violently with the curtain. Resident extensive assist of four into Geri chair. Resident very combative. Hitting staff. Ripping clothes off, ripped shirt of writer. Unable to control resident. Resident at high risk of hurting others. The nurse wrote she contacted the resident's physician two times that week, and he refused to give an order for [REDACTED]. At 3:35 PM, the nurse wrote that the Psychiatric ARNP (advanced resgistered nurse practitioner) gave a new order for [MEDICATION NAME] at bedtime. The nurse wrote the resident refused on second shift, and no other medication or IM available to this writer to prevent any possible injuries to resident or others. MD would not order anxiety med (medication) or IM. Nursing judgement resident at risk to self and others. Increased agitation and more combative. No safety awareness. On [DATE] at 3:33 AM, Resident #1 was combative with staff. The nurse wrote in her progress note, Resident up in wheelchair until 3:00 AM then complained of being tired. Assisted to bed by the CNA. Easily excitable. Staff attempted to keep voices soft when speaking near resident so as not to over stimulate. Became combative times one (1) when attempting to toilet resident after resident attempted to urinate on floor in day room. Refused snack when offered. Self-propelled in wheelchair in hallways. Intrusive to other resident's space but re-directable. On [DATE] at 2:42 AM, per the nurse's note, Resident #1 was found asleep across his roommate's bed. He was assisted to the correct bed. The nurse wrote he was legally blind. Redirected with verbal cues. No apparent injuries to resident or roommate. On [DATE] at 2:47 PM, the nurse documented, Resident was very agitated this AM as CNA attempted to wake him to assist with bath as he had urinated all over bed, floor, and self. RN (registered nurse) went to room to assist and resident refused. Instructed CNA to wait ,[DATE] minutes. Reassessed in 30 minutes. More cooperative and took meds. On [DATE] at 11:37 PM, the nurse documented, Resident alert and oriented, verbally and physically combative throughout shift. Refused medications. Redirected from wandering into others' rooms during shift. Urinated in hallway several times during shift after constant redirection, refused food, fluid, and meds. Refused all activities of daily living assistance. Contacted family to speak with resident. Resident became more upset. Administered 0.5 milliliters (ML) of intramuscular (IM) [MEDICATION NAME] and resident tolerated well. On [DATE] at 3:11 AM, per the nurse's note, Resident yelling and aggressive toward staff. IM [MEDICATION NAME] administered, reassurance offered and used a quiet tone. On [DATE] at 1:28 AM, Resident noted to be verbally abusive toward staff, yelling without purpose and also urinating on the floor after refusing assistance with toileting care. Different approaches tried all ineffective. On [DATE] at 2:42 PM, the nurse documented, Yelling and cursing at staff several times throughout shift. Not easily re-directed. On [DATE] at 3:22 AM, the nurse documented, Resident noted to be verbally abusive with staff and attempt to be combative several times this shift and is not easily redirected, multiple approaches tried with little effect. On [DATE] at 11:55 PM, the nurse documented, Per second shift, resident urinated in hallway and on his pants. Resident reluctant to take off wet pants and to be changed. Resident became irate. Resident tore off the side rail to his bed and was swinging it as a weapon. Resident would not let go of side rail. He stated that he would use it to bash in the head of the girl who took his pants. Resident finally fell asleep with side rail under him and it could be retrieved. He was also combative on the day shift. On [DATE] at 10:31 PM, the nurse documented, It was reported to the nurse the resident threw his TV on the ground and knocked over his bedside table. On [DATE] at 10:36 AM, Resident screaming in room. Appeared he had gotten out of bed to find the bathroom. He had moved dresser away from wall and was standing behind it. He had knocked over his roommate's TV from the stand and cracked it. On [DATE] at 2:05 AM, the nurse documented, (Resident #1) urinating in hallway. Wandering in wheelchair. Difficult to direct. Combative to hygiene care. Resident was screaming for his pants that were removed. He was dressed in sleep bottoms. He wanted his shoes I got to get out of this place! Reassured and redirected many times throughout the night. Resident yelling and kicking at staff and stating that he would shoot them. A review of a social services note, dated [DATE] at the quarterly assessment, noted the resident was alert with confusion. Able to communicate most basic needs and wants. Looking for the exit this afternoon. Yelling out for staff to call a cab. Upon asking why resident stated he was going up town. Staff identified resident had personal care needs likely adding to confusion and care for him. Otherwise staff reports his behaviors have stabilized in general. No problems, concerns or needs identified today. There were no documented events of aggressive behavior again until [DATE], when a nursing note revealed that Resident #1 was found on the floor next to the bed with a hematoma and abrasion, and he was difficult to redirect. On [DATE] at 10:02 PM the nurse documented, (Resident #1) was having some refusal behaviors, but can often be redirected with a different approach. No new labs or incidents in the last 30 days. On [DATE] at 9:11 PM the nurse documented, At approximately 8:00 PM resident was yelling and screaming for staff to call police because he wanted to be out of the facility. Unable to direct behaviors. Resident was observed by staff for safety and went to bed at 9:10 PM without further episodes. There was a second note that documented at the time of this incident the resident was self-propelling his wheelchair while screaming. On [DATE] at 3:45 AM, the nurse noted at the start of shift the resident was up and in his wheelchair cursing loudly and trying to hit staff who was attempting to get the resident in bed. On [DATE] at 6:45 PM, the nurse documented that at 3:45 PM, the resident was yelling and screaming in hallways, actively exit seeking and asking staff to call the police. Resident's behaviors continued to escalate, at this time resident was at risk to cause harm to self or others, resident was in close observation by staff at this time to keep resident, staff and peers safe. Call placed to psych ARNP and order for IM [MEDICATION NAME] was obtained at 4:29 PM. IM [MEDICATION NAME] was administered in left arm. On [DATE] at 3:45 AM, the nurse documented she was called into Resident #1's room by a CNA who was yelling for help. Resident #1 was standing over Resident #2's bed. He was leaning over the bed. His right hand held a bloody remote for the bed. His other hand was clenched in a fist. Staff separated the residents. Resident #2 was observed to have two closed eyes with [MEDICAL CONDITION], a laceration on his forehead and another on his right cheek. All of the nurses on the third shift came into the room. They applied pressure to stop the bleeding. They applied a pressure dressing to the eyes and forehead. Resident #1's care plan was updated on [DATE] with an intervention of 1:1 supervision for safety. A review of the (MONTH) 2019 physician's orders [REDACTED]. On [DATE], an order was written for [MEDICATION NAME] (anxiolytic) 2 milligrams/milliliters (mg/ml) vial, administer 1 mg intramuscular (IM) every 12 hours as needed for severe agitation. On [DATE], a new order was written for an increase in [MEDICATION NAME] (anti-convulsant that can be used as a mood stabilizer) DR (delayed release) 125 mg sprinkle capsule, administer 2 capsules (250 mg) twice a day for agitation. The resident had been on [MEDICATION NAME] (a hormone used to help with [MEDICAL CONDITION]/difficulty sleeping) 5 mg tablet at the hour of sleep for [MEDICAL CONDITION] and [MEDICATION NAME] (an anti-depressant that also works to stimulate appetite) 7.5 mg, 1 tablet at the hour of sleep for poor appetite. A review of the (MONTH) 2019 medication administration record (MAR) found the resident received [MEDICATION NAME] 2 mg/ml vial, administer 1 mg IM every 12 hours as needed for a [DIAGNOSES REDACTED]. Further review also found the resident did not have his 5:00 PM dose of [MEDICATION NAME] DR 125 mg for agitation on [DATE], nor did he take his 8:00 PM [MEDICATION NAME] and [MEDICATION NAME] 7.5 mg. The medications were documented on the medication administration record (MAR) as having been refused. The ARNP documented that Resident #1 was seen on [DATE] due to the violent attack on his roommate. The documented concerns were have been happening for months but is worse. Listed were depression, anxiety, agitation, aggression, confusion, and refusing care. Oriented to person and place. Behavior hostile. Insight/judgement poor. Anxious and irritability increased. Resident was physically aggressive at the time of the visit. The ARNP documented the resident was a danger to self and others. During an interview with the acting director of nursing (DON) on [DATE] at 1:32 PM, she was asked for any evidence they notified the doctor that Resident #1 refused his evening medication on [DATE]. She stated the physician had not been notified, as it was something the resident frequently did. During an interview with Resident #1's nurse, Licensed Practical Nurse (LPN) A, on [DATE] at 10:40 AM, she stated she worked with Resident #1 for almost five months. He was alert and oriented to self only. He did have some vision as he knew when you were close to him and entered the room. He had behaviors. He would tell you to call the police because he wanted to leave. She recalled an instance when he was aggressive. On Thursday [DATE], he was self-propelling down the hallway. He got to the front hall and wanted to call the police to get out of the facility. He picked up a wet floor sign and started to swing the sign. LPN A immediately went down the hall, took the sign and instructed the certified nursing assistant (CNA) to put one on one staffing in place. She instructed another staff member to contact the physician. They received a physician's orders [REDACTED].#1 allowed LPN A to administer the IM [MEDICATION NAME], and he took the evening medications. LPN A stated the one to one was to be discontinued once the IM med was effective. LPN A stated the day of the incident she had worked a double shift. Resident #1 had no sundowning behaviors according to her observations of him. She stated she did not know if he even had Alzheimer's or dementia. On [DATE] she informed the unit manager and the DON and the information was passed on to the 11:00 PM-7:00 AM nurse. During an interview with the psychiatric ARNP on [DATE] at 3:12 PM, she stated she first saw Resident #1 on [DATE]. He was blind and did not say very much. She was asked to see him for sleep difficulty. She put him on [MEDICATION NAME] and recommended the nurses approach him in a calm manner, as he would easily become combative and defensive due to his visual impairment. She stated it was a normal behavior, and he was not on any medication for behaviors. She stated she saw Resident #1 again on [DATE] and he was combative with dementia. He had pain issues and [MEDICAL CONDITION]. On [DATE] and [DATE] he was put on [MEDICATION NAME] 1 milligram (mg) as needed every 12 hours for combative behavior, and [MEDICATION NAME] .25 mg at night. She further stated he had dementia and usually behaviors got worse at night. She saw him again on [DATE]. The issue was he wanted to do his own activities of daily living (ADL) care. She stated the [MEDICATION NAME] had finished as it was only for 14 days and the [MEDICATION NAME] had continued. Eventually the [MEDICATION NAME] was discontinued and he was put on [MEDICATION NAME] for the Dementia. She stated she was available and visited the facility every Wednesday. She did not see the resident again until she came to the facility on [DATE] to Baker Act him. She had been contacted prior to that via telephone, had increased his [MEDICATION NAME] and gave a new order for IM [MEDICATION NAME]. She confirmed it was on [DATE]. She stated she would have seen the resident on her next visit to the facility, which was a Wednesday, but the incident occurred and she was called into the facility to Baker Act him. During an interview with LPN A on [DATE] at 5:16 PM, she was asked about Resident #1 refusing his medication on [DATE]. She stated if a resident refused medication and it was a one-time occurrence, it was not an issue. If the refusal occurred for three consecutive days or three consecutive shifts, the nursing staff notified the physician and the family. If it was an alert and oriented resident they had a right to refuse, and nurses would provide education. They made three attempts and then educated. If the resident was not alert and oriented, they would notify the family and physician, then write a note. She stated she would have passed on the information to the next shift that Resident #1 did not take his medication. She further stated that missing his medication was not detrimental to him. She did not see any behaviors that evening. As of 11:00 PM, he was in his bed with his eyes closed, and his roommate was in his bed with his eyes closed. During an interview with Resident #1's CNA (B) on [DATE] at 5:27 PM, she stated she worked with Resident #1 often on the 3:00 PM to 11:00 PM shift. He went to bed at varying times. Sometimes he would be up as late as 11:00 PM. The night of the incident he was very agitated. He did not want to go to bed. She got him in bed right before she left at 10:45 PM. She had to beg him. His nurse was aware. He had aggressive behaviors in (MONTH) and (MONTH) and until he was discharged . He would go in other residents' rooms and not come out. He was going up and down the halls in February. This was continual. He would refuse to take medications. During an interview on [DATE] at 10:00 AM with the acting DON and the nurse consultant, the nurse consultant stated they put the resident on behavior monitoring on [DATE], and he continued on the behavior monitoring through [DATE]. She provided the physician's orders [REDACTED]. She provided the monitoring sheets and the approaches used to deal with behaviors. According to the monitoring sheets, the last behaviors were documented on [DATE], [DATE] and [DATE], and they documented all three times that they redirected the resident. The monitoring was for combative behavior toward staff. She stated they did monitor [MEDICAL CONDITION] for a while. She was asked about his behaviors of yelling and exit seeking. She stated he was care planned for those behaviors, but they did not do monitoring sheets, as these would be documented in progress notes. She stated they did not complete a monitoring tool for all the other behaviors. Once the behaviors stopped, the facility did not hold an interdisciplinary team (IDT) meeting. The last IDT note was [DATE] and stated he had improved. During an interview with the administrator on [DATE] at 12:26 PM, she was asked why, in light of Resident #1's behaviors, had they not moved either Resident #1 or Resident #2 out of the room. She replied, Historically his behavior was against caregivers, and the interventions were effective. She would see him in the facility and interact. She did not feel his behavior was dangerous in the past. They felt he was oriented to the left side of the room, A bed. Historically he acted out to caregivers and he had a roommate that was bed bound. If you addressed something and redirected him, he did not go back to the same activity. They felt the medical management was appropriate. He was stable for a long period of time. On [DATE] at 12:28 PM, a telephone interview was conducted with Resident #1's physician. He stated the resident was transferred from the hospital to the facility. He had some behavioral issues at that time. He was stable after a month or so on the medication until recently when this incident occurred. There were no issues, and if so, he would have obtained an opinion from the psychiatrist. He was aware of the resident's refusal of medications at some times, but was unable to provide details. He stated the resident's behaviors were normal for someone with dementia. CNA [NAME] was interviewed on [DATE] at 3:25 PM. She stated aggressive residents were reported to the nurse(s). The nurses documented the behaviors in their charting. CNA F was interviewed at 3:32 PM on [DATE], and stated she had seen Resident #1 act out with staff. He was verbally abusive and he would hit. Resident #1 was combative. He was confused and he didn't want the care. We notify the nurse and give him time to calm down. Sometimes it worked and sometimes it didn't. We notify the nurse when they are combative, try to keep them from hurting themselves, and document it in the computer. She confirmed she had training on behaviors, and used redirection and provided activities. Once we get them calm and keep them from hurting themselves, we come in as a team, then we may put them on 1 to 1 watch. At 3:40 PM on [DATE], CNA G stated when residents were combative or aggressive, she would move out of their way, report it to the nurse, and document it. LPN [NAME] stated in an interview at 3:46 PM on [DATE], that if a resident went from one status to another then the SBAR (situation, background, assessment, recommendations) form was completed, otherwise it was documented in nurses' notes, and then put in the 24 hour report. It would go to the DON, the unit managers, and upper management was alerted in the morning meetings. LPN F was interviewed at 4:01 PM on [DATE] and said the 24 hour report for behaviors was passed on to everyone in the morning meeting. There was a lot of documentation. He stated they had nurses' meetings where pertinent information was reviewed with the risk manager. RN A was interviewed at 4:10 PM on [DATE]. She stated she was the primary nurse on that unit. When resident behaviors occurred, they let the unit manager know, then the assistant DON and the DON. If none of the nursing management staff were available, then the administrator would be notified. The physician was always called first. It was documented in the shift report, progress notes and the 24 hour report. The 24 hour report was reviewed in the morning meeting. She believed they received all three reports in the morning meeting, but the 24 hour report stayed on for 24 hours. The South Wing unit manager was interviewed at 4:30 PM on [DATE], and reported that Resident #1 had a lot of confusion. If a behaviors occurred, the first thing to do was to get help and notify the nurse immediately. The nurse would assess the resident to see why they were combative. If there were no interventions in place, the psychiatrist, the physician, the charge nurse or the DON would be notified, and it would be documented. We have a 24 hour report sheet that anyone can write on. It specifically asks about behaviors. Each morning it is reviewed. We have morning clinical meetings with all managers and decide as a team what should be done. The DON should already know of the situation, because staff notify her of behaviors and we come to a conclusion as a team. We also have a separate meeting for just the nurses to go over certain topics that might be an issue. An interview was conducted with CNA C at 2:20 PM on [DATE]. She stated all residents were checked every two hours, and difficult residents might be put on one to one staffing supervision. If she observed a resident with violent behaviors she would report it immediately to a nurse. An interview was conducted with LPN C at 2:30 PM on [DATE]. She stated that typically residents with behaviors were kept in a high visibility area like near the nursing station or in the day room. More confused impulsive residents were checked on hourly, and/or each time staff passed by if they were in their room(s). If a violent behavior occurred, staff were to safely remove the patient or other patients in the area. If unable to redirect the behaviors, staff would remain present and provide one to one supervision for the resident. All behaviors were documented on the electronic medication administration record (EMAR) on every shift. Any unusual behavior would be reported to the supervisor. An interview was conducted with LPN D at 4:38 PM on [DATE]. She stated all behaviors were documented on every shift, including staff response and interventions. We would monitor the resident throughout the shift especially if behaviors were observed. We would put interventions in place, we would do something! She stated interventions might include redirecting the resident, offering food, or even providing one to one staff supervision if needed. The policy was to notify the doctor of any behaviors. An interview with CNA D at 4:50 PM on [DATE] found any escalation in behavior would be reported to the nurse and if needed, one to one staff supervision would be provided. 2. A record review found Resident #2 was admitted to the facility on [DATE] and was discharged [DATE]. The quarterly minimum data set (MDS) assessment with an assessment reference date of [DATE] found Resident #2 had unclear speech, but was usually able to make himself understood. His vision was impaired and he did not wear corrective lenses. He usually understood others. He had a brief interview for mental status (BIMS) score of 8, indicating moderately impaired cognitive ability, and he exhibited no behaviors. His [DIAGNOSES REDACTED]. Resident #2 was care planned on [DATE] for his multiple medical conditions including gout, [MEDICAL CONDITIONS] and pain. He was care planned as at risk for falls related to his dependence on others for transfers, his impaired mobility, and [MEDICAL CONDITION]. Interventions included to assist with him with mobility. Resident #2 was care planned for impaired communication related to a [DIAGNOSES REDACTED]. Resident #2 was care planned for requiring assistance with all activities of daily living (ADLs) related to his bilateral upper extremity contractures. The goal was to maintain self-care for 90 days as evidenced by his continued ability to feed himself after set up, and assist with bathing his face and upper body. Approaches included allowing time to eat, choices, assisting with oral care, dressing, shaving and bathing per schedule. Resident #2 was also care planned for an inability to tolerate usual activities due to his poor endurance and refusal to get up. A review of a restorative note dated [DATE], revealed that Resident #2 had impaired mobility or range of motion (ROM, full movement in a joint), left and right arm contractures, left and right hand contractures, and left and right leg contractures. He used a wheelchair as a mobility device, and was dependent on others for its use. During an interview with the South Wing unit manager on [DATE] at 10:19 AM, she stated she had worked with Resident #2 in the past. He was very sweet. He was bedbound and could only move one arm. He was pretty much paralyzed. He was alert with confusion. She had not worked on the 100 unit in a while, but when she worked on a cart she remembered that he liked to stay in bed. A lot of noise bothered him. He had been on Hospice. He required total care. He could not defend himself. A review of facility's guidance for Daily Clinical Meetings instructed the following: 1. Review 24 hour shift report from previous day/days. 2. Review all progress notes for all Residents/Guests from previous day/days. 3. Review dashboard for behavior monitoring or new or worsening behaviors . A review of the facility's Quality Assurance Behavior/[MEDICAL CONDITION] Subcommittee process, revised [DATE], found the purpose of the committee was to identify residents/guests at risk r

Based on resident record review and staff interviews, the facility failed to ensure the resident's care plan was reviewed and revised to reflect the current level of care and services required for 1 of 38 sampled residents identified to be at risk for falls, Resident #7. The findings include: A review of the Care Plan written on 7/02/12 revealed that Resident #7 had a potential for falls related to weakness, [DIAGNOSES REDACTED]. An addition to the care plan on 9/28/12 revealed that the resident had [MEDICAL CONDITION] with therapy at times. Clinical record review of Resident #7's Nursing Notes dated 11/6/12, revealed that the Restorative CNA reported that while weighing the resident, the resident almost fell , but did not go all the way to the floor. According to the note, the resident complained of left knee and ankle pain. No signs of distress noted. On 11/6/12 at 10:16 PM the Nurse Notes revealed that the resident stated he was getting weighed today when he injured his left knee and ankle standing wrong. An x-ray of the knee and ankle was taken revealing soft tissue swelling laterally with linear lucency of medial malleolus. Follow up was needed to rule out a possible fracture. A repeat x-ray was ordered for 11/8/12 at 10:30 PM. [MEDICATION NAME] 15 mg. by mouth was ordered and given with good results and the left leg was elevated and iced as ordered. On 11/8/12 at 2:24 PM the Nurse Notes revealed that the x-rays showed a fracture. The note also revealed that the resident was being weighed and lost his balance and was lowered to the floor by the CNA. The resident was to be weighed in the wheelchair in the future. On 11/9/12 at 4:35 PM a nurse note revealed that the resident went to an orthopedic appointment and returned with a cast on his left ankle. On 1/16/13 at 3:00 PM an interview with the Restorative CNA regarding the accident revealed that she got the resident up to his wheelchair to take him to weigh. The CNA helped the resident to stand up. The CNA revealed that the resident buckled when he went to step on the scale. The resident stated that he stepped on the wrong leg, his left leg, and it buckled. The CNA caught the resident and she got him back into the chair. After that, the resident stood up on his own so the weight could be completed and the resident was taken back to his room in a wheelchair. He stated that he had pain in his leg and the CNA took him to his nurse. The nurse brought him pain medication. There were no other witnesses and no one was helping the CNA with taking the weight. The CNA said that she had previously weighed him on the standing scale with no problems. A review of the Minimum Data Set (MDS) Assessment of 6/8/12 revealed that under Functional Status the resident was coded as needing two plus persons physical assist for transfers. A review of the MDS of 10/12/12 revealed that under functional status that transfers required two plus persons. A review of the CNA Activities of Daily Living (ADL) record for the month of October revealed that there was no documentation of additional assistance with transfers and ambulation. On 1/17/13 at 10:15 AM, an interview with the MDS Coordinator revealed that she did the MDS Assessments for Resident #7. In the MDS Assessment of 10/12/12 it was noted that under Functional Status, Transfers were coded as a 3 level, which indicates that two persons need to assist the resident. On the 12/28/12 under Functional Status, Transfers are coded as a 3. The MDS Coordinator reviewed the Care Plan for Resident #7 which revealed that the Care Plan had not been updated based on the MDS assessments of the need for two person assist for transfers. The MDS Coordinator indicated that she should have initiated an update to the Care Plan. She indicated that the nurse should have updated the Nursing Assistant work sheet regarding needing two person assist. .

Based on resident record review and staff interviews, the facility failed to ensure that each resident receives adequate supervision and assistance to prevent accidents for one of 38 sampled residents identified to be at risk for falls (Resident #7). Resident #7 suffered a fractured ankle when assisted by only one staff member rather than two which was required. The findings include: A review of the Care Plan written on 7/02/12 revealed that Resident #7 had a potential for falls related to weakness, [DIAGNOSES REDACTED]. An addition to the care plan on 9/28/12 revealed that the resident had vertigo with therapy at times. Clinical record review of Resident #7's Nursing Notes dated 11/6/12, revealed that the Restorative CNA reported that while weighing the resident, the resident almost fell , but did not go all the way to the floor. According to the note, the resident complained of left knee and ankle pain. No signs of distress noted. On 11/6/12 at 10:16 PM the Nurse Notes revealed that the resident stated he was getting weighed today when he injured his left knee and ankle standing wrong. An x-ray of the knee and ankle was taken revealing soft tissue swelling laterally with linear lucency of medial malleolus. Follow up was needed to rule out a possible fracture. A repeat x-ray was ordered for 11/8/12 at 10:30 PM. Oxycodone 15 mg. by mouth was ordered and given with good results and the left leg was elevated and iced as ordered. On 11/8/12 at 2:24 PM the Nurse Notes revealed that the x-rays showed a fracture. The note also revealed that the resident was being weighed and lost his balance and was lowered to the floor by the CNA. The resident was to be weighed in the wheelchair in the future. On 11/9/12 at 4:35 PM a nurse note revealed that the resident went to an orthopedic appointment and returned with a cast on his left ankle. On 1/16/13 at 3:00 PM an interview with the Restorative CNA regarding the accident revealed that she got the resident up to his wheelchair to take him to weigh. The CNA helped the resident to stand up. The CNA revealed that the resident buckled when he went to step on the scale. The resident stated that he stepped on the wrong leg, his left leg, and it buckled. The CNA caught the resident and she got him back into the chair. After that, the resident stood up on his own so the weight could be completed and the resident was taken back to his room in a wheelchair. He stated that he had pain in his leg and the CNA took him to his nurse. The nurse brought him pain medication. There were no other witnesses and no one was helping the CNA with taking the weight. The CNA said that she had previously weighed him on the standing scale with no problems. A review of the Minimum Data Set (MDS) Assessment of 6/8/12 revealed that under Functional Status the resident was coded as needing two plus persons physical assist for transfers. A review of the MDS of 10/12/12 revealed that under functional status that transfers required two plus persons. A review of the CNA Activities of Daily Living (ADL) record for the month of October revealed that there was no documentation of additional assistance with transfers and ambulation. On 1/17/13 at 10:15 AM, an interview with the MDS Coordinator revealed that she did the MDS Assessments for Resident #7. In the MDS Assessment of 10/12/12 it was noted that under Functional Status, Transfers were coded as a 3 level, which indicates that two persons need to assist the resident. On the 12/28/12 under Functional Status, Transfers are coded as a 3. The MDS Coordinator reviewed the Care Plan for Resident #7 which revealed that the Care Plan had not been updated based on the MDS assessments of the need for two person assist for transfers. The MDS Coordinator indicated that she should have initiated an update to the Care Plan. She indicated that the nurse should have updated the Nursing Assistant work sheet regarding needing two person assist. .