Every finding on record at Tsali Care Center

Based on record reviews, interviews, and review of the facility policy titled TCC [Tsali Care Center] Social Services-Transfers and Discharge Policy, the facility failed to ensure pertinent health information was provided to the hospital upon transfer of one (1) resident (Resident #7); failed to provide written notice of transfer to the resident for one (1) resident (Resident #7); and failed to notify the Ombudsman of a discharge for one (1) resident (Resident #99) of six (6) residents reviewed. The findings include: 1. Resident #7 was admitted to the facility on [DATE] with diagnoses including osteomyelitis, urinary tract infection, resistance to multiple antimicrobial drugs, stage 4 pressure ulcer of sacral wound region, and neuromuscular dysfunction of bladder. The resident was cognitively intact. Review of progress notes for Resident #7 revealed a note dated 5/13/26 at 3:02 PM stating Resident #7 had been vomiting yellow liquid and was agreeable to going to the hospital. Emergency Medical Services (EMS) were called at 3:05 PM. A progress note dated 5//13/26 at 3:17 PM indicated Resident #7 left the facility at 3:15 PM, and the resident's responsible party was notified the resident was being sent to the hospital. There was no documentation that Resident #7's pertinent health information including medications, test results, allergies, and current condition had been provided to the receiving hospital. The progress note dated 5/16/26 at 4:25 PM indicated Resident #7 returned to the facility. The resident was continued on intravenous (IV) antibiotics for osteomyelitis and a chronic wound on the buttocks had been debrided while in the hospital. Review of a Summary of Episode Note printed from the electronic medical record (EMR) revealed the note contained health information for Resident #7, including ordered medications, allergies, recent test results, and the resident's current condition. The note was dated and time-stamped for 5/13/26 at 7:55 PM, four (4) hours and 40 minutes after the resident had been transferred to the hospital. Review of progress notes revealed a note dated 7/29/26 at 12:41 PM, that indicated Resident #7 was lethargic that morning and was requesting to go to the hospital. The responsible party was notified and verbal consent for bed hold was given. There was no indication that a written transfer notice was provided to the family or the responsible party. Review of the progress notes revealed a note dated 8/4/26 at 2:30 PM that indicated Resident #7 had returned to the facility from the hospital. During an interview on 8/4/26 at 4:16 PM, Resident #7 stated that he had just returned to the facility within the last couple of hours after staying in the hospital for six (6) days for sepsis following a urinary tract infection (UTI). During an interview on 8/6/26 at 10:17 AM, Registered Nurse (RN) #1 stated the nurse on duty was supposed to print a Discharge and Transfer form from the EMR system that included the resident's medication and the last date and time the medication was administered to send with the resident to the hospital. The RN stated the form contained pertinent health information including any testing, provider notes, allergies, and code status. RN #1 also stated the nurse notified the resident and/or the responsible party verbally when the resident was being sent to the hospital but did not provide a written notice of transfer. During an interview on 8/6/26 at 2:48 PM, Resident #7 stated he had been to the hospital twice in the last few months. Resident #7 stated a written notice was not given to him when he was transferred to the hospital. During an interview on 8/6/26 at 5:05 PM, the Director of Nursing (DON) stated the nurses were expected to print a document that included the resident's medication list from the EMR and send it with the resident to the hospital. The DON looked in the medical record for Resident #7 and stated it appeared the printed document was not generated until after the resident was sent to the hospital and therefore, did not go with the resident. The DON stated there was no documentation in the chart to indicate a report was called to the hospital staff. The DON also confirmed written notice of transfer was not given to residents or responsible parties when residents were transferred to the hospital. Review of the facility policy titled TCC Social Services-Transfers and Discharges Policy, last reviewed 5/12/26, revealed, .TCC will provide residents with a thirty-day notice of an impending transfer or discharge except under emergency circumstances or under other circumstances as defined by regulation and as noted in the admission contract. TCC will assist the resident and their responsible party with the transfer and discharge process to provide them with sufficient preparation and to ensure a safe and orderly transfer or discharge from the facility.All documentation concerning the transfer or discharge of the resident must be recorded in the resident's medical record.Documentation from the IDT [interdisciplinary team] concerning transfers or discharges for nursing facilities residents may include, but is not limited to: the reason(s) for the transfer or discharge.That an appropriate notice was provided to the resident and/or responsible party (sponsor).When the resident is transferred to another facility or healthcare provider, information will be given to the receiving provider including, but not limited to, the following.All other information necessary to meet the resident's needs, which includes, but may not be limited to, resident status, including baseline and current mental, behavioral, and functional status, reason for transfer, recent vital signs; diagnoses and allergies; medications (including when last received); and most recent relevant labs, other diagnostic tests, and recent immunizations. 2. Resident #99 was admitted to the facility on [DATE] and was discharged on 5/5/26. Resident #99 had diagnoses including but not limited to: Dehiscense of amputation stump, end stage renal disease, type 2 diabetes, and hypertension. Review of a nursing progress note dated 5/5/26 revealed, Elder is stable and appropriate for discharge to home. VS [vital signs] are within normal limits. Elder is alert and oriented x4 [oriented to person, place, time, and situation], able to communicate needs, he has expressed how excited he is to be going home and thanked nursing staff for the great care he received. Elder was accompanied by wife at time of discharge, all belongings were taken with elder. Both spouse and elder verbalized understanding of discharge instructions. Review of facility ombudsman notification records for all residents discharged home in 2026 revealed no documentation indicating the Ombudsman was notified of Resident #99's discharge home. Interview with the DON on 8/6/26 at 9:06 AM, revealed they did not have any documentation indicating the Ombudsman was notified of Resident #99's discharge. Interview with the Administrator on 8/6/26 at 4:05 PM, revealed that the Ombudsman must be notified of discharges and hospitalizations. The Administrator revealed the facility should have notified the Ombudsman of Resident #99's discharge.

Based on document review, interview, record review, and policy review, the facility's Administrator and Director of Nursing (DON) failed to identify there was no physician order in the electronic medical record (EMR) orders to correctly identify all residents' code status, and failed to provide oversight of staff's audits of residents' EMR Code Status to ensure the audits were accurate and to make corrections to ensure sustained compliance with the citation which had the potential to affect 72 of 72 residents who resided in the facility. The findings include: During an interview on 11/14/25 at 5:28 PM, the Administrator could not provide audit tools related to the monitoring of code status in resident records. The Administrator stated, The Director of Admissions and Marketing is not in the facility and has the audit tools on her computer. She would need to come into the facility to forward the audit tools electronically. On 11/14/25 at 7:30 PM, the Administrator provided a copy of the audit tool for monitoring code status. The Administrator stated the audit tool was completed by Medical Records staff and Admissions staff. Review of the audit tool revealed the new admissions were reviewed for Advance Directives and requested code status on the clinical consent form. The audit tool did not include that orders were received for Do Not Resuscitate (DNR) wishes for Resident #110 or that code status was updated and correct in the EMR for both Resident #109 and Resident #110. During a follow up interview on 11/14/25 at 8:00 PM, the audit tool was reviewed with Administrator again. The Administrator stated she did not think the audit tool used had included the necessary information to ensure compliance. The Administrator indicated she had not previously reviewed the audit tool and had just received a copy of it. The Administrator, who should have reviewed the audit tool as part of the facility's Quality Assurance Process, had not even reviewed the tool for accuracy prior to beginning the improvement plan. During an interview on 11/15/25 at 2:58 PM, the Administrator stated that she reviewed all of the audits in the plan of correction (POC) that were conducted after the recertification survey dated 08/01/25. The Administrator confirmed she had not conducted any oversight of the audit to determine whether the audits were accurate or if the audits captured what was necessary to ensure compliance. The Administrator further stated, I reviewed all of the audits. I did not see anything that stood out as deficient. I did not audit the audits. That was a missed opportunity. I agree that audit tool did not include information regarding code status entered into the electronic medical record. The Director of Admissions was responsible for new admissions, and the Social Workers were responsible for [code status] changes when residents are admitted . Ultimately, I am responsible for oversight for each audit after the department director. The DON is more responsible for oversight involving clinical care. During an interview on 11/16/25 at 11:10 AM, Medical Records (MR) stated, I completed the audit for Advance Directives/Code status. Once a month I look at everyone's admission clinical consent form for Advance Directives and requested code status and MOST [Medical Orders for Scope of Treatment] form. I look in the EMR for clinical agreement and that documents have been uploaded. I did not verify that code status was ordered or included on the profile screen. My understanding of my audit responsibilities were to check for advance directive to be uploaded, code status requested on clinical consent, and if they have a MOST form. Review of the Administrator's job description dated 10/21 indicated, .the primary function of this position is responsible for the daily operation.maintaining the highest standard of quality services in compliance with federal.regulations that govern nursing facilities.As Administrator.will delegate as necessary to the administrative authority, responsibility, and accountability for carrying out assigned duties. Job Description Coordinate the provision of services to residents to assure that provisions of care are appropriate to resident's needs. Plan, develop, organizes, implements, evaluates and direct the facility's programs and activities in accordance with guidelines issued by the governing board.Keeps up to date on CMS [Centers for Medicare & Medicaid Services] regulations.

Based on observations, interviews, record review, and review of the facility's policy titled Quality Assessment and Assurance Committee, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to 1. ensure the QAPI committee policy addressed data collection and analysis, data and adverse event monitoring, and feedback; 2. track and analyze data and conduct at least one process improvement plan (PIP) this year; and 3. maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 08/22/24 and the complaint surveys on 10/18/24 and 04/10/25. This was for deficiencies re-cited during the recertification and complaint survey conducted 07/28/25-08/01/25. The recited deficiencies included F 550, F 578, F645, F689, F698, and F761. The continued failure of the facility during three (3) Federal Jurisdictional surveys indicates a pattern of the facility to sustain an effective QAPI program. This was for six (6) of 25 deficient practice citations.The findings include:1.Review of the facility's policy titled Quality Assessment and Assurance Committee, revised 07/23/25, did not address data collection and analysis, data and adverse event monitoring, and feedback.During an interview with the Administrator on 08/01/25 at 11:58 AM, she confirmed that data collection and analysis, data and adverse event monitoring, and feedback information was not in the policy. She stated that the QAPI policy was recently revised and that information was left out.2. During an interview with the Administrator, Director of Nursing (DON), Infection Preventionist (IP), and Medical Records Director on 08/01/25 at 12:05 PM, she stated that the facility did not do any PIPs this year. The facility's management team discussed concerns during the QAPI meetings and the cross-functional Monday meetings, but no formal PIP was started. She stated that she had no documentation supporting the tracking and analyzing of data for a PIP. The Administrator further stated that the facility had identified that this was an opportunity to improve the QAPI process. 3. During the complaint survey on 10/18/24 the facility was cited F 698. During the complaint survey on 04/10/25 the facility was cited harm at F 689. During the recertification and complaint survey on 07/28/25-08/01/25 the facility was cited F 550, F 578, F 645, and F761.During an interview with the Administrator on 08/01/25 at 12:05 PM, she stated that for the repeated deficient citations, the staff was provided with education. She confirmed that for F 578, there was a change in the Advance Directive form, but currently there was no monitoring or auditing on the repeat deficiencies nor policy changes.Review of the facility policy titled Quality Assessment and Assurance Committee, revised 07/23/25, read .Committee Audit Process.3. The Quality Assessment and Assurance Committee shall help various departments/ committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. 4. The committee shall track the progress of any active plans of correction. 5. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented.

Based on interview, record review and review of the facility policy titled Administrative-Residents Rights for Senior Service, the facility failed to ensure residents were informed of the risks of treatment of prescribed medications for four (4) of five (5) residents sampled for unnecessary medications (Resident #'s 1,4, 7 and 8). The findings include: 1.Resident #7 was admitted to the facility 06/26/25 with diagnoses that included Parkinsonism, type 2 diabetes, insomnia, benign prostatic hyperplasia, and heart failure. The resident had moderate cognitive impairment. Review of physicians orders revealed Resident #7 was receiving quetiapine (an antipsychotic) 25 milligrams (mg) as needed for agitation every afternoon/evening; empagliflozin (for diabetes) 10 mg once a day; paroxetine (antidepressant) 10 mg once a day; insulin in the morning and at bedtime; sitagliptin (for diabetes) 100 mg every morning; acetaminophen (pain reliever) 500 mg twice a day; carbidopa-levodopa (for Parkinson's disease) 25-100 mg three times a day; MiraLAX (laxative) 17 grams every morning; tamsulosin (for benign prostatic hyperplasia) 0.4 mg every night; metoprolol (for blood pressure) 25 mg half a tablet twice a day; losartan potassium (for blood pressure) 50 mg once a day; isosorbide mononitrate (for coronary artery disease) 30 mg every morning; furosemide (diuretic) 40 mg every day; and atorvastatin calcium (for cholesterol) 80 mg every day. Review of the medical record revealed no documentation Resident #7 or the resident's representative had been provided information in advance of the risks and benefits of the prescribed medications, the treatment alternatives or other options, and consented to the medications. During an interview with the Director of Nursing (DON) on 08/01/25 at 11:04 AM, she confirmed that the facility did not have documentation Resident #7 or the resident's representative had consented to the prescribed medications. 2. Resident#1 was admitted to the facility on [DATE] with diagnoses that included heart failure, depression, type 2 diabetes, anxiety, and unspecified psychosis. The resident had mild cognitive impairment. Review of the physicians orders revealed Resident #1 received Fluoxetine HCL 40 mg capsule once a day(for major depressive disorder) , hydroxyzine HCL 25 mg tablet once a day(for anxiety); Olanzapine 5 mg tablet at bedtime (for psychosis),trazodone HCL 25 mg at bedtime (for insomnia), Propranolol HCL 20 mg as needed for (for panic); Lantus Solostar 16 units at bedtime (for Diabetes). Review of the medical record revealed no documentation that Resident # 1or the resident's representative had been provided information in advance of the risks and benefits of the prescribed medications, the treatment alternatives, or other options, and consented to the medications. 3.Resident #4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, unspecified psychosis, manic episode, and type 2 diabetes. The resident was cognitively intact. Review of the physicians' orders revealed Resident #4 received quetiapine now discontinued (an antipsychotic); Ozempic 1 mg Subcutaneous twice a day (for diabetes); Lantus Solostar 72 units Subcutaneous Solution Pen -injector twice a day (for diabetes); Eliquis Oral Tablet 5 mg twice a day (anticoagulant ), Hydrocodone-Acetaminophen 1 tablet as needed (pain); NovoLog Flex Pen 29 units subcutaneous with meals (for diabetes), Gabapentin 1tablet twice a day (for neuropathy), Jardiance 25 mg tablet once a day (for diabetes). Review of the medical record revealed no documentation that Resident # #4 or the resident's representative had been provided information in advance of the risks and benefits of the prescribed medications, the treatment alternatives, or other options, and consented to the medications. 4.Resident #8 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type; post-traumatic stress disorder; depression; bipolar disorder and type 2 diabetes. The resident was cognitively intact. Review of the physicians' orders revealed Resident #8 received Gabapentin 300 mg three times a day; Ozempic Subcutaneous Solution Pen -injector 0.5 mg once a day every Wednesday (for diabetes), Risperidone 3 mg tablet at bedtime (for mood) ; Duloxetine HCL Capsule Delayed release Sprinkle 60 mg once a day (for pain). Review of the medical record revealed no documentation that Resident #8 or the resident's representative had been provided information in advance of the risks and benefits of the prescribed medications, the treatment alternatives, or other options, and consented to the medications. During an interview with the DON on 08/01/25 at 11:04 AM, she confirmed the facility did not have documentation for Residents' # 1,4, and 8 or that the resident's representative had consented to the prescribed medications. Review of the facility policy titled (Facility Name) Administrative-Residents Rights for Senior Service dated 10/30/24 read . Policy .Implementation.F552 (5.) The resident has the right to be informed of and participate in their treatment, including: (c) The right to be informed in advance of risks and benefits of proposed care, of treatment alternatives, and the right to choose the option they prefer.

Based on observations, interviews, record review and the facility's Medication Self-Administration and Storage policy, the facility staff failed to assess residents for safe self-administration and storage of medications/biologicals, i.e., medicated cough drops, Zinc Oxide topical ointment, Anesep antimicrobial skin wound cleanser, and Betadine Gluconate 4% Solution Antiseptic Surgical Scrub, left unsecured at the bedside for four (4) of 23 sampled residents (Resident #s 17, 18, 21, and 45). The findings include: 1. Resident #17 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus, unspecified sequelae of cerebral infarction, and potential/impaired skin integrity. On 07/29/25 at 4:30 PM and 07/30/25 at 11:00 AM, and 07/31/25 at 11:30 AM, an open four-ounce tube of Zinc Oxide topical ointment was observed on top of the resident's bedside table. Review of medical records revealed no evidence of an interdisciplinary team (IDT) assessment of the resident's ability to safely self-administer or store medications/biologicals at the bedside. Further reviews of medical records revealed no physician's order for residents to self-administer or store medications/biological at the bedside. On 07/31/25 at 10:05 AM, the Registered/Wound Care Nurse (RN) #1 confirmed the Zinc Oxide topical ointment was left at the bedside for the Certified Nurse Aides (CNA) to apply during personal care. RN #2 further verified Resident #17 have not been assessed for safe self-administration and/or storage of medication/biologicals at the bedside. She stated, It should not have been left in the room or should have been placed inside a drawer. 2. Resident #18 was admitted to the facility on [DATE] with diagnoses that included encephalopathy, type 2 diabetes mellitus, vascular dementia without behavioral, peripheral vascular disease and glaucoma. During observations on 07/29/25 at 4:30 PM and 07/30/25 at 11:00 AM, and 07/31/25 at 11:30 AM, an open eight-ounce spray bottle of Anesep Antimicrobial Skin and Wound Cleanser—Hospital & Professional Use—was observed on the resident's bedside table. On 07/31/25 at 10:05 AM, RN #1 confirmed the Anesep spray bottle should not have been left in the resident's room. RN #2 stated, Resident #18 had not been assessed for self-administration or safe storage of medications/biologicals at the bedside. It should not have been left there. 3. Resident #45 was admitted to the facility on [DATE] with diagnoses that included non-pressure chronic ulcer of left foot, viral intestinal infection and end stage renal disease with hemodialysis. During an observation on 07/29/25 at 11:17 AM, an open and partially used four-ounce bottle of Betadine Gluconate 4% Solution Antiseptic Surgical Scrub, with a partially intact prescription label, was on Resident #45 over bed table. Review of the medical records revealed no physician's order for the betadine solution to be self-applied or stored at the bedside. During an interview on 07/31/25 at 9:36 AM, Licensed Practical Nurse (LPN) #2 verified Resident #45 was transported to the hospital earlier for a scheduled procedure, where the betadine solution was used as a pre-surgical skin prep. On 07/31/25 at 10:05 AM, RN #1 confirmed the prescription betadine scrub solution may have been used to prep the resident before her procedure. She stated that the resident would not have been assessed for self-administration or safe storage at the bedside for the betadine solution because it was a one-time only treatment prior to the procedure. RN #1 stated, The betadine solution should not have been left in the resident's room; it should have been immediately disposed of. Review of the facility's Self-Administration of Medication policy, revised 09/21/19 revealed, .Bedside medication storage is permitted only when it does not present a risk to other residents. the facility will obtain an order to effect may keep at bedside . Medications stored at bedside shall be secure from other residents. are kept in the containers dispensed by the provider pharmacy. 4. Resident #21 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure (CHF) and dysphagia. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired. On 07/29/25 at 11:22 AM, an observation and interview were conducted with Resident #21. During the observation, three (3) bags of cough drops were on the bedside dresser. Resident #21 stated the cough drops had been there for a few weeks and that she self-administered the cough drops several times throughout the day. Resident #21 stated that she had not been assessed to take medication, she had not informed the nursing staff, and that she would like to keep the cough drops at the bedside. Photographic evidence obtained. On 07/30/25 at 1:41 PM, an observation and interview was conducted with RN#2. Three (3) bags of cough drops were on the bedside dresser. RN #2 stated that she did not notice the cough drops at the resident's bedside previously. RN #2 stated that residents were required to have a self-administration medication assessment to ensure the residents can safely self-administer medications and a doctor's order to self-administer medications. RN #2 confirmed that neither of those requirements for self-administration of medication were done for Resident #21. During an interview on 07/31/25 at 8:45 AM with the Director of Nursing (DON), she confirmed that the resident was not assessed to self-administer medications. The expectation was that the resident had an assessment to determine if she was appropriate to self-administer medications and had a physician's order. Review of the facility's Self Administration of Medication policy, revised 09/21/19 read, . A. Residents who request approval to self-administer shall be assessed by the interdisciplinary team to determine if the resident is competent. B. The interdisciplinary team will assess the resident's cognitive physical and visual ability to carry out this responsibility by reviewing the six areas on the Assessment for Self Administration of Medication . If the team determines that the resident is competent, the attending physician shall be contacted to request a specific order for self administration of the medication. C. If the resident demonstrates the ability to self administer medications, a further assessment of the safety of the bedside medication storage shall be done .

Based on interview, record review, and review of the facility's policy titled Advance Directives Policy, the facility failed to ensure appropriate Advance Directives were readily available in resident records or appropriate Advance Directives were in place for six (6) of 23 residents (Resident #'s 16, 17, 27, 34, 51, and 66) reviewed for Advance Directives. The findings include: 1.Resident #16 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus and encephalopathy She was moderately cognitively impaired. Review of Resident #16's medical record revealed an Advance Directive and Code Status Acknowledgment of Receipt form with the box checked I have chosen to formulate and issue Advance Directives. The form also indicated a Guardianship Letter. There were no Advance Directives or Guardianship Letter readily available in her medical record. 2. Resident #17 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis, and heart failure She was cognitively intact. Review of Resident #17's medical record revealed an Advance Directive and Code Status Acknowledgment of Receipt form with the box checked I have chosen to formulate and issue Advance Directives. I will provide (Facility Name) with a copy of my Advance Directives There was no copy of her Advance Directives readily available in her medical record. 3. Resident #34 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, and degenerative disease of nervous system. She was cognitively impaired. Review of Resident #34's medical record revealed an Advance Directive and Code Status Acknowledgment of Receipt form with the box checked I have chosen to formulate and issue Advance Directives. There was no copy of her Advance Directives readily available in her medical record. 4. Resident #51 was admitted to the facility on [DATE] with diagnoses that included dementia and hallucinations. She was cognitively impaired. Review of Resident #51's medical record revealed an Advance Directive and Code Status Acknowledgment of Receipt form with the box checked I have chosen to formulate and issue Advance Directives. There was no copy of her Advance Directives readily available in her medical record. 5. Resident #66 was admitted to the facility on [DATE] with diagnoses that included: major depressive disorder and type 2 diabetes mellitus. She was cognitively intact. Review of Resident #66's medical record revealed an Advance Directive and Code Status Acknowledgment of Receipt form with the box checked I have chosen to formulate and issue Advance Directives. I will provide (Facility Name) with a copy of my Advance Directives There was no copy of her Advance Directives readily available in her medical record. During an interview on [DATE] at 10:14 AM, the Director of Social Services (DSS) stated admissions took care of advance directives. Social Services was responsible for the follow up for any changes. During an interview on [DATE] at 11:03 AM, the Director of admission and Marketing confirmed the appropriate advance directives were not included in resident records for Resident #'s 16, 17, 27, 34, 51 and 66. She stated she had been in touch with Resident #66's daughter and after an investigation, discovered the resident did not, in fact, have an Advance Directive in place. Review of the facility's policy titled Advance Directives Policy, undated read, .Procedure .5. Documentation will be made in the medial record whether or not the resident has executed advance directives. If a resident or resident's responsible party indicated that the resident has executed an advance directive, facility staff will request that a copy of the advance directives be provided to the facility for inclusion in the resident's medical record as soon as possible. (Facility Name) will not honor a written advance directive unless and until a copy thereof is provided to the facility . 6. Resident #27 was admitted to the facility [DATE] with diagnoses including type 2 diabetes, major depressive disorder, anxiety disorder, and adjustment disorder with depressed mood. The resident was cognitively intact. Record review of a Medical Orders for Scope of Treatment (MOST) form dated [DATE] and signed by Resident #27 revealed Resident #27 chose Do Not Attempt Resuscitation (DNR) if the resident was found with no pulse and was not breathing. Record review of the Clinical Care Agreement signed by Resident #27 [DATE] revealed I hereby direct that in the event of my.cardiac and/or respiratory arrest, efforts at CPR (cardiopulmonary resuscitation) SHOULD NOT be initiated. Record review of a physician's order dated [DATE] revealed a DNR order for Resident #27. Record review of the monthly physician order sheet signed by the Nurse Practitioner [DATE] revealed the order sheet documented Full Code with a start date of [DATE]. Review of the record revealed no documentation supporting the resident had chosen Full Code status and no verbal or written order for Full Code. Review of the banner in the electronic medical record that indicated a resident's code status revealed Resident #27 was a full code. During an interview on [DATE] at 4:01 PM, Resident #27 stated, If it's my time to go, I want them to just let me go. The resident did not want CPR. During an interview on [DATE] at 4:18 PM, Licensed Practical Nurse (LPN) #5 reviewed Resident #27's medical record and said the nursing staff identified the code status of a resident by looking at the banner in the electronic medical record. LPN #5 stated Resident #27 was a Full Code. During an interview on [DATE] at 12:29 PM, Social Worker (SW) #1 stated she was not aware Resident #27 needed a DNR form prepared and placed in the medical record. SW #1 reviewed the medical record and confirmed that the medical record documentation of Full Code did not match Resident #27's wishes to be a DNR. Review of the facility's policy titled Advance Directives Policy, undated read, 12. The IDT, Charge Nurse, or designee will notify the Provider of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care. Neither the facility nor its staff will make any decision, even if requested by the resident or the resident's legal responsible party that a particular treatment or procedure be provided, withheld, or withdrawn without an order from the resident's provider.

Based on observation, interview, and review of the facility's policy titled Resident Rights for Senior Services Policy, the facility failed to provide privacy for one (1) of 25 resident residents (Resident #51) during a temperature monitoring. The facility also failed to ensure staff did not leave resident protected health information (PHI) unattended, uncovered and visible on top of the [NAME] neighborhood's diabetic treatment cart for 13 of 23 sampled residents (Residents #s 1, 8, 10, 15, 18, 23, 24, 32, 44, 45, 58, 61, and 71). The findings include: 1.During an observation on 07/28/25 at 4:36 PM, a clip board with a Vital Signs Chart attached, dated July 28, 2025, was observed atop of the diabetic treatment cart, which sat on the north wall inside the [NAME] neighborhood's resident day room. The vital signs sheet contained the blood pressure, temperature, pulse, respiration, and/or pulse oximetry results for Resident #s 15, 44, 58 and 71. Additionally, an 8 x 11-inch sheet of blue/white paper with the heading . HAVE THEM READY BY THIS TIME!! WEEK OF 07/28/25-08/01/25 was also observed atop of the diabetic treatment cart and revealed the full name and clinical appointment details for Resident #s 1, 8, 10, 18, 23, 24, 32, 45, and 61. The documents were uncovered and highly visible to passersby and the public. On 07/28/25 at 4:50 PM, Licensed Practice Nurse (LPN) #1 returned to the day room and performed various tasks on top of and the uncovered clip board and clinical appointment sheet for 3-5 minutes but did not attempt to cover or hide the visible PHI. During an interview on 07/30/25 at 1:30 PM, LPN #1 confirmed that the vital sign sheet and resident appointment schedule were visible on top of the cart and should have been turned over or covered. During an interview on 07/31/25 at 10:03 AM, the Director of Nursing (DON) and the Registered Nurse Manager (RNM) #3 stated that staff were expected to protect the resident's health and personal identifying information. The DON stated, The vital sign sheets should have been covered and not left out on the cart. Review of the facility's Resident Rights for Seniors policy, revised 10/30/24 read, The resident has the right to personal privacy and confidentiality of their personal and medical records . The facility must keep confidential all information contained in the resident's records. 2. Resident #51 was admitted to the facility on [DATE] with diagnoses that included dementia and abnormalities of gait and mobility. During an observation on 07/29/25 at 3:58 PM, Certified Nurse Aide (CNA) #7 was observed taking an oral temperature for Resident #51 in the common area. There were nine (9) other residents present at the time. During an interview on 07/29/25 at 4:15 PM, CNA #7 confirmed she performed an oral temperature check for Resident #51 in the common area. During an interview on 07/30/25 at 3:46 PM , RN #4 stated I've never know vital signs couldn't be done in the common areas. During an interview on 07/31/25 at 3:43 PM, CNA #11 stated Over the years, times have changed and vital signs can be taken in front of other residents as long as the screen isn't visible to others. During an interview on 07/31/25 at 4:33 PM, the DON confirmed it was her expectation that privacy be provided when care was provided. She further confirmed this included vital sign monitoring. Review of the facility's policy titled Resident Rights for Senior Services Policy, revised 10/30/24 read, 34 .Personal privacy includes accommodations, medical treatment .

Based on record review, interview, and review of the facility's policy titled Complaints and Grievances Policy, the facility failed to resolve a grievance timely for one (1) resident of 23 sampled residents (Resident #66). The findings include:Resident #66 was admitted to the facility 11/14/24 with diagnoses that included unspecified atrial fibrillation, cerebrovascular disease, and moderate persistent asthma. The resident was cognitively intact.During an interview on 07/29/25 at 11:42 AM, Resident #66 stated approximately two and a half (2 1/2) weeks ago she woke up and there were ants all over her bed. The Certified Nurse Aide (CNA) and the housekeeper tried to get all the ants up, but they were in the mattress. Resident #66 stated she continued to see ants for seven (7) days. Resident #66 stated she slept on that same mattress with the ants during that week. The facility would not change the mattress.During an interview on 07/31/25 at 9:56 AM, Housekeeper #1 stated about a week or two ago, the housekeeper saw ants in the room of Resident #66. Housekeeper #1 saw a trail of ants by the bathroom door area going across the room. They were the little black ants. The room was cleaned, the linens were changed, and later the mattress was changed out. The housekeeper stated there were ants on the resident's mattress.During an interview on 07/31/25 at 10:14 AM, Licensed Practical Nurse (LPN) #2 confirmed staff were aware that ants had been found in Resident #66's room. LPN #2 stated it occurred about a week ago and the room was deep cleaned. During an interview on 07/31/25 at 10:23 AM, CNA #12 stated there were ants in Resident #66's room. The ants were getting on the resident's mattress and staff wiped off the mattress and cleaned it, but the ants came back. CNA #12 stated the facility took the mattress out and wiped it down and brought it back.During a telephone interview with Resident #66's daughter on 07/31/25 at 11:36 AM, the daughter stated Resident #66 called the daughter on 07/17/25 and reported there were ants in the resident's room. The daughter talked to Resident #66 again on 07/24/25 and Resident #66 stated the ants were still in her room, in her bed, and they were biting her. The daughter called the hospital associated with the nursing facility and talked with two (2) administrative personnel who told her to file a complaint, and they would give it to the nursing home Administrator. The nursing home Administrator called the daughter on 07/24/25 at 8:30 PM. The daughter told the Administrator that the situation with the ants had gone on too long and something needed to be done immediately; it had been going on for seven (7) days. Resident #66 just wanted the bed to be changed out and maintenance had stated they could not change the bed because they left at 4:30 PM. The daughter stated within two (2) hours of her telephone conversation with the Administrator, the bed was replaced.During an interview on 07/31/25 at 3:00 PM, Registered Nurse (RN) #1 stated that Resident #66 reported that there were ants in the room. RN #1 did not see the ants but confirmed that it was discussed in a morning Interdisciplinary Team Meeting (IDT) and the plan was to bring in pest control, clean the room, and the resident was offered another room, which the resident refused. The ants were reported on 07/17/25. RN #1 stated that a CNA had seen ants in Resident #66's room.During a follow-up interview on 07/31/25 at 4:07 PM, Resident #66 stated that all she had wanted was to resolve her concerns and get the ants out of her room. Resident #66 stated the facility washed her sheets and blankets and cleaned her room, but they did not replace the mattress until 07/24/25. She was initially told the mattress could not be replaced because she had a specialty mattress and they did not have another one. During an interview on 08/01/25 at 10:26 AM, the Administrator stated the first time she was made aware of any issues with ants in Resident #66's room was when the resident's daughter called her. She stated there was no problem with changing the mattress out and she had a new bed and mattress moved in right after she got off the phone with the daughter. The Administrator did not know who Resident #66 initially talked to and requested the mattress be changed, but the mattress could have been changed immediately.Review of the facility's policy titled Complaints and Grievances Policy, effective 11/12/24 read (Facility Name) will make every effort to resolve grievances the resident may have in a timely manner. Complaints or grievances may be filed orally (spoken word) or in writing to any (Facility Name) team member. Complaints will be addressed immediately by (Facility Name) team members. If unable to resolve immediately, a grievance will be formulated, reviewed, and addressed within seven (7) business days from the receipt of the grievance .

Based on observations, interviews, and review of the facility's Medication Storage policy, the failed to ensure staff secured medication inside a locked medication cart and did not repeatedly leave one (1) of three (3) medication carts unlocked, unattended, and accessible to residents, staff, and the general public. The facility also failed to ensure staff did not leave one (1) of two (2) diabetic treatment carts unlocked and unattended. The findings include: 1. During multiple observations on 07/28/25 at 4:37 PM and on 07/30/25 at 10:00 AM and at 1:23 PM, the diabetic treatment cart was left unlocked and unattended. The top drawer of the cart was full of lancets (sharp device used to prick the finger for blood glucose test), chemical cleansing wipes, and a pressurized can of Febreze deodorizing spray. On 07/29/25 at 4:50 PM, Licensed Practical Nurse (LPN) #1 returned to the medication cart, parked next to the treatment cart, completed a task, and left the treatment cart unlocked. On 07/30/25 at 1:33 PM, LPN #2 was made aware of the unlocked treatment cart. She stated, The treatment cart should be kept locked. 2. On 07/30/25 at 1:28 PM, the medication cart, located in the [NAME] neighborhood's day room, was observed unlocked, unattended, and accessible to residents and staff. The cart was behind a partial wall and not within the line of sight of any licensed clinical staff. On 07/30/25 at 1:33 PM, LPN #2 returned to the unlocked cart and acknowledged she had not locked the cart, and the cart was not within her line of sight. LPN #2 stated, I knew better not to step away from the cart without locking it. Certified Nurse Aide (CNA) #s 4 and 5 were seen in the day room with the unlocked cart. 3. During a medication pass observation on the [NAME] Unit hallway on 07/31/25 at 8:47 AM, LPN #2 did not lock the medication cart while it was unattended. During an interview with LPN #2 on 07/31/25, at the time of the observation, when she noticed the medication cart was unlocked and unattended, she stated, Oh no, and then locked the medication cart. She confirmed that the medication cart should always be locked when unattended for the safety of the residents. During an interview on 07/31/25 at 10:15 AM, the Director of Nursing (DON) and the Registered Nurse Manager (RNM) #3 stated that their expectation was for staff to secure/lock the medication and treatment carts when not in use or unattended. Review of the facility's policy titled Medication Storage Policy dated 07/16/24 read, 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications, such as medication aides, are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 4. During an observation on 07/29/25 at 9:38 AM, a Lidocaine 5% patch (topical pain reliever) was observed on top of the medication cart in the nurse station on the Laurel Unit. LPN #3 was in and out of the nurse station. At 9:49 AM, the restorative aide entered the nurse station. The nurse was not present at this time. During an interview on 07/29/25 at 10:03 AM, LPN #3 confirmed the Lidocaine 5% patch was on top of the medication cart unsecured and unattended. She stated That's my fault. She stated the patch should have been secured inside the medication cart. During an interview on 07/31/25 at 4:50 PM, the DON confirmed the medication should have been locked inside the cart. Review of the facility's policy titled Medication Storage Policy dated 07/16/24 read, 3. Medications shall be stored in a orderly manner in the medication cart.

Based on observations, interviews, and review of the facility's policies titled Personal Protective Equipment Policy, Catheter Drainage Bags and Tubing-Clinical Protocol, and Infection Control- Hand Hygiene, the facility failed to ensure 1. staff appropriately donned and doffed personal protective equipment (PPE) when providing laundry services; 2. staff kept indwelling catheter bags and/or tubing off the floor for one (1) of three (3) residents sampled for indwelling catheters (Resident #21); and 3. that during dining ,the staff performed hand hygiene before and after resident contact and after touching soiled surfaces (i.e. garbage can lid), and avoided touching inside of the residents' plates with while serving food.The findings include: 1. During an observation and simultaneous interview on 07/29/25 at 9:55 AM, Laundry Aide #2 was observed wearing an N95 face mask, a face shield, gown, and gloves while walking around on the Laurel Unit. He touched the nurse station door attempting to locate staff. During the interview, he stated he had donned the personal protective equipment (PPE) prior to sorting dirty laundry that morning. He confirmed he was wearing the same PPE at the time. He stated he was attempting to locate staff to see if any laundry needed to be washed. After the interview, he continued to the porch door and opened it with his gloved hand to talk to staff. During an interview on 07/31/25 at 4:51 PM, the Director of Nursing (DON) confirmed PPE should be doffed in an appropriate container inside a room prior to exiting. She further confirmed PPE should not be worn in the hallways and common areas. She stated He should have removed the PPE before he left the laundry room. Review of the facility policy titled Personal Protective Equipment Policy dated 1/28/25 read, Gowns .6. To remove the gown: .Remove the gloves [sic] and discard them into a waste receptacle in the room .Gloves .2. Glove should be worn only once and discarded into the appropriate receptacle located in the room where the procedure or task was performed . Face Masks .3. A face mask should only be used once and then discarded into the appropriate receptacle located in the room where the procedure or task is being performed . 2. Resident #21 was admitted to the facility on [DATE] with diagnoses that included flaccid neuropathic bladder and a history urinary tract infection (UTI). During an observation on 07/29/25 at 11:04 AM, Resident #21's catheter was in a privacy bag on the floor and the catheter tubing was on the floor with clear yellow urine visible. During an observation and interview on 07/30/25 at 1:41 PM with Registered Nurse (RN) #2, Resident #21 was observed sitting up in the bedside chair with the catheter bag partially in the privacy bag on the floor and the other half of the catheter bag on the floor. The catheter tubing was on the floor with clear yellow urine visible. RN #2 stated that the catheter bag and tubing should be off the floor to prevent an infection. During an interview on 07/30/25 at 11:55 AM with the DON, she stated that the expectation was that urinary catheter tubing and bags should not be on the floor. Review of the facility's policy titled Catheter Drainage Bags and Tubing-Clinical Protocol, revised 9/10/24, read .9. Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage . 3. During a dining observation on 07/28/25 at 5:45 PM, Certified Nurse Aide (CNA) #s 2 and 3 did not consistently perform hand hygiene while serving and assisting Resident #s 15, 22, 35, 43, 44, 48, 71, 33, and 50, who ate in the [NAME] neighborhood's dining room. During the same time window, CNA #s 2 and 3 handled the resident's meal plates with their thumb on the inner edge of plate's rim. CNA #1 did not conduct hand hygiene between direct contact between multiple residents, including Resident #s 22, 43, 71, 44, and 33; or after she lifted the garbage lid with her ungloved hand to discard refuse. During an interview on 07/31/25 at 10:15 AM, the DON stated that it was her expectation that staff follow the policy and wash or sanitize their hands frequently, but especially before, after, and between contact with each resident, when passing trays, and after touching multiple surfaces. Review of the facility's policy titled Infection Control- Hand Hygiene dated 12/03/24, read .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the following situations: .Before and after direct contact with residents.After handling soiled or used linens, dressings, bedpans, catheters, and urinals, equipment, or utensils.Before and after assisting resident with meals.

Based on interviews, record review, facility policy review, and the online resource from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure residents received education and were given the opportunity to accept or decline immunizations according to the CDC Adult Immunization schedule for four (4) residents (Resident #'s 21, 23, 45, and 71) of the five (5) residents reviewed for Immunizations.The findings include:1. Resident #21 was admitted on [DATE] with diagnoses that included methicillin-resistant Staphylococcus aureus (MRSA), urinary tract infection (UTI), heart failure, and diabetes mellitus type two (2).Review of Resident #21's immunization record revealed the followingInfluenza administered - 10/11/23Pneumonia vaccination - no documentation 2. Resident #23 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) type two (2), and end-stage renal disease (ESRD).Review of Resident #23's immunization record revealed the following:Influenza administered - 10/11/04Pneumonia vaccination - 11/02/18 3. Resident #45 was admitted on [DATE] with diagnoses that included cardiovascular disease, infection, methicillin-resistant Staphylococcus aureus (MRSA), and hypertension.Review of Resident #45's immunization record revealed the following:Pneumonia vaccination - no documentationReview of Resident #45's consent form titled, (Facility Name) Vaccine Consent Form dated 1/9/25 revealed the following information: .Vaccine Consent Form: 2024-2025 COVID, RSV, and Influenza. Please provide the Vaccine Information Sheet(s) (VIS) that have been provided. This form serves as a record of your consent to receive vaccinations during your stay, based on the last national guidelines and your eligibility. The form indicated a Yes consent to COVID-19 and Influenza vaccines. 4. Resident #71 was admitted on [DATE] with diagnoses that included coronary artery disease (CAD) and retention of urine.Review of Resident #71's immunization record revealed the following:Pneumonia vaccination - 12/13/19Further review of the medical record for Residents #21, #23, and #71 revealed there was no Vaccine Consent Form to indicate the residents were provided education, offered, and/or administered the appropriate vaccinations.During an interview with the Infection Control Preventionist (ICP) on 07/31/25 at 3:47 PM, she stated that while she was on leave, the staff member responsible for the residents' immunizations had not been consistent with the facility's immunization program. She stated that she was only able to locate two (2) of the five (5) residents' information, and it was not complete. She confirmed that the facility should annually offer the influenza vaccine during flu season and assess, review, and offer pneumonia vaccinations according to the CDC Adult Immunization Schedule. During an interview with the ICP on 08/01/25 at 10:12 AM, she stated the facility did not have vaccination declination documentation for Residents #21, #23, #45, and #71. A review of the facility's policy titled (Facility Name) Infection Control - Immunization of Residents Policy dated 12/12/24 read. Purpose: The purpose of this policy is to provide (Facility Name) teammates with guidelines for immunization of residents to aid in preventing infectious diseases. Policy: All residents will be offered the influenza, pneumonia, and COVID-19 vaccinations to aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been immunized. Herpes Zoster and respiratory syncytial virus (RSV) vaccinations may also be offered, as noted at the end of this policy. Administration of all vaccinations is made in accordance with the current CDC recommendations at the time of the vaccination. Refer to the CDC for vaccine information statements.Procedure: General Guidelines. 2. Prior to the immunization, the resident or the resident's responsible party will be provided information and education regarding the benefits and potential side effects of the vaccination being offered. Vaccine information statements and educational materials are updated yearly by the CDC and can be obtained on the CDC website. Written consent should be obtained from the resident or the personal legal representative prior to administering any vaccination. If it is not possible to obtain written consent, verbal consent may be given if witnessed by a teammate and documented in the electronic medical record (EMR). 3. Prior to admission, residents will be assessed for eligibility to receive. vaccines, and when indicated, will be offered the vaccinations within 30 days of admission to the facility. 4. The resident or the resident's responsible party may refuse immunization for any reason. If immunizations are refused, the refusal should be documented in the resident's medical record or on the appropriate form, which is scanned into the medical record. 5. If the resident receives an immunization, at least the following information should be documented in the resident's medical record: Site of administration; Date of administration; Lot number of the vaccine and manufacturer (located on the vial); Expiration date (located on the vial); Name of person administering the vaccine.Influenza Vaccination: The influenza vaccine will be available to all residents between October and March of each year. Pneumococcal Vaccination: Refer to the Pneumococcal Vaccine Timing for Adults document on the CDC Website. 11. (Facility Name) will maintain a record of the vaccination status of residents in the EMR.

Based on observations, interviews, and record reviews, the facility failed to treat two (2) residents (Resident #6 and #23) in a dignified manner to promote the residents' quality of care and quality of life in a sample size of 23 residents who were reviewed for resident rights. The findings include: 1.Resident #6 was admitted on [DATE] with diagnoses that included vascular dementia, type 2 diabetes, and major depressive disorder. Resident #6’s quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively impaired, dependent on activities for daily living (ADLs) and required a two person assist Hoyer lift transfer. In a telephone interview with the resident representative for Resident #6 on 07/29/25 at 11:12 AM, she stated she filed a complaint/grievance with Social Worker (SW) #3 regarding an incident that occurred with her uncle while she visited the facility sometime in June. She recounted that, on this day, she requested that the Certified Nurse Aide (CNA) staff put her uncle in his chair so that he could visit with them out on the covered porch. She stated, “When my uncle appeared from his room sitting in the chair, his hair was uncombed, his clothes were twisted, and his socks were on wrong.” She stated, “no one should be treated that way.” During an interview with SW #3 on 07/30/25 at 2:34 PM, she verified that resident representative for Resident #6 did file a complaint/grievance on 06/16/25 regarding an incident in which Resident #6 when put in his chair and not properly groomed. She stated the Director of Nursing (DON) was made aware and provided a resolution. Review of the facility Concern, Complaint or Grievance form on 07/30/25 revealed, the incident was reported by the resident representative for Resident #6 on 06/16/25 but occurred on 06/8/25 around 3:00 PM. She reported that the resident wanted to get up. She asked both CNAs to get Resident #6 up. They both rolled their eyes. CNA #10 glared and ran the Hoyer lift into the wall. When asked, CNA #10 stated, I’m not mad, I’m just a bad driver.” After 8-9 minutes, the resident representative for Resident #6 reported, Resident #6 was brought out of his room with his shirt all twisted up, his socks halfway up and uncombed hair.” During an interview with the DON on 07/31/25 at 11:00 AM, she verified that she received a complaint/grievance reported by the resident representative for Resident #6 and interviewed both CNAs. She stated she discussed providing resident care with dignity with both CNAs. She stated her expectation was that when a resident is gotten out of bed, all of the ADLS are provided. She stated she completed verbal coaching/coaching for success with both CNAs and removed CNA #10 from Resident #6’s staffing assignment on the 7 AM to 7 PM shift to prevent any future interactions with Resident #6 or his representative as requested. Review of the facility's policy titled “(Facility Name) Administrative-Residents Rights for Senior Service, dated 10/30/24 read “…. Policy …(Facility Name) will treat each resident with respect and dignity and will care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life…. F550 1. The resident has the right to a dignified existence, …. with persons and services inside and outside of the facility.” 2. Resident #23 was admitted on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD) and anxiety disorder. Review of Resident #23's quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #23 was cognitively intact and required staff assistance with activities of daily living (ADL), including bathing and grooming. Review of the medical record for ADL bathing documentation dated 07/29/25 revealed that Resident #23 had received a shower. During an observation and interview on 07/30/25 at 4:00 PM, Resident #23 was lying in bed watching television. She appeared groomed except for the visible scattered chin hairs of different lengths. She stated she was supposed to have her chin hairs shaved on shower days. She stated she had a shower yesterday, but the staff had not shaved her or asked her if she wanted to be shaved. During an interview with Certified Medication Aide (CMA) #10 on 07/30/25 at 4:00 PM while she was standing outside of Resident #23's room, she stated that as a female resident, she would not want her chin hairs to look like how Resident #23's chin hairs looked. She stated that with each shower, the residents should be shaved or offered to be shaved. Review of the facility's policy titled Resident Rights for Senior Service, dated 10/30/24 read .to provide (Facility Name) teammates with guidelines for resident rights for senior services . Policy: It is the policy of (Facility Name) to recognize that all residents have the right to a dignified existence, self-determination, and access to persons and services inside and outside the facility. (Facility Name) will treat each resident with respect and dignity and will care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. (Facility Name) will protect and promote the rights of all residents .I. The resident has the right to a dignified existence, self-determination, and communication with persons and services inside and outside of the facility. 2. The resident has the right to exercise their rights as a resident of (Facility Name) and as a citizen or resident of the United States without interference, coercion, discrimination, or reprisal from the facility, and to be supported by (Facility Name) in the exercising of these rights. 3. (Facility Name) provides equal access to quality care regardless of diagnosis, severity of condition, or payment source. (Facility Name) has established and maintained identical policies and practices regarding transfer, discharge, and the provision of services under the state plan for all residents regardless of payment source .

Based on interview, record review and review of the facility's policy titled (Facility Name) Administrative-Residents Rights for Senior Service, the facility failed to ensure Resident #4 was provided appropriate durable medical equipment (DME) that allowed the use of the bathroom for one (1) of twenty-three (23) sampled residents.The findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included obesity, acute respiratory failure, unspecified psychosis, manic episode, and type 2 diabetes.Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact, dependent for activities for daily living (ADLs) and required a one person assist for transfers.During an observation and interview on 07/30/25 at 4:32 PM Resident #4 reported he smashed the pointer finger on his left-hand a couple of months ago while attempting to self-propel his wheelchair (WC) through the threshold of the bathroom to access the sink. He stated, look at the dark marks on the wall, those marks are from my WC wheels. My WC can barely fit. It is a very tight fit. The resident stated once he was up in the WC, he would access the sink to perform activities of daily living (ADLs). The resident did not notify the facility staff how he injured his finger. He stated, I did ask for a band-aid. It was noted that Resident #4 had an extra wide WC at the bedside. The resident stated, Physical Therapy (PT) ordered me a smaller WC about three weeks ago, but I haven't heard anything about it since. He stated, Me and another resident told the Physical Therapy Assistant (PTA) in the hall that we had problems getting in the bathroom and we wanted smaller chairs.During an interview on 07/31/25 at 9:05 AM, the Certified Occupational Therapy Assistant (COTA) verified that a WC had not been ordered for Resident #4, that Resident #4 started physical therapy/occupational therapy (OT) service on 03/07/25 and ended service on 07/16/25, and the resident was non-ambulatory due to hip pain. She stated she was unaware the resident had injured his finger and that if the WC did not fit through the door, a bedside commode should be provided to accommodate the resident's needs.During an interview on 07/31/25 at 10:15 AM with the PTA , she stated she was unaware that the resident injured his finger due to the tight fit of his WC through the threshold of the bathroom door. During an interview on 07/31/25 at 4:05 PM , the Administrator, Director of Nursing (DON) and Administration staff #6 were notified that Resident #4 injured his finger when entering the bathroom with his WC. The Administrator was aware the resident was unable to enter and exit the bathroom, but no additional accommodations had been offered.Review of the facility policy titled (Facility Name) Administrative-Residents Rights for Senior Service dated 10/30/24 read . Policy .Implementation.F558 (10.) The resident has the right to reside and received services in the (Facility Name) facility with reasonable accommodation of the resident needs and preferences except when to do so would endanger the health or safety of other residents.

Based on record review, observation, interview, and review of the facility's policy titled Medication Regimen Review, the facility failed to ensure an order for an as needed (PRN) antipsychotic had a stop date and a supporting diagnosis for use for one (1) resident of five (5) sampled for unnecessary medications (Resident #7). The findings include:Resident #7 was admitted to the facility 06/26/25 with diagnoses that included Parkinsonism, type 2 diabetes, insomnia, benign prostatic hyperplasia, and heart failure.Review of the admission Minimum Data Set, dated [DATE] revealed Resident #7 was moderately cognitively impaired; had verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, and rejected care one (1) to three (3) days during the seven (7) day look back period; did not have any psychiatric or mood disorder diagnoses; and in the past seven (7) days had received antianxiety, antidepressant, and hypnotic medications.Review of the physician's orders revealed an order dated 07/29/25 at 2:15 PM for quetiapine fumarate (antipsychotic) 25 milligrams (mg) give 0.5 tablet by mouth as needed for agitation PM PRN; may give in the afternoon/evening once daily. The start date was 07/29/25 at 2:15 PM and there was no end date written for the PRN antipsychotic order.Review of the nurse's notes revealed the following:1. 7/25/2025 19:27 [7:27 PM].Resident had multiple new orders today from physician. Trazadone [antidepressant] was discontinued for reports of history of causing hallucinations.2. 7/29/2025 16:40 [4:40 PM] Orders - Administration Note.Quetiapine Fumarate Oral Tablet 25 MG Give 0.5 tablet by mouth as needed for agitation PM PRN; may give in the afternoon/evening once daily PRN Administration was: Ineffective.3. 7/30/2025 20:31[8:31 PM] Orders - Administration Note.Quetiapine Fumarate Oral Tablet 25 MG Give 0.5 tablet by mouth as needed for agitation PM PRN; may give in the afternoon/evening once daily. There was no documentation whether it was effective.4. 07/31/2025 00:58 [12:58 AM].Resident has not been comfortable this evening. PRN melatonin [herbal sleep aid] and PRN ibuprofen [anti-inflammatory] administered d/t [due to] insomnia and leg pain. Vital signs have been consistent throughout this evening. Resident has been restless and is consistently being transferred from the recliner to the bed per resident request. Resident has been receptive to care and the call light has remained in reach. When resident is in bed fall mats X 2 [fall mats on each side of the bed] are in place to help prevent fall or injury. Currently there is a CNA [Certified Nurse Aide] providing one on one care and supervision.5. 07/31/2025 04:16 [4:16 AM] Orders - Administration Note.Quetiapine Fumarate Oral Tablet 25 MG Give 0.5 tablet by mouth as needed for agitation PM PRN; may give in the afternoon/evening once daily PRN Administration was: Ineffective.During an observation and interview on 07/29/25 at 3:12 PM, attempts were made to interview Resident #7 for approximately 20 minutes, but the resident would only be able to answer one (1) or two (2) questions before falling asleep while sitting in a recliner. Resident #7 appeared very tired and had difficulty staying awake.Observation on 07/30/25 at 1:11 PM, revealed Resident #7 in his room with CNA #14. Resident #7 was in his recliner, trying to stand up, and CNA #14 was standing with a wheelchair between her and the resident. CNA #14 was talking to the resident in an argumentative tone and the resident was agitated.During an observation on 07/30/25 at 1:31 PM, Resident #7 was yelling out help me while attempting to get up out of a chair. A staff member entered the resident's room and asked Resident #7 what he was doing and if he wanted to get in his wheelchair. The resident was placed in his wheelchair and the resident was calm and cooperative.During an observation and interview on 07/31/25 from 3:30 PM to 3:39 PM, Resident #7 was in the unit dayroom sitting in his wheelchair with two (2) staff members. The resident was falling asleep in his wheelchair. CNA #15 took Resident #7 back to his room and put him to bed. Resident #7 was cooperative and went to bed without any problems. During an interview, CNA #15 stated she had never had any problems caring for Resident #7 and he had never had any behaviors with her.During an interview on 07/31/25 at 10:50 AM, Licensed Practical Nurse (LPN) #5 stated Resident #7 had Parkinson's with behaviors and the providers were adjusting his medications to achieve a balance between managing his anxiety and behaviors, and not over sedating him. The Nurse Practitioner had just ordered a prn medication he started the night before. LPN #5 stated Resident #5 had worked lot of night hours previously now seemed to have a problem with being awake all night and not being able to sleep. During an interview on 08/01/25 at 9:52 AM, Registered Nurse (RN) #5 stated she was the one who took the order for the PRN antipsychotic. She stated the medication was ordered because Resident #7 showed behaviors recently when he put his hands around a CNA's neck. RN #5 called the Nurse Practitioner (NP) who gave RN #5 the order. RN #5 stated she was aware there had to be a 14 day stop date for all PRN antipsychotics and a diagnosis for using antipsychotics. She stated the facility was thinking Resident #7 would only be on the medication for a few days then they would prescribe something else.Review of the facility's policy titled Medication Regimen Review effective June 2025 read, .'Irregularity' refers to use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services. An irregularity also includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy.Evaluating medication orders to determine that the resident's orders represent optimal therapy for that individual: A written diagnosis or indication supports each medication order. As-needed (PRN) orders include indications for use. Indications for use and therapeutic goals are consistent with current medical literature and clinical practice guidelines.The duration of therapy is indicated and is appropriate for the resident .Evaluating response to drug therapy to assure that each resident receives optimal drug therapy: The resident's response to drug treatment is evaluated through the use of laboratory data, physical assessment, medication administration record, and other data to determine if therapeutic goals are achieved. The use of a medication without identifiable evidence of adequate indications for use, such as, the use of a medication to treat a clinical condition without identifiable evidence that safer alternatives or more clinically appropriate medications have been considered.Medical condition and response to drug therapy are used to evaluate the drug regimen for unnecessary medications.The pharmacist's review considers factors such as: Whether the physician and staff have documented objective findings, diagnoses, symptom(s), and/or resident goals and preferences to support indications for use.Whether the medication dose, frequency, route of administration, and duration are consistent with the resident's condition, manufacturer's recommendations, and applicable standards of practice. Whether the physician and staff have documented progress towards, decline from, or maintenance of the resident's goal(s) for the medication therapy.

Based on observations, interviews, record reviews, and a review of the facility's Resident Assessment Instrument policy, facility staff failed to identify and document a skin tear injury on the comprehensive Minimum Data Set (MDS) for one (1) of three (3) residents reviewed for skin integrity (Resident #18). The findings include:Resident #18 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, type 2 diabetes mellitus, vascular dementia without behavior, and encephalopathy.Review of the comprehensive Minimum Data Set (MDS) dated [DATE] revealed Resident #18's skin was intact without notation of skin tears, abrasions, or open wounds/injuries. During an observation and interview on 07/29/25 at 2:41 PM, Resident #18 sat in his room in a recliner chair with both legs elevated engaging with his sister. The skin on his lower legs was dry with dark pin-head size scabs and a two-centimeter redden/open and moist skin tear was visible on his lower left leg/shin.During an interview on 07/30/25 at 1:00 PM, the MDS Coordinator confirmed the MDS assessment reflected Resident #18's was intact and that she was not aware of the skin tear injury. Review of Resident #18's medical records, progress notes, wound assessment, and physician notes revealed no documented evidence of doctor/nurse treatment orders or acknowledgment of injury. During an interview on 07/30/25 at 10:05 AM, Registered Wound Care Nurse (RN) #1 confirmed weekly skin assessments are completed but she was not aware and did not document the skin tear. Review of the facility's Resident Assessment policy revised 01/18/24 read, The MDS Coordinator (or designee) is responsible for ensuring that the Interdisciplinary Care Plan Team conducts timely resident assessments. (Facility Name) will use a variety of other sources, including communication with licensed and unlicensed staff members on all shifts, discussion with the physician, family members. Data entered in Section GG will be a collaboration of clinical assessments completed by licensed health care clinicians.

Based on record review, interviews, and review of the facility's policy titled Pre-admission Screening and Resident Review (PASRR), the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level II upon a new qualifying mental health diagnosis for one (1) out of two (2) residents sampled for PASRR Level II (Resident #4 ). The findings include:Resident #4 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure, obesity, and type 2 diabetes.Resident #4's quarterly Minimum Data Set (MDS) dated [DATE] revealed that he was cognitively intact, dependent with activities for daily living (ADLs) and required one person assist for transfers. Review of past MDS revealed a diagnosis of unspecified. psychosis not due to a substance or known physiological condition dated 2/19/2025 and Manic episode, unspecified dated 11/12/24.During an interview on 07/30/25 at 4:20 PM, Resident #4 denied any behavioral health or mental health concern. He reported his mood was stable and doesn't have the desire to talk to anyone regarding his mood. During an interview on 07/31/25 at 2:00 PM with Social Worker (SW) #1, she presented the Preadmission Screening and Resident Review (PASRR) Level I and stated that she was unaware of the reason why Resident #4 received a diagnosis of Psychosis on 02/19/25. SW #1 verified that resident# 4 was not referred for PASRR Level II.During a telephonic interview on 08/01/25 at 10:00 AM with the Minimum Data Set (MDS) coordinator, SW #1 and SW #2, the MDS coordinator verified Resident #4's medical record supported the diagnosis of bipolar. She stated the resident was prescribed Seroquel, an antipsychotic medication. SW #1 stated due to the current Behavioral Health referral process she was unaware Resident #4 received a new mental health diagnosis that indicated a significant change in his mental status that required a Level II PASRR referral. She verified that Resident #4 should have been referred for PASSR Level II.Review of the facility's policy titled (Facility Name) Admissions-Pre-admission Screening and Resident Review (PASRR) dated 10/08/24 read .Procedures:.4. A Level 1 screen remains valid unless there is a significant change in a resident's status that affects their mental health or IDD treatment needs. This means that if a resident is discovered to have SMI, IDD or RC after the Level 1 was performed, the facility must call the PASRR contractor to perform an updated Level 1.

Based on record review, interviews, and review of the facility's policy titled Pre-admission Screening and Resident Review (PASRR), the facility failed to ensure the accurate completion of the Level I PASRR and referral for Level II PASRR for a resident with a mental health diagnosis for one (1) out of two (2) residents sampled for PASRR (Resident #5). The findings include:1. Resident #5 was admitted on [DATE] with diagnoses that included delusional disorders, history of left below the knee amputation, peripheral vascular disease, and diabetes.Review of Resident #5's PASRR Level I Assessment, dated 12/05/24, revealed .The individual does not meet the federal definition for mental illness/ mental retardation. No further PASRR screening is required unless a significant change occurs with the individual's status which. suggests a diagnosis of mental illness or mental retardation or, if present, suggests a change in treatment needs for those conditions.no qualifying mental health diagnosis.Review of Resident #5's medical record revealed prior to admission to the facility, a new diagnosis of delusional parasitosis disorder was documented on 12/20/24 and then referenced on 12/24/24 in the health care provider's notes.Review of Resident #5's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/02/25 revealed a diagnosis of delusional disorders and the resident was not assessed for PASRR Level II.Review of the Resident #5's Physician's progress note dated 12/20/24 revealed . Delusional parasitosis: wife and patient are dealing with depression and delusional parasitosis. patient is not sleeping throughout the night. added on low dose Seroquel at 25mg q hs. May help with delusions as mentioned above.Review of the Resident #5's Physician's progress note dated 12/24/24 revealed . has dx of delusional parasitosis, detailed on inpat d/c summary as follows: wife and patient are dealing with depression and delusional parasitosis .During an interview and medical record review for Resident #5 on 07/31/25 at 3:35 PM with Social worker (SW) #1, she confirmed that the mental health diagnosis for Resident #5 of delusional parasitosis was received after completion of the PASRR Level I on 12/05/24 and prior to admission to the facility. She stated that with this new qualifying mental health diagnosis prior to admission, the resident would need an updated PASRR Level I and a PASRR Level II completed.Review of the facility's policy titled Pre-admission Screening and Review (PASRR), dated 10/08/24 read 4.A Level I screen remains valid unless there is a significant change in a resident's status that affects their mental health or IDD treatment needs. This means that if a resident is discovered to have SMI, IDD, or RC after the Level I was performed, the facility must call the PASRR contractor to perform an updated Level I .6. It is the responsibility of the referral source to initiate the PASRR process. The Social Worker or admission and Marketing Director or designee will be responsible for ensuring the PASRR level is obtained and documented. Evidence that the PASRR process was followed must be present in the medical record.

Based on record reviews, observations, interviews, and review of the facility's policies Resident Rights for Senior Services, Behavioral Health Services and Trauma-Informed Care, and Care Plans - Nursing Facility, the facility failed to ensure staff developed and/or implemented comprehensive care plans for three (3) of 23 sampled residents reviewed, that included person-centered interventions for behaviors (Resident #7), trauma informed care (Resident #8), and restorative services (Resident #45). The findings include: 1. Resident #7 was admitted to the facility 06/26/25 with diagnoses that included Parkinsonism and insomnia. Review of the admission Minimum Data Set, dated [DATE] revealed Resident #7 was moderately cognitively impaired; had verbal behavioral symptoms directed towards others, other behavioral symptoms not directed towards others, and rejected care one (1) to three (3) days during the seven (7) day look back period; and required substantial/maximal assistance with personal care and mobility. Review of the care plan for Resident #7 initiated 06/30/25, revealed, .I am resistive to care r/t [related to] adjustment to nursing home, Anxiety.Give clear explanation of all care activities prior to an [and] as they occur during each contact.I have a behavior problem r/t yelling out and yelling for help.Caregivers to provided [provide] opportunity for positive interaction, attention.Approach/Speak in a calm manner. Divert attention.Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Updates to the care plan included on 07/11/25, .I have impaired cognitive function or impaired thought processes r/t history of subdural hematoma which had significant impact to my cognitive ability.Ask yes/no questions in order to determine the resident's needs.Communication: Use the resident preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions- turn off TV, radio, close door etc. The resident understands consistent, simple, directive sentences.Cue, reorient and supervise as needed.Engage the resident in simple, structured activities that avoid overly demanding tasks. And on 07/30/25, .I am at risk for aggressive behavior r/t attempting to choke a CNA [Certified Nurse Aide].Provide education about how aggression and violence are not appropriate ways to respond to others.Staff will approach me in a calm manner and explain what they are about to do. During an observation on 07/30/25 at 1:11 PM, Resident #7 was in his room with Certified Nurse Aide (CNA) #14. Resident #7 was in his recliner, trying to stand up, and CNA #14 was standing with a wheelchair between her and the resident. CNA #14 was talking to the resident in an argumentative tone and the resident was speaking too low to be heard. CNA #14 could be heard saying, .You can't keep calling me and asking me for help and then telling me you going to knock me out cause that doesn't make sense. Does that make sense? [Resident #7 with an inaudible response] I don't even know what that is. [Resident #7 with an inaudible response] Because I am not the nurse. I am not supposed to know your medicines that's not my job.Now I'm going to go find someone else that wants to talk to you so you can cuss someone else out because you're not going to cuss me out. I don't know what you want me to do. [Resident #7 with an inaudible response] Because you don't want me to touch you. Then I get close to you, and you say you are going to knock me out. CNA #14 exited the room and walking down the hall with CNA #16 and stated I don't know what he wants. During an interview on 07/30/25 at 1:28 PM, CNA #16 stated CNA #14 told her Resident #7 was debating between sitting in the recliner or wheelchair and not knowing what it was he wanted. Resident #7 had threatened to punch CNA #14, and CNA #16 told CNA #14 she should report the behaviors to the Administrator. CNA #16 stated she was not allowed to work with Resident #7 anymore because last night when she was trying to untangle the resident's oxygen tubing, the resident put his hands around her neck and started to choke her. The resident made it very clear that he did not want CNA #16 in his room. She said she handled the situation by moving back and saying, Please don't put your hands on me. Resident #7 told her to get out. She asked the resident if she could put his oxygen back on and he told her to get out. CNA #16 left the room and told another CNA that the resident's oxygen was off so they could go in and care for him. Later in the evening, a housekeeper told CNA #16 that Resident #7 was attempting to get up unassisted, so CNA #16 went back in to try and assist him, and he again told her to get out of his room and she did. CNA #16 would not be caring for Resident #7 anymore so as not to agitate him. CNA #16 stated when caring for a resident like Resident #7, it was best to try and de-escalate the situation and if you cannot, walk away and try to find someone else to assist. She stated she would not argue with a resident because it was their home and that was not appropriate. CNA #16 did not hear CNA #14 talking to Resident #7, but stated she would not have responded the way CNA #14 did because That is not very ethical. During an observation on 07/30/25 at 1:31 PM, Resident #7 was yelling out help me while attempting to get up out of a chair. A staff member entered the resident's room and asked Resident #7 what he was doing and if he wanted to get in his wheelchair. The resident was placed in his wheelchair and the resident was calm and cooperative. During an interview on 07/30/25 at 1:37 PM, CNA #14 stated she had been out of the facility for a week and a half and before she left, she had a good relationship with Resident #7. CNA #14 was shocked that he threatened to knock me out. The resident said, Bring it [the wheelchair] over here or I am going knock you out. CNA #14 stated every time she got close to him, he would shake and threaten her. During an interview on 07/31/25 at 10:50 AM, Licensed Practical Nurse (LPN) #5 stated Resident #7 had Parkinson's with behaviors and the providers were adjusting his medications to achieve a balance between managing his anxiety and behaviors, and not over sedating him. Resident # 7 told LPN #5 today that CNA #14 was in all of his business when he wanted to get in his wheelchair and the CNA asked him where he wanted to go. LPN #5 stated CNA #14 was an agency CNA, and the LPN was not aware of any issues with the CNA. LPN #5 confirmed the exchange between CNA #14 and Resident #7 overheard earlier was not appropriate and definitely not dignified. During an observation and interview on 07/31/25 from 3:30 – 3:39 PM, Resident #7 was in the unit dayroom sitting in his wheelchair with two (2) staff members. The resident was falling asleep in his wheelchair. CNA #15 took Resident #7 back to his room and put him to bed. During the process of putting him back to bed, CNA #15 explained everything she was going to do and asked the resident's permission before proceeding. Resident #7 was cooperative and went to bed without any problems. During an interview, CNA #15 stated she had never had any problems caring for Resident #7 and he had never had any behaviors with her. During an interview on 08/01/25 at 10:34 AM, the Director of Nursing confirmed CNA #14 failed to implement Resident #7's care plan. Review of the facility's policy titled Resident Rights for Senior Services Policy effective 10/30/24 read, .It is the policy of (Facility Name) to recognize that all residents have the right to a dignified existence, self determination, and access to persons and services inside and outside the facility. (Facility Name) will treat each resident with respect and dignity and will care for each resident in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. (Facility Name) will protect and promote the rights of all residents. Review of the facility's policy titled Behavioral Health Services and Trauma-Informed Care Policy, effective 10/08/24 read, .(Facility Name) provides the necessary behavioral health care and services to residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being.Additionally, a resident who displays or is diagnosed with mental disorder or psychosocial disorder or has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to attain the highest practicable mental and psychosocial well-being and to minimize triggers or re-traumatization.Ensuring that necessary care and services are person-centered and reflect the resident's goals for care, while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice, and safety. Ensuring that direct care teammates interact and communicate in a manner that promotes mental and psychosocial well-being, in addition to using approaches which are culturally competent and account for experiences and preferences.Providing an environment and atmosphere that is conducive to mental and psychosocial well-being.Anxiety and anxiety disorders include symptoms such as excessive fear and intense anxiety that can cause significant distress. Anxiety can be triggered by loss of function, changes in relationships, relocations, or medical illness. It may also be a symptom of other disorders, such as dementia.Additionally, all teammates are trained in the ability to communicate and interact with residents in a way that promotes meaningful engagement and psychosocial and emotional well-being.Teammates that support and provide care for residents will receive additional training on behavioral health, including trauma-informed care, during orientation and as required though the online learning program. Review of the facility's policy titled Care Plans – Nursing Facility last reviewed 01/18/24 read, (Facility Name) will develop a comprehensive care plan for each nursing facility resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.Care plans are available to staff members who have responsibility for providing care and services to the resident. 2. Resident #8 was admitted to the facility 06/24/24 with diagnoses that included schizoaffective disorder, bipolar type; post-traumatic stress disorder (PTSD); depression and type 2 diabetes. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #8 had mild cognitive impairment; a diagnosis of PTSD; no behaviors during seven-day (7) day look back period and is independent with activities of daily living (ADLS). Review of the care plan initiated 06/24/24 revealed, there were no specific interventions that addressed Resident #8's specific needs to related to her PTSD diagnosis to minimize triggers and to prevent re-traumatization of the resident while receiving care. During an observation and interview on 07/30/25 at 4:42 PM, Resident #8 was observed fully dressed; reclined in bed. The resident stated she was not aware of a behavioral health diagnosis and denied talking to anyone about her mood. She stated, sometimes I feel sad and would like to talk to someone. During an observation and interview on 07/31/25 at 11:00 AM, Resident #8 was observed in room dressed and playing music. The resident stated, I'm getting ready to go walking. She denied any concerns. During an interview on 7/31/25 at 11:30 am, with Social Worker (SW) #1 regarding Resident #8's PTSD diagnosis and specific interventions, she denied completing a social history or trauma assessment. She stated, I know the resident personally; I live on the same street as her mother. SW #1 reported resident was a registered sex offender; has a history of sexual molestation and was triggered by men that she does not know. She confirmed Resident #8 was recently triggered by a new male CNA. She did inform the Director of Nursing so that the resident would not be assigned the CNA. SW #1 confirmed that this information was not listed in the resident's care plan. She agreed that the care plan should be completed with information and resident specific interventions that would assist the facility staff to provide trauma-informed care for the resident. Review of the facility policy titled (Facility Name) Social Services-Behavioral Health Services and Trauma-Informed Care Policy dated 10/08/24 read, . Trauma informed care. Procedure:. 4. Care Planning to Address Past Trauma: The facility collaborates with resident trauma survivors, and as appropriate, the resident's family and any other health care professionals.to develop and implement individualized interventions. If the trauma survivor is reluctant to share their history, teammates will try to identify triggers which may re-traumatize the resident and develop care plan interventions which minimize effect of the rigger on the resident .5. Additionally, trauma-specific interventions should recognize the interrelation between trauma and symptoms of trauma.Trauma- specific interventions recognize the survivors need to be respected, informed, connected, and hopeful regarding their recovery . 3. Resident #45 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hemiplegia (paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease affecting the left non-dominate side, morbid obesity, spinal stenosis and chronic respiratory failure. Review of the Comprehensive Minimum Data Set (MDS) dated [DATE] revealed the Resident #45's cognition was moderately impaired. The resident was dependent on staff for assistance with activities of daily living (ADLs), and substantial assistance for bed mobility and transfers. Review of Resident #45's comprehensive care plan revised, 07/21/25 revealed no focus, goals, or resident-centered interventions to address the maintenance and/or prevention of decreased ROM and bed mobility related to the resident's hemiplegia/hemiparesis (paralysis/weakness) diagnoses. On 07/31/25 at 10:30 AM, the Director of Nursing (DON) and RN #3 confirmed that staff was expected to ensure care plans are accurate and reflect the resident's care needs. Review of the facility's Restorative Nursing Care policy, dated 11/12/24, read The restorative nursing care program is designed to assist each resident in achieving and maintaining an optimal level of self-care and independence. A resident may be referred to the restorative nursing program. Functional decline or maintenance need identified at time of admission or during stay and resident is not appropriate for therapy.

Based on record review, interview, policy review, and review of Up To Date medical reference, the facility: 1. failed to ensure arrangements were made for a dermatology consult in accordance with a physician order for one (1) resident (Resident #27); 2. failed to ensure assessment and treatment for potential insect bites for one (1) resident (Resident #66); and 3. failed to ensure arrangements were made for a speech and language evaluation in accordance with an order for one (1) resident (Resident #21) of 23 sampled residents. The findings include: 1. Resident #27 was admitted to the facility 06/12/25 with diagnoses that included type 2 diabetes, major depressive disorder, anxiety disorder, and adjustment disorder with depressed mood. The resident was cognitively intact. During an interview on 07/28/25 at 5:35 PM, Resident #27 stated she was admitted [DATE] and the only complaint the resident had since being admitted was this itching that won't go away.from head to toe. The resident stated the itching made it hard to sleep at night. Resident #27 stated facility staff and providers told her the itching was due to anxiety, but she did not believe that was the problem and had suffered from the same itching before. Resident #27 wanted to see a dermatologist. Review of the physician Initial Assessment for Resident #27 dated 6/24/25 revealed .also has h/o [history of] itching in scalp and in throat.Episodic Problems .Itching of skin .no rashes.Review of physician's orders for Resident #27 revealed an order dated 07/01/25 for a dermatology consult for itching and a history of eczema and an order written 07/18/25 for cetirizine (medication for allergies) 10 milligrams (mg) for a diagnosis of pruritic (itching). Review of a nurse's note dated 07/19/25 at 5:34 AM, revealed, .Resident [#27] c/o [complaint of] itching all over. Resident having trouble sleeping d/t [due to] itching. N.O. [New Order] Cetirizine 10 mg tab, take one tablet daily.Resident is requesting an appointment with an allergist. Review of the medical record for Resident #27 revealed no documentation for an appointment with a dermatologist or allergist had been arranged or that the resident was seen by a dermatologist or allergist for the complaints of itching. During an interview on 07/31/25 at 10:36 AM, [NAME] Clerk #5 stated orders for consults were placed in a folder for transportation staff to arrange appointments. The orders did not get placed in the medical record until transportation had made the appointment and the resident had come back from the appointment. During an interview on 07/31/25 at 11:03 AM, Certified Medication Aide/Transportation (CMA) #13 stated she was responsible for scheduling appointments with outside physician's offices and specialists. CMA #13 stated the orders for outside consults were put in a folder at the nurse's station for her. She would then review the orders, make the appointments, and arrange transportation. She reviewed the medical record and confirmed there was an order written for a dermatology consult for Resident #27 and she was not aware of the order. CMA #13 stated she had not been given the order in her folder. CMA #13 confirmed she had not made an appointment for Resident #27 to see a dermatologist. During a follow up interview on 07/30/25 at 4:01 PM, Resident #27 stated the itching was awful and confirmed she had not seen a dermatologist since being in the facility. She did not know there was an order for a dermatology consult, but she would like to see the dermatologist. During a follow up interview on 08/01/25 at 8:31 AM, CMA #13 stated Resident #27 had been seen by a dermatologist when she resided at the nursing facility she transferred from. Resident #27 had oral and topical medications prescribed by the dermatologist and the facility was working on having the prescriptions transferred to their pharmacy. CMA #13 scheduled a dermatology appointment for Resident #27. During an interview on 08/01/25 at 10:32 AM, the Director of Nursing (DON) stated the order for the dermatology consult for Resident #27 should have been put in the folder for transportation and given to CMA #13 to arrange the appointment and transportation. 2. Resident #21 was admitted to the facility on [DATE] with a diagnosis of dysphagia. Review of Resident #21's Minimum Data Set (MDS) dated [DATE] revealed the resident was moderately cognitively impaired. During an interview with Resident #21 on 07/29/2025 at 11:27 AM, the resident stated that the facility's diet ordered for her was not appetizing. She did not like the consistency of the meat and that she was informed by the Registered Dietician (RD) that she would have an evaluation with the Speech Language Pathologist (SLP) in regard to changing her diet, but to date no one had changed her diet or followed up with her. Review of Resident #21's diet order revealed an order dated 08/28/24 for Regular diet, Mechanical Soft Ground texture, Regular consistency and an order dated 12/30/24 Resident requests to speak with SLP re her diet. Review of the RD note dated 12/30/24 revealed that .Resident continues to complain about her diet and request to speak to the SLP to downgrade her diet. Resident does not want her food ground up .Plan: request SLP to speak with resident re her diet . Review of Resident #21's medical record did not reveal any SLP documentation. During an interview with the NP on 07/31/25 at 3:14 PM, she stated that the expectation was for any changes in diet consistency, residents will need to have an order for an evaluation by the SLP. Based on the recommendations for the type of diet, the resident can decide to adhere to the diet or sign a waiver regarding their decision to eat whatever they want. The NP reviewed Resident #21's medical record and confirmed that the resident did not have any SLP documentation regarding an evaluation for change in diet nor did Resident #5 have a waiver. During an interview with the SLP on 08/01/25 at 8:57 AM, she confirmed that an order was placed for a SLP referral to evaluate the resident on 12/30/24 and that there was no documentation to support that the resident received a SLP evaluation. The expectation was that the resident was seen by SLP to evaluate the resident and determine if the diet preference was appropriate. During an interview with the DON on 08/01/25 at 9:39 AM, she stated that her expectation was that nursing staff ensure all orders written are completed and the appropriate referrals are made. During an interview with the RD on 08/01/2025 at 10:25 AM, she stated that she wrote the order for SLP, due to the resident's concern regarding her diet and food choice. She stated that her expectation was that if an order was placed for a referral, then the staff should make the appropriate referrals. Review of the facility's policy Referrals to Outside Agencies Policy effective 06/23/25 read, The purpose of this Policy is to provide (Facility Name) teammates with guidelines for referrals are made timely and appropriately to meet the needs of the resident .This policy is a guideline for making timely and appropriate referrals to meet resident's routine and emergency needs while at (Facility Name) If the physician orders an outside referral, nursing staff should notify the social worker (or designee) of the referral. The social services teammate may collaborate with nursing or other pertinent disciplines to arrange for the services that have been ordered by the physician . 3. Resident #66 was admitted to the facility 11/14/24 with diagnoses that included unspecified atrial fibrillation, cerebrovascular disease, and moderate persistent asthma. The resident was cognitively intact. During an interview on 07/29/25 at 11:42 AM, Resident #66 stated approximately two and a half (2 1/2) weeks ago she woke up and there were ants all over her bed. The Certified Nurse Aide (CNA) and the housekeeper tried to get all the ants up, but they were in the mattress. Resident #66 stated she continued to see ants for seven (7) days. She got ant bites on her upper back and neck area and a few bites on her left arm. She stated the doctor said, Oh that's just a rash. Resident #66 stated, I'm not completely stupid. I know bug bites from a rash. Resident #66 reported that she was prescribed a cream, but the staff only applied the cream one time. Review of a nurse's note dated 07/17/25 at 10:20 PM revealed, Resident [#66] is noted to have a rash to back side of left shoulder. Resident complaints of itching, she is provided hydrocortisone cream to area and encouraged not to scratch at area. Area is noted red, and raised areas, no drainage or open areas noted. Review of a Skin/Wound Note for Resident #66 dated 07/18/25 at 3:33 PM, revealed .Report of rash to L [left] posterior shoulder/back. Small, slightly red papules are noted. Scattered cluster pattern noted. No apparent rash. No drainage or induration. Resident denies itching at present. Resident reports she believes this is related to bug bites. Site to be monitored for change in appearance or symptom. Review of a Nurse Practitioner (NP) note dated 07/18/25 at 3:33 PM, revealed, .[Resident #66] Has itchy rash on left shoulder; hydrocortisone cream applied. Under the Physical Exam portion of the note was documented, .Skin: No rashes. There was no other documentation in the notes regarding assessment or treatment of the area where Resident #66 stated she had gotten ant bites. During an interview on 07/31/25 at 9:56 AM, Housekeeper #1 stated about a week or two ago, the housekeeper saw ants in the room of Resident #66. Housekeeper #1 saw a trail of ants by the bathroom door area going across the room. It was little black ants, and the ants were on the resident's mattress. During an interview on 07/31/25 at 10:23 AM, CNA #12 stated there were ants in Resident #66's room. The ants were getting on the resident's mattress and staff wiped off the mattress and cleaned it, but the ants came back. CNA #12 stated Resident #66 showed the CNA an ant bite on the left arm. During a telephone interview with Resident #66's daughter on 07/31/25 at 11:36 AM, the daughter stated Resident #66 had called the daughter on 07/17/25 and reported that she had ants in her room. She talked to Resident #66 again on 07/24/25 and Resident #66 stated the ants were still in her room and in her bed and they were biting her. The facility physician saw Resident #66 on 07/24/25 and told her it was dermatitis. Resident #66 and the daughter did not believe the area to be dermatitis. The daughter had taken pictures of the area and shown them to her doctor who told her they looked like bug bites. The daughter provided photographs to show the area Resident #66 was complaining were bug bites. Review of the photographs showed many areas of distinct raised papules that were reddened and were scattered on the resident's upper back area, with a cluster of approximately 10 distinctly separate papules to the back of the left shoulder, one (1) very large raised papule to the back of the right shoulder, and one (1) large papule on the underside of the left upper arm. Two (2) papules to the upper back appeared to have small open areas in the center. Review of the medical record revealed no documentation of an assessment by the facility's physician. During an interview on 07/31/25 at 2:40 PM, the NP reviewed her notes and stated that she did not describe in detail the appearance of Resident #66's skin when she assessed her. From memory, she stated it was reddened area, slightly raised area, and she was responding well to hydrocortisone cream. I don't think it was a new rash. The NP stated she recalled a discussion at some point about whether there were ants in the resident's room as reported by the resident and whether the resident was having some cognitive, behavioral, or delirium symptoms. The NP stated that had she known about bugs being confirmed in the room, she may have evaluated her different. The NP was unable to describe what a bug bite looked like and said, I don't know because I have never had a patient with bug bites. During an interview on 07/31/25 at 3:00 PM, Registered Nurse (RN) #1 stated staff reported to her that Resident #66 thought she had insect bites. RN #1 assessed Resident #66 on 07/18/25 and saw papules on the left shoulder that appeared scattered and clustered and there was no evidence of scratching. Resident #66 reported that she thought it was ant bites. RN #1 stated by the appearance, it could have been bug bites. The Interdisciplinary Team met the next morning and discussed that ants had been seen in the room and the plan was to have pest control come to the facility and housekeeping did a deep cleaning of the room. RN #1 stated Resident #66 was cognitively intact, a reliable historian, and had never shown any signs of delirium or behaviors. RN #1 stated hydrocortisone cream was prescribed and confirmed it was documented as having only been administered one time and that was on 07/17/25. Review of the Up To Date reference article titled Insect and Other Arthropod Bites last updated 05/22/25, revealed, .The bites of insects and other arthropods may be a minor nuisance or may lead to serious medical problems, including transmission of insect-borne illnesses and severe allergic reactions .Most arthropods are insects, but the phylum Arthropoda also includes spiders, centipedes, and crustaceans .Insect bites may result in several types of local reactions, papular urticaria, or systemic allergic reactions. Rarely, other forms of systemic reactions occur, such as serum sickness .he normal reaction to an insect bite is an inflammatory reaction at the site of the punctured skin, which appears within minutes and consists of pruritic local erythema and edema. A single punctum may be visible .Local reactions are caused by irritant substances concentrated in insect saliva (eg, anticoagulants such as factor Xa inhibitors, digestive enzymes such as amylases and esterases, agglutinins, and mucopolysaccharides). In some cases, a local reaction is followed by a delayed skin reaction consisting of local swelling, itching, and redness .

Based on interviews, record review, and review of the facility's policy titled Restorative Nursing Care, the facility failed to initiate restorative care nursing services for Activities of Daily Living (ADL) for two (2) residents out six (6) residents sampled for ADL decline and rehabilitation and restorative care (Residents' #3 and #5). The findings include:1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, contracture of right hand, adult failure to thrive, and end stage renal disease (ESRD). Review of Resident #3's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.During an interview on 07/29/25 at 10:50 AM with Resident #3, she stated that she was not getting any stronger and still weak. She stated she was informed that she would continue with exercises, but the facility staff had done nothing. Review of Resident #3's therapy note dated 07/08/25 revealed .Pt will be DC on Thursday and be placed on restorative.PTA assisted POC supervisor with restorative paperwork. Communicated with restorative aide regarding clarification on goals for pt. once on the restorative program. Paperwork completed and restorative aide is confident in completing goals.Review of Resident #3's therapy note dated 07/10/25 revealed Per previous notes, pt. will be d/c today from PT to restorative program. Maximum progress/potential has been met with PT. Patient in agreement with this plan.Review of Resident #3's care plan revealed a care plan for ADL self-care performance deficit related to activity intolerance, impaired balance, decreased safety awareness, and limited mobility with no restorative nursing care interventions.Review of Resident #3's medical record revealed no restorative assessment or notes in the chart.Review of the Restorative Nursing List revealed Resident #3's name was missing.During an interview on 07/31/25 at 12:15 PM with the Physical Therapy Assistant (PTA), she stated that Resident #3 was discharged to the restorative program on 07/10/25 and was no longer on the therapy schedule. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses that included below the knee amputation of left lower leg, peripheral vascular disease, chronic obstructive pulmonary disease (COPD), and morbid obesity.Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact.During an interview with Resident #5 on 07/31/25 at 2:38 PM, he stated facility staff had not provided restorative care and he was advised by the physical therapist that someone would provide those services after he completed therapy.Review of Resident #5's therapy note dated 07/01/25 revealed .Patient was informed of findings and given opportunity to ask questions throughout. At this time, patient would like to be placed in the restorative program to maintain current functional status. Patient in agreement with plan.Review of Resident #5's care plan revealed a care plan for ADL self-care performance deficit related to debility, left below the knee amputation, peripheral arterial disease, diabetes, obesity and impaired balance with no restorative nursing care interventions.Review of Resident #5's medical record revealed no restorative assessment or notes in the chart.Review of the Restorative Nursing List revealed Resident #5's was listed as never enrolled.During an interview on 07/31/25 at 12:02 PM with the PTA, she stated Resident #5 was referred to the restorative program on 07/01/25 and was no longer on the therapy schedule.During an interview on 70/31/25 at 3:00 PM with the Nurse Practitioner (NP), she stated that if a resident completed therapy and was referred to the restorative program, the expectation was that staff would follow the physical therapist orders. During an interview on 07/31/25 at 4:28 PM with the Restorative Nurse Program (RNP) Coordinator/MDS Coordinator, she stated the process was that a restorative referral form was completed by therapy staff who provide that information to the restorative aide. The therapy staff then train the restorative Certified Nurse Aide (CNA) with the residents to help them to understand the exercises and care goals. The RNP Coordinator confirmed that Resident #3 and Resident #5 restorative therapy program referrals were missed.During an interview on 08/01/2025 at 9:34 AM with the Director of Nursing, she stated the expectation was that if a resident was referred to restorative nursing care, then a restorative nursing assessment form was completed, and the resident should receive those services.Review of the policy titled Restorative Nursing Care, effective 11/12/24, read The purpose of this Policy is to provide (Facility Name) teammates with guidelines for restorative nursing care assisting each resident in achieving and maintaining an optimal level of self-care and independence. Restorative nursing care is rehabilitative nursing care that does not require the use of a qualified professional therapist. A resident may be referred to the restorative nursing program due to: In conjunction with, or at discharge from, therapy [physical therapy (PT), occupational therapy (OT), speech therapy. After a triggering event (such as weight loss, pressure ulcer, choking). Functional decline or maintenance need identified at time of admission or during stay and resident is not appropriate for therapy.

Based on interviews, record review, and review of facility documents, the facility failed to ensure one (1) of three (3) residents (Resident #1) was safely transferred from the facility van. The findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: Complete Traumatic Amputation to Left Lower Leg and Type 1 Diabetes Mellitus. He was cognitively intact. During an interview on 4/8/25 at 9:00 AM, Resident #1 stated on 12/27/24 he was returning to the facility from an appointment in Asheville for suture removal to his stump (amputated leg). He arrived back to the facility via Tsali's van with facility's staff driver #1. While she was getting him out of the van, and on the ramp down, I slid out of the chair and landed on my stump. This was the leg that just had sutures removed. He stated van driver #1 explained to him the reason he came out of the chair was due to the cushion not being properly secured to his wheelchair. He stated the accident caused him to have to be sent via ambulance to the hospital for staples to his stump. During an interview on 4/10/25 at 1:27 PM, the Assistant Administrator (AA) and the Director of Nursing (DON) stated they both responded to the scene when van driver #1 came into the building requesting help stating Resident #1 had slid from his wheelchair. The DON stated she arrived and observed the wheelchair's back wheels had crossed the threshold of the ramp and had begun the decent down the ramp. The front wheels had not yet crossed the threshold and remained in the van. The resident was sitting on the floor of the van in front of the wheelchair. She stated she performed an assessment and during this time the resident told her that as the chair began being brought down the ramp by van driver #1, he leaned forward with his arms at the front of wheelchair arms. When he did this, he slid from the chair and landed on the floor. The cushion in the chair had slid from the chair with the resident. Both the AA and the DON agreed the cushion was not properly secured to the wheelchair. She stated an ambulance was called and the resident was transported to the hospital and required staples to his stump. During an interview on 4/10/25 at 3:00 PM, Occupational Therapy Assistant (OTA) #1 stated Resident #1 was provided a cushion to his wheelchair by the facility's therapy department. She stated this was to help prevent skin breakdown and sores for people that sit up in the chair for long periods. The cushion covered the entire wheelchair seat and was secured with a buckle clip at the back of the wheelchair. She stated the cushion should always be clipped while in a chair. The cushion can be slick if not secured. If someone is trying to get up with their arms at the front of the chair and leaning forward, it could cause the cushion to slide out from under the resident. During an interview on 4/10/25 at 5:06 PM, van driver #1 stated she had transported Resident #1 to a physician appointment for suture removal to his recently amputated leg. Upon return to the facility, she began removing the resident in his wheelchair from the facility's transport van down the ramp. As the back tires began coming down the ramp, the resident leaned forward grabbing onto the drink holders in the van. When he did this, he slid out of the chair. She stated the resident landed on his stump and ended up sitting in front of the chair. The cushion slid out from under him and ended up behind his back. She confirmed the cushion was not securely clipped to the chair. She stated she then went into the building and requested help. Review of a facility progress note dated 12/27/24 written by Licensed Practical Nurse (LPN) #2 read, Called to go downstairs at entrance to care center to assist with resident who slid out of wheelchair while being assisted out of transport van. Resident was sitting on the van floor with wheelchair behind him. Resident reports pain at a 10-12 for left lower leg, stump area, and lower back. EMS contacted to assist with transferring resident off of the floor of van onto the wheelchair or stretcher. Resident is requesting transport to the ER for evaluation. Review of a facility progress note dated 12/27/24 written by LPN #2 read, Resident returned to facility via [NAME] [Cherokee Indian Hospital Authority] EMS [Emergency Medical Services] .Resident has diagnosis of dehiscence of external surgical wound . Review of the emergency room Discharge Progress Notes dated 12/27/24 read, My Diagnosis today was: 1) Fall from wheelchair .2) Dehiscence of external surgical incision wound - Left BKA [Below Knee Amputation] stump with dehiscence of wound on ground impact . Review of the facility document entitled Tsali Care Center Plan of Correction Event: Fall from Wheelchair dated 12/27/24 read, 2 .b. Consideration of cause for event: The transportation specialist and Director of Nursing noted the wheelchair seat cushion strap was not completely 'buckled,' allowing the cushion to slid from secure position in wheelchair seat .c. The seat cushion was able to move from its position due to smooth surfaces of cushion and wheelchair seat. Review of instructions for Permobil Kwik Strap provided by OTA #1 dated 10/29/21 read, 3 Connect the buckle, and pull the strap tight. 4 Confirm the correct position of the cushion in the wheelchair, and adjust KWIK STRAP if needed.

Based on observations, medical record review, staff, resident and physician interviews, and facility policy titled Pain Management Protocol Policy, the facility failed to manage pain for one (1) of five (5) residents (Resident #159). The findings include: Resident #159 was admitted to the facility on [DATE]. The resident's diagnoses included hemiplegia, personal history of transient ischemic attack (TIA), cerebral infarction without residual deficits, anxiety disorder, depression, adjustment disorder with mixed anxiety and depressed mood, psychoactive substance, other psychoactive substance dependence, and disorder of the kidney and ureter. A review of the Minimum Data Set (MDS) revealed that the MDS was in progress. A review of the care plan-focused concern revealed, I have/or am at risk for pain r/t (related to) dx (diagnoses) of neuropathy, decreased mobility. Interventions reflected Give medications as ordered by the physician. Monitor/document side effects and effectiveness. Focused concern also included I have/or am at risk for pain r/t dx of neuropathy, decreased mobility, Interventions revealed Administer analgesia as per orders .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Evaluate the effectiveness of pain interventions after administration. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition .Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician .Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment .Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain .Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care . A review of the admission pain assessment completed on 08/15/24 revealed Resident #159 had pain present within the last five days; pain frequency almost constant; pain effect on sleep almost constant; pain interference with therapy activities almost constant; limited day-to-day activities almost constant; and pain intensity on a numeric rating scale from 00-10 with pain of 9. A review of a pain assessment completed on 08/20/24 revealed Resident #159 had pain present within the last five days; pain frequency frequently; pain effect on sleep frequently; pain interference with therapy activities rarely or not at all; pain limited day-to-day activities rarely or not at all; pain intensity on a numeric rating scale from 00-10 with pain of three (3). A review of a pain assessment in the electronic health record with an effective date of 08/21/24 revealed a pain assessment; however, the assessment was blank. On 08/21/24 at 10:36 AM, LPN #1 confirmed that the pain assessment needed to be completed, signed, and dated. LPN #1 was uncertain why the pain assessment was not completed. A review of the medication administration record (MAR) revealed that Tylenol 325 mg (milligrams), two (2) tablets as needed for pain, or Tylenol 650 mg suppository for mild pain was not administered to the resident and/or any refusals for pain management noted. The MAR further revealed a discontinued order for Hydro/apap (combination pain medication including opioid) 5-325 mg, one (1) tablet twice daily as needed for pain for three (3) days, with an order date of 08/14/24 and a stop date of 08/16/24. The MAR reflected that no medications were administered or the resident refused. Further review of the MAR revealed Hydro/apap 5-325 mg, one tablet by mouth twice daily as needed for pain for three (3) days with an order date of 08/16/24 and a stop date of 08/19/24. The MAR reflected no medications were administered or the resident refused. A review of the narcotic sheet revealed prescription #2167268 (Hydro/apap 5-325 mg), a quantity of six (6) pills, was sent from the pharmacy. The medications were noted received on 08/15/24. The narcotic sheet reflected six (6) pills were sent back to the pharmacy on 08/20/24 due to discontinued. The document did not reflect that the resident received any pain management medications. The narcotic sheet reflected that one (1) tablet was wasted on 08/16/24 at 0025 (12:25 AM) and one (1) tablet was wasted on 08/20/24 at 2130 (9:30 PM). A review of the narcotic sheet revealed that prescription #2167325 (Hydro/apap 5-325 mg) contained six (6) pills sent from the pharmacy. The medications were noted received on 08/17/24. The narcotic sheet reflected that six (6) pills were sent back to the pharmacy on 08/20/24 due to discontinuation. The document did not reflect that the resident received any pain management medications. A review of the MAR reflected that Gabapentin 300 mg, one capsule, was administered three times daily for neuropathy. During an interview on 08/20/24 at 10:44 AM, Resident #159 stated that he was in pain eight (8) out of 10 on his right side. He stated he had not received anything for pain, nor had he notified the primary nurse (LPN #1) or Medication Aide (MA) #1. Upon departing the resident's room, MA #1 was in the process of a medication pass and notified of the resident's complaint of pain. During an interview on 08/20/24 at 2:20 PM, LPN #1 stated, Usually, the medication aide will inform me if a resident complains of pain. Once notified by the medication aide, I will assess the resident. LPN #1 acknowledged that she was aware that the resident complained of right-side pain today, and the resident had informed her that Tylenol would not work for the pain he was having. She further shared that labs were drawn last night. LPN #1 concluded that she notified the medical director (MD) regarding the resident's pain via tiger text and was awaiting a response. On 08/21/24 at 9:20 AM, the Physical Therapy Assistant (PTA) #1 was observed in the resident's room by his bedside. The PTA confirmed she was providing stretching exercises to the resident's lower extremities. The PTA was positioned on the resident's right side/lower extremities. The resident stated that he was having pain eight (8) out of 10 all over. The PTA continued with the stretching exercises. During an interview on 08/21/24 at 9:30 AM, LPN #2 confirmed that she had not been made aware of any complaints of pain from Resident #159. She stated that the medication aide was responsible for assessing, identifying, and documenting any pain medications administered and their effectiveness. During an interview on 08/21/24 at 9:33 AM, LPN #1 indicated the MD responded via tiger text on 08/20/24 at 3:28 PM with new orders for pain management that included Lidocaine patch 5% every 12 hours as needed for pain and Diclofenac gel two grams 1% twice daily as needed to the affected area for pain. LPN #1 indicated she did not provide education to the resident regarding how the medication worked in managing pain because the resident stated he already knew how the medications worked. LPN #1 elaborated that the resident refused the medications because he wanted Hydrocodone. Additionally, LPN #1 confirmed that she did not initially transcribe the physician's order because the resident refused, nor did she document the resident's refusal of the medication in the medical record. During an interview on 08/21/24 at 9:36 AM, MA #2 confirmed she did not inquire from the resident regarding any pain or administer any pain medications before his therapy session. MA #2 stated the PTA notified her that the resident was having pain after the treatment session was completed. During an interview on 08/21/24 at 10:09 AM, the PTA stated she assumed Resident #159 received pain medication before the therapy session. The PTA indicated she did not inquire from the resident's medication aide or primary nurse if pain medications were administered before the start of the therapy session. The PTA explained Resident #159's therapy session included low load long duration manual stretching with Joint mob. The PTA stated the therapy treatment session lasted 30 minutes and included 15 minutes of stretching alternating with 15 minutes of joint mob. The PTA explained that joint mob helps with joint stiffness and allows for more movement. The PTA elaborated that she used hot packs during the therapy session to assist with the resident's pain. The PTA concluded that Resident #159 complained of pain ranging from eight (8) to 10 during the 30-minute treatment session. During an interview on 08/21/24 at 11:03 AM, Resident #159 stated, They will not give me anything for pain. My pain is eight (8) out of 10, and my right side constantly ached all day yesterday. The resident stated that during his therapy treatment session this morning, his pain was 10 out of 10 in his feet during the exercises, and he informed the therapist. He concluded that he was not aware or informed of an order for the Lidocaine patch and would consider wearing the patch to help with his pain; however, he would like to know why he cannot have Hydrocodone. During an interview on 08/21/24 at 11:19 AM, LPN #1 was made aware of Resident #159's interview related to the Lidocaine patch and that he said he would consider the patch to help alleviate his pain; however, he would like to know the status of the Hydrocodone he had previously. During an interview on 08/22/24 at 5:37 PM, the Director of Nursing (DON), accompanied by the Administrator, the DON stated if therapy enters a resident's room and the resident complains of pain, the concern should be immediately reported to the resident's nurse. The DON added that the MA should be notified if the nurse was unavailable. The DON explained that the MA must get permission from the licensed or registered nurse before administering pain medication to residents. The DON elaborated that if a nurse is unavailable, the MA is expected to notify the on-call supervisor. The DON explained that it is the responsibility of the licensed or registered nurse to assess and evaluate pain medication effectiveness after administration. The DON stated that the resident's refusal of medication should be documented in the medical record (MAR), a progress note reflecting why the resident refused the medication and any education provided to the resident on why the medication is important. The DON confirmed that the initial physician order for the Lidocaine patch was on 08/20/24 and was not added to the MAR until 08/21/24. The DON reviewed the medical record and acknowledged that pain was a concern for Resident #159. The DON confirmed that Resident #159 did not receive any of the medication (hydro/apap 325 mg) during the time frame ordered for pain management. During an interview on 08/22/24 at 7:09 PM, the MD explained that upon admission, she copied the resident's discharge orders and extended the hydro/apap 325 mg as needed for pain management to monitor and track during the trial period. She acknowledged the medication was available for the resident's use while ordered. The MD stated that Resident #159 was experiencing post-stroke pain, which was not an indicator of treatment with opioids. She stated that the goal was to try other alternatives. The MD indicated Resident #159 was having neuropathic pain and take gabapentin three times daily. The MD concluded she would look at other options after a review of the medical record to determine the best approach to manage the resident's pain moving forward and that Resident #159 had a history of strokes. The policy dated 03/26/24 read, Documentation and Reporting: 1. Nursing teammates should document the pain assessment and the resident's reported level of pain with adequate detail (i.e., enough information to gauze the status of pain and the effectiveness on interventions for pain) as necessary and in accordance with the pain management program. 2. Nursing teammates should report the following information to the Provider: significant changes in the level of the resident's pain; Prolonged, unrelieved pain despite care plan interventions.

Based on record review and staff interview the facility failed to complete a thorough fall investigation to identify root cause(s) and appropriate interventions to prevent future falls for one (1) of three (3) residents (Resident #3). This failure resulted in the resident sustaining a right femoral neck fracture, a type 4 fracture of the sacrum and a rib fracture. The findings include: Resident #3 was admitted on [DATE] and most recently readmitted [DATE] with diagnoses including: unspecified fracture of right femur, dysphasia, type 4 fracture of sacrum, muscle weakness, unspecified dementia and anxiety disorder. Review of the progress notes dated 6/20/24 revealed 2041 (8:41 PM) Resident yelling for help, found res (resident) lying on her left side next [sic] with her walker lying sideways next to the closed door. Res reported 'I fell '. Res c/o (complained) pain to her left arm. BLE (bilateral lower extremities) in proper alignment, able to bear weight BLE denies hitting her head. Res did not have her shoes on when found and the left tennis ball was off her walker when found. Assisted res with her shoes reminded to make sure she has her shoes before walking . On 7/19/24 at 12:00 PM the Nurse Consultant confirmed the facility could not locate the Fall Questionnaire, which was a form the Nurse was to fill out when a fall incident occurred. The Nurse Consultant (NC) stated that the falls questionnaire was what started the incident review and investigation process. On 7/19/24 at 1:14 PM the NC stated that the cause of the fall documented by Nurse #2 was that the resident did not put on her shoes. The NC said that since Nurse #2 made this determination, no further review or investigation was necessary. However, this was not a thorough investigation and determination of cause since the tennis ball slider device that came off the left leg of Resident #3's walker, during the 6/20/24 fall, was not addressed in a root cause review to identify additional interventions to prevent future falls. Review of the progress notes dated 7/10/24 revealed, 1915 (7:15 PM) CNA (Certified Nursing Assistant) who was sitting at the nurses' station while charting witnessed res. walking up in A hall and fell on her right side and hit her head against the wall. The tennis ball on the bottom of her walker came off causing her to fall. Res c/o right rib cage pain and right leg pain (femur). No external rotation nor shortening observed to RLE (right lower extremity). Redness noted to parietal-occipital area of head, but no hematoma noted post fall. Assisted res up x3 person assist, able to bear weight BLE and took a few steps. Assisted in w/c (wheelchair) then to bed. Skin assessment done. 2 skin tears to RFA (right forearm) with bruising. Area cleansed with NS, xeroform applied and covered with Allevyn dressing. Neurological check initiated. Old walker removed to prevent further fall. Review of the progress notes dated 7/11/24 revealed Resident #3 had been sent to the emergency room and was found to have fractured ribs and a right femoral neck fracture. Review of the Fall Questionnaire dated 7/10/24 revealed the time of the resident's fall was 7:15 PM. Tennis ball came off of walker was written as the Environmental Observation. The resident was wearing her shoes at the time of her fall. Dysfunctional walker removed was written as the Immediate Action. The resident's range of motion was documented as decreased to her right lower extremity and the resident was sent to the emergency room after 2 hours. The incident report for the 7/11/24 fall was reviewed with the Nurse Consultant and Administrator present. The report was not printed by the facility, but sections as requested could be viewed on the computer screen. The information revealed that Certified Nursing Assistant (CNA) #1 witnessed the fall and saw the resident hit her head on the right side near the utility door. No additional information regarding the fall, beyond what was in the Progress Notes, was noted. The Administrator stated that the facility had other tennis ball slider devices for the walkers previously, but they had all been changed out and a new purchase order was just placed for a new tennis ball slider device (brand name Therafin) and another style that was like ski glides. She indicated that the Therapy Manager had been checking the tennis ball slider devices on all the walkers that had them, but confirmed there was no documentation regarding this. During an interview with the Therapy Manager and Physical Therapy Assistant (PTA) on 7/18/24 at 11:45 AM, the PTA stated that there had been one (1) previous incident quite a while ago when the tennis ball device came off Resident #3's walker but the previous Administrator had changed over to the current brand (Therafin) and Resident #3's tennis ball slider device was changed out at that time. This was the same brand she had at the time of her 6/20/24 and 7/10/24 falls. Upon observation this device had a plastic piece that the leg of the walker fit into and a plastic claw that held a tennis ball in place. The Therapy Manager stated she checked the tennis ball slider devices on the walkers periodically for wear and tear and changed them out as needed but confirmed she did not keep any documentation regarding this. During an interview with Nurse #2 on 7/18/24 at 6:15 PM, she stated she had been passing medications when Resident #3 fell on [DATE]. The resident was complaining of rib pain and the tennis ball and attachment had come off her walker. The whole thing came off; I just didn't know what to call it. She added that CNA #2 witnessed the fall. Nurse #2 confirmed she was also the nurse on shift when Resident #3 fell on [DATE]. She confirmed the tennis ball and plastic attachment came of the resident's walker at that time as well and Nurse #2 said she put the same one back on the walker for the resident. Nurse #2 also confirmed the tennis ball and attachment came off the left side both times. She did not know why the facility could not locate the Fall Questionnaire from 6/20/24, she thought she would have completed the form but added that it was easy to forget. She said the Fall Questionnaires were supposed to be reviewed in the morning meetings the next day and any additional interventions that were needed were to be added at that time. During a telephone interview with CNA #2 on 7/18/24 at 6:50 PM she stated when Resident #3 fell on [DATE] she heard metal clinking and the resident hollered out, then she saw the resident fall and the tennis ball and attachment that came off her walker. She stated the fuzz wasn't worn away on the tennis ball but it looked like there was a problem with the plastic piece that screwed into the walker (the plastic connector on the tennis ball slider devices did not screw into the walkers they were held in place by friction). Review of the 10/1/19 facility policy titled Fall Risk Reduction and Management revealed, Fall management includes the review of fall risk indicators, evaluation of interventions, and care of the resident following a fall, including investigation of possible causes and modifications of interventions. Immediately after a fall an investigation is initiated to attempt to define possible causes for the fall Causes refer to factors that are associated with or that directly result in a fall A root cause analysis should be initiated to determine if intrinsic, environmental, or operational factors or a combination of factors contributed to the fall . Often, multiple factors contribute to a falling problem.

Based on observation, record review, and resident and staff interview, the facility failed to prevent an avoidable pressure ulcer for one (1) of one (1) sampled residents for pressure ulcers, Resident #23, who was at risk for skin impairment, developed a pressure ulcer to the penis due to the facility's failure to promptly identify that the catheter tubing was causing pressure injury to the resident's penis resulting in harm to the resident. The findings include: Resident #23 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Benign Prostatic Hyperplasia (BPH), Type 2 Diabetes, Retention of Urine, History of Urinary Tract Infection (UTI), and Hypertension. Review of Resident #23's Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact, total dependence for bathing, extensive assistance for toileting and personal hygiene, was at risk for developing pressure ulcers and had unhealed pressure ulcers. During an interview with Resident #23 on 07/11/23 at 10:51 AM, he stated that he was admitted to the facility with an indwelling catheter and left heel wound, but now had a wound on his penis from the catheter that developed while at the facility. During the interview the resident denied memory of the exact incident, any pain and stated he received wound care daily. Review of Resident #23's care plan with date initiated 05/09/23 revealed the resident had a Foley catheter upon admission related to diagnosis of BPH and urinary retention. Interventions included: position catheter bag and tubing below the level of the bladder and away from entrance room door, change catheter per facility protocol, check tubing for kinks each shift, ensure my privacy bag is in place covering my catheter, evaluate for removal of catheter/trial as indicated, monitor and document intake and output as per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, monitor/document for pain/discomfort due to catheter, monitor/record/report o MD for s/s UTI. Review of Resident #23's care plan with date initiated 05/15/23 revealed the resident was at risk for impaired skin related to fragile skin, frequent bowel incontinence, Foley catheter, decreased mobility. Interventions included: encourage good nutrition and hydration in order to promote healthier skin, encourage off-loading of my heels each shift, encourage resident off load heels/feet and utilize wheelchair cushion, keep skin clean and dry, use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface, utilize gait belt or draw sheet when transferring/repositioning resident secondary to anticoagulant and risk for bruising. Review of Resident #23's medical record revealed a weekly Skin Observation Tool. The Skin Observation Tool completed on admitted d 05/04/23 did not reflect any wounds to the resident's genitalia and a Skin Observation Tool completed on 05/22/23 revealed .slight erythema noted to L side of foreskin-friction/shear R/T silicone catheter. Cath securement device in place to L thigh. Repositioned cath and applied Thera cream to site, monitoring . Review of Resident #23's medical record revealed a weekly Wound Evaluation. The Wound Evaluation dated 05/30/23 revealed Pressure-Medical Device Related Pressure Injury-unstageable (slough and/or eschar), Body Location: penis, Acquired: In-House Acquired .dimensions area 1.63 cm, length 1.68 cm, width 1.38 cm . and the most recent Wound Evaluation dated 07/10/23 revealed Pressure-Medical Device Related Pressure Injury-Stage 2, Body Location: penis, Acquired: In-house Acquired .dimensions area 0.19 cm, length 0.68 cm, width 0.4 cm . Review of Resident #23's Urology Progress Notes dated 05/18/23 and 06/01/23 under physical exam revealed none recorded. Review of Resident #23's Physician's Progress notes dated 06/20/23 revealed Assessments .ulcer of penis-associated with device . Review of the facility's Skin Incident Report dated 05/22/23 revealed .shear force injury r/t catheter being pulled to one side. Catheter strap was in place for securement device. Silicone catheter had sheared across foreskin . During an interview on 07/12/23 at 10:45 AM with the Wound Care Nurse, she stated the wound to Resident #23's penis developed from a sheer injury related to the indwelling catheter tubing. She stated the wound was preventable and identified on 05/22/23 by the nursing staff during catheter removal. The physician was notified immediately, and wound care orders were received. She stated the resident was not referred to wound care clinic as the wound was healing. During an interview on 07/13/23 at 12:30 PM with Certified Nursing Assistant (CNA) #2 she stated she had provided catheter care and perineal care to the resident. She stated she was to report anything unusual to the nursing staff regarding the catheter such as skin breakdown, wounds, sores, and bleeding. She stated she had received catheter and perineal training in the past and most recently in June 2023. During an interview on 07/13/23 at 12:09 PM with the Interim Director of Nursing, she stated that the expectation was that any skin irritation or wounds were reported immediately. The CNAs along with licensed nursing staff provided perineal and catheter care daily and were educated and aware of preventable injuries. She stated all staff were re-educated on catheter and perineal care in June 2023. During an interview on 07/13/23 at 3:40 PM with the Administrator, she stated the expectation was for a resident at risk for skin breakdown with an indwelling catheter should have had a care plan, discussed in morning meetings, and observed daily for any changes. She stated she was informed of the pressure ulcer in June when the resident was readmitted to the facility from the hospital for an unrelated medical condition. She stated the injury was unfortunate and all nursing staff were re-educated in June 2023. A review of the facility's In-Service dated 06/16/23 titled Proper Catheter Peri-Care read .Summary: Please ensure that when you are caring for resident with a catheter that you are following the proper steps to clean and protect that area from any issues. If it is a male that is uncircumcised you need to properly and gently pull back the foreskin and clean the area and replace the foreskin after care. Please make sure that all folly [sic] catheters have and [sic] leg band or stat-lock to keep the catheter tube from pulling. Please make sure that all catheter bags have a cover over them as well, whether they are on the residents [sic] wheelchair or on their bed .

Based on observation, record review, and staff interviews, the facility Quality Assurance and Performance Improvements (QAPI) committee failed to self-identify and [MEDICATION(S)] to ensure one (1) of four (4) unvaccinated residents did not remain in the same room on a COVID-19 unit, with a COVID-19 positive resident (Resident #4). The QAPI committee was unaware Resident #4 had been on the COVID hall (A) since the resident's admission on 01/07/22. In addition, the QAPI committee failed to ensure the facility sustained compliance related to infection control practices previously identified on the past two surveys. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, or impairment or death to residents. The Immediate Jeopardy (IJ) was related to 483.75 Quality Assurance and Performance Improvement for failure to implement an effective plan of action related to infection control and prevention, as evidenced by the quality assurance committee being unaware and failed to identify that a resident who was unvaccinated resided in a room with a COVID-19 positive resident. The facility also failed to utilize their resources effectively, to move an unvaccinated resident to an empty room when there was capability. The Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA), Director of Nursing (DON), Infection Control Nurse (ICN), and Registered Nurse Supervisor (RNS) were notified that an IJ existed on February 4, 2022 at 12:33 p.m. The Immediate Jeopardy was removed on February 4, 2022 at 10:15 p.m., after an acceptable removal action plan was received and further observations, staff interviews and review of training to verify the immediate corrective action had been implemented. The facility remained out of compliance at a lower scope and severity (D) at F-867. The findings include: Cross reference F880. The facility failed to ensure one (1) of four (4) unvaccinated residents did not remain in the same room on a COVID-19 unit, with a COVID-19 positive resident (Resident #4). The facility also failed to conduct a root-cause-analysis (RCA) at the onset of the COVID-19 outbreak to prevent the transmission and spread of COVID-19. The facility confirmed there were empty rooms in the facility that were not located on the COVID unit. The facility also acknowledged there was facility capability to house the unvaccinated resident in a room that was not on the COVID unit or with a COVID positive resident. The facility allowed Resident #4 who was unvaccinated to remain on the COVID unit which placed the resident at serious risk. The failures occurred during a coronavirus pandemic. The facility's census was 54. During an interview with the RNS, on 02/04/22 at 12:10 p.m., she acknowledged, she was responsible for new admissions but was not involved with Resident #4 admission, and therefore was unaware of his vaccination status. She stated she did not have a current list of all COVID-19 negative and positive residents at present. She confirmed there were empty rooms in the facility. Review of the facility's survey history dated 09/24/21, revealed the facility was cited F880, for staff's failure to perform or assist residents with hand hygiene before meals. The facility's staff also failed to clean and disinfect a mechanical lift between resident use. In addition, on 08/28/20, the facility was cited F880, for their failure to ensure residents practiced social distancing and wore facial covering over their mouth and nose when in close proximity to residents. The facility also failed to ensure that kitchen staff wore their facial covering over their mouth and nose while working in the kitchen, and performed hand hygiene, after touching their facial covering. The failures occurred during a COVID-19 pandemic. During an interview with the Medical Director (MD) on 02/04/22 at 5:09 p.m., the MD stated It would be her expectation that the Infection Control Nurse would be monitoring the situation closely to help mitigate the spread of COVID-19. The facility provided an acceptable removal action plan on February 4, 2022 that read: 1. The unvaccinated resident received Moderna Covid vaccination 02/04/22 by Registered Nurse at 2:45 p.m. 2. The Quality Assurance Nurse along with the Staff Development Nurse went to two COVID-19 positive residents to explain the importance of being moved to a quarantine hall. The Social workers called all family members on 02/04/22 of the importance to move Covid positive residents to D hall. Hall D is now the only positive Covid hall in the facility. 3. A root cause analysis was started by the Assistant Nursing Home Administrator (ANHA) and Director of Nursing (DON) to help facilitate process improvement to ensure the COVID-19 positive and unvaccinated residents are not on the same hall, or positive and negative residents reside in the same room when other empty rooms are available to accommodate residents. 4. The Infection Control Preventionist will be assigned on 02/04/22 to read updated COVID-19 modules sent out by CMS and CDC verified by the Infection Control Manager at adjacent hospital. 5. The Staff Development Nurse started an Inservice for all nursing and social workers on 02/04/22 regarding revised policy to not allow unvaccinated residents to reside on halls designated for covid-19 positive residents. On February 4, 2022 at 10:15 p.m., the removal action plan was validated by the surveyor. Observation and staff interviews were completed of A and D halls, with nursing staff assigned to the halls responsible for the care of the residents. The interviews confirmed that staff were educated regarding unvaccinated residents. Additional interviews with administration revealed a process in place for ensuring the safety of unvaccinated residents, and safe management of COVID positive residents. The facility's removal action plan reflected immediate corrective actions were in place during the validation. There were no further concerns identified during the validation.

Based on observations, record review, staff interviews, and review of the facility's policy entitled Coronavirus Disease 2019 (COVID-19) Plan and Protocols, the facility failed to ensure one (1) of four (4) unvaccinated residents did not remain in the same room on a COVID-19 unit, with a COVID-19 positive resident (Resident #4). The facility also failed to conduct a root-cause-analysis (RCA) at the onset of the COVID-19 outbreak to prevent the transmission and spread of COVID-19. The facility confirmed there were empty rooms in the facility that were not located on the COVID unit. The facility also acknowledged there was facility capability to house the unvaccinated resident in a room that was not on the COVID unit or with a COVID positive resident. The facility allowed Resident #4 who was unvaccinated to remain on the COVID unit which placed the resident at serious risk. The failures occurred during a coronavirus pandemic. The facility's census was 54. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, or impairment or death to residents. The Immediate Jeopardy (IJ) was related to 483.80 Infection Control for failure to ensure an unvaccinated resident did not remain on a COVID unit in the same room with a COVID positive resident when there was capacity in the facility to accommodate the resident in a safe environment. The Nursing Home Administrator (NHA), Assistant Nursing Home Administrator (ANHA), Director of Nursing (DON), Infection Control Nurse (ICN), and Registered Nurse Supervisor were notified that an IJ existed on February 4, 2022 at 12:33 p.m. The Immediate Jeopardy was removed on February 4, 2022 at 10:15 p.m., after an acceptable removal action plan was received and further observations, staff interviews and review of training to verify the immediate corrective action had been implemented. The facility remained out of compliance at a lower scope and severity (D) at F-880. The findings include: During an interview on 02/03/22 at 12:10 p.m., the ANHA reported 29 active COVID positive residents since January 18, 2022. At 12:30 p.m., observation of Hall A and D revealed plastic covering over hall doors and staff could be seen on both halls without PPE. During an interview on 02/03/22 at 4:05 p.m., the Registered Nurse (RN #1), serving as the facility's Infection Control Nurse (ICN), stated Resident #4 had not been vaccinated and was residing in a room with a COVID-19 positive resident, on a COVID unit. Review of the facility's COVID positive resident log reflected Resident's #4's room-mate on the list. Resident #4 consented for the COVID-19 vaccine on 01/07/22, but they had not gotten around to it. The ICN stated there were so many COVID positive resident's, two (2) halls (A and D) were put on isolation because the facility had no empty rooms to accommodate just the COVID-19 positive residents. The ICN confirmed both COVID positive and negative residents where in the same rooms and on the same halls. Review of Resident #4's, admission record revealed the resident was admitted to the facility on [DATE]. The medical record reflected the resident's cognitive ability was moderately impaired. The medical record revealed the resident's responsible party signed the COVID-19 vaccination consent form on 01/07/22, however, the resident did not receive the vaccine. Review of Resident #4's Nurses Notes (NN), revealed no signs and symptoms of COVID-19 infection since her 01/07/22 admission. The NN dated 02/01/22 revealed COVID-19 test performed and the resident tested negative. A follow-up interview on 02/04/22 at 10:00 a.m., was conducted with the ICN and the NHA. The NHA stated with the large number of COVID-19 positive residents, the facility simply did not have the room capacity or staff to manage the outbreak. She further stated there was dedicated staff members who work each hall (A and D), and go in between each resident changing out full PPE before making contact with residents. The ICN acknowledged, she had not consulted the local Public Health Department or referenced any guidance from the CDC related to cohorting and help prevent the further spread of COVID-19, once the facility's positivity rate increased. The ICN confirmed she only made contact to report the number of cases. She further stated, she tracks the staff by where they work to indicate which resident would potentially be next to get it. The ICN confirmed a root cause analysis was not conducted to determine the increase in the facility's positivity rate. She said, it had not been done, and with her nursing duties and covering extra shifts, due to staff out sick, there was not much time left to do anything else. In addition, she added, it is pretty self-explanatory, it is an airborne virus, what more is there to know. Review of the Coronavirus Disease 2019 (COVID-19) Plan and Protocols with a revised date of 01/14/22 revealed, under Guidance for unvaccinated new admissions or readmissions with unknown COVID-19 status, Facility will make every attempt to cohort unvaccinated new admissions and those returning from a hospital stay (admission) in one area or hall. During an interview with the NHA, on 02/04/22 at 10:00 a.m., she confirmed there were at least four (4) empty rooms in the facility to accommodate Resident #4. During an interview with the Medical Director (MD) on 02/04/22 at 5:09 p.m., the MD stated the plan to house all residents on two halls was in response to the increased number of COVID-19 positive residents and the decrease in available staff to help manage the residents. The MD further stated, she consulted the hospital infection control department and decided to shelter in place as opposed to moving residents throughout the facility. She reported the facility once had the support of the local hospital to take some resident's but that was no longer an option as they are currently stretched to the limits. She also stated it would be her expectation that the ICN would be monitoring the situation closely to help mitigate the spread of COVID-19. The facility provided an acceptable removal action plan on February 4, 2022 that read: 1. The unvaccinated resident received Moderna Covid vaccination 02/04/22 by Registered Nurse at 2:45 p.m. 2. The Quality Assurance Nurse along with the Staff Development Nurse went to two Covid positive residents to explain the importance of being moved to a quarantine hall. The Social workers called all family members on 02/04/22 of the importance to move Covid positive residents to D hall. Hall D is now the only positive Covid hall in the facility. 3. A root cause analysis was started by the Assistant Nursing Home Administrator (ANHA) and Director of Nursing (DON) to help facilitate process improvement to ensure the Covid positive and unvaccinated residents are not on the same hall, or positive and negative residents reside in the same room when other empty rooms are available to accommodate residents. 4. The Infection Control Preventionist will be assigned on 02/04/22 to read updated Covid 19 modules sent out by CMS and CDC verified by the Infection Control Manager at adjacent hospital. 5. The Staff Development Nurse started an Inservice for all nursing and social workers on 02/04/22 regarding revised policy to not allow unvaccinated residents to reside on halls designated for Covid positive residents. On February 4, 2022 at 10:15 p.m., the removal action plan was validated by the surveyor. Observation and staff interviews were completed of A and D halls, with nursing staff assigned to the halls responsible for the care of the residents. The interviews confirmed that staff were educated regarding unvaccinated residents. Additional interviews with administration revealed a process in place for ensuring residents the safety of unvaccinated residents, and safe management of COVID positive residents. The facility's removal action plan reflected immediate corrective actions were in place during the validation. There were no further concerns identified during the validation.

Based on observation, record review, review of the facility policy entitled, Safe Lifting and Movement of Residents, and staff interview, the facility failed to ensure one (1) of six (6) sampled residents (Resident #3) was provided adequate supervision to prevent accidents and ensure staff followed the facility policy for using a mechanical lift to ensure resident safety. Resident #3 was dropped from a mechanical lift when facility staff did not secure the resident in the lift, which resulted in actual harm. The findings include: The facility's policy entitled, Safe Lifting and Movement of Residents, dated [DATE], read, Policy Interpretation and Implementation 1. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents .2. Staff responsible for direct resident care will be trained in the use of mechanical lifting devices. When a resident is being moved using a mechanical lift (2) two staff members must be present and assist with moving the resident. 3. Staff will be observed for competency in using mechanical lifts and observed periodically for adherence to policy and procedures regarding the use of equipment and safe lifting techniques. Resident #3 was admitted to the facility [DATE] with diagnose of Early-Onset Cerebellar Ataxia (an inherited disorder of the cerebellum and spinal cord causing unsteady gait, defective movements of the upper limbs, defective speech and loss of sensation), Major [MEDICAL CONDITION], Lack of Coordination, Abnormal Posture and [MEDICAL CONDITION]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident required two person physical assistance for bed mobility and dressing and was totally dependent on staff for transfer, toilet use and personal hygiene. Review of the medical record revealed Resident #3 was discharged to the hospital on [DATE] after a fall from the mechanical lift and subsequently expired. The Nurse's Notes dated [DATE] read, CNA #18 (Agency CNA) came running down the Hall A hollering she 'needed help now.' Followed CNA #18 to resident room. Resident #3's head was in the floor with feet stuck in sling of left. Released resident legs. Resident bleeding from L (left) ear and back of head. Unsure of condition of back of the head did not lift head to assess Right pupil fixed; Left pupil reactive; resident unresponsive for approximately 2 (two) min (minutes). When resident started coming around she was babbling, not answering appropriately. EMS (Emergency Medical Services) called and they responded. Resident left via stretcher with EMS. Employee #8 (the resident's family member) .left with resident in ambulance. Review of an Incident Report dated [DATE] revealed Resident #3's described injure was due to Fall form Lift .Location of occurrence: Resident Room. Activity: putting back in chair from toilet . The type of fall was listed as Fall from Lift; observed by CNA's. The incident report also documented the resident was lying on her back with her feet still caught in the lift sling. After Resident #3's fall, the facility initiated an investigation. Review of the investigative report revealed the lift was taken out of operation after the resident's fall and subsequently no malfunction was found with the lift. All other lifts were examined for malfunctions. The investigation further indicated the two (2) CNAs involved in the incident (CNA #18 and CNA #19) were immediately re-trained on the use of the mechanical lift. Both CNAs were placed on leave with the investigation was conducted. The findings of the facility's investigation were as follows: 1. Lift legs were found together when staff responded at time of incident 2. Lift spotter stayed on opposite side of bed and behind resident's chair instead of spotting the resident during the transfer. 3. The lift was in the highest position when staff responded at the time of incident. 4. Lift pad wasn't locked into place or it couldn't have come loose during the transfer. The report indicated the aides did not follow the proper procedure when conducting the transfer. This investigation was signed by the Administrator. A telephone interview was conducted with CNA #19 on [DATE] at 2:44 p.m. She stated she had worked at the facility for four (4) months through a contracted agency. She also stated that she was in orientation for ten (10) days when she started with the facility, but had received no formal training regarding the use of a mechanical lift. She stated that she had watched a video on how to use the lift, but was not required to perform return demonstration for safe use. She further stated on [DATE] she entered the room of Resident #3 to change the resident, who was soiled. She indicated CNA #18 assisted her during care for Resident #3. She stated CNA #18 operated the lift. The CNA said, Everything happened so fast. She said the sling was under the resident and attached to the lift. She further stated the lift was in the highest position when the resident fell . She further said, I never touched the lift. Never. Not once. The CNA indicated it did not take two (2) staff members to operate the lift, but two (2) people had to be in the room. On [DATE] a telephone interview was conducted with CNA #18. She stated that on [DATE], she was called to the resident's room to provide incontinence care. She indicated CNA #19 came into the room to assist with the resident's transfer via mechanical lift. She stated the resident was placed on the lift sling. She further stated that during the transfer, one (1) side of the lift sling came loose. She stated she had hooked her side of the sling on the upper right and lower right side. She indicated she communicated with CNA #19 during the transfer and went step by step when hooking the sides of the lift and waited for her to say we're good before proceeding. She stated she immediately went to get assistance when the resident fell . CNA #19 indicated she had not been provided formal instruction from the facility on how to use the mechanical lift until after Resident #3 fell . During an interview with Registered Nurse (RN) #26 on [DATE] at 10:50 a.m., she stated she was on duty the day Resident #3 was dropped from the mechanical lift. She stated CNA #18 came done the hall stating she needed help. RN #26 indicated she rushed to the resident's room and saw Resident #3's feet were in the sling and her head was on the floor. She stated her feet were immediately removed from the sling. She stated that CNA #19 indicated all of the sling clips were attached and that CNA #18 stated the lift had broken. RN #26 also indicated CNA #18 had stated she could not be sure if the sling clips were attached. RN #26 instructed staff to call 911 and the resident was sent to the hospital. During an interview with Licensed Practical Nurse (LPN) #11 on [DATE] at 11:02 a.m. she stated she was on duty the day Resident #3 was dropped from the mechanical lift. LPN #11 indicted the nursing staff recognized the resident was hurt very badly and staff attempted to stabilize her. LPN #11 stated she saw the left arm sling was not attached on the left side of the mechanical lift. During an interview with the Director of Nursing (DON) and Nurse Educator on [DATE] at 11:40 a.m. they verified both CNAS involved with the incident for Resident #3 were contracted employees through a staffing agency. They did not have documentation the CNAs had been trained to use the lift or that either had been observed for competency according to facility policy. During an interview with the Administrator on [DATE] at 2:29 p.m. and again at 4:35 p.m., she stated all mechanical lifts in the building had been assessed for functional ability. She further stated that after the incident an investigation was conducted and both CNAs involved in the incident had been terminated for user error. The Administrator stated that on [DATE], herself and the DON were in room [ROOM NUMBER] (the incident occurred in 111). She stated she went across the hall and into Resident #3's room and saw the resident's legs in the lift's sling and the resident's head was on the floor. She said the left side of the lift sling was not connected at the head part of the lift. She further stated that all staff had been re-trained for use of the lift by [DATE].

Based on record review, Nurse Staffing Agency contract review, mandatory training review, and staff interview, the facility failed to ensure two (2) of two (2) Certified Nursing Assistants (CNAs), who worked for the facility through a staffing agency, were required to demonstrate competency skills to transfer residents using a mechanical lift. One (1) of six (6) sampled residents (Resident #3) was not secured in the mechanical lift, and subsequently fell . Resident #3 sustained actual harm from the fall and required hospitalization . Additional findings, that did not rise to the level of harm included: The facility failed to ensure 16 of 25 CNAs reviewed had documentation of competency skills testing completed, per facility policy, to ensure safe lifting techniques were utilized. The findings include: Cross Refer to F689. Resident #3 required two (2) person transfer using a mechanical lift. On 01/13/2020, CNA #'s 18 and 19, attempted to transfer the resident using a mechanical lift. The left side of the sling was not attached securely, and the resident fell from the sling. The resident hit her head, sustained multiple injuries and was transferred to the hospital, according to the medical record. Review of training records revealed the facility had no documentation CNA #18 and #19 had been trained to use the mechanical lift by the facility. During an interview with CNA #18, on 1/23/2020 at 12:00 p.m., she said, I received formal training on mechanical lifts in the CNA training class many years ago. She confirmed she worked for a staffing agency. She further stated she had watched a video training about the mechanical lift after Resident #3 fell . She communicated she had received direction from other CNAs at the facility on how to use the mechanical lift, but was not required to perform return demonstration to a licensed nurse. She said, We trained each other. During an interview with CNA #19 on 1/22/2020 at 2:30 p.m., revealed she had received no formal training on how to use the mechanical lift from the facility. She confirmed she worked for a staffing agency. She further communicated she was required to demonstrate competency using the mechanical lift after Resident #3 fell and was injured. During an interview with the Registered Nurse (RN) Supervisor/Education RN on 1/22/2020 at 3:20 p.m., she said, The only written observational competency required before Resident #3's accident was for the glucometer. She indicated the staffing agency was responsible for training the aides that were sent to the facility. She indicated the facility had an orientation for the staffing agency CNAs but it did not include return demonstration for use of the mechanical lift. During an interview with the Director of Nursing (DON) on 1/22/2020 at 3:45 p.m., she said, The agency staff does not take the facility's required on-line training. She further communicated the staffing agency performed its own training. The DON further indicated the facility had begun to require return demonstration of use of the lift after Resident #3's fall. Review of the contracts Nurse Contract Agency A and Nurse Contract Agency B revealed the following: Agency A: 1. Float or reassign healthcare professionals only to areas where competency is established, and the healthcare professional has been oriented, including placing healthcare professionals in areas of practice within the scope of their license, certification, and clinical competence. Agency B: Section 3(d), Client Duties and Responsibilities (facility), will provide the assigned Employees with a copy of applicable job description and provide appropriate orientation, education, and training regarding the Client's facility, rules, regulations, policies, and procedures (on or before the first day of work) .Section 3(e) facility/client is responsible for ensuring that the Assigned Employees follow and comply with Client's rules, regulations, policies, and procedures; 3(f) direct and supervise Assigned Employees work and activities during all times that the Assigned Employees are working at the Client's facility. The facility had no documentation the contract sections were followed to ensure agency staff were observed to demonstrate how to safely use the facility's mechanical lift, until after Resident #3 sustained injuries from a fall. Additional findings that did not rise to the level of harm included: Review of staff training records revealed 16 of 25 CNAs reviewed had not been observed for competency for use of a mechanical lift. This was confirmed with the Registered Nurse (RN) Supervisor/Education RN during an interview on 1/22/2020 at 3:20 p.m. Review of the facility's policy, entitled, Safe Lifting and Movement of Residents, dated 09/21/2009, revealed the following: Policy interpretation and implementation: .2. Staff responsible for direct resident care will be trained in the use of mechanical lifting. 3. Staff will be observed for competency using mechanical lifts and observed periodically for adherence to policies and procedures regarding the use of the equipment and safe lifting techniques. The facility had no documentation the policy was followed to ensure the safety of resident's who required a mechanical lift for transfers.

Based on observations, medical record review, staff interviews and review of the facility policy, entitled, Medication Administration - General Guidelines, the facility failed to provide supervision to ensure three (3) of seven (7) cognitively impaired residents, who resided on the secured memory unit, did not have medications left unattended (Resident #s 6, 20 and 41). This practice put residents at risk for consuming other residents' medications, that contained controlled drugs. Specifically, Resident #'s 6, 20 and 41 morning medications were crushed, mixed in beverages and left unattended while the residents ate breakfast with other cognitively impaired residents present. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents existed on (MONTH) 31, 2019 at 8:12 a.m., when Licensed Practical Nurse (LPN) #1 mixed morning medications, that contained controlled drugs, in beverages and left the medications unattended on both tables in the dining area/day room. The Interim Administrator, Director of Nursing, Assistant Administrator, Executive Director of Nursing and Director of Quality/Compliance Officer, were made aware the Immediate Jeopardy existed on (MONTH) 31, 2019 at 1:24 p.m. Immediate Jeopardy was removed on (MONTH) 01, 2019 at 10:00 a.m., after an acceptable removal action plan was received and further observations, revised policy reviews, staff interviews and review of training's were conducted to verify the immediate correction. The facility remained out of compliance at a lower scope and severity of D, (not actual harm with the potential for more than minimum harm that is not Immediate Jeopardy) for isolated deficiency at F689. In addition, the facility failed to to ensure a smoking apron was used for one (1) of one (1) resident who was identified at risk for injury while smoking (Resident #12). This finding did not rise to the level of Immediate Jeopardy. The findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's MDS dated [DATE] revealed the resident was severely cognitively impaired. Review of the (MONTH) 2019 MAR indicated [REDACTED]. 3. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's MDS, dated [DATE], revealed the resident was cognitively impaired. Review of the (MONTH) 2019 MAR indicated [REDACTED]. During an interview on 10/31/19 at 8:12 a.m., LPN #1 stated she had prepared Resident #s 6, 20, and 41's medications and previously placed them in the resident's beverages. These residents were observed in the day room area for breakfast. During an observation on 10/31/19 at 8:25 a.m., LPN #1 left an unsampled resident's medication cup on the nurse's station counter with the half door open. LPN #1 left the day room to administer medications to a resident in room [ROOM NUMBER]. The medication was left unattended in day room with six (6) cognitively impaired residents present, without supervision from licensed staff. During an interview on 10/31/19 at 9:25 a.m., LPN #1 confirmed Residents #'s 6, 20, and 41 had medications in their beverages and the unsampled resident's medications had remained on the nurse's station counter when she left the room to distribute medications to a resident in room [ROOM NUMBER]. During an observation on 10/31/19 at 9:29 a.m., LPN #1 left the unit and returned at 9:39 a.m. Resident #'s 6, 20, and 41 were in the day room. Their beverages containing medications, which included controlled substances, remained on the table without any supervision to ensure the correct resident received the correct medication or the medication was not taken by another resident or discarded by an unknowing staff member. During an interview on 10/31/19 at 9:32 a.m., Certified Nursing Assistant (CNA) #1 stated if a resident had medications in their cup she would not allow the resident to get another resident's cup. The CNA pointed over her shoulder to the table behind her, out of her vision, where three (3) residents were sitting, and said, Especially at that table. Resident #6 likes to share her beverages at times. The CNA had her back to this table with no other staff present in the room. During an interview on 11/1/19 at 9:45 a.m., the facility's Pharmacist stated it was the standard of practice for the nurse to watch the resident during the medication pass and ensure the entire dose was administered. During an interview on 10/31/19 at 9:56 a.m., LPN #1, confirmed Resident #'s 6, 20 and 41 still had liquid in their cups, which contained medications. She also confirmed there had been no supervision of the beverages containing medications since she had left them at the table earlier that morning. During an interview on 10/31/19 at 11:38 a.m., the Director of Nursing (DON) said she expected all listened nurses or medication technicians to stay with residents during medication administration, until medications were completely consumed. The DON agreed LPN #1 had not provided supervision of the medications during the above observations. During an interview on 10/31/19 at 3:50 p.m., CNA #1 shared that during the breakfast meal, she was not informed which cups for which resident's had medications in them. She stated she knew Resident #6's cup had medications in it, because the nurse always administered medication in the resident's breakfast beverage. She stated she knew Resident #20 had medications in her cup because she could see crushed particles on the side of the cup. The CNA further stated, It would be easy for some of these residents to drink another resident's drink. Review of the facility's policy, dated (MONTH) 2014, entitled, Medication Administration - General Guidelines, revealed, .The resident is always observed after administration to ensure that the dose was completely ingested . The facility provided an acceptable removal action plan on (MONTH) 01, 2019, that read: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 10/31/19, at approximately 12:00 pm was made aware that the LPN was observed to provide crushed medications in coffee to Resident #6, Resident #41, and Resident #20 without providing supervision while Resident #6, Resident #41 and Resident #20 consumed their medications. LPN worked in the memory care wing on 10/31/19. Since all residents who reside on the memory care wing have the potential to be affected, the Director of Nursing instructed a floor nurse to complete vital signs for all seven residents who currently reside on the memory care wing and no medical concerns were noted. Beginning 10/31/19, a full set of vitals will be taken for two shifts (since this facility operates with 12 hours shifts) for all residents who reside on the memory care wing to ensure no adverse outcomes. On 10/31/19, at approximately 12:14 pm the LPN was removed from the medication cart and suspended. The Director of Nursing emailed the nursing agency and shared that the LPN should not be permitted to return to (name of provider) or any other facility pending investigation. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 10/31/19, education began with all nursing staff/medication aides which included in-services on the following (name of provider) policies: General Guidelines for Medication Administration, Oral Medications. All nurses and medication aides will be trained on the above policies by 10/31/19 or before their next working shift by the Director of Nursing and/or RN Supervisors. The General Guidelines for Medication Administration policy includes specific language related to the need to supervise residents during medication administration and to administer medications with generally accepted standards of practice. Further, on 10/31/19, an audit began using the Medication Administration Audit Form which will be used to audit every nurse/medication aide during one med pass to ensure the standards of practice and the process and procedures in the Medication Administration policy are being followed. The audit will be completed by the Director of Nursing and RN Nurse Supervisors for every nurse/medication aide in the building on 10/31/19 or on their next working shift. If it is determined that the process and procedures outlined in the Medication Administration policy are not being followed, education for all nurses and medication aides will be given by the director of nursing. In addition, an audit process will be implemented. The audit will include auditing a med pass for the person determined to not be following the policy. The facility will conduct random audits for two selected nurses/medication aides twice a week for four weeks to monitor for continued compliance. If it is observed or reported that generally accepted standards of practice are not being followed during medication administration, for the resident(s) affected the following will occur: A physical assessment including full set of vitals, Vitals will be taken for the next two shifts. Validation of the removal plan was completed on (MONTH) 01, 2019 at 10:00 a.m., after the survey team verified corrective actions taken by the facility had been implemented. This included ensuring nurses and medication aides followed current facility policy for medication administration, and safeguard of medication during medication administration. In addition, observations and interviews were completed with the facility staff related to training or in-service received, in accordance with the removal action plan. An additional finding that did not rise to the level of Immediate Jeopardy is as follows: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set completed on 8/22/19, revealed, Resident #12 was cognitively intact. Review of the Smoking Safety Evaluation dated 9/13/19 revealed, If a 'No' is indicated for any response, a smoking care plan may be indicated. Further review of the Smoking Safety Evaluation revealed, a No response was checked for 6 out of 18 risk factors. Review of the summary section of the Smoking Safety Evaluation, the following requirements were identified: Resident exhibits poor safety awareness when smoking and a care plan must be in place to promote smoking safety. Resident must wear smoking apron at all times. Resident requires use of a cigarette holder. Review of the care plan revised on 10/8/19, revealed a plan of care for the resident is a supervised smoker. The care planned goal was The resident will not suffer injury from unsafe smoking and care planned interventions included: must use cigarette extension for safety, staff to light cigarette, resident requires smoking apron while smoking, the resident requires supervision while smoking, and the resident's smoking supplies are stored at the Nurse's Station. During an interview on 10/28/19 at 5:14 p.m., Resident #12 stated, he was not assisted by staff for smoking but normally went to smoke once a day when Family Member #1 came to assist him. During an interview on 10/30/19 at 2:22 p.m., Resident #12 stated that Family Member #1 probably wasn't going to be able to visit that day but usually Friend #1 would come, and take him for a smoke when Family Member #1 could not make it. On 10/30/19 at 2:23 p.m., Friend #1 was observed pushing Resident #12's wheelchair to the nursing station. The nursing station was a circular structure with half walls and two entrance points with no doors. Friend #1 stopped at the entrance to the nurse's station, closest to the resident's hall, reached around the counter near the fax machine and picked something up, then wheeled Resident #12 into the smoking room. On 10/30/19 at 2:30 p.m., an observation of the smoking room was made from the hallway by looking through the small window in the door. Resident #12 was not visible inside the smoking room and Friend #1 was only partially visible. Further observation inside the smoking room revealed Resident #12 was smoking a cigarette and using a cigarette holder; however, he was not wearing a smoking apron. Upon inquiry, Friend #1 stated that she should have assisted the resident with a smoking apron but forgot. She also revealed that the resident's cigarettes were stored in a drawer at the nursing station and that's where she had picked them up. Friend #1 then got a smoking apron from the supply hanging on the wall, directly beside the resident, and place it on Resident #12. During an interview on 10/30/19 at 2:35 p.m., Licensed Practical Nurse (LPN) #1 revealed during the day Resident #12's cigarettes were stored on the nurses station counter top, in a specific spot between a half wall and the fax machine; they were not stored in a drawer. She added that after the resident went to bed the cigarettes were locked in the medication room. LPN #1 indicated that because Resident #12 was a frequent smoker his cigarettes were stored on the counter at the nurse's station during the day. During an interview on 10/30/19 at 3:41 p.m., with Registered Nurse (RN) #6 and with the Director of Nursing (DON) present, RN #6 indicated that the resident's cigarettes should have been stored in the medication room until his family came to ask for them. She also said that there was no system in place to monitor whether family were ensuring Resident #12 used the smoking apron that he needed. RN #6 added that facility staff would need to meet with the family to reinforce the safety requirements and ensure the family was capable of and willing to follow them, if they were going to continue to supervise the resident's smoking. Review of the facility policy, entitled, (Name of Facility) Smoking Policy reviewed or revised on 1/03/08 revealed, . residents that smoke must demonstrate their ability to perform the act of smoking safely, independent and unsupervised. The facility will use a smoking assessment to help determine residents' ability to smoke and what type of assistance, restrictions or equipment, if any, that they might need in order to smoke safely .

Based on observations, medical record review, staff interviews, and review of the facility policy, entitled, Medication Administration - General Guidelines, the facility failed to ensure medications were administered according to the standard of practice for three (3) of seven (7) cognitively impaired residents, who resided on the secured memory unit. Specifically, the medications for Resident #'s 6, 20, and 41, which contained controlled drugs, were crushed by LPN #1 and added to beverages. LPN #1 did not observe the residents consume their medications which increased the risk of the resident not receiving the full dose, or not receiving the dose at all. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents existed on (MONTH) 31, 2019 at 8:12 a.m., when LPN#1 prepared medications which contained controlled drugs, mixed the medications in beverages, and did not ensure the residents consumed the medications when the doses were provided, according to the standard of practice and facility policy. The Interim Administrator, Director of Nursing, Assistant Administrator, Executive Director of Nursing and Director of Quality/Compliance Officer, were made aware the Immediate Jeopardy existed on (MONTH) 31, 2019 at 1:24 p.m. Immediate Jeopardy was removed on (MONTH) 01, 2019 at 10:00 a.m., after an acceptable removal action plan was received and further observations, revised policy reviews, staff interviews and review of trainings were conducted to verify the immediate correction. The facility remained out of compliance at a lower scope and severity of D, (not actual harm with the potential for more than minimum harm that is not Immediate Jeopardy) for an isolated deficiency at F755. An additional finding, that did not rise to the level of IJ, was as follows: The facility failed to ensure medicated shampoo was available for resident use as ordered for one (1) of one (1) sampled residents with a scalp condition (Resident #12). The findings included: Cross Refer F689. The facility failed to provide supervision to ensure three (3) of seven (7) cognitively impaired residents, who resided on the secured memory unit, did not have medications left unattended (Resident #s 6, 20 and 41). This practice put residents at risk for consuming other residents' medications, that contained controlled drugs. Resident #'s 6, 20 and 41 medications were crushed, mixed in beverages and left unattended in their cups, while the residents ate their breakfast. The administering nurse did not ensure the residents consumed the entire beverage, or the entire dose of their morning medications, per the standard of practice. During an interview on 10/31/19 at 8:12 a.m., LPN #1 confirmed she prepared medications for Resident #'s 6, 20, and 41 and mixed the medications in beverages the residents were given with their breakfast meal. LPN #1 confirmed the residents had the following medications in their beverages at the time of the observation: 1. Resident #6: [MEDICATION NAME] (an [MEDICAL CONDITION]) 400 mg (milligrams), [MEDICATION NAME] (an antidepressant) 20 mg, [MEDICATION NAME] (a narcotic pain reliever) 5/325 mg, [MEDICATION NAME] (an antihypertensive) 25 mg, PEG3350 powder (for constipation) 17 grams, and [MEDICATION NAME] (for constipation) 1 tablet. LPN #1 did not ensure Resident #6 consumed the drink in which she added the medications. 2. Resident #20: Calcium 250+D (vitamin supplement) tablet, Cranberry (a natural supplement) 250 mg (milligram) capsule, [MEDICATION NAME] Oxalate (an antidepressant) 5 mg, Flintstones tablet chewable (a vitamin supplement) 1 tablet, Memantine (for treatment of [REDACTED]. LPN #1 did not ensure Resident #20 consumed the drink in which she added the medications. 3. Resident #41 [MEDICATION NAME] (an antihypertensive) 25 mg (milligrams), [MEDICATION NAME] (a narcotic pain reliever) 5 mg, PEG3350 powder (for constipation) 17 grams, and Vitamin D3 (a vitamin supplement) 1000 units. LPN #1 did not ensure Resident #41 consumed the drink in which she added the medications. Observation on 10/31/19 at 8:25 a.m., revealed LPN #1 left the day room to administer medication to a resident in room [ROOM NUMBER]. At 9:25 a.m., LPN #1 acknowledged Residents #'s 6, 20, and 41 still had medications in their supplements that had not been fully consumed, when she left the room to distribute medications to a resident in room [ROOM NUMBER]. At 9:29 a.m., LPN #1 left the secured memory unit and returned at 9:39 a.m. LPN #1 did not check to see if the residents had consumed their medications. During an interview on 10/31/19 at 9:32 a.m., Certified Nursing Assistance (CNA) #1 shared that Resident #6 was known to share or give her coffee to other residents. During an observation on 10/31/19 at 9:55 a.m., the dishes and cups for Resident #'s 6, 20, and 41 were cleared from the tables and placed on the cart to go back to the kitchen. LPN #1 did not examine or look at any of the cups to ensure the resident's medications had been administered according to the physician's orders. Upon inquiry on 10/31/19 at 9:56 a.m., LPN #1, confirmed Resident #'s 6, 20 and 41 had remaining liquid in their cups which contained their morning medications. She confirmed the following: Resident #6 had approximately 2% (two percent) of her beverage remaining; Resident #29 had approximately 3% (three percent) of the beverage left in her cup and confirmed the cup had heavy medication residue present; and Resident #41 had approximately 1% (one percent) of the beverage left in her cup, with heavy medication residue present. LPN #1 agreed if the entire beverage was not consumed and there was visible residue, the residents did not receive the entire dose of their morning medications. During an interview on 10/31//19 at 11:38 a.m., the Director of Nursing (DON) stated she expected nurses to stay with residents during medication administration until medications were completely consumed. The DON confirmed the nurse did not follow the facility's policy or the standard of practice. During an interview on 11/1/19 at 9:45 a.m., the facility's Pharmacist stated the practice of having more than one resident's medications out at one time, without being consumed was not an acceptable practice. He said, All meds are to be watched being fully consumed. He concluded he also had concerns with medications settling in cups, and the residents not receiving all of their prescribed medications. He indicated it was the standard of practice for the staff administering the medication to ensure the entire dose was consumed at the time of administration. He indicated staff should not mix medications in a beverage and not ensure the medications were consumed. Review of the facility's policy, dated (MONTH) 2014, entitled, Medication Administration- General Guidelines, revealed, The resident is always observed after administration to ensure that the dose was completely ingested . Further review of the facility's policy revealed, The individual who administers the medication dose records the administration on the resident's MAR indicated [REDACTED]. LPN #1 did not follow the facility's policy or the standard of practice of medication administration and did not ensure safe and effective medication administrative was provided. Review of the contract between the Pharmacy and the facility, dated 8/27/19, revealed the pharmacy would provide medication pass observations upon the facility's request. Review of the pharmacy requests revealed the last medication observation requested by the facility was conducted 12/5/18. The facility provided an acceptable removal action plan on (MONTH) 01, 2019, that read: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 10/31/19, at approximately 12:00 pm was made aware that the LPN was observed to provide crushed medications in coffee to Resident #6, Resident #41, and Resident #20 without providing supervision while Resident #6, Resident #41 and Resident #20 consumed their medications. LPN worked in the memory care wing on 10/31/19. Since all residents who reside on the memory care wing have the potential to be affected, the Director of Nursing instructed a floor nurse to complete vital signs for all seven residents who currently reside on the memory care wing and no medical concerns were noted. Beginning 10/31/19, a full set of vitals will be taken for two shifts (since this facility operates with 12 hours shifts) for all residents who reside on the memory care wing to ensure no adverse outcomes. On 10/31/19, at approximately 12:14 pm the LPN was removed from the medication cart and suspended. The Director of Nursing emailed the nursing agency and shared that the LPN should not be permitted to return to (name of provider) or any other facility pending investigation. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 10/31/19, education began with all nursing staff/medication aides which included in-services on the following (name of provider) policies: General Guidelines for Medication Administration, Oral Medications. All nurses and medication aides will be trained on the above policies by 10/31/19 or before their next working shift by the Director of Nursing and/or RN Supervisors. The General Guidelines for Medication Administration policy includes specific language related to the need to supervise residents during medication administration and to administer medications with generally accepted standards of practice. Further, on 10/31/19, an audit began using the Medication Administration Audit Form which will be used to audit every nurse/medication aide during one med pass to ensure the standards of practice and the process and procedures in the Medication Administration policy are being followed. The audit will be completed by the Director of Nursing and RN Nurse Supervisors for every nurse/medication aide in the building on 10/31/19 or on their next working shift. If it is determined that the process and procedures outlined in the Medication Administration policy are not being followed, education for all nurses and medication aides will be given by the director of nursing. In addition, an audit process will be implemented. The audit will include auditing a med pass for the person determined to not be following the policy. The facility will conduct random audits for two selected nurses/medication aides twice a week for four weeks to monitor for continued compliance. If it is observed or reported that generally accepted standards of practice are not being followed during medication administration, for the resident(s) affected the following will occur: A physical assessment including full set of vitals, Vitals will be taken for the next two shifts. Validation of the removal plan was completed on (MONTH) 01, 2019 at 10:00 a.m., after the survey team verified corrective actions taken by the facility had been implemented. This included ensuring nurses and medication aides followed current facility policy for medication administration, and safeguard of medication during medication administration. In addition, observations and interviews were completed with the facility staff related to training or in-service received, in accordance with the removal action plan. An additional finding that did not rise to the level of Immediate Jeopardy is as follows: Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set completed on 8/22/19, revealed, Resident #12 was cognitively intact and required staff assistance of two (2) persons when bathing. Review of the Physician's Orders dated 9/26/19 revealed an order for [REDACTED]. During an interview on 10/28/19 at 3:37 p.m., Resident #12 indicated that he had a scalp condition that he called cradle cap and needed to have his hair shampooed at least three (3) days a week. He added that the facility got him some [MEDICATION NAME] t-gel shampoo for it but no one ever knew where it was. Resident #12 said the shampoo, started off being stored in his room and then at the nurses station, and then sometimes it was on the medication cart. He added that the Nursing Assistants couldn't find it when it was time for his shower, or left it in the shower room, and it was never located again. Resident #12 indicated the [MEDICATION NAME] T-gel shampoo was not replaced after it went missing. Observation of Resident #12 at this time revealed the resident's hair was disheveled and greasy looking. During an interview on 10/29/19 at 2:52 p.m., Resident #12 stated he had a shower the previous evening (Monday evening), which was one of his regular shower days, but his hair was not shampooed. He again stated that he needed his hair shampooed because he had cradle cap. Observation of Resident #12 at this time revealed his hair was greasy and disheveled looking. The resident also had flakiness and white residue on his forehead, scaly flakes in his hair above his right ear, and dry skin on top of his left hand. During an interview on 10/30/19 at 2:22 p.m., Resident #12 indicated that he had not yet had his hair shampooed. Observation of Resident #12 at this time revealed he had white residue on his forehead and white scaly flakes on his shirt at his left chest area. During an interview on 10/30/19 at 4:20 p.m., Certified Nursing Assistant (CNA) #3 said that Resident #12 had a lot of dryness to his forehead and his scalp flaked. She indicated that she thought he needed a shampoo like [MEDICATION NAME] T-gel shampoo and said she had mentioned that to one of the nurses; but she did not think the shampoo was ordered. CNA #3 was unable to locate Neutogena T-gel that was ordered on [DATE], for Resident #12. During an interview on 11/1/19 at 9:45 a.m., the DON indicated that the [MEDICATION NAME] T-gel should be ordered from the pharmacy and available for the resident's use when his hair needed to be shampooed.

Based on observation, record review and staff interview, the facility failed to ensure Certified Nursing Assistants who preformed blood glucose testing recieved training to perform the test and were provided with a policy and procedure that addressed the current standards of practice for 33 of 33 records reviewed. This practice had the potential to affect 17 of 17 residents who received accuchecks, resulting in an Immediate Jeopardy. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents existed as of November 29, 2017 at 4:31 p.m., when a Certified Nursing Assistant (CNA) failed to clean and disinfect a multi-use blood glucose meter between residents. The Administrator and Director of Nursing were made aware the Immediate Jeopardy existed on November 29, 2017 at 6:10 p.m. Immediate Jeopardy was removed on December 1, 2017 at 9:00 a.m., after an acceptable Credible Allegation of Compliance was received and further observations, revised policy reviews, staff interviews and review of training were conducted to verify the immediate correction. The facility remained out of compliance at a lower scope and severity of F, for widespread, systemic deficiencies at F726, F835, F867, and F880. The findings incude: 1. On 11/29/17 at 4:26 p.m., CNA #1 was observed performing an Accu-Check for Resident #23. The CNA obtained the uncovered Quintet AC glucometer out of a large, black cloth carrying case that resembled a tackle box. The case was labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from a large container labeled PDI Sani-Cloth Plus (Red top). Without allowing the glucometer to dry, the CNA dropped it back into the carrying case and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. 2. On 11/29/17 at 4:31 p.m. CNA #1 was observed performing an Accu-Check for Resident #34. The CNA obtained the uncovered Quintet AC glucometer out of the carrying case labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from the container labeled PDI Sani-Cloth Plus. Without allowing the glucometer to dry, the CNA dropped it back into the carrying case box and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. CNA #1 was interviewed immediately after observing the accu-check for Resident #34. She stated she obtained the carrying case from the nurses' station, checked it for supplies and began performing accu-checks. She stated she did not clean and disinfect the glucometer before usage. She also confirmed there was only one glucometer in the carrying case that was being used on multiple residents. She also stated she was the only staff member performing accu-checks for the entire facility on the 3-11 shift this day (11/29/17). Review of the training file for CNA #1 revealed no documentaion she had been provided training related to accu checks. 3. During an interview with the Director of Nursing (DON) and both RN Supervisors on 12/1/17 at 10:27 a.m., the DON stated there were no skills assessments for CNAs to ensure they were provided training in areas of weakness. The DON indicated there was no documetnation that any of the CNAs had received training regarding the correct procedure to obtain blood glucose levels or how to clean and disinfect the monitor. 33 of 33 records for CNAs were reviewed. There was no documentation the CNAs had been trained on how to safely obtain blood glucose levels, which put all residents at risk. An allegation of compliance was accepted on 11/30/17, at 3:45 p.m.: 1. As of 4:30 p.m. on November 29, 2017, all residents who required glucometers will not longer share equipment. 2. On Noveber 29, 2017 all glucometers were cleaned by DON, Wound Care Nurse & RN Supervisor. They are all SPICE Certified. They cleaned and sanitized the glucometers with Clorox wipes. After November 29, 2017, glucometers will never be reassigned and/0r used for more than one resident. Currently the facility uses the McKesson Quintet AC Unit. If for any reason the type of glucometer changes the facility will ensure that all units are changed at the same time for all residents. If they are changed the facility will follow the manufacturer's instructions for cleaning and disinfecting. 3. On November 29, 2017, all residents that receive daily blood sugar checks were given personal glucometers. The residents that receive monthly blood sugar checks will be assigned a glucometer and case on December 1, 2017. All units will be labeled with the resident name. The policy was revised to follow CDC guidelines and the manufacturer's recommendations for the safe and sanitary distribution and cleaning of glucometers. Staff on duty were trained on the new policy by the DON and/or RN Supervisor(s). The criteria for distributing, cleaning and sanitizing is: Each resident that requires blood glucose monitoring will be given a glucometer. The unit and case will be kept in the resident's beside table, except in the Memory Care Unit where the units will be kept on the mediation cart. The unit and case will be labeled with the resident name. Each resident will be given a bottle of strips that will be kept in the case with the glucometer. Once assigned to a resident the glucometer and strips cannot be used for another resident. Once batteries are put in a until they may not be removed and used in another unit unless they are removed from a soiled or broken unit and placed in the new unit for the same resident. The glucometer must be cleaned & disinfected before and after each use. The unit must be cleaned & disinfected with Cavi-Wipes or the SaniWipes Orange Top wipes. Wipe all surfaces, top, bottom and sides avoiding the test strip hole and electrical connections. Wrap machine with clean wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. The cups are considered a barrier. If the cup turns over you must start the procedure described in this bullet over. All glucometers that are visibly soiled will be cleaned and disinfected using this detailed cleaning procedure: A. use a fresh wipe to thoroughly clean all external surfaces (top, bottom & sides) avoiding the test strip holeand electrical connector. Discard the wipe. B. Using a fresh wipe thoroughly wipes all external surfaces of the meter in both horizontal and vertical direction again avoiding the test strip area and electrical connector. C. Gently wipe the surface area of the test strip post making sure that no fluid enters the port. D. Wrap machine with wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. E. The units may never be carried in a pocket. If a monitor is too badly soiled or broken replace the unit with a new one labeling both the unit and the case with the resident's name. When a resident is discharged they may take their glucometer with them. If they don't take the glucometer or in the event a resident passes away the glucometer will be discard. A glucometer shall never be reassigned to another resident once it has been put into use. To ensure that all staff are trained and following the correct procedure the following steps will be implemented: Each shift the nursing staff will be in-serviced by the DON and/or RN Supervisor(s) on the new policy until all nursing staff are trained. Staff will not perform the process until they have received training. Starting on November 30, 2017, the DON and/or RN Supervisor(s) will observe each staff taking blood sugars for proper use, cleaning and sanitizing of glucometers. These observations will occur each day on every shift with every staff member working who performs the checks that day. Observations will continue for one month. To ensure that the facility always has enough glucometers to handle the replacement of lost, broken or worn out machines, the facility has taken the following steps: On November 30, 2017, 30 extra glucometers and batteries were ordered. They will arrive on December 1, 2017. This will give the facility an excess of 26 machines. The extra units will be kept by the DON or designee. At the time that the number of glucometers drops to 10 the DON will reorder 12 more units. This monitoring will continue daily for each month. The results of the monitoring will be reported at the next Quarter QAPI Steering Committee Meeting. The Steering Committee will ensure that the monitoring and/or training continues until substantial compliance is achieved. Validation Observations for Glucometer Cleaning and Disinfecting: 1) On 12/01/17 at 7:45 a.m., LPN #2 was observed performing accu-checks for Resident #6 on the Memory Unit with the Restorative/Registered Nurse (RN) Supervisor present. LPN #2 obtained the glucometer from the locked cabinet on the unit. The glucometer was secured within its own case which had the resident's name on the case and on the glucometer. She took the glucometer along with the other supplies to the resident's room enveloped in a large white piece of paper. After placing the paper on the over bed table, she opened the case, took out the glucometer, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach (which is effective against[DIAGNOSES REDACTED], Bactericidal, Tuberculocidal, Virucidal and Fungicidal). She left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she changed gloves, cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case, took it to the nurses' station and locked it in the cabinet. 2) On 12/01/17 at 8:17 a.m., LPN #2 was observed performing accu-checks for Resident #13 on E Hall with the Restorative/RN Supervisor present. The LPN took some supplies into the resident's room enveloped in a large white piece of paper. She placed the paper on the over bed table. The glucometer was secured within its own case in the drawer of the bedside table in the resident's room. The glucometer and the case were both labeled with the resident's name, also the test strips were within the glucometer case.She took the glucometer out of the case, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach, left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and returned it to the resident's bedside table. 3) On 12/1/17 at 7:30 a.m., LPN #1 was observed performing accu-checks for Resident #23 on A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the overbed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. 4) On 12/1/17 at 7:45 a.m., LPN #1 was observed performing accu-checks for Resident #34 on the A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the overbed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. On December 30, 2017, at 9:00 a.m., after observations, review of training, review of the new policy entitled, Policy & Procedure for Distribution and Cleaning of Glucometers, and staff interviews, the immeidate jeopardy was removed.

Based on observation, record review and staff interview, the facility failed to be administered in manner to ensure policies related to infection control practices were reviewed and updated to ensure the current standards of practice were followed for cleaning and disinfecting multi-use blood glucometers, which put 17 of 17 residents, who required finger stick blood glucose monitoring, at risk for the spread of blood borne pathogens. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents existed as of November 29, 2017 at 4:31 p.m., when a Certified Nursing Assistant failed to clean and disinfect a multi-use glucometer between residents. The Administrator and Director of Nursing were made aware the Immediate Jeopardy existed on November 29, 2017 at 6:10 p.m. Immediate Jeopardy was removed on December 1, 2017 at 9:00 a.m., after an acceptable Credible Allegation of Compliance was received and further observations, revised policy reviews, staff interviews and review of training were conducted to verify the immediate correction. The facility remained out of compliance at a lower scope and severity of F, for widespread, systemic deficiencies at F726, F835, F867, and F880. The findngs include: 1. On 11/29/17 at 4:26 p.m., CNA #1 was observed performing an Accu-Check on Resident #23. The CNA obtained the uncovered Quintet AC glucometer out of a large, black cloth carrying case that resembled a tackle box. The case was labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from a large container labeled PDI Sani-Cloth Plus (Red top). Without allowing the glucometer to dry, the CNA dropped it back into the carrying case and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. 2. On 11/29/17 at 4:31 p.m. CNA #1 was observed performing an Accu-Check on Resident #34. The CNA obtained the uncovered Quintet AC glucometer out of the carrying case labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from the container labeled PDI Sani-Cloth Plus. Without allowing the glucometer to dry, the CNA dropped it back into the carrying case box and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. CNA #1 was interviewed immediately after observing the accu-check for Resident #34. She stated she obtained the carrying case from the nurses' station, checked it for supplies and began performing accu-checks. She stated she did not clean and disinfect the glucometer before usage. She also confirmed that there was only one glucometer in the carrying case that was being used on multiple residents. She also stated that she was the only staff member performing accu-checks for the entire facility on the 3-11 shift this day (11/29/17). 3. Review of the facility's undated policy entitled, Accu-Check Meter Care, revealed the following, Purpose: To keep the Accu-Check meter in good working condition and to prevent the spread of infection between residents. Procedure: 1. Make sure meter is turned off. 2. After each use and between residents each resident (sic), gently wipe the meter's surface with a germicidal disposabe cloth slightly damped with 70% alcohol, or 10% household bleach (1-part bleach in 10 parts water) made the same day. 3. Do not get any moisture in the code key slot or test strip slot. 4. Do not spray any cleaning solution directly onto the meter. 5. Do not put the meter under water or any liquid. 6. After cleaning let dry for at least 3 minutes before next use- solution must be in contact with accu-meter for at least 3 minutes. The facility's policy did not address and/or include the manufacturer's instructions on how to clean the blood glucose meters used by the facility. The facility's Administration failed to review and revise the policy to ensure appropriate products for the cleaning and disinfection of meters were followed. In addition the facility's policy did not take into account how to protect residents from [MEDICAL CONDITION] blood borne pathogens, since current standards indicate the solution the policy indicated to use was not effective. The Administration's lack of identification, action and policy revision, put all residents who received blood glucose monitoring with a shared machine at risk. 4. Review of the facility assessment revealed part of the facility's resident population had a [DIAGNOSES REDACTED]. 5. The Quality Assurance Committee failed to identify the systemic failure to ensure Certified Nursing Assistants were provided training to conduct blood glucose testing and failed to identify staff competencies were not being monitored. 6. During an interview with the Administrator and the Director of Nursing (DON) on 12/1/17, at 12:15 p.m., they confirmed the policy for cleaning and disinfecting blood glucose meters did not address the components outlined in the regulation. They both confirmed the policy developed by the facility was not followed and the manufacturer's recommendations were not followed. The DON indicated the facility had previously monitored and documented the Certified Nursing Assistants training but was uncertain when the practice stopped. An allegation of compliance was accepted on 11/30/17, at 3:45 p.m.: 1. As of 4:30 p.m. on November 29, 2017, all residents who required glucometers will not longer share equipment. 2. On Noveber 29, 2017 all glucometers were cleaned by DON, Wound Care Nurse & RN Supervisor. They are all SPICE Certified. They cleaned and sanitized the glucometers with Clorox wipes. After November 29, 2017, glucometers will never be reassigned and/0r used for more than one resident. Currently the facility uses the McKesson Quintet AC Unit. If for any reason the type of glucometer changes the facility will ensure that all units are changed at the same time for all residents. If they are changed the facility will follow the manufacturer's instructions for cleaning and disinfecting. 3. On November 29, 2017, all residents that receive daily blood sugar checks were given personal glucometers. The residents that receive monthly blood sugar checks will be assigned a glucometer and case on December 1, 2017. All units will be labeled with the resident name. The policy was revised to follow CDC guidelines and the manufacturer's recommendations for the safe and sanitary distribution and cleaning of glucometers. Staff on duty were trained on the new policy by the DON and/or RN Supervisor(s). The criteria for distributing, cleaning and sanitizing is: Each resident that requires blood glucose monitoring will be given a glucometer. The unit and case will be kept in the resident's beside table, except in the Memory Care Unit where the units will be kept on the mediation cart. The unit and case will be labeled with the resident name. Each resident will be given a bottle of strips that will be kept in the case with the glucometer. Once assigned to a resident the glucometer and strips cannot be used for another resident. Once batteries are put in a until they may not be removed and used in another unit unless they are removed from a soiled or broken unit and placed in the new unit for the same resident. The glucometer must be cleaned & disinfected before and after each use. The unit must be cleaned & disinfected with Cavi-Wipes or the SaniWipes Orange Top wipes. Wipe all surfaces, top, bottom and sides avoiding the test strip hole and electrical connections. Wrap machine with clean wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. The cups are considered a barrier. If the cup turns over you must start the procedure described in this bullet over. All glucometers that are visibly soiled will be cleaned and disinfected using this detailed cleaning procedure: A. use a fresh wipe to thoroughly clean all external surfaces (top, bottom & sides) avoiding the test strip holeand electrical connector. Discard the wipe. B. Using a fresh wipe thoroughly wipes all external surfaces of the meter in both horizontal and vertical direction again avoiding the test strip area and electrical connector. C. Gently wipe the surface area of the test strip post making sure that no fluid enters the port. D. Wrap machine with wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. E. The units may never be carried in a pocket. If a monitor is too badly soiled or broken replace the unit with a new one labeling both the unit and the case with the resident's name. When a resident is discharged they may take their glucometer with them. If they don't take the glucometer or in the event a resident passes away the glucometer will be discard. A glucometer shall never be reassigned to another resident once it has been put into use. To ensure that all staff are trained and following the correct procedure the following steps will be implemented: Each shift the nursing staff will be in-serviced by the DON and/or RN Supervisor(s) on the new policy until all nursing staff are trained. Staff will not perform the process until they have received training. Starting on November 30, 2017, the DON and/or RN Supervisor(s) will observe each staff taking blood sugars for proper use, cleaning and sanitizing of glucometers. These observations will occur each day on every shift with every staff member working who performs the checks that day. Observations will continue for one month. To ensure that the facility always has enough glucometers to handle the replacement of lost, broken or worn out machines, the facility has taken the following steps: On November 30, 2017, 30 extra glucometers and batteries were ordered. They will arrive on December 1, 2017. This will give the facility an excess of 26 machines. The extra units will be kept by the DON or designee. At the time that the number of glucometers drops to 10 the DON will reorder 12 more units. This monitoring will continue daily for each month. The results of the monitoring will be reported at the next Quarter QAPI Steering Committee Meeting. The Steering Committee will ensure that the monitoring and/or training continues until substantial compliance is achieved. Validation Observations for Glucometer Cleaning and Disinfecting: 1) On 12/01/17 at 7:45 a.m., LPN #2 was observed performing accu-checks for Resident #6 on the Memory Unit with the Restorative/Registered Nurse (RN) Supervisor present. LPN #2 obtained the glucometer from the locked cabinet on the unit. The glucometer was secured within its own case which had the resident's name on the case and on the glucometer. She took the glucometer along with the other supplies to the resident's room enveloped in a large white piece of paper. After placing the paper on the over bed table, she opened the case, took out the glucometer, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach (which is effective against[DIAGNOSES REDACTED], Bactericidal, Tuberculocidal, Virucidal and Fungicidal). She left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she changed gloves, cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case, took it to the nurses' station and locked it in the cabinet. 2) On 12/01/17 at 8:17 a.m., LPN #2 was observed performing accu-checks for Resident #13 on E Hall with the Restorative/RN Supervisor present. The LPN took some supplies into the resident's room enveloped in a large white piece of paper. She placed the paper on the over bed table. The glucometer was secured within its own case in the drawer of the bedside table in the resident's room. The glucometer and the case were both labeled with the resident's name, also the test strips were within the glucometer case.She took the glucometer out of the case, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach, left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and returned it to the resident's bedside table. 3) On 12/1/17 at 7:30 a.m., LPN #1 was observed performing accu-checks for Resident #23 on A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the overbed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. 4) On 12/1/17 at 7:45 a.m., LPN #1 was observed performing accu-checks for Resident #34 on the A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the overbed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. On December 30, 2017, at 9:00 a.m., after observations, review of training, review of the new policy entitled, Policy & Procedure for Distribution and Cleaning of Glucometers, and staff interviews, the immeidate jeopardy was removed.

Based on observation, record review and staff interview, the facility failed to ensure the Quality Assurance and Assessment Committee developed and implemented policies related to infection control practices, identified and implemented corrective action and performance plans related to infection control and identified facility policies did not incorporate the current standards of practice, and failed to monitor the facility's system to educate staff who conduct blood glucose testing, which put 17 of 17 residents, who required finger stick blood glucose monitoring, at risk for the spread of blood borne pathogens and resulted in Immediate Jeopardy. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents existed as of November 29, 2017 at 4:31 p.m., when a Certified Nursing Assistant failed to clean and disinfect a multi-use glucometer between residents. The Administrator and Director of Nursing were made aware the Immediate Jeopardy existed on November 29, 2017 at 6:10 p.m. Immediate Jeopardy was removed on December 1, 2017 at 9:00 a.m., after an acceptable Credible Allegation of Compliance was received and further observations, revised policy reviews, staff interviews and review of training were conducted to verify the immediate correction. The facility remained out of compliance at a lower scope and severity of F, for widespread, systemic deficiencies at F726, F835, F867, and F880. The findings include 1. On 11/29/17 at 4:26 p.m., CNA #1 was observed performing an Accu-Check on Resident #23. The CNA obtained the uncovered Quintet AC glucometer out of a large, black cloth carrying case that resembled a tackle box. The case was labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from a large container labeled PDI Sani-Cloth Plus (Red top). Without allowing the glucometer to dry, the CNA dropped it back into the carrying case and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. In additon, there was no documentation the CNA was trained to perform the blood glucose testing. 2. On 11/29/17 at 4:31 p.m. CNA #1 was observed performing an Accu-Check on Resident #34. The CNA obtained the uncovered Quintet AC glucometer out of the carrying case labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from the container labeled PDI Sani-Cloth Plus. Without allowing the glucometer to dry, the CNA dropped it back into the carrying case box and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. 3. Review of the facility's undated policy entitled, Accu-Check Meter Care, revealed the following, Purpose: To keep the Accu-Check meter in good working condition and to prevent the spread of infection between residents. Procedure: 1. Make sure meter is turned off. 2. After each use and between residents each resident (sic), gently wipe the meter's surface with a germicidal disposable cloth slightly damped with 70% alcohol, or 10% household bleach (1-part bleach in 10 parts water) made the same day. 3. Do not get any moisture in the code key slot or test strip slot. 4. Do not spray any cleaning solution directly onto the meter. 5. Do not put the meter under water or any liquid. 6. After cleaning let dry for at least 3 minutes before next use- solution must be in contact with accu-meter for at least 3 minutes. The facility's policy did not address and/or include the manufacturer's instructions on how to clean the blood glucose meters used by the facility. The facility's Quality Assurance Committee failed to review and revise the policy to ensure appropriate products for the cleaning and disinfection of meters were followed, even though infection control was reported to the committee at each meeting. In addition the facility's policy did not take into account how to protect residents from [MEDICAL CONDITION] blood borne pathogens, since current standards indicate the solution the policy indicated to use was not effective. The Quality Assurance Committee's lack of identification, action and policy revision, put all residents who received blood glucose monitoring with a shared machine at risk. 4. The Quality Assurance Committee failed to identify the systemic failure to ensure Certified Nursing Assistants were provided training to conduct blood glucose testing and failed to identify staff competencies were not being monitored. 5. During an interview with the Administrator and Director of Nursing on 12/1/17, at 12:15 p.m., they confirmed the blood glucose testing and current standards of practice for infection control had not been addressed by the Committee. An allegation of compliance was accepted on 11/30/17, at 3:45 p.m.: 1. As of 4:30 p.m. on November 29, 2017, all residents who required glucometers will not longer share equipment. 2. On November 29, 2017 all glucometers were cleaned by DON, Wound Care Nurse & RN Supervisor. They are all SPICE Certified. They cleaned and sanitized the glucometers with Clorox wipes. After November 29, 2017, glucometers will never be reassigned and/0r used for more than one resident. Currently the facility uses the McKesson Quintet AC Unit. If for any reason the type of glucometer changes the facility will ensure that all units are changed at the same time for all residents. If they are changed the facility will follow the manufacturer's instructions for cleaning and disinfecting. 3. On November 29, 2017, all residents that receive daily blood sugar checks were given personal glucometers. The residents that receive monthly blood sugar checks will be assigned a glucometer and case on December 1, 2017. All units will be labeled with the resident name. The policy was revised to follow CDC guidelines and the manufacturer's recommendations for the safe and sanitary distribution and cleaning of glucometers. Staff on duty were trained on the new policy by the DON and/or RN Supervisor(s). The criteria for distributing, cleaning and sanitizing is: Each resident that requires blood glucose monitoring will be given a glucometer. The unit and case will be kept in the resident's beside table, except in the Memory Care Unit where the units will be kept on the mediation cart. The unit and case will be labeled with the resident name. Each resident will be given a bottle of strips that will be kept in the case with the glucometer. Once assigned to a resident the glucometer and strips cannot be used for another resident. Once batteries are put in a until they may not be removed and used in another unit unless they are removed from a soiled or broken unit and placed in the new unit for the same resident. The glucometer must be cleaned & disinfected before and after each use. The unit must be cleaned & disinfected with Cavi-Wipes or the SaniWipes Orange Top wipes. Wipe all surfaces, top, bottom and sides avoiding the test strip hole and electrical connections. Wrap machine with clean wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. The cups are considered a barrier. If the cup turns over you must start the procedure described in this bullet over. All glucometers that are visibly soiled will be cleaned and disinfected using this detailed cleaning procedure: A. use a fresh wipe to thoroughly clean all external surfaces (top, bottom & sides) avoiding the test strip hole and electrical connector. Discard the wipe. B. Using a fresh wipe thoroughly wipes all external surfaces of the meter in both horizontal and vertical direction again avoiding the test strip area and electrical connector. C. Gently wipe the surface area of the test strip post making sure that no fluid enters the port. D. Wrap machine with wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. E. The units may never be carried in a pocket. If a monitor is too badly soiled or broken replace the unit with a new one labeling both the unit and the case with the resident's name. When a resident is discharged they may take their glucometer with them. If they don't take the glucometer or in the event a resident passes away the glucometer will be discard. A glucometer shall never be reassigned to another resident once it has been put into use. To ensure that all staff are trained and following the correct procedure the following steps will be implemented: Each shift the nursing staff will be in-serviced by the DON and/or RN Supervisor(s) on the new policy until all nursing staff are trained. Staff will not perform the process until they have received training. Starting on November 30, 2017, the DON and/or RN Supervisor(s) will observe each staff taking blood sugars for proper use, cleaning and sanitizing of glucometers. These observations will occur each day on every shift with every staff member working who performs the checks that day. Observations will continue for one month. To ensure that the facility always has enough glucometers to handle the replacement of lost, broken or worn out machines, the facility has taken the following steps: On November 30, 2017, 30 extra glucometers and batteries were ordered. They will arrive on December 1, 2017. This will give the facility an excess of 26 machines. The extra units will be kept by the DON or designee. At the time that the number of glucometers drops to 10 the DON will reorder 12 more units. This monitoring will continue daily for each month. The results of the monitoring will be reported at the next Quarter QAPI Steering Committee Meeting. The Steering Committee will ensure that the monitoring and/or training continues until substantial compliance is achieved. Validation Observations for Glucometer Cleaning and Disinfecting: 1) On 12/01/17 at 7:45 a.m., LPN #2 was observed performing accu-checks for Resident #6 on the Memory Unit with the Restorative/Registered Nurse (RN) Supervisor present. LPN #2 obtained the glucometer from the locked cabinet on the unit. The glucometer was secured within its own case which had the resident's name on the case and on the glucometer. She took the glucometer along with the other supplies to the resident's room enveloped in a large white piece of paper. After placing the paper on the over bed table, she opened the case, took out the glucometer, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach (which is effective against[DIAGNOSES REDACTED], Bactericidal, Tuberculocidal, Virucidal and Fungicidal). She left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she changed gloves, cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case, took it to the nurses' station and locked it in the cabinet. 2) On 12/01/17 at 8:17 a.m., LPN #2 was observed performing accu-checks for Resident #13 on E Hall with the Restorative/RN Supervisor present. The LPN took some supplies into the resident's room enveloped in a large white piece of paper. She placed the paper on the over bed table. The glucometer was secured within its own case in the drawer of the bedside table in the resident's room. The glucometer and the case were both labeled with the resident's name, also the test strips were within the glucometer case. She took the glucometer out of the case, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach, left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and returned it to the resident's bedside table. 3) On 12/1/17 at 7:30 a.m., LPN #1 was observed performing accu-checks for Resident #23 on A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the overbed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. 4) On 12/1/17 at 7:45 a.m., LPN #1 was observed performing accu-checks for Resident #34 on the A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the over bed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. On December 30, 2017, at 9:00 a.m., after observations, review of training, review of the new policy entitled, Policy & Procedure for Distribution and Cleaning of Glucometers, and staff interviews, the immediate jeopardy was removed.

Based on observations, staff interviews, and review of the facility policy entitled, Accu-Check Meter Care, the facility failed to ensure nursing staff cleaned and disinfected a multi-use blood glucose meter between residents for two (2) of two (2) residents observed (Resident #'s 23 and 34). This practice had the potential to affect 17 of 17 residents who received accuchecks, resulting in an Immediate Jeopardy. It was determined the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents existed as of November 29, 2017 at 4:31 p.m., when a Certified Nursing Assistant failed to clean and disinfect a multi-use blood glucose meter between residents. The Administrator and Director of Nursing were made aware the Immediate Jeopardy existed on November 29, 2017 at 6:10 p.m. Immediate Jeopardy was removed on December 1, 2017 at 9:00 a.m., after an acceptable Credible Allegation of Compliance was received and further observations, revised policy reviews, staff interviews and review of training were conducted to verify the immediate correction. The facility remained out of compliance at a lower scope and severity of F, for widespread, systemic deficiencies at F726, F835, F867, and F880. In addition, the facility failed to ensure staff performed hand hygiene according to the facility's policy entitled Handwashing/Hand Hygiene, before and after contact for two (2) of two (2) resident's observed for accu-checks (Resident #'s 23 and 34). The findings include: 1. On 11/29/17 at 4:26 p.m., CNA #1 was observed performing an Accu-Check on Resident #23. The CNA obtained the uncovered Quintet AC glucometer out of a large, black cloth carrying case that resembled a tackle box. The case was labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from a large container labeled PDI Sani-Cloth Plus (Red top). Without allowing the glucometer to dry, the CNA dropped it back into the carrying case and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. 2. On 11/29/17 at 4:31 p.m. CNA #1 was observed performing an Accu-Check on Resident #34. The CNA obtained the uncovered Quintet AC glucometer out of the carrying case labeled A Hall. She quickly wiped the glucometer with a wipe she obtained from the container labeled PDI Sani-Cloth Plus. Without allowing the glucometer to dry, the CNA dropped it back into the carrying case box and entered the resident's room. Upon completion of the accu-check, the CNA quickly wiped the glucometer and put it back into the carrying case. The CNA did not correctly clean and disinfect the glucometer prior to and after performing the accu-check. 3. CNA #1 was interviewed immediately after observing the accu-check for Resident #34. She stated she obtained the carrying case from the nurses' station, checked it for supplies and began performing accu-checks. She stated she did not clean and disinfect the glucometer before usage. She also confirmed that there was only one glucometer in the carrying case that was being used on multiple residents. She also stated that she was the only staff member performing accu-checks for the entire facility on the 3-11 shift this day (11/29/17). 4. According to the State Operations Manual (SOM) regarding the use of blood glucose glucometers: Although the package instructions for some fingerstick devices may indicate or imply the potential for multiple resident use, CMS (Centers for Medicare and Medicaid Services) guidance, based upon nationally recognized standards of practice from the CDC (Centers for Disease Control) and FDA (Food and Drug Administration), prohibits the use of fingerstick devices for more than one resident. 5. Review of the product information for the McKesson Quintet AC Glucometer (glucometer that was used by the facility), recommended to use CaviWipes. However, the facility did not use the recommended germicidal wipes, instead they used PDI Sani-Cloth Plus. 6. Review of the instructions for the PDI Sani-Cloths Plus read as Treated surface must remain visibly wet for a full 3 minutes .Use 2nd wipe to thoroughly wet surface for 2 minutes .Allow to air dry. Review of the label for the PDI Sani-Cloths Plus revealed it is effective against Bactericidal, Tuberculocidal and Virucidal; however, it was not effective against [MEDICAL CONDITION] (C Diff). 7. During an interview 11/29/17 at 5:48 p.m., Licensed Practical Nurse (LPN) #4 stated the Medication Technicians normally do the accu-checks during the day shift, but during the 3-11 shift it is the CNAs who do the testing. She also stated they refer to the carrying case that is used for the glucometers and supplies as a tote. The facility has two (2) totes that are used for all the units except the Memory Unit. She stated there is a small container that is used for the Memory Unit. She confirmed the supplies in the totes are glucometers, alcohol pads, PDI wipes, test strips, needles, etc. 8. During an interview on 11/29/17 at 6:17 p.m., CNA #1 stated she performed this afternoon's accu-check for Resident #200 who was on contact isolation for[DIAGNOSES REDACTED]. She also confirmed that she used the PDI Sani-Cloths Plus to wipe the glucometer. When asked about what training she received before performing accu-checks, she stated that she received training about 2-3 months ago, but she could not recall what she learned. She also added that she doesn't normally perform accu-checks. 9. Review of the CNA #1's employee file revealed she did not receive training for the use and maintenance of glucometers. 10. Review of the facility's undated policy entitled, Accu-Check Meter Care, revealed the following, Purpose: To keep the Accu-Check meter in good working condition and to prevent the spread of infection between residents. Procedure: 1. Make sure meter is turned off. 2. After each use and between residents each resident (sic), gently wipe the meter's surface with a germicidal disposabe cloth slightly damped with 70% alcohol, or 10% household bleach (1-part bleach in 10 parts water) made the same day. 3. Do not get any moisture in the code key slot or test strip slot. 4. Do not spray any cleaning solution directly onto the meter. 5. Do not put the meter under water or any liquid. 6. After cleaning let dry for at least 3 minutes before next use- solution must be in contact with accu-meter for at least 3 minutes. The facility's policy did not address and/or include the manufacturer's instructions on how to clean the blood glucose meters used by the facility. The facility failed to review and revise the policy to ensure appropriate products for the cleaning and disinfection of meters was followed. In addition the facility's policy did not take into account how to protect residents from [MEDICAL CONDITION] blood borne pathogens, since current standards indicate the solution the policy indicated to use was not effective. The lack of identification, action and policy revision, put all residents who received blood glucose monitoring with a shared machine at risk. 11. During an interview on 12/1/17 at 8:50 a.m., the Infection Control Coordinator (ICC) stated she identified CNAs did not clean the glucometers between residents and this was not an acceptable practice. She stated she immediately started doing 1:1 training with the CNAs and since then has conducted random audits. The ICC also stated she did not know the exact date or month she identified the concern; she was not able to produce evidence of the education she provided, nor the random audits she completed with the staff. An allegation of compliance was accepted on 11/30/17, at 3:45 p.m.: 1. As of 4:30 p.m. on November 29, 2017, all residents who required glucometers will not longer share equipment. 2. On November 29, 2017 all glucometers were cleaned by DON, Wound Care Nurse & RN Supervisor. They are all SPICE Certified. They cleaned and sanitized the glucometers with Clorox wipes. After November 29, 2017, glucometers will never be reassigned and/0r used for more than one resident. Currently the facility uses the McKesson Quintet AC Unit. If for any reason the type of glucometer changes the facility will ensure that all units are changed at the same time for all residents. If they are changed the facility will follow the manufacturer's instructions for cleaning and disinfecting. 3. On November 29, 2017, all residents that receive daily blood sugar checks were given personal glucometers. The residents that receive monthly blood sugar checks will be assigned a glucometer and case on December 1, 2017. All units will be labeled with the resident name. The policy was revised to follow CDC guidelines and the manufacturer's recommendations for the safe and sanitary distribution and cleaning of glucometers. Staff on duty were trained on the new policy by the DON and/or RN Supervisor(s). The criteria for distributing, cleaning and sanitizing is: Each resident that requires blood glucose monitoring will be given a glucometer. The unit and case will be kept in the resident's beside table, except in the Memory Care Unit where the units will be kept on the mediation cart. The unit and case will be labeled with the resident name. Each resident will be given a bottle of strips that will be kept in the case with the glucometer. Once assigned to a resident the glucometer and strips cannot be used for another resident. Once batteries are put in a until they may not be removed and used in another unit unless they are removed from a soiled or broken unit and placed in the new unit for the same resident. The glucometer must be cleaned & disinfected before and after each use. The unit must be cleaned & disinfected with Cavi-Wipes or the SaniWipes Orange Top wipes. Wipe all surfaces, top, bottom and sides avoiding the test strip hole and electrical connections. Wrap machine with clean wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. The cups are considered a barrier. If the cup turns over you must start the procedure described in this bullet over. All glucometers that are visibly soiled will be cleaned and disinfected using this detailed cleaning procedure: A. use a fresh wipe to thoroughly clean all external surfaces (top, bottom & sides) avoiding the test strip hole and electrical connector. Discard the wipe. B. Using a fresh wipe thoroughly wipes all external surfaces of the meter in both horizontal and vertical direction again avoiding the test strip area and electrical connector. C. Gently wipe the surface area of the test strip post making sure that no fluid enters the port. D. Wrap machine with wipe and place in a clean cup for 1 minute. Remove wipe from machine and place in another clean cup and is then allowed to dry for 3 minutes before placing the unit back in the case. E. The units may never be carried in a pocket. If a monitor is too badly soiled or broken replace the unit with a new one labeling both the unit and the case with the resident's name. When a resident is discharged they may take their glucometer with them. If they don't take the glucometer or in the event a resident passes away the glucometer will be discard. A glucometer shall never be reassigned to another resident once it has been put into use. To ensure that all staff are trained and following the correct procedure the following steps will be implemented: Each shift the nursing staff will be in-serviced by the DON and/or RN Supervisor(s) on the new policy until all nursing staff are trained. Staff will not perform the process until they have received training. Starting on November 30, 2017, the DON and/or RN Supervisor(s) will observe each staff taking blood sugars for proper use, cleaning and sanitizing of glucometers. These observations will occur each day on every shift with every staff member working who performs the checks that day. Observations will continue for one month. To ensure that the facility always has enough glucometers to handle the replacement of lost, broken or worn out machines, the facility has taken the following steps: On November 30, 2017, 30 extra glucometers and batteries were ordered. They will arrive on December 1, 2017. This will give the facility an excess of 26 machines. The extra units will be kept by the DON or designee. At the time that the number of glucometers drops to 10 the DON will reorder 12 more units. This monitoring will continue daily for each month. The results of the monitoring will be reported at the next Quarter QAPI Steering Committee Meeting. The Steering Committee will ensure that the monitoring and/or training continues until substantial compliance is achieved. Validation Observations for Glucometer Cleaning and Disinfecting: 1) On 12/01/17 at 7:45 a.m., LPN #2 was observed performing accu-checks for Resident #6 on the Memory Unit with the Restorative/Registered Nurse (RN) Supervisor present. LPN #2 obtained the glucometer from the locked cabinet on the unit. The glucometer was secured within its own case which had the resident's name on the case and on the glucometer. She took the glucometer along with the other supplies to the resident's room enveloped in a large white piece of paper. After placing the paper on the over bed table, she opened the case, took out the glucometer, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach (which is effective against[DIAGNOSES REDACTED], Bactericidal, Tuberculocidal, Virucidal and Fungicidal). She left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she changed gloves, cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case, took it to the nurses' station and locked it in the cabinet. 2) On 12/01/17 at 8:17 a.m., LPN #2 was observed performing accu-checks for Resident #13 on E Hall with the Restorative/RN Supervisor present. The LPN took some supplies into the resident's room enveloped in a large white piece of paper. She placed the paper on the over bed table. The glucometer was secured within its own case in the drawer of the bedside table in the resident's room. The glucometer and the case were both labeled with the resident's name, also the test strips were within the glucometer case. She took the glucometer out of the case, sanitized her hands and donned gloves. She wiped the glucometer with PDI Sani-Cloths Bleach, left the glucometer in the wipe and placed it in a plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, put the glucometer in another cup and allowed to air dry for three (3) minutes. She removed her gloves, sanitized her hands, donned gloves and then performed the accu-check. Upon completion of the accu-check, she cleaned the glucometer with the PDI Sani-Cloths Bleach wipe, left it in the wipe and placed in another plastic cup for one (1) minute. She removed her gloves, sanitized her hands, donned gloves, removed the glucometer from the wipe and placed in another cup, where she let it air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and returned it to the resident's bedside table. 3) On 12/1/17 at 7:30 a.m., LPN #1 was observed performing accu-checks for Resident #23 on A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the overbed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. 4) On 12/1/17 at 7:45 a.m., LPN #1 was observed performing accu-checks for Resident #34 on the A Hall with the ICC present. LPN #1 carried the lancets, gloves, alcohol preps, two cups and a barrier into the resident's room. The glucometer was in its own case (along with test strips) on the over bed table and labeled with the resident's name. LPN #1 washed her hands, gloved, cleaned the glucometer and wrapped the glucometer in the PDI Sani-Cloths Plus wipe for one (1) minute. She removed the wipe, then placed in another cup and allowed to air dry for three (3) minutes. Upon completion of the accu-check, she washed her hands, donned gloves, cleaned the glucometer with the PDI Sani-Cloths Plus wipe, left in the wipe and placed in another cup for one (1) minute. Then she removed the glucometer from the cup, removed the wipe and placed in another cup where she allowed it to air dry for three (3) minutes. After the glucometer dried, she placed it back in the glucometer case and placed it in the resident's bedside table. On December 30, 2017, at 9:00 a.m., after observations, review of training, review of the new policy entitled, Policy & Procedure for Distribution and Cleaning of Glucometers, and staff interviews, the immediate jeopardy was removed. Further Deficient practice, which did not rise to the level of Immediate Jeopardy, included: 1) On 11/29/17 at 4:26 p.m., CNA #1 was observed performing accu-checks for Resident #23. The CNA did not wash and/or sanitize her hands, but donned gloves after entering the resident's room. Upon completion of the accu-check, the CNA removed her gloves and exited the room without washing and/or sanitizing her hands. 2) On 11/29/17 at 4:31 p.m., CNA #1 was observed performing accu-checks for Resident #34. The CNA did not wash and/or sanitize her hands, but donned gloves after entering the resident's room. Before performing the accu-check, she dropped an item on the floor, picked it up, threw it in the trash and without changing gloves, performed the accu-check. Upon completion of the accu-check, the CNA removed her gloves and exited the room without washing and/or sanitizing her hands. During an interview on 11/29/17 at 6:17 p.m., CNA #1 confirmed she did not wash and/or sanitize her hands while performing accu-checks. Review of the facility's policy entitled Handwashing/Hand Hygiene adopted from the Infection Control Policy and Procedure Manual 2001 MED-PASS, Inc with a revision date of 2015 revealed the following: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively soap (antimicrobial or non-antiicrobial) and water for the following situations: b) Before and after direct contact with resident; d) Before performing any non-surgical invasive procedures; j) After contact with blood or bodily fluids; and m) After removing gloves. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on record review, staff interview, review of Policies and Procedures for the Prevention and Investigation of: Abuse, Neglect, Involuntary Seclusion, and Misappropriation of Resident's Property, Behavior Policy and Resident Admission and Discharge Guidelines for the facility's Memory Care Unit (Unit), the facility failed to provide the necessary services to ensure a safe environment for residents and that they were protected from aggressive threats, and potentially violent and harmful behaviors displayed by one (1) of eight (8) sampled residents (Resident #5 closed record). In addition, the facility failed to do a comprehensive screening of Resident #5 (RI#5), who was admitted with a mental health [DIAGNOSES REDACTED]. Resident #5 physically assaulted staff; became very aggressive, grabbed/pushed residents and entered the rooms of female residents with resistive behavior to staff for removal. The resident ' s behavior directly affected seven (7) residents (RI ' s A-G) on the Unit, with a total capacity of 12 residents. During the survey the Unit census was 11 residents. On [DATE] at 1:05 p.m., the facility Administrator and Director of Nurses (DON) were notified that Immediate Jeopardy existed. It was determined to exist as of [DATE]. It was also determined that the provider's non-compliance had caused, or was likely to cause, serious injury, harm, impairment or death to residents. A Credible Allegation of Compliance was received on [DATE], at 6:11 p.m. The Immediate Jeopardy was removed on [DATE], at 4:00 p.m., and the facility remained out of compliance at a lower scope and severity of "E," while the facility continues to implement and monitor new policy for reporting and addressing aggressive/unsafe behaviors; monitor the accuracy of resident assessments and ensure appropriate preventative actions are put in place for all residents on the Unit, and to continue staff training on aggressive behaviors prior to working with residents on the Unit. The findings include: Resident #5 was admitted to the Memory Care Unit on [DATE] with [DIAGNOSES REDACTED]. The nursing home initial assessment by the attending physician on [DATE] documented that this resident was admitted to the facility from home for continuing care with a [DIAGNOSES REDACTED]. The facility's admission Minimum Data Set (MDS) done on [DATE] assessed the cognitive status of Resident # 5 as severely impaired. Review of the medical records for RI#5 revealed the following information by his treating physician related to his history and current assessments and treatments. The resident had a recent admission at a psychiatric facility on ,[DATE] and placement was recommended. It was documented that the family elected trial of care at home. "The resident ' s aggressive behaviors to family members and wandering behaviors have been a game changer for adult daughter care givers." The [DATE] Discharge Summary from the psychiatric facility read, " Axis IV Diagnoses: [REDACTED]. The resident was also noted to have had irritability escalating into a fulminant (full) psychotic episode at the time of his admission. He was having visual hallucinations, severe agitation and increasing paranoia." The summary noted ... " Although given his likelihood of continued progressive dementia, there is chronic risk of escalation at home; particularly should he have any medical decompensation (worsening of mental health condition)." This summary of potentially escalating behaviors prior to admission reinforced the risk of these behaviors being exhibited toward the vulnerable residents on the Unit and their need for protective interventions from RI#5. Review of the Nurses Notes in RI#5's medical record revealed the following aggressive and/or threatening behaviors: 1. On [DATE] at 0115, the " resident was noted in room (room#) (Resident A) with door shut. The aides stated they had been unable to open the door. Tightness noted in the door handle. It was reported that the resident was in the room trying to go to the bathroom. The roommate, Resident B, was resting in bed with the covers pulled up. " Nurse documented that both residents were okay and in no distress. RI#5 is identified in this Nurse's Note as the resident who entered the room. " Puddles of urine noted on floor to right side of (Resident A's) bed ... Resident (#5) was standing in doorway in underwear. Escorted resident back to room, medicated at 0130 [MEDICATION NAME] mg." 2. Review of the Nurse's Notes from ,[DATE]/-,[DATE], revealed the resident began to display an increase in pacing up and down the hall. On [DATE] the resident was in and out of other resident rooms and putting combs, toothpaste, cards in his back pocket. "Silverware from tray wrapped in napkin in back pocket (knife)." 3. Continued review of the Nurse's Notes revealed from ,[DATE]-,[DATE], the resident's behaviors continued to escalate. He pulled the fire alarm x 2 on [DATE]. 4. On [DATE] at 2330, the resident's " agitation and wandering increased; " his clenched fist was raised to C.N.A's (certified nursing assistant) face, punching the closet. " The nurse spoke with the doctor and [MEDICATION NAME] 0.5 mg IM given at 2335. The family was also contacted at this time regarding a psychiatric evaluation to be done on [DATE]. 5. On [DATE] at 1755, " the resident became very aggressive with the C.N.A. and punched the C.N.A. in the throat with his fist and then pushed her to the floor. Never said anything to the C.N.A., stood watching the C.N.A. and then tried to help C.N.A. up by holding out his hand. Then begin to pace through the unit..." When RI#5 displayed this episode of violent aggressive behavior, the facility failed to implement a safety plan for other residents on the unit or seek an emergency evaluation/reassessment of RI #5. The facility ' s current Behavior Policy (with no date listed) lacked direction on how to determine and handle emergency behavioral situations. On [DATE] RI #5 was evaluated by the psychiatrist. The psychiatrist interventions were medication changes which included an as needed (PRN) intramuscular (IM) antipsychotic ([MEDICATION NAME]) medication for " escalating aggressive problematic behaviors. " There were no non- pharmacological interventions, directions, support or education shared with the staff at the nursing home to assist with a more effective approach for the management of abnormal aggressive behaviors to ensure protection of all residents. Further review of the Nurses ' Notes revealed the following: 1. On [DATE], at 0835, the resident " pushed the food cart up against the door and the resident was in and out of (resident) rooms ' sweeping ' still agitated. " The doctor was called for PRN [MEDICATION NAME] 0.5 mg IM now. The resident's behaviors continued with pacing, smiling and sitting for only a short time. 2. On [DATE] at 1600, the resident is " experiencing an increase in agitation and wandering in and out of other resident rooms, pacing up and down the hall. He raised his hands a few times to staff and residents. Staff was unable to redirect or distract resident. Resident continued the behaviors, raising fists at his reflection in the window and acting like he is going to punch the windows. " The resident is reported to be " argumentative with staff and giving hateful looks. " No safety plan was established for the residents on the unit. 3. On [DATE]-[DATE] nurses continue to document that RI#5 " displays agitated, aggressive, inappropriate (undressing) wandering behaviors into other female resident rooms. " The PRN administration of IM [MEDICATION NAME] is the only documented interventions for each escalating episode. 4. On [DATE] at 1530, RI #5 " threw a ball at another resident's face " (type of ball not indicated in note or affected resident). [MEDICATION NAME] PRN given. 5. On [DATE] at ,[DATE], the C.N.A. reported three times that the resident became very aggressive with the resident in (room#) (Resident C). RI #5 " grabbed the resident's wheel chair and started pushing the resident and the wheel chair into the door/glass window. Resident was very resistive to staffs attempts to intervene. He would not let go of the wheel chair and became more upset and more aggressive when staff attempted to redirect. He went in and out of rooms, uncovering residents who were in bed. Increasing verbal threats were made towards staff about (punching people, shooting people in the eyes). " 6. On [DATE] at 2335, the resident " wandered into a female's room (room#) (Resident D) and uncovered her. " 7. On [DATE] at 1530, RI #5 " pushed a resident in wheel chair into her room (room #) (Resident F). When staff attempted bringing the female out of the room he became upset with staff and stated, ' I told you No. ' He then turned back to the wheel chair with the resident in it and put his hand around the back of her neck and attempted to push resident and wheel chair further into the room. " The facility's intervention of choice was PRN [MEDICATION NAME] 5 mg IM. 8. On ,[DATE]-,[DATE], the nurses documented RI #5's behavior of " pacing, wandering and grabbing resident ' s wheel chairs while they were in them and forcefully pushing them/ and or racing down the halls to the doors, shoving them into rooms and closing the room door and refusing to let go of the firm grip on the wheel chairs. " 9. On [DATE] at 2340 RI #5's behavior escalated as evidenced by, " shoving his fist towards staff, making verbal threats and going from room to room getting into other ' s beds. The resident was refusing to leave the bedroom of other residents while they were using the bathroom. [MEDICATION NAME] 5 mg IM PRN administered. " RI #5 was seen by his attending physician on [DATE] at 1601 with initiation of [MEDICATION NAME] 250 mg (milligrams) as new medication in evening. 10. On [DATE] at 1815 RI #5 was in another resident ' s room (room #) with his shirt off standing at the foot of the bed. Staff heard the resident in room (Resident E) yelling for RI #5 to get out. She stated, " Oh my God, Oh my God. " Staff reported the resident who lived in room quickly exited the room and was attended to by staff while another staff member removed Resident (#5) from the room. The staff documented that within 5 minutes, RI #5 reentered the room of Resident E and again staff had to remove him. 11. On [DATE] at ,[DATE], the Nurse's Note documented the following: " Resident (#5) in (room #) sitting on the bed (A) with pants down, jerking his fists at resident in bed (B) (Resident G). Resident stood up as if he was going to harm resident in bed (B). Resident G was yelling out at this resident (RI#5) and yelling for help. " 12. Resident #5 was transported to the hospital on [DATE] at 1605 by EMS (emergency medical services). The transfer form in the medical record documented indication for transfer as "Alzheimer's with Aggressive Behaviors to evaluate and treat." The facility's policies, procedures and guidelines reviewed on [DATE] did not have dates reflecting when they were developed or reviewed for revisions by the facility. The facility's policy entitled, Prevention and Investigation of: Abuse Neglect Involuntary Seclusion Misappropriation of Resident ' s Property revealed under..... #3: Training of Employees-Initial and On-Going --- " A. Definitions (2) Neglect-Means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. (Guidelines 483.13 (c) Neglect occurs when facility staff fails to monitor and /or supervise the delivery of resident care and services to assure that care is provided as needed by the residents." The facility's Memory Care Unit Resident Admission and Discharge Guidelines documented the following: " Admission: The intent of the unit is to care for individuals with [DIAGNOSES REDACTED]. (Usually individuals with mental [MEDICAL CONDITION] or mental health [DIAGNOSES REDACTED]. The individuals that need the special care and safety features of this unit typically have the following conditions: -They are ambulatory, sometimes residents that propel themselves in a wheelchair would be appropriate to gain entry and /or remain on the unit. -They have very few medical needs and /or medications. -They benefit from the activities and programs designed for the unit. Discharges: -When a resident ' s ambulation and /or their ability to propel themselves in a chair have diminished to the point that they are no longer at risk for elopement. - Their physical condition has deteriorated and their needs become more medical. These are just guidelines and not all inclusive nor do they describe all conditions that might constitute admission on or discharge off the Memory Care Unit. In all cases, the admission team and medical staff will consider the whole person and will make decisions based on the professional training. " The facility's guidelines for admission and discharge on the Memory Care Unit did not address how to effectively screen residents prior to admission and how to effectively assess and manage residents with agitated aggressive behaviors to determine need for timely discharge from the Unit. The facility's Behavior Policy documented the following: Policy Statement-Problematic behavior will be identified and managed appropriately. - " Residents will have minimal complications associated with the management of problematic behavior- The facility will comply with regulatory requirements related to the use of medications to manage problematic behavior. " The facility's policy was vague and the implementation on the Unit was ineffective with the management of threatening and/or aggressive behaviors on the Unit to ensure safety of all residents. The Administrator, Director of Nurses (DON), the Physician (Medical Director who serves as attending physician) and the Social worker were interviewed on [DATE] at 1:40 p.m. They verified they were aware of the very aggressive frequent behaviors being displayed by RI #5 and of the aggression towards other residents. They did not provide any documentation as to how they handle challenging difficult behaviors on the Unit or what indicators are used to decide if a resident is no longer manageable on the Unit. They also confirmed that the facility did not maintain documented evidence, incident reports or assessment notes related to any of the residents who had experienced intrusions into their rooms, beds or aggressive acts from RI #5. An interview was conducted on [DATE] at 10:15 a.m. with Nurse #1. She reported the staff " felt nervous for the other residents " when RI #5 was on the Unit. . She stated the resident presented very aggressive behaviors with other residents in wheel chairs and had increasing inappropriate behaviors. She stated, "He became more psychotic and unable to redirect." She reported the other residents " acted fearful " of RI #5 The Administrator and DON were notified of the immediate jeopardy on [DATE] at 1:05 p.m. The facility provided an acceptable Credible Allegation of Compliance on [DATE] at 6:11 p.m. which included the following: 1. Resident #5 was transferred to the hospital on [DATE] and did not return to the facility. (Resident expired on [DATE] in the hospital.) 2. DON, MDS Coordinators, RN Supervisors and Social Worker reviewed each chart on the Memory Care Unit on [DATE] and conducted staff interviews to identify any other residents who were displaying aggressive behaviors that place themselves and others at risk for harm. Updates were made to the care plans for interventions by nursing and activities. 3. Facility administration revised Behavioral Policy on [DATE] that outlined increased behavioral symptoms for staff intervention; collaboration on residents for care plan development, documentation enhancement and use of non-pharmacologic approaches, and establishment of referral and/or intervention by a licensed/trained behavioral care provider (contract Psychologist and Psychiatric Nurse Practitioner) when indicated. 4. The facility conducted inservice training on [DATE] and [DATE] for all available staff on "Reporting and Dealing with Aggressive and Inappropriate Behaviors." The facility will continue training those staff not in attendance prior to working with residents on the Memory Care Unit. They also contacted a local group to provide additional training that specializes in geriatric & adult mental health and received a catalogue of the courses to begin ASAP. 5. On [DATE], DON, MDS Coordinators, RN Supervisors and RN Consultant began monitoring resident ' s charts for aggressive and or/unsafe behavior documentation. This will be done twice daily for one week by Nursing Administrative Staff to ensure resident safety and staff understanding of policy changes for effective implementation of therapeutic interventions and then on a regular monitoring schedule. Immediate Jeopardy was removed on [DATE] at 4:00 p.m. following a review of all 11 Unit residents ' charts on [DATE] that confirmed care plan review and revision for residents. 1. On [DATE], the "Accident/Incident Report" for Resident's A and B were reviewed in conjunction with the Allegation of Compliance. Resident A was playing dominos on the Memory Unit. Resident B came up to the table and began to touch the dominos. Resident A grabbed Resident B's wrist with both her hands. According to the documentation in the medical records, the residents were immediately separated and one on one supervision was provided. Both of the residents were re-assessed and the plans of care were updated. Resident A, who was higher functioning, had a plan developed to take her off the unit for more activities. Resident B, who was a homemaker and enjoyed domestic chores, was provided additional tasks to help busy her (the facility determined the resident did not desire to play dominos). The family and physician were notified and all actions taken by facility as directed in the revised Behavior Policy. 2. Observations were made on the Unit between 1:30 and 3:45 p.m. Resident B was observed on [DATE] at 1:30 p.m. and had no injury to her wrist. Resident A and Resident B were both observed in this period of observation with no further incidents. The other residents on the Unit were observed to be calm and staff were engaging them in activities of puzzles, exercise and word games and one resident was looking at television. 3. Staff inservice records for [DATE] and [DATE] were reviewed and validated for staff attendance and content related to documentation for monitoring and reporting behaviors and interventions. 4. On [DATE], during the above observation period, the surveyor interviewed both nurses and the six (6) C.N.A. ' s assigned to the Unit on two (2) shifts to ensure all staff was aware of the change in the Behavioral Management Policy and what actions should be taken if aggressive and/or any other type behaviors were witnessed by residents. All were able to give the correct answers and knowledge of the policy. 5. On [DATE], at approximately 1:00 pm, an interview was held with the Administrator, DON and MDS coordinator about the audits for charting aggressive/unsafe behaviors. They were able to provide copies of the monitoring as planned.

Based on record review, staff interview, review of facility's Behavior Policy and the facility failed to ensure appropriate treatment and services and to provide effective therapeutic management for aggressive behaviors displayed by one (1) of eight (8) sampled residents (Resident #5 closed record), who was admitted to the Unit with a history of mental health [DIAGNOSES REDACTED]. The facility also failed to ensure staff was trained to implement effective therapeutic interventions that included more than medication management, to assist the resident to maintain the highest level of mental functioning. The resident's severe behavior problems presented physical and emotional acts and threats to residents and staff on the Unit and directly affected seven (7) residents (RI ' s A-G) on the Unit, with a total capacity of 12 residents. During the survey the Unit census was 11 residents. On [DATE] at 1:05 p.m., the facility Administrator and Director of Nurses (DON) were notified that Immediate Jeopardy existed. It was determined to exist as of [DATE]. It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. A Credible Allegation of Compliance was received on [DATE], at 6:11 p.m. The Immediate Jeopardy was removed on [DATE], at 4:00 p.m., and the facility remained out of compliance at a lower scope and severity of "E," while the facility implements and monitors new Accident/Incident Investigation and Reporting policy for resident to resident incidents; monitors the implementation and effectiveness of appropriate preventative actions put in place for all residents on the Unit, and to continue staff training on aggressive behaviors prior to working with residents on the Unit and implement additional training from a professional mental health group. The findings include: Resident #5 (RI#5) was admitted to the Memory Care Unit (Unit) on [DATE], with multiple [DIAGNOSES REDACTED]. The resident had a recent admission at a psychiatric facility on ,[DATE] and placement was recommended. It was documented that the family elected trial of care at home; however, additional documentation revealed, "The resident ' s aggressive behaviors to family members and wandering behaviors have been a game changer for adult daughter care givers." Based on these increasing behaviors, the family admitted resident from home to the Unit. The [DATE] Discharge Summary from the psychiatric facility noted, " Problems with social and occupational impairment due to cognitive impairment and other psychiatric symptoms. " The resident was also noted to have " irritability escalating into a fulminant (full) psychotic episode at the time of his admission. He was having visual hallucinations, severe agitation and increasing paranoia." The summary noted ... " Although given his likelihood of continued progressive dementia, there is chronic risk of escalation...particularly should he have any medical decompensation (worsening of mental health condition)." The discharge summary also documented useful information that was relevant to the resident's treatment. The report documented that RI#5 ' s " thinking was becoming more disorganized and his behaviors were more dangerous. " The summary also documented (RI#5) was " making sexually inappropriate comments to female staff and other patients " during his hospital stay and was " very confused. " Review of the RI#5 's admission Minimum Data Set (MDS) and the Care Area Assessment (CAA), dated [DATE], revealed the assessment was not reflective of the resident ' s complete behavior picture which was needed to develop a comprehensive assessment and plan of care. The BIMS (Brief Interview for Mental Status) for RI #5 was a score of 4 out of 15, which indicated his cognition was severely impaired. The CAA did not include all of the available medical record history noted above related to the areas of concern that would impact the resident ' s adjustment and care on the Unit. Resident #5' s initial Behavior care plan, developed on [DATE], did not address behaviors with potential for escalating aggression or sexually inappropriate behaviors. Documented on the care plan were the following problems, listed as: -Resident at times appears to prefer sleeping without clothing on. At times, he will come out of his room without wearing clothing. - Wanders into other resident's rooms and attempts to decode the exit doors. -Demonstrates severe cognitive impairment related to [DIAGNOSES REDACTED]. He is hard of hearing but refuses to wear his hearing aide. " Cross Refer to F224: The facility failed to provide the necessary services to ensure a safe environment for residents and ensure they were protected from aggressive threats, and potentially violent and harmful behaviors displayed by RI#5. The resident ' s behavior directly affected seven (7) residents (RI ' s A-G), and placed all residents at risk on the Unit. Residents A, B, D, E and G were subjected to room intrusions and threatening behavior by RI#5. Resident C was pushed by resident in wheelchair (w/c) into the glass door. RI #5 pushed the w/c of Resident F into her room and put his hand around the back of her neck to push her into the room again when staff attempted to bring Resident F out of the room. Behavior was exhibited from [DATE] until [DATE] when the resident was discharged for violent aggressive behavior. Further review of the Nurses ' Notes for October revealed the following additional behaviors exhibited by RI#5: 1. On [DATE], " removed all of his clothing and was pacing the hall. " 2. On [DATE] the resident was " in and out of other resident ' s rooms and putting combs, toothpaste, cards in his back pocket. Silverware from tray wrapped in napkin in back pocket (knife)." 3. On [DATE] at 0130, the resident " making remarks to the Certified Nursing Assistants (C.N.A.) as they attempt to place him back in bed. ' Would you like to spank me? Which one of you would like to spank me first? ' The resident also removed his underwear while the aides were trying to place him back in bed. " 4. Nurses continued to document RI # 5's behaviors continued; " disorientation increased, the resident was walking around the bed, voiding on the floor, pulling curtains, taking his clothes off. " Further review of the medical record, and Nurse's Notes for [DATE] revealed the following documented behaviors: 1. On [DATE] at 1100, for the first time the resident refused morning medications, refused to participate in activities and refused snacks. His wandering behaviors increased more. Resident #5 was observed by the staff going out the door within the dining area of the Unit. The note read, " He had to punch the code to even get the door to open, resident was nearly out the door and C.N.A. redirected resident back in facility." 2. From ,[DATE]-,[DATE], staff documented the resident's behaviors continued to escalate. " He pulled the fire alarm x 2 on [DATE], attempting to remove his clothes in the Activity Room on [DATE]. " 3. On [DATE], RI#5 was diagnosed with [REDACTED]. 4. On [DATE] at 2330, the resident's " agitation and wandering increased; his clenched fist was raised to C.N.A. ' s face, punching the closet. " The nurse spoke with the doctor and [MEDICATION NAME] 0.5 mg IM given at 2335. The family was also contacted at this time regarding a psychiatric evaluation to be done on [DATE]. Review of the physician's orders [REDACTED]. The facility did not attempt to reassess underlying causes, such as changes in medical condition that occurred with the URI, for escalation in the resident's agitation and potential harmful behaviors. There were no adjustments in psychosocial interventions, level of supervision or monitoring. The facility continued the same approach of administering a dose, as needed (PRN) antipsychotic medication. The notes documented, " PRN IM medication given and continue to monitor " in response to each behavior episode displayed above by RI #5. They did not seek urgent assessments/reevaluations and/or changes in approaches. There was no evidence that reeducation, direction and/or support were provided for direct care staff. On [DATE] at 1755, the nurse documented, " the resident became very aggressive with the C.N.A. and punched the C.N.A. in the throat with his fist and then pushed her to the floor. Never said anything to the C.N.A., stood watching the C.N.A. and then tried to help C.N.A. up by holding out his hand. Then begin to pace through the unit, would smile on and off. " The physician again ordered [MEDICATION NAME] 5 mg IM x 1 (one) now agitation/aggression. When RI #5 displayed this violent aggressive episode, the facility failed to seek an emergency evaluation/ underlying assessment of RI#5's violent episode or show how the resident's aggressive behaviors were monitored. There were no adjustments made in the resident's physical environment and only the use of [MEDICATION NAME] for an intervention. Care Plan updated on [DATE]: Potential for Behaviors related to advanced [MEDICAL CONDITION], documents resident became very aggressive with C.N.A. Hitting and pushing. Other staff members intervened and redirected resident. Orders for [MEDICATION NAME] obtained. Approach: Resident has psychiatric evaluation at {name of psychiatric group) on [DATE]. No other interventions or safety plan noted. The psychiatrist evaluated RI#5 on [DATE], accompanied by his daughter. The note documented that the daughter " noticed an increase in her father's confusion at the nursing home after he developed a URI last week. " It was reported that he became more agitated and required PRN (as needed) [MEDICATION NAME]. The psychiatrist's evaluation noted that the resident was " illogical and seems pleasantly confused. " The daughter reported to the Psychiatrist that on Friday she noticed him to have more paranoia. The report stated, " He denies any avh (auditory, visual hallucinations), although difficult to assess. The reports indicate Alzheimer's dementia, severe with behavioral disturbances. " The Psychiatrist noted that the increased paranoia/agitation may be secondary to some mild [MEDICAL CONDITION]. Plan: add [MEDICATION NAME] 2.5 mg daily; continue 7.5 mg qhs (every bedtime). PRN agitation: [MEDICATION NAME] 5 mg IM PRN agitation is appropriate use. Follow up ,[DATE] weeks to monitor behaviors. The Nurse's Notes documented that the resident's behaviors continued; " pacing, smiling and sitting for only a short time. " On [DATE], at 0835, the resident "pushed the food cart up against the door and the resident was in and out of rooms.. sweeping, still agitated. " The doctor was again called for PRN [MEDICATION NAME] 0.5 mg IM now. The resident ' s behavior care plan, updated on [DATE], read " Resident became agitated pushing food cart up against door causing trays to fall in floor. No injuries noted. Again on [DATE], the care plan was updated- " Resident carrying chairs and trying to place them on his bed. No new/or additional approaches listed. The updated care plan did not address any increased monitoring, there were no reassessments related to underlying cause for behaviors, no adjustments in the physical environment and/ or guidance or direction for staff. The care plan did not include any recommendations or collaborative treatment interventions related to the evaluation by the psychiatrist. The psychiatrist interventions were medication changes which included an as needed (PRN) intramuscular (IM) antipsychotic ([MEDICATION NAME]) medication for escalating aggressive problematic behaviors. There were no non-pharmacologic (non-medication) interventions or guidance for staff resident interactions. Review of the physician's orders [REDACTED]. 1. [DATE]: [MEDICATION NAME] 5 mg IM x 1 now agitation/aggression 0830 ([DATE]), [MEDICATION NAME] 5 mg po give 2100 dose now (1600) ([DATE]); The addition of the IM antipsychotic medication was given in response to the resident's increasing display of aggression and agitated behaviors. The resident was already receiving two (2) medications that had the potential side effects of anxiety, agitation and hostility. The Nursing Drug Handbook, 22nd edition list under [MEDICATION NAME] (antipsychotic) as having potential central nervous system (CNS) adverse reactions of agitation and hostility. [MEDICATION NAME] (antidepressive medication) list potential CNS side effects as anxiety and agitation. [MEDICATION NAME] IM administration is indicated for [MEDICAL CONDITION] until control is obtained. Resident # 5 was given IM [MEDICATION NAME] (antipsychotic medication) for episodes of agitation and aggression towards other residents and staff. Resident #5 received IM [MEDICATION NAME] three (3) times for the month of December. 2. [DATE] - [MEDICATION NAME] 7.5 mg Po twice a day, [MEDICATION NAME] Sprinkle 250 mg take 2 capsules in evening for Dementia with Behaviors. [MEDICATION NAME] 5 mg IM PRN increased in the frequency and was administered ten (10) times that month. On [DATE], RI#5 was accompanied by his daughter to the Psychiatrist for a follow-up appointment. The report documented, "Dtr (daughter) noticed an improvement in his behaviors for a few weeks after increasing the [MEDICATION NAME] dose, however, over the past week, he has been seeming to be more paranoid." Psychiatrist plan is discussed with the daughter. Listed in the plan: " #3-Confusion: discussed that severe dementia can start to cause chronic confusion, and this may be new baseline for him. There is always concern when confusion that there could be [MEDICAL CONDITION], however, no new physical sx (symptoms) reported this visit, will defer med mgmt (medication management) to Dr. {name} if any suspicion of underlying med condition. #4- Follow up one month to monitor behaviors." The facility ' s interdisciplinary treatment team was not an active participant in the coordination of the psychosocial care needs and interventions for RI#5. Resident #5 received a total of fifteen (15) PRN IM doses of [MEDICATION NAME] over a two 2 month period, [DATE]-[DATE],without evidence of other interventions to manage his escalating, aggressive behaviors. On [DATE] at 1815, nurse documented that RI #5 was in another resident ' s room (room #) (Resident E) " with his shirt off standing at the foot of the bed. Staff heard the resident in room (Resident E) yelling for RI #5 to get out. She stated, " Oh my God, Oh my God. " The staff documented that within 5 minutes, RI #5 reentered the room of Resident E and again staff had to remove him. On [DATE] at ,[DATE], the Nurse's Note documented the following: " Resident (#5) in (room #) sitting on the bed (A) with pants down, jerking his fists at resident in bed (B) (Resident G). Resident stood up as if he was going to harm resident in bed (B). Resident G was yelling out at this resident (RI#5) and yelling for help. " The physician was contacted and ordered [MEDICATION NAME] 5 mg IM x1 (one) now for increased agitation at 1230, [MEDICATION NAME] 5mg IM Q (every) 20 minutes for a total of 3 doses until resident is calm. ([MEDICATION NAME] 5mg IM given at 1230, 1500, 1530) Resident #5 was transported to the hospital on [DATE] at 1605 by EMS (emergency medical services). The transfer form in the medical record documented indication for transfer as "Alzheimer's with Aggressive Behaviors to evaluate and treat." Review of the facility's Behavior Policy, which did not have date when developed, documented the following "Policy Statement: " 1. Problematic behavior will be identified and managed appropriately. 2. Residents will have minimal complications associated with the management of problematic behavior. 3. The facility will comply with regulatory requirements related to the use of medications to manage problematic behavior." The facility ' s Behavior Policy under "Policy Interpretation" documented....#2. "The nursing staff will identify, document, and inform the physician about an individual's mental status, behavior and cognition, including: a. Onset, duration and frequency of problematic behaviors or changes in behavior, cognition or mood; b. Any precipitating or relevant factors. #3-The staff will identify and discuss with the practitioner situations where non-pharmacologic approaches are indicated, and will institute such measures to the extent possible. #4- If the resident is being treated for [REDACTED]." During an interview with the Administrator, Director of Nurses, the resident's Physician (Medical Director) and the Social Worker on [DATE] at 1:40 p.m., they stated that Memory Care Unit was designed for, "This type of person (residents with Dementia and [MEDICAL CONDITION])." They were able to validate that disruptive, intrusive, aggressive/violent behaviors were presented by RI #5; however, they viewed the "behaviors as being managed because the resident was in a locked unit." During the interview they did not provide any documentation as to how they handle challenging difficult behaviors on the Unit, what indicators are used to decide if a resident is no longer manageable on the Unit, or evidence of how resident to resident incidents were tracked and/or investigated as related to behaviors displayed by RI #5. In interviews with the staff on the Unit on [DATE] at 10:00 a.m., C.N.A. #1 reported she had been " working at the facility for about a year and that she received some training related to aggressive behavior during orientation, she thinks. " C.N.A. #2 stated she has been " working at the facility for about 3 ,[DATE] years but working on the Unit for two (2) weeks. She did receive some training related to aggressive behaviors when the Unit opened approximately a year ago. " Both C.N.A. ' s stated they had not received any recent training related to approaches for dealing with residents who showed aggressive, violent behaviors. Nurse #1 was interviewed on [DATE] at 10:15 a.m.; the nurse reported her training was from completing a course (training program) on [MEDICAL CONDITION] in school over the past year. The facility did not provide evidence that staff received ongoing training for managing and monitoring reoccurring problematic behaviors. The Administrator and DON were notified of the immediate jeopardy on [DATE] at 1:05 p.m. The facility provided an acceptable Credible Allegation of Compliance on [DATE] at 6:11 p.m. which included the following: 1. Resident #5 was transferred to the hospital on [DATE] and did not return to the facility. (Resident expired on [DATE] in the hospital.) 2. Facility administration revised Behavioral Policy on [DATE] that outlined increased behavioral symptoms for staff intervention; collaboration on residents for care plan development, documentation enhancement and use of non-pharmacologic approaches, and establishment of referral and/or intervention by a licensed/trained behavioral care provider (contract Psychologist and Psychiatric Nurse Practitioner) when indicated. 3. Facility revised Accident/Incidents Investigating and Reporting Policy on [DATE] related to all resident to resident occurrence that will be initiated immediately under the direction of Supervisor/Charge Nurse and/or the department director. 4. The facility conducted inservice training on [DATE] and [DATE] for all available staff on "Reporting and Dealing with Aggressive and Inappropriate Behaviors." The facility will continue training those staff not in attendance prior to working with residents on the Memory Care Unit. They also contacted a local group to provide additional training that specializes in geriatric & adult mental health and received a catalogue of the courses to begin ASAP. 5. On [DATE], DON, MDS Coordinators, RN Supervisors and RN Consultant began monitoring resident ' s charts for aggressive and or/unsafe behavior documentation. Immediate Jeopardy was removed on [DATE] at 4:00 p.m. following a review of all 11 Unit residents ' charts that confirmed care plan review and revision for all residents. 1. On [DATE], the "Accident/Incident Report" for Resident's A and B were reviewed in conjunction with the revised policy guidance in the AOC related to an incident involving Resident A and B. Resident A grabbed Resident B's wrist with both her hands when Resident B touched her dominoes. The investigation included witness statements and corrective actions, and the family and physician were notified and all actions taken by facility as directed. Both of the residents were re-assessed and the plans of care were updated as per revised Behavioral policy with new resident specific interventions. 2. Staff inservice records for [DATE] and [DATE] were reviewed and validated for staff attendance and content related to documentation for monitoring and reporting behaviors and interventions. 3. On [DATE], during the above observation period, the surveyor interviewed both nurses and the six (6) C.N.A. ' s assigned to the Unit on two (2) shifts to ensure all staff was aware of the change in the Behavioral Management Policy and what actions should be taken if aggressive and/or any other type behaviors were witnessed by residents. All were able to give the correct answers and knowledge of the policy.

Based on record review, staff interview, review of Policies and Procedures for the Prevention and Investigation of: Abuse, Neglect, Involuntary Seclusion, and Misappropriation of Resident's Property; review of facility's Behavior Policy and Resident Admission and Discharge Guidelines for the Memory Care Unit (Unit), the facility's administration failed to have an effective system in place to ensure residents were appropriately admitted to the Memory Care Unit; monitor residents with aggressive behaviors to ensure safety and protection of residents; ensure that all resident incidents were reported and investigated; and ensure staff received ongoing training to effectively evaluate/ manage problematic behaviors in a therapeutic setting (Unit) for the treatment of [REDACTED]. The facility also failed to implement policies to protect all residents from physical and emotional harmful threats and to develop and/or revise policies with knowledge of escalating aggressive behaviors that placed all residents at significant risk for harm or serious injury. This behavior was displayed by one (1) of eight sampled residents (Resident #5 closed record), directly affected seven (7) residents (RI ' s A-G) on the Unit, with a total capacity of 12 residents. During the survey the Unit census was 11 residents. On 5/1/13 at 1:05 p.m., the facility Administrator and Director of Nurses (DON) were notified that Immediate Jeopardy existed. It was determined to exist as of December 3, 2012. It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. The Immediate Jeopardy was related to non-compliance with CFR 483.13 Resident Behavior and Facility Practice (F224 S/S K), CFR 483.20 Resident Assessment (F278 S/S J), CFR 483.25 (F319 S/S K) and CFR 483.75 Administration (F490 and F520 S/S K). In addition, Substandard Quality of Care was determined to exist at 42 CFR 483.13 and 483.25 (F224 S/S K and F319 S/S K). A Credible Allegation of Compliance was received on 5/2/13, at 6:11 p.m. The Immediate Jeopardy was removed on 5/3/13, at 4:00 p.m., and the facility remained out of compliance at a lower scope and severity of "E," while the facility continues to implement and monitor new policy for reporting and addressing aggressive/unsafe behaviors; implement the new policy for admissions to the Unit; implement and monitor new Accident/Incident Investigation and Reporting policy for resident to resident incidents; monitor the accuracy of all resident assessments and that appropriate preventative actions are put in place for any identified behavior monitor, and to continue staff training on aggressive behaviors prior to working with residents on the Unit. The findings include: Cross Refer F224: The facility failed to provide the necessary services to ensure a safe environment for residents and ensure they were protected from aggressive threats, and potentially violent and harmful behaviors displayed by Resident #5. The resident ' s behavior directly affected seven (7) residents (RI ' s A-G), and placed all residents at risk on the Unit. Residents A, B, D, E and G were subjected to room intrusions and threatening behavior by RI#5. Resident C was pushed by resident in wheelchair (w/c) into the glass door. RI #5 pushed the w/c of Resident F into her room and put his hand around the back of her neck to push her into the room again when staff attempted to bring Resident F out of the room. Behavior was exhibited from 10/23/12 until 2/8/13 when the resident was discharged for violent aggressive behavior. Cross Refer to F278: The facility failed to do an accurate admission comprehensive assessment of a resident admitted to the Memory Care Unit (Unit) with a mental health [DIAGNOSES REDACTED]. One (1) of eight (8) sampled residents (Resident #5 closed record) was incorrectly assessed for behavior risks and the appropriate behavioral interventions to address escalating aggressive behaviors that placed the resident and the other vulnerable residents on the Unit at significant risk. Cross Refer to F319: The facility failed to ensure appropriate treatment and services and to provide effective therapeutic management for aggressive behaviors that involved a comprehensive approach to managing behaviors that included more than medication management, to assist Resident #5 (RI#5) to maintain the highest level of mental functioning and that staff were trained to implement effective therapeutic interventions. RI #5, with a history of mental health [DIAGNOSES REDACTED]. Behavior was exhibited from 10/23/12 until 2/8/13 when the resident was discharged for violent aggressive behavior. Cross Refer to F520: The facility failed to have an effective Quality Assurance Committee (QAA) that identified issues with management of problematic aggressive behaviors on the Memory Care Unit (Unit) and failed to develop and implement a system to analyze root cause and implement program changes to alleviate or reduce potential for serious harm, injury, impairment or death to residents on the Unit, with a capacity of 12 residents. During an interview on 4/30/13 at 1:40 p.m., the facility Administrator and DON confirmed that they failed to monitor residents with aggressive behaviors to ensure the safety and protection of all residents; and ensure staff received the necessary ongoing training to effectively report, evaluate/manage problematic behaviors on the Unit. They confirmed that the Behavior and Abuse/Neglect Policies were not effective and were not being implemented in a way to attain and/or maintain residents ' safety, emotional and physical well-being on the locked Unit and they During the same interview with the Administrator on 4/30/13, he revealed that cameras were used to track the residents' behaviors on the Unit. When questioned, he acknowledged the cameras did not monitor in-room activities. He stated, "I could see when he (RI #5) went in and out of the room." The Administrator did not state how staff interventions were changed or/modified based of the video camera monitoring done by him. The Administrator verbalized that the resident was on the locked unit and failed to determine there was a need to do anything further with the video observations. The Administrator and DON also confirmed that the facility did not maintain documented evidence, incident reports or assessment notes related to any of the residents who had experienced intrusions or aggressive acts from RI #5. During interviews with the staff on the Unit on 5/1/13 at 10:00 a.m., Certified Nursing Assistant #1(C.N.A. #1) and C.N.A. #2 confirmed they had not received any recent training related to approaches for dealing with residents who showed aggressive, violent behaviors since orientation of one (1) year for C.N.A.#1 and since the Unit opened last year for C.N.A. #2. Nurse #1 was interviewed on 5/1/13 at 10:15 a.m. and she confirmed her training was from completing a course (training program) on [MEDICAL CONDITION] in school over the past year. The DON provided an agenda from a nurses meeting on 4/23/13 when asked to provide training documentation related to dealing with problematic behaviors on the Unit. The meeting agenda included ..."Review PRN's charting results and reviewed behavior sheets and documenting behaviors." The facility did not provide any additional documentation on training to show a training that addressed the issues of dealing with problematic behaviors. The Administrator and DON were notified of the immediate jeopardy on 5/1/13 at 1:05 p.m. The facility provided an acceptable Credible Allegation of Compliance on 5/2/13 at 6:11 p.m. which included the following: 1. DON, MDS Coordinators, RN Supervisors and Social Worker reviewed each chart on the Memory Care Unit on 5/1/13 and conducted staff interviews to identify any other residents who were displaying aggressive behaviors that place themselves and others at risk for harm. Updates were made to the care plans for interventions by nursing and activities. 2. Facility administration revised Behavioral Policy on 5/2/13 that outlined increased behavioral symptoms for staff intervention; collaboration on residents for care plan development, documentation enhancement and use of non-pharmacologic approaches, and establishment of referral and/or intervention by a licensed/trained behavioral care provider (contract Psychologist and Psychiatric Nurse Practitioner) when indicated. 3. Facility revised Accident/Incidents Investigating and Reporting Policy on 5/2/13 related to all resident to resident occurrence that will be initiated immediately under the direction of Supervisor/Charge Nurse and/or the department director. 4. Facility developed a policy which included a plan to for all new admissions to be evaluated using all behaviors prior to admission on 5/2/13. 5. The facility conducted inservice training on 5/1/13 and 5/2/13 for all available staff on "Reporting and Dealing with Aggressive and Inappropriate Behaviors." The facility will continue training those staff not in attendance prior to working with residents on the Memory Care Unit. They also contacted a local group to provide additional training that specializes in geriatric & adult mental health and received a catalogue of the courses to begin ASAP. Immediate Jeopardy was removed on 5/3/13 at 4:00 p.m. following a review of all 11 Unit residents ' charts on 5/3/13 that confirmed care plan review and revision for residents. 1. On 5/3/13, the "Accident/Incident Report" for Resident's A and B were reviewed in conjunction with the revised policy guidance in the AOC related to an incident involving Resident A and B. Resident A grabbed Resident B's wrist with both her hands when Resident B touched her dominoes. The investigation included witness statements and corrective actions, and the family and physician were notified and all actions taken by facility as directed. Both of the residents were re-assessed and the plans of care were updated as per revised Behavioral policy with new resident specific interventions. 2. Staff inservice records for 5/1/13 and 5/2/13 were reviewed and validated for staff attendance and content related to documentation for monitoring and reporting behaviors and interventions. 3. A review of all charts on the Unit confirmed that staff had reviewed all 11 residents for behaviors and accuracy of assessment. There have been no new admissions since 5/1/13 to implement the new admission process. 4. DON, MDS Coordinators, RN Supervisors and Social Worker reviewed each chart on the Memory Care Unit on 5/1/13 and conducted staff interviews to identify any other residents who were displaying aggressive behaviors that place themselves and others at risk for harm. Updates were made to the care plans for interventions by nursing and activities. 5. On 5/3/13, during the above observation period, the surveyor interviewed both nurses and the six (6) C.N.A. ' s assigned to the Unit on two (2) shifts to ensure all staff was aware of the change in the Behavioral Management Policy and what actions should be taken if aggressive and/or any other type behaviors were witnessed by residents. All were able to give the correct answers and knowledge of the policy. 6. On 5/3/13, at approximately 1:00 pm, an interview was held with the Administrator, DON and MDS coordinator about the audits for charting aggressive/unsafe behaviors. They were able to provide copies of the monitoring as planned.

Based on staff interview, the facility failed to have an effective Quality Assurance Committee (QAA) that identified issues with management of problematic aggressive behaviors on the Memory Care Unit (Unit) and failed to develop and implement a system to analyze root cause and implement program changes to alleviate or reduce potential for serious harm, injury, impairment or death to residents on the Unit, with a capacity of 12 residents. The facility Administrator and Director of Nurses (DON) were notified on 5/1/13 at 1:05 p.m. that Immediate Jeopardy existed. It was determined to exist as of December 3, 2012. It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. A Credible Allegation of Compliance was received on 5/2/13, at 6:11 p.m. The Immediate Jeopardy was removed on 5/3/13, at 4:00 p.m., and the facility remained out of compliance at a lower scope and severity of "E" while the facility continues to implement the new monitoring system for reviewing aggressive and/or unsafe behaviors and discussing in QAA for further action. The findings include: Cross Refer F224: The facility failed to provide the necessary services to ensure a safe environment for residents and ensure they were protected from aggressive threats, and potentially violent and harmful behaviors displayed by Resident #5. The resident ' s behavior directly affected seven (7) residents (RI ' s A-G), and placed all residents at risk on the Unit. Residents A, B, D, E and G were subjected to room intrusions and threatening behavior by RI#5. Resident C was pushed by resident in wheelchair (w/c) into the glass door. RI #5 pushed the w/c of Resident F into her room and put his hand around the back of her neck to push her into the room again when staff attempted to bring Resident F out of the room. Behavior was exhibited from 10/23/12 until 2/8/13 when the resident was discharged for violent aggressive behavior that placed the residents at significant risk of harm and/or serious injury. During an interview with the Administrator and the Director of Nurses (DON) on 4/30/12 at 1:40 p.m., they reported the behavior incidents on the Memory Care Unit were not being tracked and trended. They confirmed the facility had not identified any quality of care items related to care and services on the Unit that had been brought to QAA for corrective actions. The facility did not have documented evidence that behavior situations had been addressed by the Quality Assurance Committee (QAA) and or that the violent resident to staff assault episode was analyzed and staff re-education and monitoring was implemented. The facility did not have a process in place for evaluating these types of behaviors that were displayed by the Resident #5. There was no plan developed by the facility for potential problematic behaviors which continued to place residents at risk without facility monitoring. The Administrator and DON were notified of the immediate jeopardy on 5/1/13 at 1:05 p.m. The facility provided an acceptable Credible Allegation of Compliance on 5/2/13 at 6:11 p.m. which included the following: 1. Beginning 5/1/13, all documentation for any resident identified with behaviors would be monitored twice daily for one week by Nursing Administrative Staff to ensure resident safety and staff understanding of policy changes for effective implementation of therapeutic interventions. Reviews will be adjusted based on results of monitoring to not less than monthly. 2. DON, MDS Coordinators, RN Supervisors and Social Worker reviewed each chart on the Memory Care Unit on 5/1/13 and conducted staff interviews to identify any other residents who were displaying aggressive behaviors that place themselves and others at risk for harm. Updates were made to the care plans for interventions by nursing and activities. 3. Administration defined QAA schedule to start in July based on chart audits established on 5/1/13 as noted in #1 above. Immediate Jeopardy was removed on 5/3/13 at 4:00 p.m. following a review of all 11 Unit residents ' charts on 5/3/13 that confirmed care plan review and revision for residents. 1. A review of all charts on the Unit confirmed that staff had reviewed all 11 residents for behaviors and accuracy of assessment. There have been no new admissions since 5/1/13 to implement the new admission process. 2. On 5/3/13, at approximately 1:00 pm, an interview was held with the Administrator, DON and MDS coordinator about the audits for charting aggressive/unsafe behaviors. They were able to provide copies of the monitoring as planned.

Based on record review and staff interview the facility failed to do an accurate admission comprehensive assessment of a resident admitted to the Memory Care Unit (Unit) with a mental health [DIAGNOSES REDACTED]. One (1) of eight (8) sampled residents (Resident #5 closed record) RI #5) was incorrectly assessed for behavior risks and the appropriate behavioral interventions to address escalating aggressive behaviors that placed the resident and the other vulnerable residents on the Unit at significant risk. The Unit had a capacity of 12 residents and a census of 11 residents at the time of survey. On 5/1/13 at 1:05 p.m., the facility Administrator and Director of Nurses (DON) were notified that Immediate Jeopardy existed. It was determined to exist as of 10/29/12 when RI #5 's initial admission assessment was inaccurately completed which impacted the facility's ability to do an appropriate comprehensive care plan to address his problematic behaviors.. It was also determined that the provider's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment or death to residents. A Credible Allegation of Compliance was received on 5/2/13, at 6:11 p.m. The Immediate Jeopardy was removed on 5/3/13, at 4:00 p.m., and the facility remained out of compliance at a lower scope and severity of "E," while the facility implements the new policy for admission resident assessments and monitors the accuracy of all resident assessments and ensures that appropriate preventative actions are put in place for any identified behaviors. The findings include: Resident #5 (RI#5) was admitted to the Memory Care Unit (Unit) on 10/17/12, with multiple [DIAGNOSES REDACTED]. The resident had a recent admission at a psychiatric facility and was discharged on [DATE]. It was documented that the family elected trial of care at home; however, additional documentation revealed, "The resident ' s aggressive behaviors to family members and wandering behaviors have been a game changer for adult daughter care givers." Based on these increasing behaviors, the family admitted the resident from home to the Unit. The 9/27/12 Discharge Summary from the psychiatric facility addressed two (2) incidents of particular concern. One incident was related to the resident's " belief of someone breaking into his neighbor's house, which led to him getting a gun. " In the second incident the resident was " convinced that his wife was having an affair. He became very threatening while attempting to strike her." The report documented that RI #5 " presented thought patterns of increasing disorganization and dangerous behaviors. The resident was noted to be making sexually inappropriate comments to female staff and other patients. He was very confused. " A review of RI #5 ' s Admission Minimum Data Set (MDS) and the Care Area Assessment (CAA), dated 10/29/12, with Assessment Reference Date 10/24/12 revealed the assessment was not reflective of the resident's complete behavior picture which was needed to develop a comprehensive assessment and plan of care. The MDS assessed Resident #5 as " sometimes having the ability to understand others and responded adequately to simple directed communication only. " The BIMS (Brief Interview for Mental Status) was conducted with the resident, and given a score of 4 out of 15 (cognition severely impaired). The assessment also documented that the resident was coded for having " wandering behaviors daily, wandering places which place the resident at significant risk for getting to a potentially dangerous place. " Some of the areas addressed on the CAA were Cognitive Loss/Dementia, Communication, Behavior Symptoms and Psychoactive Drug use (The CAA provides a basis for additional assessment of potential issues, including related risk factors and is used to provide the interdisciplinary team (IDT) additional information to help them develop a comprehensive plan of care). The CAA did not include all of the available medical record history related to the areas of concern that would impact the resident ' s adjustment and care on the unit. The assessment did not address prior psychiatric treatment, antipsychotic medication use, behavior/mood changes that may be indicative of escalating aggression or potential changes in resident's medical condition that may have a significant impact on his behaviors. RI #5's mood and behavior patterns were not comprehensively assessed as it related to his psychosocial well-being and the safety of the other residents on the unit and his wandering significantly intruded on the privacy or activities of others. The resident's history from the psychiatric facility included assessment data that was not incorporated in the initial assessment on admission to the facility on [DATE]. The assessment did not address prior psychiatric treatment, antipsychotic medication use, behavior/mood changes that may be indicative of escalating aggression and potential changes in resident's medical condition that may have a significant impact on his behaviors. An interview was conducted with the Minimum Data Set (MDS) Coordinator, Social Worker and the Director of Nurses (DON) on 5/1/13 at 8:30 a.m., which confirmed that the baseline data was not comprehensive and reflective of the picture presented by the resident. The Administrator and DON were notified of the immediate jeopardy on 5/1/13 at 1:05 p.m. The facility provided an acceptable Credible Allegation of Compliance on 5/2/13 at 6:11 p.m. which included a plan to for all new admissions to be evaluated using all behaviors prior to admission on 5/2/13. The Nursing Administrative Staff and the Social Worker reviewed each chart on the Memory Care Unit to identify any resident with potential for aggressive behaviors on 5/1/13. Immediate Jeopardy was removed on 5/3/13 at 4:00 p.m. following a review of all 11 Unit residents ' charts that confirmed review for behaviors and accuracy of assessment. There have been no new admissions since 5/1/13 to implement the new admission process.