Every finding on record at Belmont Terrace Nursing and Rehabilitation Center

Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 sampled residents reviewed for infection control, Resident (R) 65.Observation on 06/11/2026 on the 100 Unit Hall of medication administration for R65 revealed Licensed Practical Nurse (LPN) 4 dispensed R65's medication from a blister pack into his bare hand and then into the medicine cup. Continued observation revealed LPN4 used his bare hands to break scored medication in half, and then he placed it into the medicine cup.The findings include:Review of the facility's policy titled, Infection Control, reviewed 08/20/2025, revealed facility infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Further review revealed infection control policies and practices were to prevent, detect, investigate, and control infections in the facility.Review of the facility's policy titled, Medication Administration Policy, dated 08/04/2024, revealed if breaking tablets was necessary to administer the proper dose, hands were washed or sanitized, and gloves were applied prior to handling tablets. Per the policy, a tablet-splitter could be used to avoid hand contact with the tablet. Alternately, gloves should be used by the nurse splitting the tablet.Review of an admission Record, found in R65's electronic medical record (EMR), revealed the facility admitted R65 on 04/10/2026 with diagnoses to include infection and inflammatory reaction due to internal left knee prosthesis, subsequent encounter; traumatic arthropathy, left knee; and acquired absence of left knee.Review of R65's admission Minimum Data Set [MDS], found in R65's EMR, with an Assessment Reference Date (ARD) of 04/15/2026, revealed a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated the resident was cognitively intact.Review of the Comprehensive Care Plan, dated 04/15/2026, revealed R65 was care planned for enhanced barrier precautions due to chronic infection of the internal left knee prosthesis. Interventions initiated on 04/15/2026, included staff using personal protective equipment (PPE) when providing care for R65.Observation on 06/11/2026 at 7:12 AM of medication administration on the 100 Unit revealed LPN4 dispensed medication for R65 of pantoprazole 40 mg tablet (used to treat excess stomach acid) from a blister pack into his bare hand and dropped it into the medicine cup and sertraline two tablets (used to treat depression) from a blister pack into his bare hand and dropped them into the medicine cup. LPN4 then retrieved one sertraline tablet and broke it in half with his bare hands and placed 1/2 of the tablet into the medication already in the medicine cup and discarded the other 1/2 tablet into the waste receptacle. LPN4 then dispensed one nifedipine 60 mg tablet (used to lower blood pressure) from the blister pack into his bare hand and dropped it into the medicine cup.During an interview with LPN4 at the time of the observation, he stated the medication should be dispensed from the blister pack directly into the medication cup. LPN4 stated he knew he dispensed the medication into his bare hand, but he should have put the medication directly into the medicine cup. LPN4 discarded the pulled medications and repulled the medications. LPN4 then dispensed one sertraline tablet into the medicine cup but dispensed the other sertraline tablet into his bare hand to break it apart. When asked if he was aware he used bare hands, LPN4 stated he forgot. LPN4 then donned gloves and dispensed one sertraline tablet into his gloved hands and broke it in half. LPN4 stated the impact to residents from having their medications in his bare hands could be contaminated medications that would be passed to the residents. LPN4 stated there was a pill splitter on the medication cart, but the sertraline tablet was scored, and the pill splitter was not needed. During an interview on 06/11/2026 at 9:40 AM with LPN5 on the 200 Unit, she stated medications were dispensed from the blister pack into the medication cup. LPN5 stated bare hands were not used because it would create an infection control issue for the resident.During an interview on 06/11/2026 at 9:47 AM with LPN8 on the 300 Unit, she stated the medication was dispensed from the blister pack into the medication cup. LPN8 stated if the medication popped out of the cup, gloves were put on, and the medication was wasted. Then, she stated another dose of medication was dispensed into the medication cup. LPN8 stated using bare hands in touching medication would be an infection control problem if the resident received medications from staff not wearing gloves.During an interview on 06/11/2026 at 9:50 AM with Kentucky Medication Aide (KMA) 1 on the 300 Unit, she stated she put on gloves, picked up the medication, and disposed of the medication if it popped out of the medicine cup. KMA1 stated not to touch medication with bare hands due to the possibility of infecting the resident.During an interview on 06/11/2026 at 10:00 AM with Registered Nurse (RN) 1 on the 100 Unit, she stated hands were sanitized and gloves were worn when handling medication to be split. RN1 stated there was a pill splitter on the medication cart used to divide pills.During an interview on 06/11/2026 at 10:13 AM with the 200 Unit Manager, she stated staff was required to sanitize hands and don gloves when handling medication. She stated handling medication with bare hands created an infection control issue which could be transferred to the resident.During an interview on 06/11/2026 at 1:47 PM with the 100 Unit Manager, she stated LPN4 had reported to her that he used his bare hands when handling a resident's medication. She stated when medication came in contact with bare hands it was possible for germs to be transmitted to the resident. During an interview on 06/11/2026 at 2:57 PM with the Infection Preventionist (IP)/Assistant Director of Nursing (ADON), she stated if staff was to touch medications with their bare hands and give to residents, it would create cross-contamination for the residents and put them at risk for infection.During an interview on 06/11/2026 at 4:50 PM with the 200 Unit Manager, she stated it was her expectation for nurses to use gloves if medications need to be split/divided.During an interview on 06/12/2026 at 12:05 PM with the Director of Nursing, she stated it was her expectation for staff to wear gloves when handling medication.During an interview on 06/12/2026 at 12:10 PM with the Administrator, he stated it was his expectation staff would not use bare hands when handling medication. He stated handling medication without gloves would spread germs to residents.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, the facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices, for 1 of 27 sampled residents, Resident (R) 84. The facility also failed to provide sanitary storage of residents' supplies to help prevent the development and transmission of communicable diseases and infections, which had the potential to affect all of the current 114 residents. 1. Observation of the 200 Hall revealed R84 was seated in his wheelchair self-ambulating down the hall outside of his room with his suprapubic catheter bag anchored to the underside of the seat of the wheelchair. The bag was dragging on the floor as he ambulated. 2. Observation of the Employee Locker Room and the Central Supply Storage Room revealed multiple boxes of resident supplies were stored on the floor. The findings include: Review of the Centers for Disease Control Infection Control and Prevention's Catheter-Associated Urinary Tract Infections (CAUTI) Prevention Guide, updated 04/12/2024, revealed it was part of Standard Precautions. Further review revealed infection prevention and control practices should be employed for management of catheters and associated drainage systems to include ensure the urine drainage bag was kept off the floor. Review of the facility's policy, Infection Control, dated 08/04/2024, revealed the facility's infection prevention and control program (IPCP) was intended to maintain a safe, sanitary, and comfortable environment to help prevent and manage the transmission of disease and infection. Continued review of the policy revealed the facility would establish guidelines for the implementation of Standard Precautions. 1. Review of an Admission Record, found in R84's electronic medical record (EMR), revealed the facility admitted R84 on 03/14/2022 with diagnoses to include anemia, atrial fibrillation, and congestive heart failure. Review of R84's quarterly Minimum Data Set [MDS], found in R84's EMR, with an Assessment Reference Date (ARD) of 02/25/2025, revealed a Brief Interview for Mental Status [BIMS] score of nine out of 15, which indicated the resident had moderate cognitive impairment. Review of the Comprehensive Care Plan, dated 01/07/2025, revealed R84 was care planned for an indwelling supra-pubic catheter due to urethral stricture/obstructive uropathy. The goal, revised on 11/26/2024, revealed the resident would have no signs and symptoms of urinary tract infection through the next review. Interventions initiated on 04/09/2024, included to keep the catheter drainage bag off the floor. Observation of the 200 Hall on 04/21/2025 at 11:07 AM, revealed R84 was seated in his wheelchair and self-ambulating down the hall outside of his room. R84's suprapubic catheter drainage bag was anchored to the underside of the wheelchair's seat and dragged on the floor as he ambulated up and down the hall. During an interview with Licensed Practical Nurse (LPN) 2 on 04/21/2025 at 11:17 AM, she stated catheter bags needed to be secured to the wheelchair in a manner that prevented them from dragging on the floor. LPN2 stated this was an infection control issue and should be addressed to reduce the risk of urinary tract infections. During an interview with the Director of Nursing (DON) on 04/24/2025 at 3:29 PM, she stated catheter collection bags should never touch the floor. She stated it should be anchored to the bed or a wheelchair so that urine drains away from the bladder and should never touch the floor. She stated staff should clean the bag if it touched the ground. She stated it would not be replaced unless the integrity of the catheter bag was compromised. The DON stated the facility did not have a policy for the care of catheter bags. 2. a. Observation of the Employee Locker Room on 04/23/2025 at 8:10 AM, revealed approximately 40 visible boxes of resident supplies. Of those, 13 were stored on the floor in an unsanitary manner. Several of the boxes stored directly on the floor were opened. Additionally, an opened bag containing suction canister tops was also on the floor and spilling out. There were two bags of resident briefs on the floor. One of these bags was torn open, and two of the canister tops were observed directly on the floor. Other boxes contained drinking straws, urinary drainage bags, briefs, tissues, water pitchers, sharp containers, bed pads, pads, and aqua packs. b. Observation of the Central Supply Storage Room on 04/23/2025 at 8:15 AM, revealed multiple boxes containing resident supplies were found stored on the floor: During an interview with State Registered Nurse Aide/Central Supply Manager (SRNA/CSM) 5 on 04/23/2025 at 8:15 AM, referring to the storage room, she stated, I'm just letting you know that it's a mess. SRNA/CSM5 stated boxes should not be placed on the floor due to the risk of water damage or contamination from pest and other contaminants, which could lead to infection control issues. She stated she had requested additional storage space and shelving from the Administrator. She stated there was not a lot of storage for resident supplies. She stated the night shift staff used the employee lounge to store supplies because the storage room was locked during the night shift. She stated storing boxes off the floor was important to prevent the spread of infection. During an interview with the Infection Preventionist (IP) on 04/23/2025 at 9:30 AM, she stated her concern with opened boxes and bags with supplies being stored on the floor would be that the supplies could become contaminated and spread infection. She stated storing boxes off the floor was important to prevent the spread of infection. During an interview with the Regional Nurse Consultant (RNC) on 04/24/2025 at 11:25 AM, she stated it was her expectation that the facility staff followed the facility's infection control policies to prevent the spread of infectious disease. She stated it was important for the health and safety of residents. During an interview with the Director of Nursing (DON) on 04/24/2025 at 3:29 PM, she stated it was her expectation that all facility staff followed the facility's IPCP to prevent the spread of infections and disease to ensure the health and safety of residents and staff. During an additional interview with the IP on 04/24/2025 at 3:55 PM, she stated the facility followed the CDC's recommendation for infection control. The IP stated it was important to follow the CDC's recommendations and the facility's infection prevention and control program (IPCP) to prevent the spread of disease and infections and to protect residents from healthcare associated infections. During an interview with the Administrator on 04/24/2025 at 3:48 PM, he stated he expected all of the facility's policies to be followed. When asked who was responsible for monitoring the infection prevention program, he stated the IP was responsible to oversee the facility's IPCP and monitor for infectious disease. During an interview with the Medical Director on 04/24/2025 at 5:36 PM, she stated it was her expectation that the facility's leadership and staff followed the facility's IPCP to prevent the spread of infection. The Medical Director stated it was important for the health and safety of the facility's residents.

Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policy, the facility failed to provide immunization as required or appropriate; to ensure the resident or the resident's representative had the opportunity to refuse immunizations; and failed to ensure the medical record included documentation of the resident's or resident representative's education regarding the benefits and potential side effects of immunizations for 5 of 6 sampled residents, Resident (R) 23, R50, R74, R99, and R103. The findings include: Review of the facility's policy titled, Influenza and Pneumococcal Immunization Policy, dated 08/13/2024, revealed to minimize the risk of influenza and pneumococcal disease, the facility ensured that each resident or their representative received education on immunization benefits and potential side effects. Per the policy, residents were offered annual influenza immunization and could refuse it, while pneumococcal immunization was offered unless medically contraindicated. The policy stated medical records must detail that education was provided and whether the resident received the immunization. The policy stated a resident or the resident's legal representative could refuse the vaccine for any reason, and if a vaccine was refused, the refusal would be documented in the resident's medical record. Review of the Centers for Disease Control and Prevention's (CDC) document Recommended Vaccines for Adults, updated 10/26/2024, revealed the CDC recommended all adults [AGE] years of age or older should receive the pneumococcal vaccine (PCV) unless indicated otherwise by the physician. In addition, at least one year after the last PCV13 dose, adults should receive one dose of PCV20 or one dose of PCV21. Also, the document stated if the previous vaccination history was unknown, one dose of PCV15, PCV20, or PCV21 should be given. 1. Review of R23's Resident Face Sheet revealed the facility admitted the resident on 03/19/2019 with diagnoses including anemia, Alzheimer's disease, and depression. Review of R23's quarterly Minimum Data Set [MDS], found in the resident's Electronic Health Record (EHR), with an Assessment Reference Date (ARD) of 04/18/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of three out of 15, indicating the resident was severely cognitively impaired. Review of R23's immunization status revealed there was no documented evidence the resident had received the recommended pneumococcal immunizations. Additionally, it was documented that R23 refused the immunization. A Vaccine Consent Form, provided by the facility, showed Refused in the signature line with an unrecognizable date. The form was not completed with the type of vaccine refused. Additionally, the facility did not provide documentation of R23's vaccine education. 2. Review of R50's Resident Face Sheet revealed the facility admitted the resident on 09/25/2017 with diagnoses including malnutrition, liver failure, and dysarthria (facial muscle weakness) due to traumatic brain injury. Review of R50's annual MDS, found in the resident's EHR, with an ARD of 02/11/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Review of R50's immunization status revealed the resident received his last Pneumovax (pneumococcal PCV13) immunization on 02/12/2018. Based on CDC recommendations, R50 should receive one dose of PCV20 or one dose of PCV21 at least one year after the last PCV13 dose. Additionally, the facility did not provide documentation of pneumococcal vaccine refusal or education. During an interview with R50 on 04/21/2025 at 11:30 AM, he stated he had not been offered a pneumonia vaccine since his admission. He stated it had been longer than five years since his last pneumonia immunization. 3. Review of R74's Resident Face Sheet revealed the facility admitted the resident on 09/17/2021 with diagnoses including cancer, anemia, and coronary artery disease. Review of R74's quarterly MDS, found in the resident's EHR, with an ARD of 12/03/2024, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Review of R74's immunization status revealed no documentation of a pneumococcal vaccination refusal. Per CDC guidelines, if the previous vaccination history was unknown, one dose of PCV15, PCV20, or PCV21 should be given. 4. Review of R99's Resident Face Sheet revealed the facility admitted the resident on 11/14/2024 with diagnoses including Alzheimer's disease, malnutrition, and dementia. Review of R99's quarterly MDS, found in the resident's EHR, with an ARD of 02/06/2025, revealed the facility assessed the resident to have a BIMS score of zero out of 15, indicating the resident had severe cognitive impairment. Review of R99's immunization status revealed she received the Pneumococcal PCV13 vaccination on 08/27/2019. According to CDC recommendations, R99 should receive one dose of PCV20 or one dose of PCV21 at least one year after the last PCV13 dose. Additionally, the facility did not provide documentation of pneumococcal vaccine refusal or education. 5. Review of R103's Resident Face Sheet revealed the facility admitted the resident on 09/17/2021 with diagnoses including type 2 diabetes mellitus, disorders of the immune mechanism, and congestive heart failure. Review of R103's quarterly MDS, found in the resident's EHR, with an ARD of 03/28/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Review of R103's immunization status revealed there was no documented evidence the resident had received the recommended pneumococcal vaccine. Per CDC guidelines, if the previous vaccination history was unknown, one dose of PCV15, PCV20, or PCV21 should be given. Additionally, it was documented that R103 refused the Prevnar 15 immunization (no date). A Vaccine Consent Form, provided by the facility, revealed the word Refused in the signature line on 11/13/2024. However, the form did not specify who refused the vaccination, and the form was not completed with the type of vaccine refused. Additionally, the facility did not provide documentation of R103's vaccine education. During an interview with the Infection Preventionist (IP) on 04/24/2025 at 3:55 PM, she stated the facility followed the CDC's recommendation for all immunizations and vaccines. She stated she was unsure why residents had not received their recommended vaccination. She stated she expected all residents to receive vaccinations according to the CDC's recommended guidelines. The IP stated it was important to follow the CDC's recommendations and the facility's infection prevention and control program (IPCP), including influenza and pneumococcal vaccines, to prevent the spread of disease and infections that could be controlled with vaccines and immunizations. During an interview with the Regional Nurse Consultant (RNC) on 04/22/2025 at 10:45 AM, she stated the facility lacked much of its surveillance data and documentation, including resident vaccine and immunization records. She stated this issue arose when a former infection preventionist self-terminated her position [01/13/2025]. The RNC stated the former infection preventionist destroyed electronic data and took the infection surveillance binder, along with other infection prevention records, with her when she left the facility. The RNC stated, while the facility had been updating resident immunization records, it had not conducted an audit of pneumococcal vaccinations. During additional interview with the RNC on 04/24/2025 at 11:25 AM, she stated, I truly don't think we will find documentation of updated [immunization] records. The RNC stated residents should get vaccinated to protect themselves and others from infectious diseases. During an interview with the Administrator on 04/24/2025 at 3:48 PM, he stated he expected all of the facility's policies to be followed. When asked who was responsible for monitoring the infection prevention program, he stated the IP was responsible to oversee the facility's infection prevention and control program (IPCP) and monitor for infectious disease. The Administrator stated it was important for the health and safety of residents and staff to follow the facility's IPCP related to immunization to prevent the spread of infections. During an interview with the Medical Director on 04/24/2025 at 5:36 PM, she stated when residents were admitted , the admission nurse asked them or their representative about their vaccination history. She stated all residents were offered vaccines. She stated the unit managers ensured that residents' vaccinations were up-to-date. The Medical Director stated it was important for residents to receive their vaccines to protect both themselves and others in the facility from the spread of infectious disease.

Based on observation, interview, record review, review of the facility's Incident Reports, and review of the facility's policies, the facility failed to keep residents free from abuse and neglect for 3 of 11 sampled residents, Resident (R) 36, R40, and R169. 1. On 02/28/2025, R36 reported to a day shift State Registered Nurse Aide (SRNA) that the previous night shift SRNA purposefully removed his call device from the wall and replaced it with something plastic so he would be unable to use the call device during the previous night shift. The day shift SRNA observed R36's call device was not plugged in, and a plastic device had been put in the call device port. 2. On 11/15/2024, R169 walked into R40's room. R40 hit R169, causing a nose bleed. R40 fell while hitting R169, injuring her ankle. The findings include: Review of the facility's policy titled, Abuse Prohibition, revised 07/01/2019, revealed potential hires were screened for history of abuse, neglect, and mistreatment. It also stated potential hires would have a license verification completed, and required background checks were done. Further review revealed all employees received training on abuse prevention, abuse identification, and reporting of abuse. It also stated any employee alleged to have committed an act of abuse would be immediately removed from duty, pending investigation. Review of the facility's policy titled, Resident Rights, effective date 08/13/2024, stated, The facility will make every effort to support each resident in exercising his/her right to assure that the resident is always treated with respect, kindness, and dignity. 1. Review of R36's admission Record revealed the facility admitted him on 02/23/2023 with diagnoses of functional quadriplegia, autonomic neuropathy, and myoneural disorder with bed confinement status. Review of R36's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 03/07/2025, revealed a Brief Interview for Mental Status [BIMS], a test for cognitive impairment, was not conducted because resident is rarely/never understood. The assessment of memory/recall ability revealed R36 was able to recall the current season, location of his room, staff name and faces, and where he was currently located and was able to make decisions regarding daily life tasks. Further review revealed R36 did not have any indicators of hallucinations, delusions, no physical or verbal behavioral symptoms, and had functional range of motion limitation on both sides, upper and lower extremities, that made him dependent in all care areas. Review of R36's Care Plan Report, revealed a focus area, initiated on 03/23/2023, of threatening to call state or corporate on staff when need or want could not be met immediately, excessive use of call light, manipulative behaviors, making false accusations of staff, using racial slurs, screaming out, and making sexual remarks to staff. Further review revealed interventions included providing a flat call light to be kept within reach. Review of the facility's Initial Investigation Report, dated 02/28/2025, revealed the incident occurred on 02/27/2025 at approximately 9:00 PM, and R36 reported it to SRNA9 on 02/28/2025 at approximately 3:00 PM. Per the report, upon notification by R36, SRNA9 immediately returned the call light to working order and reported the allegation and findings to management, appropriate notifications were made, and the investigation was initiated. Further review of the report revealed the Administrator interviewed SRNA8, and she admitted to removing the call light from the wall due to being unable to shut off and had forgotten to tell the oncoming shift. Per the report, SRNA8 also stated she had forgotten to place a work order for repair; and SRNA8 was placed on leave pending the investigation. Review of facility's Final/5 Day Investigation Report, dated 03/05/2025, revealed a full investigation was completed and findings substantiated the call light was unplugged, but it could not be proven it was an intentional action. Per the report, all staff received training on call lights and the abuse policy; all residents were interviewed that had a high BIMS; all low BIMS score residents had a skin assessment; and no other issues were identified. The report stated a facility-wide audit of all call lights did not identify any issues with the call system or individual devices, including R36's call device, which was identified to be in working order. Review of SRNA8's employee file revealed a date-of-hire of 04/10/2024. Further review revealed a background check, adult caregiver misconduct registry, sex offender registry, and licensure verification had been performed. Additional review revealed on 04/23/2024, SRNA8 signed she completed and acknowledged the employee code of conduct and the policy for adult protection, abuse, neglect, and resident rights. In an interview with R36 on 04/23/2025 at 9:18 AM, he stated a night shift SRNA removed his call light device from the wall and placed a plastic syringe cap in the port to keep him from being able to use the call light because she did not like him. R36 stated, during the night, he would have verbally called out to get help if needed, and he did not feel isolated, but it made him mad. R36 stated he told the oncoming SRNA the following morning about what the night SRNA did, and she immediately re-connected his call device and told someone. R36 stated he had not seen the SRNA since that incident, had no issues from the event, and had not had any further incidents with his call device. The State Survey Agency (SSA) Surveyor attempted to interview SRNA8, who no longer worked at the facility, by telephone on 04/22/2025 at 8:00 PM, and a second attempt was made on 04/23/2025 at 7:30 PM. However, with both attempts, there was no answer, and no voicemail was available. The SSA Surveyor attempted to interview SRNA9, who no longer worked at the facility, by telephone on 04/23/2025 at 11:26 AM, but the only available contact number provided was not a working number. In an interview with the Maintenance Director on 04/23/2025 at 9:35 AM, he stated he was involved in the call light audit during the investigation, and no devices or system issues were identified as having malfunctioned, including the specialty call device used by R36. He stated Maintenance was available 24 hours a day by phone, and his contact information was located on all units. He stated any issue with a call device was considered high priority, and a device that was not functioning should have been called into him. He stated he would have come to the facility and replaced or repaired the device if needed. He stated his expectation was for a work order to be placed by staff who identified the issue. He stated review of his work order electronic tracking system revealed no work order was placed on the corresponding dates of the incident for R36's call device. In an interview with the Director of Nursing (DON) on 04/24/2025 at 3:19 PM, she stated abuse of residents by any staff member was unacceptable, and any allegation of abuse or neglect by an employee required immediate suspension. She stated, after any allegation of abuse, mandatory staff education should be instituted based on the specifics of the allegation. She stated the facility doing pre-employment background checks and verifying the abuse registry were important for screening potential employees. In an interview with the Administrator on 04/24/2025 at 2:55 PM, he stated he was notified by a staff member, whom he could not recall, that R36 had complained that a night shift SRNA had purposefully removed his call device from the wall and placed a plastic device in its place, so he would not continue to call out during her shift. The Administrator stated he interviewed R36 who told him the same story, and he made the required notifications. He stated, in his interview with SRNA8, she admitted to removing the device due to a malfunction, and she had forgotten to put in a work order or pass it off to day shift in report. The Administrator stated, during the investigation, all call lights were tested as well as the call system and no malfunctions were identified, including with R36's call device. He stated the finding of the investigation was the event occurred, but intent could not be determined. So, he stated, out of an abundance of caution, SRNA8 was separated from employment. 2. Review of the facility's Investigation Report, dated 11/15/2024, revealed on 11/15/2024, R169 was walking down the 300 Hall when she entered R40's room. Per the report, R40 did not like that R169 was in her room, stood up from her wheelchair, and hit R169 in the face. The report stated when R40 hit R169, R40 fell, hurting her ankle. The report stated R169 had a nosebleed, the physician was notified, and the physician ordered an x-ray for R40's ankle and to monitor R169's nose. The investigation revealed both residents did not remember the incident. Per the report, the residents were immediately separated, and R40 was placed on one-on-one supervision. The report stated both residents' families were notified as well as the physician, Office of Inspector General, Department for Community Based Services, law enforcement, and the Ombudsman. Per the report, a 72 hour psychosocial monitoring was performed which revealed no concerns, and the x-ray of R40's ankle was negative for acute injury. The report stated the facility was able to verify that the incident occurred, and a stop sign was placed on R40's room door to prevent wandering residents from entering. a. Review of R40's admission Record revealed the facility admitted the resident on 01/17/2024 with diagnoses to include unspecified dementia, epilepsy, and chronic obstructive pulmonary disease (COPD). Review of R40's quarterly MDS, with an ARD of 10/30/2024, revealed the facility assessed the resident to have a BIMS score of three of 15, indicating R40 was severely cognitively impaired. Observation on 04/24/2025 at 9:56 AM revealed R40 was sitting in a wheelchair. The resident was dressed in street clothes and was clean, with no odors or visible injuries. R40 did not show any signs of fear or anxiety. In an interview with R40 at the time of the observation, she stated she had not been harmed in the facility. She further stated, They better not, my father is a cop. She also stated she felt safe in the facility. b. Review of R169's admission Record revealed the facility admitted the resident on 02/17/2024 with diagnoses which included Alzheimer's disease, glaucoma, and degenerative disease of the nervous system. Review of R169's quarterly MDS, with an ARD of 08/25/2024, revealed the resident was not given a BIMS score because she was rarely/never understood. Observation on 04/24/2025 at 10:04 AM revealed R169 was sitting in the dining room. R169 was clean and did not have any odors or visible injuries. R169 did not show any signs of fear or anxiety. R169 was unable to be interviewed because of her cognitive status. In an interview with SRNA13 on 04/24/2025 at 10:14 AM, she stated she worked the evening of the event, 11/15/2024. SRNA13 stated she was down the hall, and staff heard a noise. She stated she and a nurse ran down the hall, and she heard R40 yell, You better get out of this room. She stated, when she got to the room, she saw R40 hit R169 in the face, and R40 fell. SRNA13 stated she took R169's vital signs and cleaned her nose. She stated R169 was not afraid, but she was confused because she did not know why R40 had hit her. In an interview with Licensed Practical Nurse (LPN) 4 on 04/24/2025 at 10:30 AM, she stated she worked the evening of the event, 11/15/2024. She stated she was at the end of her shift when she heard someone scream. She stated she ran down the hall and saw R40 hit R169 and fall. She stated she helped R40 up, and R40 stated, She [R169] was in my room. She stated she redirected both residents. She stated R40 told her that R40's ankle hurt. She stated R40 was sent out for an ankle x-ray. She stated both residents were placed on 15 minute checks. She stated R169 did not show signs of pain. She stated there had been no change in either residents' behavior. In an interview with the Social Services Director on 04/24/2025 at 2:52 PM, she stated if there was a resident-to-resident altercation, she did a psychosocial visit with each resident for three days. In an interview with the Director of Nursing (DON) on 04/23/2025 at 3:53 PM, she stated the main thing she did to prevent abuse was to educate staff so they knew if residents had certain behaviors, to monitor them closely. She also stated staff was proactive to prevent abuse. She stated staff met as a team to determine if any changes in resident behavior needed to be addressed. She stated staff did a 72 hour assessment of each resident if there was an altercation. She stated staff was trained to provide individualized care. In an interview with the Administrator on 04/23/2025 at 4:03 PM, he stated the main thing he did to prevent abuse was to do background checks and to train the staff. He stated staff was taught to monitor residents for any change in behaviors, and they knew to keep the residents safe. He stated staff was also taught to report abuse immediately. He stated he talked with residents, and they had resident council meetings. He stated whenever there was an allegation, he interviewed the residents involved. He stated the first thing staff was taught to do was to separate the residents and make sure they were safe. He stated staff then put the residents on one-on-one supervision. He stated he reported all allegations of abuse within two hours.

Based on interview, record review, and review of the facility's policies, the facility failed to notify the State Guardian and a representative from the Office of the State Long-Term Care (LTC) Ombudsman of its intentions to discharge a resident and the reasons for the discharge in writing for 1 of 27 sampled residents, Resident (R) 219. R219 was transferred to a Behavioral Health (BH) facility on 11/02/2024 from the facility for a psychiatric evaluation. On 11/11/2024, the Discharge Planner (DCP) at the BH facility notified the State Guardian that after discussions with the facility, the facility would not be accepting R219 back. The facility did not communicate this with the State Guardian or obtain the approval of the State Guardian. Additionally, the facility did not provide a written 30-day notification of transfer/discharge to the State Guardian or the office of the State Long-Term Care Ombudsman. The findings include: Review of the facility's policy titled, Transfer/Discharge Notice, revised 01/27/2025, revealed when the facility anticipated discharge, a post discharge plan of care was developed with the participation of the resident and with the resident's consent. The policy did not address the required 30-day Notice of Transfer/Discharge. Review of the facility's policy titled, Bed Hold, revised 01/27/2025, revealed the facility would provide written information to residents and/or their representatives regarding the bed hold policy. Per the policy, it ensured compliance with federal regulations and state Medicaid requirements while maintaining the rights and care continuity of residents. Review of an Acute Change in Condition Note, dated 11/02/2024 at 12:05 PM, found in R219's electronic medical record (EMR), revealed the resident was combative with staff. According to the note, R219 threw a coffee cup at a nurse and then began throwing computers from the nurse's station after threatening to punch the staff. Additionally, the note stated R219 directed racial slurs toward the staff. Per the note, the nurse failed to document the facility to which the resident was being transferred. According to the note, the State Guardian was not notified. The note stated, Family notification: self. Date notified: 11/02/2024 12:00 PM. Review of a Transfer and Discharge, notification, dated 11/02/2024 at 12:30 PM, revealed it was completed upon R219's transfer to the local emergency room. It stated that R219's Guardian was notified on 11/02/2024. It was recorded that R219 was unable to sign the form. Additionally, it was noted that a copy of the form was mailed to CHFS. However, there was no documentation explaining when, where, or how the form was sent to the responsible party. Review of a General Note, dated 11/02/2024 at 7:00 PM, found in R219's EMR, revealed the facility's nurse spoke to the nurse from the Behavioral Health (BH) facility. The note stated, They will be admitting resident for a 3-10-day program. Resident will discharge back to this facility thereafter. Supervisor notified. Additionally, it was documented that the BH facility would notify R219's State Guardian of the admission. Review of a Discharge Planner Clinical Note, dated 11/08/2024 at 11:44 AM, revealed the Discharge Planner at the BH facility attempted to call the Administrator. The note stated, Writer called [the facility] and asked to speak with an administrator in regard to [R219] Admin did not answer and writer left a VM with call back information. Review of a Discharge Planner Clinical Note, dated 11/08/2024 at 11:50 AM, revealed the Discharge Planner at the BH facility emailed R219's Guardian to inform him of R219's discharge date . According to the note, the Discharge Planner was unable to speak with staff at the facility. Review of an e-mail dated 11/11/2024, from the Discharge Planner at the BH facility to R219's State Guardian, revealed the Discharge Planner informed R219's Guardian that the facility would not readmit R219. Review of a Discharge Planner Clinical Note, dated 11/11/2024 at 12:43 PM, revealed the Discharge Planner at the BH facility called the facility in regard to R219. According to the note, [The facility] is not accepting [R219] and the Dr will not accept him back. Review of a Discharge Planner Clinical Note, dated 11/11/2024 at 12:48 PM, revealed the Discharge Planner at the BH facility emailed R219's Guardian. The note stated the Guardian was emailed informing him that R219 was not able to return to the facility. Review of an email from R219's Guardian to the Discharge Planner at the BH facility on 11/12/2024 at 8:54 AM, revealed the Guardian wrote that he was unaware that the facility would not accept R219 back. Review of an email from the Discharge Planner at the BH facility on 11/12/2024 at 8:59 AM, revealed she told the Guardian that the Director of Nursing at the facility informed her, due to R219's behavior, the facility's physician would no longer treat R219. Review of an email from R219's Guardian to the Discharge Planner at the BH facility on 11/12/2024 at 9:17 AM, revealed the Guardian wrote that he was still trying contact someone with [the facility] about the situation and the reasons for refusal to readmit. Review of an email from R219's Guardian to the Discharge Planner at the BH facility on 11/12/2024 at 4:18 PM, revealed that Guardian Services still planned to have R219 return to the facility when he was ready for discharge. Review of an email from the Supervisor of Guardian Services for the Cabinet for Health and Family Services (CHFS) to the facility's Administrator, dated 11/12/2024, revealed the Supervisor noted concerns about the facility refusing to allow R219 to return. She stated that no Discharge Notice had been issued, and without such notice, R219's rights were violated. Review of a letter from R219's Guardian to the Secretary of the CHFS, dated 11/18/2024, revealed it was in regard to an appeal of involuntary discharge from the facility and request for a stay of discharge. The letter stated, when the facility sent R219 to the local emergency department (ED) on 11/02/2024, it did not issue a bed hold notice or a discharge notice. Per the letter, the State Guardianship Office was made aware of the transfer only after the local hospital contacted them. The letter stated, on 11/02/2024, the local ED transferred R219 to a Behavioral Health (BH) facility for ongoing treatment. Per the letter, although R219 was ready to be discharged back to the original facility, on 11/11/2024, the BH facility informed the Guardian that the facility declined to readmit him. Further review of the letter revealed that, as of the date of the letter, the facility had not issued a written discharge notice despite being requested to do so, and they [the Guardian] had retained legal counsel to request a stay of discharge. Review of a letter from the Legal Aid Counsel to the facility's Administrator, dated 11/20/2024, revealed she had been retained to represent R219 because the facility wrongfully dumped [R219] at the hospital and refused to readmit him. Review of an email from the facility's Administrator to the Psychiatric Hospital, dated 11/21/2024 at 10:20 AM, revealed the Administrator requested documentation that R219 was not a danger to self or others. Review of an email from the facility's Administrator to R219's Counsel, dated 11/21/2024 at the 11:21 AM, revealed if R219 did not pose a threat to himself or others, the facility would readmit R219. Review of an Order Staying Discharge, dated 11/22/2024 and filed on 11/26/2024, revealed the facility was prohibited from taking any further actions or steps toward discharging R219. According to the Order, the State Guardian, on behalf of R219, claimed the facility took actions to involuntarily discharge R219 without a notice of discharge or notification of bed hold. Review of R219's Face Sheet found in the resident's EMR revealed the facility initially admitted the resident on 09/10/2023 with diagnoses to include dysphagia, schizophrenia, and bipolar disorder. Review of the R219's annual Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 09/18/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of eight of 15, which indicated the resident had moderate cognitive impairment. During an interview with the Business Office Manager (BOM) on 04/22/2025 at 2:25 PM, she stated the nurse was responsible for completing the Transfer/Discharge sheet, which included the reason for transfer or discharge, the facility to which the resident was being transferred, and an explanation of the Bed Hold policy. She stated the white copy was given to the resident to take to the hospital; the yellow copy was kept for the resident's EMR; and the pink copy was provided to the resident's responsible party. She stated the facility would mail the pink copy to the resident's Power of Attorney (POA), Resident Representative (RR), or resident's State Guardian. She stated the notice was sent by regular mail, and the yellow copy would indicate mailed if it had been sent. Additionally, she stated the Ombudsman received last month's transfer/discharge information at the beginning of each month. She stated she gave R219 a copy of the bed hold policy and mailed a copy to the Resident's Guardian. During an interview with the Director of Nursing (DON) on 04/22/2025 at 2:35 PM, she stated the floor nurse on duty was responsible for notifying the resident, the resident's representative (RR), and/or the guardian about the provider's order for transfer. She stated the resident's representative was informed of the reason for the transfer and the facility to which the resident was being transferred. The DON stated nursing staff was responsible for completing the Transfer/Discharge form, which included the reason for the transfer or discharge, the name of the facility where the resident was being transferred, and an explanation of the Bed Hold policy. The DON stated the nurse must ensure the receiving hospital received a report on the resident, including the reason for the transfer. She stated, while these notifications should occur in a timely manner, they could sometimes be delayed in emergency circumstances. The DON stated the nurse should complete the bed hold/transfer paperwork, which accompanied the resident. She stated one copy of the paperwork was scanned into the resident's chart. Additionally, the DON stated the Business Office followed up with the resident's representative or guardian on the next business day. She stated notification to the RR was important to ensure compliance with the resident's rights. During a telephone interview with R219's Legal Counsel (LC) on 04/24/2025 at 8:36 AM, she stated she was retained by the State Guardian's Office in 11/2024 after R219 was not allowed to return to the facility from the BH facility on 11/11/2024. She stated there was no notice of discharge provided to the Guardian. Furthermore, the LC stated, according to the Guardian, he and the Discharge Planner at the BH facility had difficulty reaching anyone at the facility to discuss the matter. She stated the Guardian was told by the Discharge Planner on 11/11/2024 that the facility would not be readmitting R219. The LC stated on 11/20/2024 she sent the facility's Administrator a letter that she was retained as R219's counsel because the facility dumped R219 at the hospital and refused to readmit him. She stated she also notified the facility's Administrator that she had filed a motion to stay his discharge. During an interview with the Guardian on 04/24/2025 at 9:36 AM, he stated, on 11/02/2024, R219 exhibited a change in condition to include behaviors. He stated the facility sent R219 to the local ED, and R219 was not admitted to that hospital but was sent to a BH facility on the same day. The Guardian stated, on 11/04/2024, R219 was admitted to the local hospital from the BH facility due to having seizures and was discharged back to the BH facility on 11/06/2024. The Guardian stated R219 went from the BH facility to a Psychiatric hospital on [DATE], and finally returned to the facility on [DATE] after a Court Order staying the discharge. The Guardian stated he was informed by the Discharge Planner at the BH facility that the facility would not accept R219 back due to needing a higher level of care and continued behavioral issues. He stated both he and the Discharge Planner would contact the facility regarding R219; however, no one at the facility would return their calls. He stated, We did not receive a bed hold or notice of discharge. Additionally, the Guardian stated the facility did not accept R219 back until the facility was presented with a stay of discharge by R219's counsel. During a telephone interview with the District LTC Ombudsman on 04/22/2025 at 10:25 AM, she stated R219 was sent to a Behavior Health (BH) facility on 11/02/2024. She stated when the BH facility's Discharge Planner attempted to notify the facility of R219's anticipated discharge, they would not return her calls. The Ombudsman stated the facility did not want to take R219 back because they felt he was not appropriate for the facility due to recent behaviors. She stated the District LTC Ombudsman's office was not notified of the facility's intention to discharge R219 after his transfer to the BH facility in November 2024. She stated the facility did not notify her in writing with a 30-day Notice of Discharge letter, and that was why they had to bring him back to the facility. She stated she notified Legal Aid of the situation when she was made aware. She stated, When there is a non-admit, a discharge appeal is made to legal aid. She stated R219 stayed longer than necessary at the BH facility, ultimately being sent to the State Psychiatric Hospital. The Ombudsman stated the facility had a history of sending off [residents] to the hospital and dumping. She stated the facility did not communicate well with the Ombudsman on necessary matters. She stated she received emails from the facility at the beginning of the next month regarding all prior month's transfer/discharges. During an interview with the facility's Administrator on 04/23/2024 at 11:30 AM, he stated R219 was sent to a BH facility on 11/02/2024, for evaluation, due to his inappropriate outbursts and conduct toward staff. The Administrator stated he did not send a Notice of Transfer/Discharge to R219's Guardian or Ombudsman after the transfer to the BH facility because it was not their intent to refuse to readmit R219. He stated the BH facility transferred R219 to the State Psychiatric Hospital (SPH) on 11/14/2024. He stated upon R219's arrival at the SPH, the facility then required documentation from the physician treating R219 to confirm that he was no longer a danger to himself or others. Furthermore, the Administrator stated the only delay in transferring R219 back to the facility was waiting for the paperwork indicating R219 did not pose a potential harm to himself or others. He stated R219 was admitted back into the facility from the SPH on 11/26/2024. During continued interview with the Administrator on 04/23/2024 at 11:30 AM, he stated R219 exhibited numerous behaviors over his course of stay at the facility that caused over $10,000 in damage to equipment. He stated R219 displayed verbal and physical abuse toward staff. He stated R219 wanted to move to a personal care home, but his appointed State Guardian would not allow it due to R219's health situation, which required a higher level of care and a modified diet. He stated once the facility conducted a modified barium swallow (MBS) study, which R219 passed, he was later able to transition to a lower level of care. The Administrator stated once back from the SPH, and after he passed the MBS study, R219 continued to have outbursts, prompting the facility to provide the resident and his representatives with a 30-day Notice of Transfer/Discharge. He stated R219 was discharged from the facility to a lower level of care in early 2025. During an additional interview with the Administrator on 04/23/2025 at 3:00 PM, he stated, despite R219 being under the care of the facility's in-house psychiatric service, R219 exhibited continued disruptive behaviors, including breaking property and striking a nurse with a pill crusher. He stated these episodes were becoming more frequent and severe. The Administrator stated the facility determined that R219 needed inpatient psychiatric services. He stated the reason for discharge was not related to the resident's clinical or behavioral condition. He stated he was only concerned about R219's potential to endanger himself and the safety of others within the facility. The Administrator stated it was important to follow the facility's policy to ensure compliance related to all transfers and discharges. During an interview with the Regional [NAME] President (RVP) on 04/23/2025 at 3:00 PM, he stated the facility could address the resident's activities of daily living (ADL) and medical needs. However, they noted the resident would become upset, leading to property destruction. The RVP maintained the reason for discharge was not related to the resident's clinical or behavioral condition. He stated that adhering to the facility's discharge policy was important to remain compliant. During an interview with the Medical Director on 04/24/2025 at 5:36 PM, she stated the facility initiated R219's transfer due to behavioral issues and R219's need for continuous one-on-one care. She stated the facility offered both inpatient and outpatient psychiatric services, and the contracted psychiatric provider had oversight of R219's behavioral health needs. Additionally, she stated the facility would not refuse to readmit R219 because of behavioral concerns. The Medical Director stated the facility had adequate staff to care for R219. She stated she was not consulted about the plans for R219's discharge after he was admitted to the Psychiatric Hospital in 11/2024.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs for eight (8) of one hundred and four (104) sampled residents (Resident #3, #63, #112, #101, #105, #126, #71, and #86). 1. Resident #3 developed a Stage 4, facility-acquired avoidable pressure ulcer. The facility failed to develop and implement a Comprehensive Care Plan (CCP) for Resident #3 to prevent development of a pressure ulcer by offloading (shifting weight) and to ensure the wound bed of the pressure ulcer remained as dry as possible, due to the resident's urostomy/ileostomy (surgically created outlet on the abdomen for passage of urine), which frequently leaked. 2. Resident #63 eloped from the facility on 06/11/2022. The facility failed to develop and implement interventions on Resident #63's care plan to prevent the elopement. 3. Resident #112 eloped from the facility on 10/16/2022. The facility failed to develop and implement interventions on Resident #112's care plan to prevent the elopement. In addition, the facility failed to identify and develop an intervention on the care plan for Resident #112's inability to consent to sexual activity with any other person. 4. Resident #101 engaged in sexual activity with another resident. The facility failed to identify and develop an intervention on the care plan for Resident #101's inability to consent to sexual activity with any other person and to ensure his/her safety. In addition, the facility failed to implement the CCP for Resident #101 which directed staff to use the Language Line or interpreter services to effectively communicate with the resident. This led to the facility's inability to properly assess Resident #101's needs. 5. Resident #105 had an indwelling urinary catheter. The facility failed to implement Resident #105's care plan related to maintaining the catheter bag off the floor, providing a dignity bag, and utilizing a leg bag when appropriate. 6. Resident #126 had a gastrostomy (G-tube) for feedings. The facility failed to implement care plan interventions to prevent skin excoriation around the G-tube insertion site. 7. Resident #71 expressed concerns about his/her wheelchair brake not working properly, and the fear of falling during a transfer if his/her wheelchair moved. The facility failed to develop a care plan intervention to ensure staff was aware of the resident's concerns and put a plan in place to prevent the chair from moving. 8. Resident #86 had a G-tube for feedings. The facility failed to implement care plan interventions to prevent skin excoriation around the G-tube insertion site. The findings include: Review of the facility's policy, Comprehensive Person-Centered Care Plans,dated 03/2022, revealed person-centered care plan interventions were derived from a thorough analysis of information gathered as a part of the comprehensive assessment and were to address the underlying causes of the problem area, not just the symptoms. Further review revealed the care plan included measurable objectives and timeframes and described services furnished to the resident to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. Additionally, the policy revealed the care plan reflected currently recognized standards of practice for problem areas and conditions. Review of the facility's policy, Resident's Rights, dated 11/28/2016, revealed the resident had the right to receive the services and/or items included in the resident's plan of care. 1. Review of Resident #3's Admission Record revealed the facility admitted the resident on 01/03/2023 with diagnoses including paraplegia, spina bifida, epilepsy, and colostomy status. Review of Resident #3's Quarterly Minimum Data Set (MDS) Assessment, dated 01/21/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having a Stage 4 facility acquired pressure ulcer and dependent on staff for bed mobility and transfers. Additional review revealed the facility assessed the resident to be able to roll a manual wheelchair 150 feet once seated in the wheelchair. Review of Resident #3's care plan, initiated 01/04/2023 and last updated 01/11/2024, revealed the facility identified the resident was at risk for pressure ulcer development and included interventions such as assisting and encouraging the resident to reposition every one (1) to two (2) hours due to decreased sensation in his/her lower extremities. Further review revealed the facility noted in the interventions that Resident #3 preferred to stay up in his/her wheelchair for long periods of time without taking breaks back in bed. However, the facility failed to include resident-centered interventions to encourage the resident to shift his/her weight for off-loading in the wheelchair. Continued review revealed the facility failed to include interventions to address the need to ensure the wound bed remained as dry as possible, due to the resident's urostomy/ileostomy (surgically created outlet on the abdomen for passage of urine), which frequently leaked. Review of Resident #3's Kardex (care plan form utilized by State Registered Nurse Aides (SRNAs)), dated 02/27/2024, revealed the Kardex described Resident #3 as requiring accommodation for cognitive limitations by reminders and demonstration of care tasks. Further review revealed the Kardex described Resident #3 as requiring encouragement and assistance from staff with turning and repositioning every one (1) to two (2) hours. In an interview on 02/26/2024 at 6:28 PM, Resident #3 stated he/she developed pressure ulcers while a resident in the facility from staff leaving him/her in bed too long. He/she further stated that, due to short-term memory problems secondary to a seizure disorder, he/she was dependent on staff for repositioning reminders, as well as physical assistance. Resident #3 stated he/she wanted to be in his/her wheelchair to move about in the facility to maintain mobility and strength in his/her upper arms, as well as to participate in activities and socialize with other residents. Continuous observation on 02/29/2024, from 1:30 PM through 3:46 PM, revealed staff failed to remind Resident #3 about repositioning in his/her wheelchair and failed to assist him/her with repositioning. Observation on 02/29/2024 at 3:39 PM, revealed staff failed to identify that Resident #3's ileostomy was leaking, even when there were wet spots on the floor beneath the resident's wheelchair and the area smelled of urine. In an interview on 02/29/2024 at 4:21 PM, SRNA #17 stated she saw Resident #3 in his/her wheelchair in the dining room for an extended period of time earlier in the afternoon. Per interview, SRNA #17 stated Resident #3 was able to lift up using his/her arms to reposition while in the wheelchair but required cueing due to short-term memory problems. SRNA #17 stated she failed to remind and encourage Resident #3 to reposition in his/her wheelchair while sitting in the wheelchair during activities. In an interview on 03/06/2024 at 2:38 PM, Licensed Practical Nurse (LPN) #7 stated SRNAs needed to check Resident #3's briefs every two (2) hours because the resident's urostomy leaked frequently and keeping his/her wound area free from urine was important for healing. LPN #7 further stated if keeping the wound free from urine was not already included as an intervention on the care plan, it should have been. LPN #7 stated the physical and occupational therapy goals and interventions were not included on the care plans where nursing staff could see them, so they could not incorporate those interventions in other areas of care, such as wound off-loading. In an interview on 02/28/2024 at 8:11 AM, the Wound Care Nurse stated, in his opinion, the biggest obstacle to healing Resident #3's wound was keeping it dry. He stated Resident #3 would receive the most benefit from offloading if he/she would agree to lay back in bed after being up in the wheelchair for a maximum of three (3) hours In additional interview on 03/07/2024 at 1:47 PM, the Wound Care Nurse stated it was the role of nursing management to add interventions to the care plan. Per interview, the wound care nurse believed having a schedule for getting Resident #3 up and a scheduled time determined by the resident to lie back down in bed for offloading would be beneficial to balance resident preference and need to promote wound healing, but the facility had not attempted this intervention. In an interview on 03/05/2024 at 10:30 AM, the Advanced Practice Registered Nurse (APRN) stated staff should be assisting/reminding Resident #3 to shift his/her weight while sitting in the wheelchair according to the care plan. In an interview on 03/08/2024 at 3:52 PM, the Minimum Data Set Coordinator (MDSC) stated adding care plan interventions for wound care was the responsibility of the Wound Care Nurse. She stated she attended Interdisciplinary team (IDT) meetings but did not recall the team discussing the difficulty with keeping Resident #3's wound dry. The MDSC stated she did not know what interventions were included for Resident #3's wound care. In an interview on 03/08/2024 at 4:25 PM, the Administrator stated she expected care plans for wound care to be resident-centered and to address the root cause of the resident's problem. She further stated the Wound Care Nurse and the APRN took care of wound care interventions. 2. Review of Resident #63's Face Sheet revealed the facility admitted the resident on 12/08/2020 with diagnoses of chronic obstructive pulmonary disease (COPD), epilepsy, and vascular dementia unspecified severity with agitation. Review of Resident #63's Quarterly Minimum Data Set (MDS) Assessment, dated 03/15/2022, revealed the facility did not complete a Brief Interview for Mental Status (BIMS), and assessed the resident for partial to moderate assistance for toileting transfer, self-showering, upper/lower body dressing, putting on and taking off shoes, and independent ambulation without an assistive device. The facility assessed the resident to be absent of any behaviors. The previous Annual MDS Assessment, dated 10/19/2021, revealed the facility assessed the resident to have a BIMS score of eleven (11) of fifteen (15), signifying moderate cognitive impairment. Review of Resident #63's Comprehensive Care Plan (CCP), initiated 07/12/2021, with a focus area for elopement risk related to the resident's expressed desire to leave the facility prematurely, not medically ready for discharge. Interventions were for staff to monitor the nature and circumstances of attempted elopement; during specific activities and involvement with other residents, watch for exit seeking; encourage the resident to participate in activities; allow the resident to express his/her feelings; provide empathy and encouragement; familiarize the resident with his/her belongings and surroundings; redirect the resident when near exits; and check wander guard for placement and operation (07/12/2021). Additionally, staff was to use redirection techniques with television, snacks, and activities (01/02/2022) and observe for risk factors and exit seeking behaviors (06/17/2022). Review of the facility's investigation, dated 06/11/2022, revealed the written statement from State Registered Nurse Aide (SRNA) #44 who reported after picking up breakfast trays on 06/11/2022, Resident #63 went to the 100 Hall Nurse's Station and told staff he/she was going to leave, and they were holding him/her hostage and against his/her will. She noted, after the supervisor talked with Resident #63, and he/she appeared fine, Resident #63 eloped from the facility. In an interview with Licensed Practical Nurse (LPN) #1 on 02/29/2024 at 2:20 PM, she stated once Resident #63 started showing signs of exit seeking behavior on 06/11/2022, he/she should have been placed on increased supervision. She stated any time a resident showed signs he/she might try to leave the facility, staff members should continue to watch them until they were sure the behavior was no longer present. She stated if the behavior was present for more than twenty-four (24) hours, it needed to be reported to management, and the management team would discuss it and determine what new interventions should be established. She stated it was reasonable to use one-to-one (1:1) supervision or fifteen (15) minute checks for exit seeking, to make sure the resident did not get out of the facility. 3. Review of Resident #112's Face Sheet revealed the facility admitted the resident on 08/02/2022 with diagnoses of dementia with agitation, dysphagia oral phase, and Alzheimer's (10/11/2022). Review of Resident #112's Quarterly Minimum Data Set (MDS) Assessment, dated 05/03/2023, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of six (6) of fifteen (15), signifying severe cognitive impairment. The resident was noted without behaviors during this assessment. He/She was assessed for partial/minimal assistance with toileting hygiene, maximum assistance for showering, supervision for upper/lower body dressing, and set-up/clean-up for all bed mobility. The resident was assessed to walk 150 feet independently. Review of Resident #112's Comprehensive Care Plan (CCP) revealed the facility initiated an Elopement care plan, related to the resident's exit seeking behaviors and related to cognitive loss and dementia (08/08/2022). The interventions were to monitor the nature and circumstances of exit seeking during activities; encourage the resident to participate in activities of choice; use and monitor security bracelet (wander guard) per protocol (Administrator stated they did not have a wander guard policy/procedure); divert the resident's attention by giving objects to hold; familiarize resident to his/her own belongings (08/08/2022); as appropriate redirect resident if near exits or doorways; ensure supervision during smoke breaks (10/12/2022); use wander guard as ordered (05/04/2023); and staff was to observe for risk factors/triggers for exit seeking behaviors, increased wandering, and to offer diversions (10/11/2023). Further review revealed there was no intervention developed to address Resident #112's inability to consent to sexual activity with any other person. Review of the facility's final report, undated, revealed, on 10/11/2022, Resident #112 was discovered outside the facility, nearby the local golf course, and had exited the facility while on a smoking break. The report stated the resident was outside the facility for approximately fifteen (15) minutes. Per the report, the resident was placed on one-to-one (1:1) supervision upon return, and when the resident's wander guard was checked for proper operation, there was no wander guard on the resident. In an interview with SRNA #9 on 02/27/2024 at 9:43 AM, she stated Resident #112 had a history of wandering and getting into other residents' property. She stated she believed the resident was care planned for extra supervision and for the wander guard. SRNA #9 stated the care plan should always be current and old interventions should have been removed. SRNA #9 stated staff was expected to follow the care plan/Kardex for every resident, and if staff did not follow the plan, a resident could be hurt or not get the proper care he/she needed. In an interview with Licensed Practical Nurse (LPN) #1 on 02/29/2024 at 2:20 PM, she stated Resident #112 required a lot of redirection. She stated the resident often wandered up near the front door, and that was a concern. LPN #1 stated any concerns needed to be documented on the care plan. 4. Review of Resident #101's Face Sheet, revealed the facility last admitted the resident on 10/22/2022 for a change in mental status. Previously the resident was admitted on [DATE] for diagnoses of calorie malnutrition, mild cognitive impairment, and unspecified hearing loss in both ears. The facility diagnosed the resident with dementia on 02/21/2024. Review of Resident #101's Admission Minimum Data Set (MDS) Assessment, dated 03/02/2022, revealed no Brief Interview for Mental Status (BIMS) score was indicated. The facility did not identify any behaviors present at this time. It was noted the resident was independent for all self care, needed some help for indoor mobility, and was not assessed for walking related to safety concerns. Section A, to identify the resident's language and desire for an interpreter was not completed. Review of Resident #101's Quarterly MDS Assessment, dated 05/01/2023, revealed the facility failed to identify a BIMS and no behaviors were noted. Section A, for the resident's language and desire for an interpreter was also incomplete. Review of Resident #101's Comprehensive Care Plan revealed the facility was to ensure the availability and functioning of adaptive resources/equipment specifically the language line, message/communication board, cue cards, etc. and to provide preferred (primary) language interpreter services such as the language line as indicated (10/26/2022). Further review revealed there was no intervention developed to address Resident #101's inability to consent to sexual activity with any other person. Review of Resident #101's Progress Notes, from 02/25/2022 to 03/04/2024, revealed sixteen (16) times staff referred to the resident's language barriers as a reason for their inability to communicate with the resident and/or assess the resident. In an interview with State Registered Nurse Aide (SRNA) #8 on 02/27/2024 at 12:20 PM, she stated aides did not have access to the care plans, but aides could see tasks linked to the Kardex. She stated the Kardex was the information used to know how to care for each resident. SRNA #8 stated she never used a Language Line with Resident #101, and she did not know how to access a language line for help. She stated when she worked with Resident #101, she usually pointed at an item and used one-word phases, and they seemed to do okay. SRNA #8 stated she could not recall if the use of a Language Line was noted on the resident's Kardex. She stated it was important to follow the Kardex because that information was what was needed to give the resident the best care. In an interview with Licensed Practical Nurse (LPN) #5 on 03/01/2024 at 8:55 AM, she stated she knew the resident was care planned for the use of a Language Line, but she had never been told how to contact a Language Line or any kind of interpreter services. In an interview with Registered Nurse (RN) #2 on 03/05/2024 at 2:20 PM, She stated she could not recall if Resident #101 was care planned for the use of a Language Line, but she did not ever recall using the Language Line to communicate with the resident. She stated she treated the resident like she would any other resident who had dementia and low cognitive ability. In an interview with State Registered Nurse Aide (SRNA) #7 on 03/01/2024 at 1:49 PM, she stated once she arrived for her shift at 7:00 AM on 06/26/2023, she was told by the off going shift to watch Resident #101 and Resident #112 because they had showed sexual behavior toward each other in a room. She stated the two (2) residents had been separated at that time. SRNA #7 stated she went to locate the residents, and she observed Resident #101 and Resident #112 in the dining room engaging in sexual behavior. Review of the facility's Five Day report, dated 06/29/2023, revealed Resident #101 and Resident #112 had been found together in bed, engaged in intimate activity prior to the incident in the dining room. In an interview with the Director of Nursing (DON) on 03/07/2024 at 3:01 PM, she stated if Resident #101 and Resident #112 were found in bed together prior to being found in the dining room engaged in sexual contact, the nursing staff on that shift should had put an intervention in place to keep the two (2) separated or provide extra supervision for both residents to prevent further prohibited contact. 5. Review of Resident #105's Admission Record revealed the facility admitted the resident on 01/15/2024 with diagnoses including metabolic encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection, and hemiplegia (partial paralysis) following cerebral infarction (stroke). Review of Resident #105's Admission Minimum Data Set (MDS) Assessment, dated 01/22/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fourteen (14) of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident to have an indwelling catheter, to be always incontinent of bowel, and to need staff supervision for toileting hygiene. Review of Resident #105's care plan, dated 01/16/2024, revealed the facility identified the resident as requiring an indwelling catheter and included interventions such as keeping the catheter off the floor and providing catheter care twice daily and as needed. Further review revealed catheter interventions, such as providing for privacy, which included the use of a privacy bag. Observation on 02/26/2024 at 5:38 PM, 02/27/2024 at 10:03 AM, 02/28/2024 at 2:39 PM and at 3:46 PM, revealed Resident #105's catheter drainage bag dragging on the ground beneath his/her wheelchair. Observation on 02/26/2024 at 5:38 PM, 03/05/2024 at 1:44 PM, 03/06/2024 at 3:40 PM, and on 03/07/2024 at 8:20 AM revealed the facility failed to have a dignity bag covering Resident #105's catheter bag. Observation on 03/07/2024 at 9:01 AM revealed State Registered Nurse Aide (SRNA) #20 failed to pull the curtain around Resident #105's bed when she pulled Resident #105's covers off his/her bed to assist the resident with morning hygiene and catheter care. SRNA #20 left the room and let the door open, leaving the resident exposed to the hallway. Continued observation on 03/07/2024 at 9:19 AM, revealed SRNA #3 knocked on the door and opened it. Resident #105 flinched and moved his/her hands in front of his/her genitals. SRNA #3 quickly closed the door but opened and closed it again without knocking with the resident still exposed for catheter care. In an interview on 03/08/2024 at 12:28 PM, SRNA #20 stated she did not realize she did not close the door behind her when she left Resident #105 uncovered. SRNA #20 stated she had received no facility specific training on processes at the facility and did not know what interventions were listed in residents' care plans. In an interview on 03/02/2024 at 11:15 AM, Licensed Practical Nurse (LPN) #7 stated residents with catheters, including Resident #105, should always have a dignity bag in place according to the care plan. In another interview on 03/06/2024 at 8:24 AM, LPN #7 stated she put a leg bag on, and the resident was care planned to be able to use it. However, she stated other staff kept switching it back to a traditional bag that ended up dragging on the floor. 6. Review of Resident #126's Admission Record revealed the facility readmitted the resident on 12/21/2023 with diagnoses that included moderate protein-calorie malnutrition, emphysema, and cerebral infarction. Review of Resident #126's Quarterly Minimum Data Set (MDS) Assessment, with a reference date of 12/23/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15), which indicated the resident had severe cognitive impairment. Review of Resident #126's Comprehensive Care Plan (CCP) revealed the facility identified the resident to have enteral nutrition requiring tube feeding by a gastrostomy (G-tube) initiated on 12/21/2023. Continued review revealed the interventions included staff was to 1) clean the skin around the stoma and keep a dressing applied as ordered; 2) inspect the skin around the stoma site for signs and infections; 3) inspect the tube for inward or outward migration; and 4) observe for leakage and monitor absence or presence of drainage and or signs or symptoms of infection at the tube site. Observation on 03/01/2024 at 8:35 AM of Resident #126's G-tube site, with State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) #12, revealed the site was excoriated (chafing/wearing off of skin) and had an area covering the upper half portion of the tube insertion site where a dried dark brown crusted substance had formed. There was no dressing covering the G-tube insertion site. Additional observation on 03/01/2024 at 1:25 PM revealed Resident #126's G-tube site remained excoriated, with the dried dark brown crusted substance remaining on the upper half of the tube insertion site. There was no dressing covering the G-tube insertion site. During an interview with Licensed Practical Nurse (LPN) #7 on 02/29/2024 at 8:05 AM, she confirmed Resident #126 had a G-tube, stated floor nurses were responsible for providing treatments to the residents. She emphasized the importance of following the care plan to ensure the resident received appropriate care to manage his/her G-tube site to prevent infections and skin breakdown. During an interview on 03/03/2024 at 11:15 AM, LPN #1 stated nurses could update the care plan, but it was usually the Unit Managers that added an intervention. She stated for a G-tube site, nurses should clean the skin around the stoma and keep a dressing applied if ordered. Additionally, she stated the nurse should check drainage and or signs or symptoms of infection at the tube site. In an interview on 03/08/2024 at 3:52 PM, the Minimum Data Set Coordinator (MDSC) stated adding care plan interventions for G-tube sites was the responsibility of the Unit Manager. The MDSC stated she did not know what interventions were included for Resident #126's G-tube site management. During an interview with Director of Nursing (DON) #1 on 03/08/2024 at 10:15 AM, she stated it was her expectation that all staff provided residents with competent care including performing ordered treatments and following the care plan. During an interview with DON #2, the current DON, on 03/08/2024 at 11:43 AM, she stated a tube feed insertion site should always be cleaned and covered with a split gauze dressing. DON #2 stated it was important to follow the care plan to provide proper site care for tube feed insertion sites to prevent infections and excoriation. During an interview with Resident #126's healthcare provider on 03/05/2024 at 10:30 AM, she stated Resident #126's G-tube was placed because the resident had experienced aspiration pneumonia, and the resident was currently stable. She further stated it was important for Resident #126 to receive G-tube site care as care planned and ordered to prevent complications and to assess for infection at the insertion site. 43694 7. Review of Resident #71's Face Sheet revealed the facility admitted the resident on 11/13/2023 with diagnoses of fracture to right femur, infection due to right hip prosthesis, and obesity. The resident was admitted for rehabilitation services while waiting for a second hip surgery. Review of Resident #71's Quarterly Minimum Data Set (MDS) Assessment, dated 01/19/2024, revealed the facility assessed the resident to have a Brief Interview of Mental Status (BIMS) score of fifteen (15) of fifteen (15), signifying the resident was cognitively intact. The facility assessed the resident for supervision and touch assistance for toileting hygiene, sit to stand mobility, chair to bed to chair transfer and for using the toilet. The resident was wheelchair bound, awaiting hip surgery. Review of Resident #71's Comprehensive Care Plan Activity of Daily Living (ADL) focus, dated 11/07/2023, revealed the resident had impaired physical functioning related to the surgical incision to the right hip. The care plan showed the resident required the assistance of one (1) staff for all ADL care. In an interview with Resident #71 on 03/01/2024 at 9:15 AM, the resident reported he/she was in the facility for rehabilitation services, after all the hardware in his/her hip had to be removed because of an infection. The resident stated his/her wheelchair had been unserviceable for several months, and he/she was told by maintenance they were waiting on a part. The resident stated the facility provided another wheelchair for temporary use; however, the resident said the brake on that chair did not hold well either and made it risky during transfers. In an interview with Occupational Therapist (OT) on 02/28/2024 at 2:05 PM, she explained she was concerned about Resident #71 not having his/her correct wheelchair and the possibility of setbacks if the resident fell because he/she did not have the proper wheelchair. The OT stated she thought an intervention should have been placed on the resident's care plan to ensure staff members were aware of Resident #71's concern about falling and to take extra care to ensure the wheelchair was secure prior to any transfers. In an interview with State Registered Nurse Aide (SRNA) #9 on 02/27/2024 at 9:43 AM, she stated Resident #71 often tried to get up to his/her wheelchair without assistance. She stated staff had asked the resident to use his/her call light and wait on staff for assistance. SRNA #9 stated the resident was care planned for assistance of one (1) staff member for all Activities of Daily Living (ADL) care. She stated she knew the resident sometimes transferred himself/herself because he/she could not wait to get to the bathroom. She stated that should be noted on the resident's care plan. 49267 8. Review of Resident #86's Face Sheet revealed the facility admitted the resident on 09/28/2020 with diagnoses of metabolic encephalopathy, dysphagia, and chronic kidney disease. Review of Resident #86's Quarterly Minimum Data Set (MDS) Assessment, Section C, dated 02/21/2024, revealed there was no score on the resident's BIMS. The resident was assessed as rarely/never understood. Review of Resident #86's Comprehensive Care Plan, revised 08/11/2023, revealed an intervention that included the skin around the gastrostomy (G-tube) site was monitored, skin care was performed, and dressing placed as ordered. Observation of Resident #86's G-tube insertion site on 02/28/2024 at 8:18 AM, revealed the absence of a gauze dressing. Additional observation revealed the insertion site was not clean, with crusted areas that surrounded the insertion site and a dime-sized amount of dried yellowish-white drainage. No odors were noted. In an interview with LPN #5 on 02/28/2024 at 8:18 AM, she stated she was Agency staff but had worked at the facility for a year. She further stated a tube feed insertion site should be cleaned daily and should have a gauze dressing in place against the skin. In an interview with Licensed Practical Nurse (LPN) #5 on 03/01/2024 at 8:55 AM, she stated the care plan was the plan of care for each resident, and it should be specific to that resident. She stated it should always be followed because that was how staff could make sure the resident received proper care. LPN #5 stated if the care plan was not followed, then staff was not meeting the needs of the resident. In an interview with Licensed Practical Nurse (LPN) #1 on 02/29/2024 at 2:20 PM, she stated all staff needed to know what residents were care planned for and use the interventions in place to prevent any incidents or bad care. She stated if the care plan was not followed for residents, staff members were not doing what they were supposed to do for that resident to get the best possible care. LPN #1 stated only man [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to provide services to prevent pressure ulcers for one (1) of one hundred and four (104) sampled residents (Resident #3). Resident #3's Admission Minimum Data Set (MDS) Assessment, dated 01/09/2023, indicated the resident had no skin breakdown. However, thirty-seven (37) days from admission the Advanced Practice Registered Nurse (APRN) documented a wound on Resident #3's left ischium (lower part of the hip) as moisture associated breakdown. Additionally, seventy-one (71) days from admission the APRN documented Resident #3's wound as a stage 4 pressure wound. Observation during the survey revealed Resident #3 sat in a heavily soiled brief, which caused the dressing to be displaced. Further observation revealed staff failed to encourage the resident to off-load pressure from the wound for longer than two (2) hours. The findings include: Review of the facility's policy, Prevention of Pressure Injuries, revised 04/2020, revealed the facility was to provide care to prevent pressure ulcer development, to include repositioning on a schedule as determined by the interdisciplinary care team (IDT), choose a repositioning frequency based on the resident's risk factors, and to remind residents to change positions if they were able to reposition independently. Further review revealed pressure ulcer prevention also included cleaning the resident promptly after incontinence episodes. Review of Resident #3's Admission Record revealed the facility admitted the resident on 01/03/2023 with diagnoses including paraplegia, spina bifida, epilepsy, and colostomy status. Review of Resident #3's Admission MDS Assessment, dated 01/09/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as dependent on staff for bed mobility and transferring. Continued review revealed the facility assessed the resident's skin as free from pressure ulcers. However, the facility did assess the resident as at risk for pressure ulcer development. Review of Resident #3's Discharge (return anticipated) Minimum Data Set (MDS) Assessment, dated 03/06/2023, revealed the facility identified the resident as having a stage 3 pressure ulcer that was not present on admission. Review of Resident #3's Quarterly MDS Assessment, dated 01/21/2024, revealed the facility assessed the resident to have a BIMS score of thirteen (13) of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having a stage four (4) facility acquired pressure ulcer. Continued review revealed the facility assessed Resident #3 as dependent on staff for bed mobility and transfers. Additional review revealed the facility assessed the resident to be able to roll a manual wheelchair 150 feet once seated in the wheelchair. Review of Resident #3's care plan, initiated 01/04/2023 and last updated 01/11/2024, revealed the facility identified the resident was at risk for pressure ulcer development and included interventions such as assisting and encouraging the resident to reposition every one (1) to two (2) hours due to decreased sensation in his/her lower extremities. Further review revealed the facility noted in the interventions that Resident #3 preferred to stay up in his/her wheelchair for long periods of time without taking breaks back in bed. However, the facility failed to include resident-centered interventions to encourage the resident to shift his/her weight for off-loading in the wheelchair. Continued review revealed the facility failed to include interventions to address the need to ensure the wound bed remained as dry as possible, due to the resident's urostomy/ileostomy (surgically created outlet on the abdomen for passage of urine), which frequently leaked. Review of Resident #3's Kardex (care plan form utilized by State Registered Nursing Assistant (SRNA)), dated 02/27/2024, revealed the Kardex described Resident #3 as requiring accommodation for cognitive limitations by reminders and demonstration of care tasks. Further review revealed the Kardex described Resident #3 as requiring encouragement and assistance from staff with turning and repositioning every one (1) to two (2) hours. Review of Resident #3's Progress Notes from the electronic health record (EHR) revealed, on 02/15/2023, Licensed Practical Nurse (LPN) #10 documented Resident #3 had a newly identified area of Moisture Associated Skin Damage (MASD), which was the first note documenting the wound on Resident #3's left ischial tuberosity (lower part of the pelvis, or sit bones). Further review revealed on 02/21/2023, the Advanced Practice Registered Nurse (APRN) assessed the wound as MASD that was slow to heal, but not worsening. Per record review, on 03/01/2023, the APRN documented Resident #3's wound as a stage 3 pressure ulcer (involved the full thickness of the skin and might extend into the subcutaneous tissue layer), which was facility acquired. In continued review, on 03/21/2023, the APRN documented the wound as a stage 4 pressure ulcer (extended deeper than a stage 3, exposing underlying muscle, tendon, cartilage, or bone). The note also stated Resident #3 came back to the facility from the hospital, where he/she had undergone surgical debridement (the cutting away of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of the wound. Review of Resident #3's Wound Clinic Progress Note, dated 04/14/2023, revealed Resident #3 was in the hospital from 03/06/2023 through 03/13/2023 for surgical debridement of his/her pressure ulcer. The wound clinic documented the debridement went into the bone, but noted the hospital did not obtain cultures of the tissue to determine if osteomyelitis (infection of the bone) was present. Review of Resident #3's Hospital Discharge Summary, dated 06/21/2023, revealed Resident #3 was admitted to the hospital for treatment of osteomyelitis and intravenous antibiotics. Review of Resident #3's Wound Clinic Progress Note, dated 01/09/2024, revealed the clinic physician evaluated Resident #3's wound and recommended continued off-loading (removing weight) to the wound. In an interview on 02/26/2024 at 6:28 PM, Resident #3 stated he/she developed pressure ulcers while a resident in the facility from staff leaving him/her in bed too long. He/she further stated that, due to short-term memory problems secondary to a seizure disorder, he/she was dependent on staff for repositioning reminders, as well as physical assistance. Resident #3 stated he/she wanted to be in his/her wheelchair to move about in the facility to maintain mobility and strength in his/her upper arms, as well as to participate in activities and socialize with other residents. 1. Observation on 02/29/2024 at 3:39 PM, revealed the Activities Aide and State Registered Nurse Aide (SRNA) #17 failed to identify that Resident #3's urostomy/ileostomy was leaking, even when there were wet spots on the floor beneath the resident's wheelchair, and the area smelled of urine. In an interview on 02/29/2024 at 1:57 PM, the Activities Aide stated she was not certified to provide hands-on care such as incontinence care for residents, so she could not assist Resident #3 with incontinence needs. She further stated she would have asked an SRNA for assistance if she had noticed the wet spot under Resident #3's wheelchair. In an interview on 02/29/2024 at 4:21 PM, SRNA #17 stated she did not notice the urine odor or wet spot on the floor under Resident #3's wheelchair while the resident was at activities that afternoon. Observations on 02/28/2024 from 2:22 PM through 2:38 PM, 02/29/2024 from 1:30 PM through 3:46 PM, and on 03/01/2024 from 12:22 PM through 12:51 PM, revealed no instances of Resident #3 picking at his/her ostomy wafer. Observation on 03/03/2024 at 3:28 PM, revealed Resident #3 sat in his/her wheelchair in the doorway to his/her room, with a wet spot noted on his/her clothing, urostomy/ileostomy bag bulging beneath the resident's clothing, and a moderate sized puddle beneath his/her wheelchair, with a strong odor of urine noted. During interview at the time of the observation, Resident #3 stated he/she did not recall when staff had last emptied his/her urostomy bag or checked to see if his/her brief was wet. Resident #3 stated that due to spina bifida, he/she had no sensation below the waist and was unable to recognize when he/she was wet and notify staff of his/her need to be changed. Resident #3 stated he/she knew that staff believed he/she picked at the urostomy wafer, causing it to leak, but Resident #3 denied engaging in this behavior. In further interview, Resident #3 stated he/she was not sure how long his/her urostomy had been leaking. Observation on 03/03/2024 at 3:38 PM revealed SRNA #3 and SRNA #23 assisted Resident #3 back to bed and removed heavily saturated briefs; both aides commented that the resident appeared to have been wet for a while. In continued observation, SRNA #23 noted a small leak in Resident #3's urostomy appliance between the wafer and the skin and commented that the dressing to the resident's pressure wound had also become saturated and fallen off. In an immediate interview, SRNA #23 stated SRNA #20 was assigned to Resident #3 from 7:00 AM to 3:00 PM and had left the facility after finishing her shift. SRNA #23 further stated she did not know when the last time SRNA #20 had checked Resident #3's urostomy/ileostomy bag and brief. In an interview on 03/04/2024 at 12:29 PM, SRNA #20 stated she had checked and emptied Resident #3's urostomy/ileostomy bag at 1:30 PM. In further interview, she could not provide an explanation for why the resident was found in saturated briefs by 3:30 PM. In an interview on 03/06/2024 at 2:38 PM, Licensed Practical Nurse (LPN) #7 stated SRNAs needed to check Resident #3's briefs every two (2) hours because the resident's urostomy leaked frequently and keeping his/her wound area free from urine was important for healing. LPN #7 further stated the facility did not have a mechanism for holding staff accountable for changing a resident's briefs. 2. Continuous observation on 02/29/2024, from 1:30 PM through 3:46 PM, revealed staff failed to remind Resident #3 about repositioning (which would off-load his/her weight) in his/her wheelchair and failed to assist him/her with repositioning as per the resident's care plan. In an interview on 02/29/2024 at 4:21 PM, SRNA #17 stated she saw Resident #3 in his/her wheelchair in the dining room for an extended period of time earlier in the afternoon. Per interview, SRNA #17 stated Resident #3 was able to lift up using his/her arms to reposition while in the wheelchair but required cueing due to short-term memory problems. SRNA #17 stated she failed to remind and encourage Resident #3 to reposition in his/her wheelchair while sitting in the wheelchair during activities as per the care plan and Kardex. In an interview on 03/03/2024 at 3:32 PM, SRNA #3 stated it was not possible to reposition Resident #3 in his/her wheelchair. SRNA #3 stated the only repositioning option was for Resident #3 to go back to bed after two (2) hours of being in the wheelchair unless he/she refused. In an interview on 03/06/2024 at 2:38 PM, LPN #7 stated she took care of Resident #3 frequently but had no idea the resident was able to use his/her arms to push up off the wheelchair to off-load pressure from his/her wound. LPN #7 stated therapy goals and interventions were not included on the care plans where nursing staff could see them. Per interview, LPN #7 stated that lack of communication made it difficult for nurses and SRNAs to know the residents' abilities and encourage the residents to participate in their care to achieve their highest practicable well-being. In an interview on 03/06/2024 at 1:59 PM, Occupational Therapist (OT) #1 stated during the last time Resident #3 was on caseload in 08/2023, he/she could perform wheelchair push-ups in which the resident would place his/her hands on the arms of the wheelchair and lift his/her body off the seat of the wheelchair. She stated the resident would need reminders to do this due to cognitive limitations. OT #1 stated Resident #3 would benefit from selecting a schedule to go back to bed to better offload the wound. In an interview on 02/28/2024 at 8:11 AM, the Wound Care Nurse stated, in his opinion, the biggest obstacle to healing Resident #3's wound was keeping it dry. He stated Resident #3 would receive the most benefit from offloading if he/she would agree to lie in bed after being up in the wheelchair for a maximum of three (3) hours. In an additional interview on 03/07/2024 at 1:47 PM, the Wound Care Nurse stated, he had not made a precise recommendation on the time that Resident #3 needed to be repositioned, but the standard of practice for wound prevention and healing was to reposition every two (2) hours. Per interview, the wound care nurse believed having a schedule for getting Resident #3 up and a scheduled time determined by the resident to lie back down in bed for offloading would be beneficial to balance the resident's preference with the need to promote wound healing. However, he stated the facility had not attempted this intervention. The Wound Care Nurse stated he had not consulted physical and occupational therapy about increasing Resident #3's ability to use his/her upper body to off-load pressure from the wound while in the wheelchair. The Wound Care Nurse stated he wondered if the therapy department could help the team develop a resident specific cushion to accommodate Resident #3's preference to socialize during the day, while providing pressure relief. However, he stated the facility had not explored that possibility. In an interview on 03/05/2024 at 10:30 AM, the Advanced Practice Registered Nurse (APRN) stated she believed Resident #3's insistence at being up in his/her wheelchair was a major barrier to wound healing. The APRN stated staff should be assisting/reminding the resident to shift his/her weight while sitting in the wheelchair and the resident should be kept dry. In an interview on 03/08/2024 at 10:10 AM, Director of Nursing (DON) #1/Resource Nurse stated she had been the interim DON for two (2) weeks but had been in the facility off and on for several months. She stated she did not know Resident #3 well and could not speak to specific interventions that were appropriate for his/her wound healing. DON #1 stated her expectations for care for any resident that had an actual wound or potential skin breakdown would be to reposition the resident every two (2) hours as needed, depending on the resident's ability to move independently, and to provide incontinence care timely. Per interview, DON #1 stated it was unacceptable for a resident to be sitting in the hallway with urine dripping onto the floor, as Resident #3 had been observed on 03/03/2024. In an interview on 03/08/2024 at 11:13 AM, Director of Nursing (DON) #2 stated she started working in the facility on 02/27/2024, the day after the State Survey Agency team entered. Per interview, DON #2 stated one of her first priorities was learning about residents with facility acquired pressure ulcers. DON #2 further stated she educated Resident #3 on the importance of taking breaks from the wheelchair throughout the day, but the resident only agreed when DON #2 informed Resident #3 that this was the recommendation of the Wound Care Nurse. DON #2 stated she was not aware of Resident #3's memory problems, and the facility would need to provide the resident with frequent cueing, rather than one-time education, for it to be effective. In an interview on 03/08/2024 at 4:25 PM, the Administrator stated her expectation was for staff to ensure Resident #3's wound remained free of urine. She further stated that meant staff needed to check on the resident frequently to prevent his/her briefs and wound dressing from becoming saturated.

Based on observation, interview, record review, and review of the facility's documents and assessment, it was determined, the facility failed to ensure sufficient numbers of nursing staff, to include nurse aides, on a 24-hour basis to provide necessary nursing care for residents in accordance with their care plans. On 03/03/2024, the facility failed to have a sufficient number of nurse aides on Sunday 03/03/2024, and triggered for low weekend staffing and a 1-star staffing rating on the Payroll Based Journal (PBJ). Residents and staff reported insufficient aides to provide timely incontinence care and insufficient nursing staff to deliver medications timely on the weekends. Additionally, Resident #152 entered the hospital on 01/07/24, wearing two (2) briefs which were saturated with urine upon arrival. Interview and review of the facility's staffing, revealed staffing had been significantly below the numbers required in the facility's assessment for that day. The findings include: Review of the facility's assessment, dated 01/24/2024, revealed the facility's average census was between one hundred thirty (130) and one hundred thirty-three (133). Continued review revealed the facility estimated caring for an average of forty (40) residents who were dependent on staff for toileting needs, with an additional seventy-nine (79) residents requiring assistance of one (1) or two (2) staff members for toileting. Per review of the assessment, the facility noted it had the ability to care for residents with behavioral symptoms and diagnoses including anxiety, depression, psychosis, schizophrenia, and bipolar disorder. Additional review revealed the facility identified the average range of nurse aide hours required to meet residents' needs in a twenty-four (24) hour period was two and hundred thirty (230) to two hundred and sixty (260) hours. Review of the facility's documents titled, Daily Staffing Assignment Sheet, dated 02/26/2024 through 03/08/2024, revealed the facility had under two hundred (200) State Registered Nurse Aide (SRNA) hours for six (6) of the twelve (12) days of survey which were: 02/29/2024, 03/03/2024, 03/04/2024, 03/05/2024, 03/06/2024, and 03/08/2024. Further review revealed the budgeted hours for the survey days was listed as two hundred and forty (240) nurse aide hours. Review of the Payroll Based Journal data from 2023, revealed the facility triggered for low weekend staffing and had an overall one (1) star staffing rating for the fourth quarter of the year, October, November, and December 2023. Review of the facility's document titled, Punch Detail, dated 11/01/2023 through 11/30/2023, revealed only three (3) SRNAs had been working in the facility the night of Thursday, 11/09/2023. Further review revealed there were only four (4) nurse aides working in the facility on Saturday, 11/18/2023. Observation on 02/26/2024 at 5:50 PM, revealed SRNA #26 feeding Resident #15, spooning each bite into the resident's mouth before he/she had a chance to swallow the previous bite. Continued observation revealed Resident #15 began to cough and SRNA #26 kept feeding him/her. In an interview during the observation, SRNA #26 stated the facility was short staffed and he felt he had to rush through resident care to move on to the next resident. In an interview on 02/26/2024 at 5:48 PM, Resident #116 stated he/she often had to wait over an hour for staff to answer his/her call light. Resident #116 further stated, when staff did answer the call light, they seemed rushed, and made him/her feel like they were just doing a task and did not care about him/her as a person. In an interview on 02/27/2024 at 9:33 AM, Resident #113 stated he/she had to wait for a long time for his/her call bell to be answered at night. In an interview on 02/27/2024 at 2:16 PM, Resident #55 stated he/she had to wait long periods of time for staff to answer his/her call light. In further interview, Resident #55 stated no staff member came when he/she yelled for help because another resident entered his/her room uninvited. In an interview on 02/27/2024 at 6:22 PM, Resident #3 stated it often took extended periods of time for staff to answer his/her call light. Resident #3 further stated staff told him/her that the delay in addressing his/her needs was due to short staffing. In an interview on 02/28/2024 at 11:44 AM, Resident #45 stated staff habitually turned off his/her call light, told the resident they would be back; however, failed to return to address his/her needs. In further interview, Resident #45 stated he/she felt nervous at night because there had not been enough staff to provide timely incontinence care, if he/she had a bowel movement before it was time for the next routine care round to occur. In an interview on 03/01/2024 at 1:02 PM, SRNA #7 stated the facility had problems with being short staffed, especially in October and November of 2023. She stated that, during that time, there were often only three (3) aides assigned to the 300 hall, which left each aide with almost twenty (20) residents to care for, many of which required incontinence care. SRNA #7 stated staff who were not familiar with residents would not have been able to manage that workload. She stated staffing was not sufficient to manage resident behaviors, particularly around smoke breaks. SRNA #7 further stated smokers were more likely to have behaviors if it was too cold to go out to smoke, or if they had to wait longer than normal for staff to be available to take them outside. Observation on 03/03/2024 at 3:28 PM, revealed Resident #3 sitting in his/her wheelchair in the doorway to his/her room, with a wet spot observed on his/her clothing. Further review revealed the urostomy bag was bulging beneath the resident's clothing, and a moderate sized puddle was noted beneath the resident's wheelchair. Continued observation revealed a strong odor of urine. During interview at the time of observation, Resident #3 stated he/she did not recall when staff had last emptied his/her urostomy bag or checked to see if his/her brief was wet. Further observation on 03/03/2024 at 3:38 PM revealed SRNA #3 and SRNA #23 assisted Resident #3 back to bed and removed a heavily saturated brief; with both aides commenting that the resident appeared to have been wet for a while. SRNA #23 observed a small leak in Resident #3's urostomy appliance between the wafer and the skin, and commented that the dressing to the resident's pressure wound had also become saturated and fallen off. During interview at the time of observation, SRNA #23 stated SRNA #20 was assigned to Resident #3 from 7:00 AM to 3:00 PM, and had left the facility after finishing her shift. SRNA #23 further stated she and SRNA #3 were now the only aides for the 100 hall, making them responsible for eighteen (18) to twenty (20) residents each. In an interview on 03/03/2024 at 3:53 PM, SRNA #23 stated there were frequently only two (2) aides per hallway, especially for the evening shift. She stated having only two (2) aides meant residents had to wait longer than they should to receive basic care, such as getting to the bathroom or transferring in and out of their wheelchairs. In further interview, SRNA #23 stated she had to stay late to make sure residents got their showers, because she knew other aides skipped them due to not having enough time or staff. In an interview on 03/03/2024 at 7:51 PM, SRNA #24 stated there were nights, especially in the fall of 2023, that she was the only aide on the hallway. She stated she did not recall any dates or the exact number of residents she had been responsible for on those nights; however, she stated it was over thirty (30) residents. She stated a common misconception was that night shift was not busy because residents were sleeping; however, there were multiple residents with behaviors who did not sleep at night, and it was harder to deal with them with less staff in the building. Per interview, SRNA #24 stated there were many residents in the facility that had mental illnesses and required supervision and redirection to keep them and other residents safe. Additionally, SRNA #24 stated night shift still had to provide incontinence care for all dependent residents, as well as other night time activities of daily living (ADLs) care. In an interview on 03/03/2024 at 7:38 PM, Licensed Practical Nurse (LPN) #8 stated she worked every weekend and was often the only nurse for the 200 Hallway, and was usually without a Kentucky Medication Aide (KMA) to help with medication administration. LPN #8 stated insufficient staffing had often caused her to be late with administering residents' medications. In continued interview, LPN #8 stated she had called the management team in the past to let them know she could not keep up with the heavy workload; however, they had not come in to help her. Additionally, LPN #8 stated on 03/03/2024, management had sent in extra staff, who did not typically work in the building because of the ongoing State Survey. In an interview on 03/07/2024 at 2:23 PM, LPN #16 stated she filled in as the scheduler, when the regular scheduler was out on maternity leave. She stated the minimum staffing on night shift was supposed to be one (1) nurse and two (2) aides on each hallway, for a total of six (6) aides and two (2) Kentucky Medication Aides (KMAs) splitting the three (3) halls. LPN #16 stated the level of staffing in the facility was not enough, even on night shift, given the higher acuity and number of residents on the 300 Hallway. Per interview, LPN #16 stated the census on the 300 hall was usually over fifty (50) residents. She stated she knew of aides putting two (2) briefs on residents at a time, thinking that meant they would not have to provide incontinence care as often. Per interview, LPN #16 stated staff had double briefed Resident #6, and double briefing was an unacceptable practice that would lead to skin breakdown for the residents, and would not meet the residents' dignity needs. In an interview on 03/08/2024 at 8:15 AM, the facility's regular scheduler stated she recalled having a rough time with periods of low staffing during the fall of 2023. She stated she could not recall any specific dates; however, she remembered the lowest level of staffing was two (2) aides per hallway. The scheduler further stated two (2) aides per hallway, for a total of six (6) aides was not sufficient and resulted in residents waiting for extended periods of time for incontinence care, which was not acceptable. In an interview on 03/05/2024 at 4:51 PM, Registered Nurse (RN) #2 stated she worked at the facility for five (5)years, primarily on day shift on the 300 Hall. She stated she worked either Saturday or Sunday most weeks. RN #2 stated over the past year there had not been sufficient staffing at the facility. She stated the 300 Hall had fifty-four (54) beds, and was usually staffed with three (3) aides, especially from 3:00 PM to 7:00 PM. In continued interview, RN #2 stated residents did not get sufficient care, including showers, because each aide was responsible for too many residents. Interview on 03/08/2024 at 11:15 AM, Director of Nursing (DON) #2 stated she had only been working at the facility since 02/27/2024. Per interview, she stated the facility's management team held a staffing meeting every morning to discuss staffing needs and try to fill them with facility staff first, then with agency. She stated there had been a lot of call-ins during the State Survey, but she believed the facility was covered adequately. DON #2 stated fully staffed for day shift meant: three (3) or four (4) nurse aides and two (2) nurses on the 300 hall; three (3) nurse aides, one (1) nurse and one (1) KMA/nurse on the 200 hall; and three (3) nurse aides, one (1) nurse and one KMA/nurse on the 100 hall. The DON stated earlier in the day on 03/03/2024, an SRNA told her they needed an extra staff member to help with resident behaviors because the current staffing levels did not leave enough time for managing residents' psychosocial needs. DON #2 further stated because the activities director had quit and the facility was also down an activities aide, the facility had not yet adjusted the staffing pattern to compensate for the psychosocial needs that were usually met by activities staff. In an interview on 03/08/2024 at 4:25 PM, the Administrator stated the budgeted hours listed on the daily staffing sheet reflected what the facility would need for one hundred fifty (150) residents. She stated the current census was one hundred twenty-nine (129), so the facility had adjusted down the actual number of hours worked. The Administrator indicated she was unable to clarify how the facility determined how many staff hours were reduced from the budgeted to actual hours, and how they ensured the actual hours worked were sufficient to meet resident needs. She further stated the facility only increased staffing for resident behaviors when they determined a resident required one-on-one (1:1) supervision. In continued interview, the Administrator stated she participated in daily staffing meetings to discuss staffing needs. Additionally, she stated she provided residents and their families with her cell phone number so they could call her with any concerns. 43694 2. Review of Resident #152's Electronic Health Record (EHR) revealed the facility admitted the resident on 06/06/2023, with diagnoses to include Dementia Without Behavioral Disturbance, Overactive Bladder, and Chronic Pain Syndrome. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #152 to have a Brief Interview for Mental Status (BIMS) score of zero out of fifteen (00/15), which indicated he/she was severely cognitively impaired. Continued review of the MDS revealed the facility assessed Resident #152 as requiring substantial/maximal assistance with toilet hygiene, and requiring substantial/maximal assistance with lower body dressing. Further review revealed the facility additionally assessed Resident #152 as not having any pressure (wounds); however, the resident was assessed as at risk. Review of Resident #152's Treatment Administration Record (TAR) for January 2024 revealed documentation noting the resident had last been toileted on 01/07/2024 at 2:59 PM. Review of Resident #152's progress note dated 01/07/2024 at 9:34 PM, revealed the resident experienced an acute mental status change, moaning, abdominal breathing, unable to obtain a blood pressure (b/p), and was sent out to the emergency room (ER). Review of hospital emergency department (ED) documentation revealed Resident #152 entered the ED on 01/07/2024 at 10:42 PM. Review of the hospital RN's signed note on 01/08/2024 at 1:42 AM, revealed the nurse documented Resident #152 as unable to talk or communicate; had been wearing two (2) briefs, upon arrival at the ED, which were both saturated with urine. Continued review of the RN's note revealed Resident #152 had wounds to his/her buttocks. Review of a Punch Detail Report dated 01/07/2024, revealed there were 154.5 SRNA hours (or, 143 hours not including a nurse aide in training's hours) documented for that date. Per the facility assessment review, the facility was to have provided between two hundred thirty (230) to two hundred sixty (260) nurse aide hours per day. However, based on that information, the facility was down 75.5 nurse aide hours at a minimum, although there was a nurse aide in training. Review of the Daily Staffing Sheet dated 01/07/2024, for the 100 Unit, revealed there were two (2) SRNA's scheduled from 7:00 PM onward. Review of the facility's Daily Census documentation for 01/07/2024, revealed there were thirty-eight (38) residents on the 100 Unit during that time. Interview on 03/07/2024 at 10:45 AM, DON #1 stated she had heard about the allegation of Resident #152 having two (2) briefs on when sent out to the hospital. She stated she had no idea why a resident would be sent to the hospital double-briefed,. She stated that was not something the facility condoned. During interview with SRNA #24 on 03/08/2024 at 6:27 AM, she stated there had been many nights under the previous company she had been working on the floor alone with forty (40) some residents to provide care. She stated since the new company took over in October 2023, there had only been one (1) occasion when she was by herself on the unit, and that was only for two (2) hours. She stated on 01/07/2024, she was late to arrive for work, arriving at approximately 8:15 PM. She stated she was doing her rounds, and had not yet rounded on Resident #152 around 9:00 PM or 10:00ish PM, when the nurse asked if she had seen the resident. SRNA #24 stated she went in to check on Resident #152, and he/she did not look good, was very agitated, was fighting a little bit. SRNA #24 stated she began cleaning Resident #152 up, and although she did not change him/her as he/she was not soiled, the resident did not appear to have multiple briefs on. In continued interview on 03/08/2024 at 6:27 AM, with SRNA #24 she stated when an allegation came in regarding Resident #152 being sent to the hospital with two (2) briefs on, as the aide responsible for the resident's care, she was suspended. She stated she should have done a more thorough check of Resident #152. SRNA #24 stated in the past she had observed Resident #30 with more than one (1) brief on, and that Resident #30 was formerly care planned to wear two (2) briefs. She further stated before the new company took over in October 2023, she would see residents with two (2) briefs on all the time. In addition, SRNA #24 further stated some nights there was only a few staff who worked hard and were able to meet residents' care needs. In interview with SRNA #10 on 03/07/2024 at 2:43 PM, she stated she worked with Resident #152 on 01/07/2024 from 7:00 AM until 3:00 PM, and Resident #152 was the last resident she cared for at 3:00 PM. She stated there had been three (3) staff working that day, and Resident #152 had been exhibiting aggressive behaviors, necessitating two (2) staff to provide care for him/her. SRNA #10 stated she knew when she left at 3:00 PM, there would only be two (2) staff working on the 100 unit, so she wanted to ensure Resident #152 was clean and cared for prior to leaving. When the SSA Surveyor asked the SRNA about any double briefing of residents, SRNA #10 shared when coming on shift, she would sometimes find Resident #152 double briefed, and believed it to be due to night shift working so short-handed. She stated on 01/07/2024, she believed there were thirty (30) something residents present on the unit that day, with quite a few of them who were two (2) person assist. SRNA #10 further stated the aides had frequently complained to management about the short staffing, and with the prior management nothing had been done; however, with the new company things had been better. In interview with the Administrator on 03/08/2024 at 12:39 PM, stated she had a hard time believing a resident was sent to the hospital double briefed. She stated she expected facility staff to do a head to toe assessment before residents were sent out to the hospital, and perform another assessment when the resident came back. The Administrator stated when she became aware of the allegation from the State's Adult Protective Services (APS) personnel, she started an investigation, and ended up suspending an SRNA. When the SSA Surveyor asked her about staffing discrepancies identified in comparing actual staffing with staffing needs as identified in the facility assessment, the Administrator stated the facility was not at one hundred one (151) residents, and was not at that census level at the time of the allegation involving Resident #152 on 01/07/2024. She further stated despite that, the facility tried to staff to a resident census of one hundred fifty (150), due to issues going on in the building and the fact that she was new. 28707

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service in the kitchen. Observation during the initial kitchen tour on 02/26/2024 revealed one (1) container of thickened orange juice, undated; a pan of chicken thawing out, unlabled and undated; one (1) dumpling bag opened, undated; and sugar cookie dough opened, undated. Further observation of the tray line area in the kitchen revealed a mop container, half filled with brown water sitting next to the tray line; a dirty rag lying on top of the garbage can lid, lying on the floor; and a light fixture over the tray line with dust noted on the fixture. Observation during the follow up kitchen tour on 02/28/2024 revealed canned spaghetti in the pantry with no delivery date; three (3) gnats were observed in the pantry; and the pantry had no thermometer. Further observation of the supply room in the kitchen revealed a sticky substance on the floor; one (1) can of beans had no delivery date; and the air conditioning unit had a broken vent at the bottom of the unit. Continued observation of the designated clean area in the kitchen revealed clean items, bowls and cups, were upright or lying sideways. The findings include: Review of the facility's policy titled, Policy and Procedure Manual: Food Storage, dated 2019, revealed the facility would provide sufficient storage to keep foods safe, wholesome, and appetizing. Continued review revealed foods would be stored at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Additionally, storage areas would be free from rodent and insect infestation, dry storage rooms would have a thermometer with the temperature between 50 degrees and 70 degrees Fahrenheit (F), food should be dated as it is placed on the shelves, and all foods should be covered, labeled, and dated. Review of the facility's policy titled, Sanitization, revised November 2022, revealed all kitchens, kitchen areas, and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. Continued review revealed kitchen wastes that are not disposed of by mechanical means are kept in clean, leakproof, nonabsorbent, tightly closed containers and disposed of daily. Additionally, garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). Observation during the initial kitchen tour, on 02/26/2024 at 5:00 PM, revealed one (1) dietary cook and two (2) dietary aides were working in the kitchen preparing for dinner service. Observation of the refrigerator revealed one (1) container of thickened orange juice with no open date, and a pan of chicken was thawing out for the next day's lunch with no label or date on the container. Observation of the freezer revealed one (1) dumpling bag opened, undated, and sugar cookie dough opened, and undated. Continued observation of the designated clean area in the kitchen revealed bowls air drying, including ten (10) of the bowls right side up with no covering, and a tray of clean cups with five (5) lying sideways with no covering. Further observation of the pantry revealed one (1) bag of hot dog buns opened, undated, and eight (8) cans of spaghetti sauce with no delivery date. Observation of the tray line area in the kitchen revealed a mop container, half filled with brown water, sitting next to the tray line, and a dirty rag lying on top of the garbage can lid that was lying on the floor. Further observation revealed a light fixture over the tray line with dust noted on the fixture. Observation during the follow up kitchen tour, on 02/28/2024 at 8:00 AM, revealed the canned spaghetti in the pantry still had no delivery date. Three (3) gnats were observed in the pantry, and the pantry had no thermometer. Observation of the supply room in the kitchen revealed a sticky substance on the the floor, one (1) can of beans had no delivery date, and the air conditioning unit had a broken vent at the bottom of the unit. Further observation of the designated clean area in the kitchen revealed the clean bowls and cups were still in the same place, upright or lying sideways with no covering. During an interview with the Interim Dietary Manager (IDM), on 02/26/2024 at 5:15 PM, she stated anything that was opened in the kitchen should have an open date. She further stated it was her expectation all food items opened had an open date and an appropriate label on the container. Furthermore, she stated items in the pantry should have a delivery date on them and when the items were removed from the box they were delivered in, then the dietary staff should mark the date on the cans. She stated any items that were thawing in the refrigerator should be covered with an appropriate label and date. During further interview with the IDM, on 03/06/2024 at 3:30 PM, she stated all clean dishes should be stored face down to prevent dust or debris from getting on the dish. She stated it was her expectation that all daily cleaning lists would be completed prior to dietary staff leaving each day. The IDM stated the kitchen should be swept and mopped after each meal, and the dishes were to be washed after each meal. During an interview with the Registered Dietician (RD), on 03/01/2024 at 1:20 PM, she stated it was her expectation that the kitchen would be cleaned daily, temperature logs would be completed daily, and any opened food items should be labeled and dated. During an interview with the Interim Director of Nursing (IDON), on 03/08/2024 at 10:10 AM, she stated the kitchen should be cleaned daily, and some things like the floors and dishes should be cleaned after each meal. She stated her expectation was any item opened should be labeled and dated, and if not, the item should be thrown away. She further stated the kitchen equipment used for the meal should be cleaned after each use. During an interview with the Administrator, on 03/08/2024 at 3:02 PM, she stated it was her expectation for any foods opened in the kitchen to be dated and labeled at the time the food item was opened. She stated the importance of dating opened items was to ensure foods were not used that had been opened too long, and foodborne illnesses could be the risk if items were not dated and labeled correctly. She further stated it was her expectation for the dietary staff to keep the kitchen always cleaned, and certain things would be cleaned after each meal, such as floors, dishes, and the tray line. The Administrator stated she also expected the dietary staff to utilize proper hand hygiene before, during, and after food service.

Based on observation, interview, review of the facility's staffing documents, and review of the facility's Plan of Correction (POC) submitted for the 03/08/2024 survey, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. This had the potential to affect all 129 current residents. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights; 42 CFR 483.24 Quality of Life; 42 CFR 483.35 Nursing Services; and 42 CFR 483.80 Infection Control. (Cross-reference F550, F677, F725, F726, F867, and F880) The findings include: Review of the facility's POC for the 03/08/2024 survey revealed the facility was to train all nursing staff on catheter care, hand hygiene, and providing resident care in a dignified manner. Further review revealed the facility would conduct regular audits to identify and correct any continued deficient practice. Continued review revealed the Administrator was responsible for ensuring adequate staffing to meet resident needs. 1. Review of the facility's document Daily Staffing Assignment Sheet, dated 05/06/2024, revealed the Administrator signed off on the schedule that only displayed 212 hours of State Registered Nurse Aide (SRNA) hours. Further review revealed the sheet the Administrator signed off on did not reflect the true staffing for night shift, as one SRNA called in for that shift. In an interview on 05/09/2024 at 6:00 PM, SRNA4 stated staffing had improved, but there were still shifts she worked recently that had been short staffed, especially for the evening hours, 3:00 PM - 11:00 PM. She further stated evening staffing levels resulted in decreased supervision of residents with behaviors and some residents missing showers because it was not possible for staff to complete all their care tasks. In further interview, SRNA4 stated there had been a lot of turnover with management at the facility, and staff was still getting to know the new management. In an interview on 05/10/2024 at 3:45 PM, the Administrator stated she verified staffing each day at the stand-down meeting with the management team in the afternoons. Per interview, if any night shift staff did not show up, she would not hear about it until the next morning. The Administrator stated she was not aware an SRNA called in for 05/06/2024 and did not have note of it in her morning meeting notes. She stated she informally interviewed staff to ask about workloads and if the staff members felt staffing was sufficient; however, she was unable to produce any evidence of these interviews. In additional interview at 5:12 PM, the Administrator stated the schedule was a work in progress, and the facility would continue to recruit new staff, as well as utilizing agency staff to ensure adequate nursing services. 2. Observation on 05/10/2024 at 10:28 AM, revealed SRNA15 removed the mechanical lift from a Resident (R) 5's room and took the lift to the clean utility room without disinfecting it. Further observation revealed SRNA15 left the clean utility room without disinfecting the mechanical lift. Observation on 05/10/2024 at 10:51 AM, revealed SRNA15 and SRNA40 were not wearing gowns to provide incontinence care, personal hygiene, and to change R163's clothes, a resident on Enhanced Barrier Precautions (EBP). Continued observation at 11:10 AM revealed LPN 28 failed to put on a gown while performing R163's sacral wound dressing care. Continued observation on 05/10/2024 at 10:51 AM, revealed SRNA40 failed to perform hand hygiene after doffing soiled gloves while providing incontinence care to R163. In an interview on 05/10/2024 at 5:12 PM, the Administrator stated she had printed and laminated signs for EBP, but failed to ensure they were posted on appropriate resident room doors to alert staff to the need to wear gowns and gloves when performing high-contact care. 3. Review of the facility's POC evidence binders revealed the facility failed to identify continued staff noncompliance with regulations related to hand hygiene, disinfection of low-level shared equipment, providing for resident dignity during care, and provision of ADL care. In an interview on 05/09/2024 at 6:00 PM, SRNA4 stated she received training on all the tags that were out of compliance on the 03/08/2024 survey. She further stated the facility management team seemed unorganized and unable to keep track of which staff members they had trained. In an interview on 05/10/2024 at 10:28 AM, SRNA15 stated she did not recall receiving recent training on disinfecting mechanical lifts. In an interview on 05/10/2024 at 2:33 PM, SRNA40 stated she recently attended training, which took almost two hours, but at the time of the interview, she did not remember if dignity had been one of the topics covered in the training. She further stated there was so much training, it was hard to remember all of the topics. Interview attempted with the Director of Nursing (DON) on 05/09/2024 at 5:40 PM and 05/10/2024 at 2:50 PM and 5:27 PM. However, the DON did not answer her phone or call the State Survey Agency (SSA) Surveyor back prior to exit on 05/10/2024. In continued interview on 05/10/2024 at 5:12 PM, the Administrator stated the facility needed to re-educate staff on disinfection of mechanical lifts. In further interview, the Administrator stated she expected staff to follow infection prevention protocols, but did not provide insight related to how the facility failed in implementing its POC related to infection control.

Based on observation, interview, review of the facility's staffing documents, and review of the facility's Plan of Correction (POC) submitted for the 03/08/2024 survey, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. This had the potential to affect all 129 current residents. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights; 42 CFR 483.24 Quality of Life; 42 CFR 483.35 Nursing Services; and 42 CFR 483.80 Infection Control. (Cross-reference F550, F677, F725, F726, F867, and F880) The findings include: Review of the facility's POC for the 03/08/2024 survey revealed the facility was to train all nursing staff on catheter care, hand hygiene, and providing resident care in a dignified manner. Further review revealed the facility would conduct regular audits to identify and correct any continued deficient practice. Continued review revealed the Administrator was responsible for ensuring adequate staffing to meet resident needs. 1. Review of the facility's document Daily Staffing Assignment Sheet, dated 05/06/2024, revealed the Administrator signed off on the schedule that only displayed 212 hours of State Registered Nurse Aide (SRNA) hours. Further review revealed the sheet the Administrator signed off on did not reflect the true staffing for night shift, as one SRNA called in for that shift. In an interview on 05/09/2024 at 6:00 PM, SRNA4 stated staffing had improved, but there were still shifts she worked recently that had been short staffed, especially for the evening hours, 3:00 PM - 11:00 PM. She further stated evening staffing levels resulted in decreased supervision of residents with behaviors and some residents missing showers because it was not possible for staff to complete all their care tasks. In further interview, SRNA4 stated there had been a lot of turnover with management at the facility, and staff was still getting to know the new management. In an interview on 05/10/2024 at 3:45 PM, the Administrator stated she verified staffing each day at the stand-down meeting with the management team in the afternoons. Per interview, if any night shift staff did not show up, she would not hear about it until the next morning. The Administrator stated she was not aware an SRNA called in for 05/06/2024 and did not have note of it in her morning meeting notes. She stated she informally interviewed staff to ask about workloads and if the staff members felt staffing was sufficient; however, she was unable to produce any evidence of these interviews. In additional interview at 5:12 PM, the Administrator stated the schedule was a work in progress, and the facility would continue to recruit new staff, as well as utilizing agency staff to ensure adequate nursing services. 2. Observation on 05/10/2024 at 10:28 AM, revealed SRNA15 removed the mechanical lift from a Resident (R) 5's room and took the lift to the clean utility room without disinfecting it. Further observation revealed SRNA15 left the clean utility room without disinfecting the mechanical lift. Observation on 05/10/2024 at 10:51 AM, revealed SRNA15 and SRNA40 were not wearing gowns to provide incontinence care, personal hygiene, and to change R163's clothes, a resident on Enhanced Barrier Precautions (EBP). Continued observation at 11:10 AM revealed LPN 28 failed to put on a gown while performing R163's sacral wound dressing care. Continued observation on 05/10/2024 at 10:51 AM, revealed SRNA40 failed to perform hand hygiene after doffing soiled gloves while providing incontinence care to R163. In an interview on 05/10/2024 at 5:12 PM, the Administrator stated she had printed and laminated signs for EBP, but failed to ensure they were posted on appropriate resident room doors to alert staff to the need to wear gowns and gloves when performing high-contact care. 3. Review of the facility's POC evidence binders revealed the facility failed to identify continued staff noncompliance with regulations related to hand hygiene, disinfection of low-level shared equipment, providing for resident dignity during care, and provision of ADL care. In an interview on 05/09/2024 at 6:00 PM, SRNA4 stated she received training on all the tags that were out of compliance on the 03/08/2024 survey. She further stated the facility management team seemed unorganized and unable to keep track of which staff members they had trained. In an interview on 05/10/2024 at 10:28 AM, SRNA15 stated she did not recall receiving recent training on disinfecting mechanical lifts. In an interview on 05/10/2024 at 2:33 PM, SRNA40 stated she recently attended training, which took almost two hours, but at the time of the interview, she did not remember if dignity had been one of the topics covered in the training. She further stated there was so much training, it was hard to remember all of the topics. Interview attempted with the Director of Nursing (DON) on 05/09/2024 at 5:40 PM and 05/10/2024 at 2:50 PM and 5:27 PM. However, the DON did not answer her phone or call the State Survey Agency (SSA) Surveyor back prior to exit on 05/10/2024. In continued interview on 05/10/2024 at 5:12 PM, the Administrator stated the facility needed to re-educate staff on disinfection of mechanical lifts. In further interview, the Administrator stated she expected staff to follow infection prevention protocols, but did not provide insight related to how the facility failed in implementing its POC related to infection control.

Based on interview, record review, review of the facility's documents, and review of the facility's Plan of Correction (POC) submitted for the 03/08/2024 survey, the facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track staffing patterns and staff failing to provide basic care, including showers. The facility failed to ensure there was an effective system in place to accurately collect and analyze audit data, including data collected under the QAPI program, and act on available data to make improvements, and maintain substantial compliance. This had the potential to affect all 129 current residents. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights; 42 CFR 483.24 Quality of Life; 42 CFR 483.35 Nursing Services; and 42 CFR 483.80 Infection Control. (Cross-reference F550, F677, F725, F726, F835, and F880) The findings include: 1. Review of the facility's POC submitted for the 03/08/2024 survey revealed the Regional [NAME] President (RVP) educated the Administrator on their responsibility to ensure staffing adequate to meet resident needs. Further review revealed the Administrator and DON would review staffing needs to ensure resident needs were met and implement corrective action immediately upon discovery daily for two weeks, then three times per week for two weeks, then weekly for eight weeks, then monthly until the facility maintained substantial compliance. Review of QAPI minutes for 04/18/2024, 04/25/2024, and 04/29/2024 revealed no concerns noted about staffing. Review of POC documentation revealed the Administrator signed off on the schedule every day from 05/01/2024 through 05/06/2024, indicating she had reviewed it and found no issues. Review of the facility documents Daily Staffing Assignments, dated 05/06/2024 revealed the Scheduler and the Administrator calculated different numbers of State Registered Nurse Aide (SRNA) hours. Further review revealed neither number was correct, which the facility was not aware of until the State Survey Agency (SSA) Surveyor asked the Administrator to demonstrate her process for auditing staffing. In an interview on 05/10/2024 at 12:38 PM, the Administrator stated the staffing sheets the facility had used prior to 05/01/2024 were confusing and made it difficult to identify gaps in staffing. Per interview, the Administrator told the Scheduler to use a new form, but the Scheduler did not always comply with this directive. The Administrator continued to state the Scheduler totaled the SRNA hours incorrectly on the daily posted staffing sheet, and the facility had more than the 208 posted SRNA hours. In further interview, the Administrator was unaware an agency SRNA had called in for the night of 05/06/2024. Per interview, the Administrator stated this was not a failure of the QAPI process because if the SRNAs absence had caused any issues, the staff would have told her, and the management team would have discussed it in the morning meeting on 05/07/2024. In continued interview, the Administrator stated the number of SRNAs working on 05/06/2024 did not meet what she wanted to staff. In an additional interview on 05/10/2024 at 5:12 PM, the Administrator stated the schedule was a work in progress. She further stated the facility was considering hiring a new Scheduler. The Administrator continued to state the new system she planned to implement should make it easier to identify gaps in the schedule that had previously been missed. 2. Review of the facility's POC submitted for the 03/08/2024 survey revealed the facility was to ensure residents received Activities of Daily Living (ADL) care, including showers, as indicated with corrective action upon discovery. Further review revealed the Administrator, Director of Nursing (DON), Licensed Nurse (LN), or SRNA would conduct a visual audit on five residents three times per week for the week of 05/05/2024 to determine if staff were following the care plan for the resident with corrective action upon discovery. Review of QAPI minutes for 04/29/2024 revealed the facility identified no concerns with ADL care. Review of R55's Admission Record revealed the facility admitted the resident on 06/04/2021 with diagnoses including hemiplegia (partial paralysis) following cerebral infarction (stoke), tracheostomy (tube used for breathing) status, and an essential tremor. Review of R55's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R55 indicated choosing a shower or bed bath was very important to her. Continued review revealed the facility assessed the resident as requiring maximal assistance for bathing. Review of shower sheet binder at the 200 Hall nurse's station revealed no shower sheets for R55 for 05/01/2024 through 05/09/2024. Review of the facility's document Task: Bathing, dated 04/09/2024 through 05/09/2024, revealed the most recent shower staff documented for R55 was on 04/28/2024. Observation on 05/09/2024 at 4:08 PM, revealed R55 sitting in bed and her long hair was greasy from the root past the top of her ears. In an immediate interview, R55 stated staff had not given her a shower in over a week. She further stated she was due a shower on Sunday night, 05/05/2024, but she believed the facility must have been short staffed because her aide did not offer a shower or ask her about when she would like to shower. In continued interview, R55 stated she had not had a shower in over a week, but she was afraid of retaliation if she complained. In an interview on 05/09/2024 at 6:00 PM, SRNA4 stated she was responsible for R55 on the evening (3:00 PM to 11:00 PM) of 05/05/2024 and she should have given R55 a shower that evening, as it was a Sunday, which was when R55 preferred to shower. SRNA4 further stated, due to low staffing, she did not have time to give the resident a shower that shift. In continued interview, SRNA4 stated she was responsible for 22 residents on 05/05/2024, several of whom were exhibiting disruptive behaviors that required additional supervision that shift. 3. Review of the facility's POC for the 03/08/2024 survey revealed the facility was to train all nursing staff on catheter care, hand hygiene, disinfection of contaminated equipment, and providing resident care in a dignified manner. Further review revealed the Director of Nursing and Unit Managers were to perform regular audits to identify and correct further deficient practice. a. Review of R74's Admission Record revealed the facility admitted the resident on 01/22/2019 with diagnoses including paraplegia (paralysis of lower half of body), peripheral vascular disease, and type 2 diabetes. Review of R74's annual MDS, with an ARD of 04/12/2024, revealed the facility assessed the resident with a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R74 had an indwelling urinary catheter. Observation on 05/10/2024 at 2:40 PM revealed Licensed Practical Nurse (LPN) 14 performed catheter care for R74 by taking a clean soapy washcloth to clean the resident's genitals and catheter tubing. Further observation revealed LPN14 placed a clean washcloth in the sink, allowing water to run over it while she used the soapy one to clean. Per observation, LPN14 failed to change her gloves when she finished with the soapy cloth and reached into the sink for the cloth to rinse the soap off. In an immediate interview, LPN14 stated she should have washed her hands and applied clean gloves between cleaning and rinsing R74's catheter. She further stated she should have used a clean basin, rather than placing washcloths directly in the sink. In continued interview, LPN14 stated she had received a lot of education recently, but could not recall if catheter care was included in the education. In an interview on 05/10/2024 at 1:41 PM, LPN28 stated she received recent training on a variety of topics, but did not recall doing a return demonstration for skills on catheter care. b. Review of R163's Admission Record revealed the facility admitted the resident on 04/08/2024 with diagnoses including a stage 4 pressure ulcer on her sacrum, tracheostomy (tube to help with breathing) status, and gastrostomy (feeding tube inserted into the stomach) status. Review of R163's admission MDS, with an ARD of 04/15/2024, revealed the resident was not able to be understood to complete a BIMS, and the facility assessed the resident's cognitive abilities as severely impaired. Further review revealed R163 was totally dependent on staff for activities of daily living (ADLs) including toileting hygiene and dressing. Observation on 05/10/2024 at 10:51 AM revealed SRNA40 failed to pull the curtain while R163 was naked while SRNAs were changing R163's briefs and gown. Further observation revealed each time staff opened the door to obtain supplies, R163's body was exposed to the hallway. Continued observation revealed R163's body could be seen in the shared mirror and her roommate was present in the room. In an interview on 05/10/2024 at 2:33 PM, SRNA40 stated staff received so much education all at once as part of the POC, it was hard to remember it all. She stated she had failed to perform hand hygiene and provide for R163's dignity during care because she was nervous. In an interview on 05/10/2024 at 5:12 PM, the Administrator stated she expected staff to provide for resident dignity during care. The Administrator did not provide any information on how the POC failed to correct staff failure to pull the curtain around the bed to shield the resident's body from view. c. Observation on 05/10/2024 at 10:28 AM, revealed SRNA15 removed the mechanical lift from R5's room and took the lift to the clean utility room without disinfecting it. Further observation revealed SRNA15 left the clean utility room without disinfecting the mechanical lift. In an interview on 05/10/2024 at 10:28 AM, SRNA15 stated she did not recall recent training about disinfecting shared equipment, such as mechanical lifts. Interview attempted with the Director of Nursing (DON) on 05/09/2024 at 5:40 PM and 05/10/2024 at 2:50 PM and 5:27 PM; however, the DON did not answer her phone or call the State Survey Agency (SSA) Surveyor back prior to exit on 05/10/2024. In an interview on 05/10/2024 at 5:12 PM, the Administrator stated the facility needed to re-educate staff on disinfection of mechanical lifts. She stated she expected staff to follow infection prevention protocols, but did not provide insight into how the facility's POC into infection control had failed.

Based on interview, record review, review of the facility's documents, and review of the facility's Plan of Correction (POC) submitted for the 03/08/2024 survey, the facility failed to have an effective process in place to address systemic failures through the Quality Assurance Performance Improvement (QAPI) process. As a result, the facility failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. The facility failed to effectively track staffing patterns and staff failing to provide basic care, including showers. The facility failed to ensure there was an effective system in place to accurately collect and analyze audit data, including data collected under the QAPI program, and act on available data to make improvements, and maintain substantial compliance. This had the potential to affect all 129 current residents. The State Survey Agency (SSA) identified continued non-compliance in the areas of 42 CFR 483.10 Resident Rights; 42 CFR 483.24 Quality of Life; 42 CFR 483.35 Nursing Services; and 42 CFR 483.80 Infection Control. (Cross-reference F550, F677, F725, F726, F835, and F880) The findings include: 1. Review of the facility's POC submitted for the 03/08/2024 survey revealed the Regional [NAME] President (RVP) educated the Administrator on their responsibility to ensure staffing adequate to meet resident needs. Further review revealed the Administrator and DON would review staffing needs to ensure resident needs were met and implement corrective action immediately upon discovery daily for two weeks, then three times per week for two weeks, then weekly for eight weeks, then monthly until the facility maintained substantial compliance. Review of QAPI minutes for 04/18/2024, 04/25/2024, and 04/29/2024 revealed no concerns noted about staffing. Review of POC documentation revealed the Administrator signed off on the schedule every day from 05/01/2024 through 05/06/2024, indicating she had reviewed it and found no issues. Review of the facility documents Daily Staffing Assignments, dated 05/06/2024 revealed the Scheduler and the Administrator calculated different numbers of State Registered Nurse Aide (SRNA) hours. Further review revealed neither number was correct, which the facility was not aware of until the State Survey Agency (SSA) Surveyor asked the Administrator to demonstrate her process for auditing staffing. In an interview on 05/10/2024 at 12:38 PM, the Administrator stated the staffing sheets the facility had used prior to 05/01/2024 were confusing and made it difficult to identify gaps in staffing. Per interview, the Administrator told the Scheduler to use a new form, but the Scheduler did not always comply with this directive. The Administrator continued to state the Scheduler totaled the SRNA hours incorrectly on the daily posted staffing sheet, and the facility had more than the 208 posted SRNA hours. In further interview, the Administrator was unaware an agency SRNA had called in for the night of 05/06/2024. Per interview, the Administrator stated this was not a failure of the QAPI process because if the SRNAs absence had caused any issues, the staff would have told her, and the management team would have discussed it in the morning meeting on 05/07/2024. In continued interview, the Administrator stated the number of SRNAs working on 05/06/2024 did not meet what she wanted to staff. In an additional interview on 05/10/2024 at 5:12 PM, the Administrator stated the schedule was a work in progress. She further stated the facility was considering hiring a new Scheduler. The Administrator continued to state the new system she planned to implement should make it easier to identify gaps in the schedule that had previously been missed. 2. Review of the facility's POC submitted for the 03/08/2024 survey revealed the facility was to ensure residents received Activities of Daily Living (ADL) care, including showers, as indicated with corrective action upon discovery. Further review revealed the Administrator, Director of Nursing (DON), Licensed Nurse (LN), or SRNA would conduct a visual audit on five residents three times per week for the week of 05/05/2024 to determine if staff were following the care plan for the resident with corrective action upon discovery. Review of QAPI minutes for 04/29/2024 revealed the facility identified no concerns with ADL care. Review of R55's admission Record revealed the facility admitted the resident on 06/04/2021 with diagnoses including hemiplegia (partial paralysis) following cerebral infarction (stoke), tracheostomy (tube used for breathing) status, and an essential tremor. Review of R55's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/12/2024, revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R55 indicated choosing a shower or bed bath was very important to her. Continued review revealed the facility assessed the resident as requiring maximal assistance for bathing. Review of shower sheet binder at the 200 Hall nurse's station revealed no shower sheets for R55 for 05/01/2024 through 05/09/2024. Review of the facility's document Task: Bathing, dated 04/09/2024 through 05/09/2024, revealed the most recent shower staff documented for R55 was on 04/28/2024. Observation on 05/09/2024 at 4:08 PM, revealed R55 sitting in bed and her long hair was greasy from the root past the top of her ears. In an immediate interview, R55 stated staff had not given her a shower in over a week. She further stated she was due a shower on Sunday night, 05/05/2024, but she believed the facility must have been short staffed because her aide did not offer a shower or ask her about when she would like to shower. In continued interview, R55 stated she had not had a shower in over a week, but she was afraid of retaliation if she complained. In an interview on 05/09/2024 at 6:00 PM, SRNA4 stated she was responsible for R55 on the evening (3:00 PM to 11:00 PM) of 05/05/2024 and she should have given R55 a shower that evening, as it was a Sunday, which was when R55 preferred to shower. SRNA4 further stated, due to low staffing, she did not have time to give the resident a shower that shift. In continued interview, SRNA4 stated she was responsible for 22 residents on 05/05/2024, several of whom were exhibiting disruptive behaviors that required additional supervision that shift. 3. Review of the facility's POC for the 03/08/2024 survey revealed the facility was to train all nursing staff on catheter care, hand hygiene, disinfection of contaminated equipment, and providing resident care in a dignified manner. Further review revealed the Director of Nursing and Unit Managers were to perform regular audits to identify and correct further deficient practice. a. Review of R74's admission Record revealed the facility admitted the resident on 01/22/2019 with diagnoses including paraplegia (paralysis of lower half of body), peripheral vascular disease, and type 2 diabetes. Review of R74's annual MDS, with an ARD of 04/12/2024, revealed the facility assessed the resident with a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed R74 had an indwelling urinary catheter. Observation on 05/10/2024 at 2:40 PM revealed Licensed Practical Nurse (LPN) 14 performed catheter care for R74 by taking a clean soapy washcloth to clean the resident's genitals and catheter tubing. Further observation revealed LPN14 placed a clean washcloth in the sink, allowing water to run over it while she used the soapy one to clean. Per observation, LPN14 failed to change her gloves when she finished with the soapy cloth and reached into the sink for the cloth to rinse the soap off. In an immediate interview, LPN14 stated she should have washed her hands and applied clean gloves between cleaning and rinsing R74's catheter. She further stated she should have used a clean basin, rather than placing washcloths directly in the sink. In continued interview, LPN14 stated she had received a lot of education recently, but could not recall if catheter care was included in the education. In an interview on 05/10/2024 at 1:41 PM, LPN28 stated she received recent training on a variety of topics, but did not recall doing a return demonstration for skills on catheter care. b. Review of R163's admission Record revealed the facility admitted the resident on 04/08/2024 with diagnoses including a stage 4 pressure ulcer on her sacrum, tracheostomy (tube to help with breathing) status, and gastrostomy (feeding tube inserted into the stomach) status. Review of R163's admission MDS, with an ARD of 04/15/2024, revealed the resident was not able to be understood to complete a BIMS, and the facility assessed the resident's cognitive abilities as severely impaired. Further review revealed R163 was totally dependent on staff for activities of daily living (ADLs) including toileting hygiene and dressing. Observation on 05/10/2024 at 10:51 AM revealed SRNA40 failed to pull the curtain while R163 was naked while SRNAs were changing R163's briefs and gown. Further observation revealed each time staff opened the door to obtain supplies, R163's body was exposed to the hallway. Continued observation revealed R163's body could be seen in the shared mirror and her roommate was present in the room. In an interview on 05/10/2024 at 2:33 PM, SRNA40 stated staff received so much education all at once as part of the POC, it was hard to remember it all. She stated she had failed to perform hand hygiene and provide for R163's dignity during care because she was nervous. In an interview on 05/10/2024 at 5:12 PM, the Administrator stated she expected staff to provide for resident dignity during care. The Administrator did not provide any information on how the POC failed to correct staff failure to pull the curtain around the bed to shield the resident's body from view. c. Observation on 05/10/2024 at 10:28 AM, revealed SRNA15 removed the mechanical lift from R5's room and took the lift to the clean utility room without disinfecting it. Further observation revealed SRNA15 left the clean utility room without disinfecting the mechanical lift. In an interview on 05/10/2024 at 10:28 AM, SRNA15 stated she did not recall recent training about disinfecting shared equipment, such as mechanical lifts. Interview attempted with the Director of Nursing (DON) on 05/09/2024 at 5:40 PM and 05/10/2024 at 2:50 PM and 5:27 PM; however, the DON did not answer her phone or call the State Survey Agency (SSA) Surveyor back prior to exit on 05/10/2024. In an interview on 05/10/2024 at 5:12 PM, the Administrator stated the facility needed to re-educate staff on disinfection of mechanical lifts. She stated she expected staff to follow infection prevention protocols, but did not provide insight into how the facility's POC into infection control had failed.

Based on observation, interview, record review, and review of the Centers for Disease Control and Prevention (CDC) guidelines on standard precautions, hand hygiene, and disinfection of shared low-level equipment; review of the manufacturers' directions for use for the Assure Prism Blood Glucose Monitoring System and Sani-Cloth Germicidal Wipes; and review of the facility's policy, it was determined the facility failed to identify and correct problems related to infection prevention practices for 8 of 104 sampled residents (Residents #24, #31, #114, #117, #120, #154, #103 and #105). The findings include: Review of the facility's policy, Infection Control, revised in 2018, revealed the policy was intended to facilitate a safe, sanitary, and comfortable environment to prevent and manage the transmission of disease and infection. Per the policy, all personnel would be trained on infection control policies and practices upon hire and periodically thereafter. Furthermore, the policy stated the policies and procedures for infection prevention were reviewed on a regular schedule and updated as needed in response to changes in regulations and standards, new equipment, or new procedures. Review of the facility's policy, Cleaning and Disinfection of Resident Care Items and Equipment, revised 09/2022, revealed the policy stated resident care equipment including reusable items and durable medical equipment would be cleaned and disinfected according to current Centers for Disease Control (CDC) recommendations for disinfection. Review of the CDC's Guidelines provided by the facility, Core Infection Prevention and Control Practices for Safe Health Care Delivery in all Settings, reviewed 09/29/2022, revealed that reusable or shared medical equipment should be cleaned and disinfected before use on another resident or when soiled. Facilities were to adhere to the manufacturer's instructions for reprocessing. The guidelines stated that facilities should maintain separation between clean and soiled equipment to prevent cross-contamination. Further review of the guidelines revealed personnel should be trained in the correct steps for cleaning and disinfection of shared equipment and competencies should be assessed and documented initially upon assignment, whenever new equipment was used, and periodically thereafter. Review of the facility's policy, Handwashing/Hand Hygiene, revised 08/2018, revealed the policy considered hand hygiene as the primary means to prevent the spread of infections. Per the policy, all personnel would follow hand hygiene procedures to prevent the spread of infection. Review of the cleaning and disinfecting instructions for the Assure Prism Blood Glucose Monitoring System, no date, revealed to minimize the risk of transmitting bloodborne pathogens the exterior of the glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection procedure, which would prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate contact time according to the disinfectant's instructions. Review of the cleaning and disinfecting instructions for the Sani-Cloth Germicidal Disposable Wipe (purple lid container) revealed to clean and disinfect non-porous surfaces the user would use one (1) or more wipes as necessary to wet surfaces sufficiently and thoroughly to clean the surface. Further review revealed the user was to unfold a clean wipe to thoroughly wet the surface and allow the treated surface to remain wet for a full two (2) minutes to ensure complete disinfection of all pathogens then allow the treated surface to air dry. Review of the facility policy titled, Catheter Care, Urinary, revised 08/2022, revealed the facility was to provide care for urinary catheters to prevent urinary tract infections. Continued review revealed such care included: keeping the urinary drainage bag and tubing off the floor; using a clean basin and clean washcloth for catheter care; and ensuring the catheter drainage spout did not come into contact with a nonsterile container when emptying the bag. Observation of Shower room [ROOM NUMBER] on the 100 Hall on 02/26/2024 at 5:20 PM, revealed SRNA #1 entered Shower room [ROOM NUMBER] wearing gloves and carrying a bag filled with soiled linen and towels. During an interview on 02/26/2024 at 5:23 PM with SRNA #1, she stated it was not appropriate to wear gloves in the hallway and that carrying contaminated laundry into another area was not allowed unless it was placed in the designated dirty linen room. She stated that carrying dirty linen into a clean area could increase the risk of spreading germs. SRNA #1 further stated she had received education on IPCP. She stated she did not recall when she received the education, but stated, A while ago. She stated as per her training, staff should remove gloves and perform hand hygiene before leaving the room. She also stated contaminated linen and trash should be taken to the Dirty Utility Room immediately. Observation and Interview of Shower room [ROOM NUMBER] in the 100 Hall on 02/26/2024 at 5:12 PM, revealed a pile of dirty, wet washcloths and towels in the sink. There was also a large pile of dirty, wet towels on the floor. In an interview with SRNA #1, she stated used towels and other dirty or soiled linen should be bagged immediately and taken to the dirty utility closet where they were put into a dirty linen bin. She stated linen should not be left in the shower rooms. She stated this was important to prevent germs from contaminating other areas and to keep the facility clean. Observation of Shower room [ROOM NUMBER] in the 100 Hall on 02/26/2024 at 5:17 PM, revealed a storage shelf unit with four (4) shelves. Each shelf held bags of unused incontinence briefs. Some of the bags were open exposing clean briefs. There were several bins containing PPE in the drawers. The room also housed a Hoyer lift, which had visible dirt and stains on the base and grab bars. Also in the room was another wheelchair. In addition, there was a high-back wheelchair pushed into a shower stall. The cushion on the chair was visibly wet and soiled with moist brown matter on it. The smell of feces and urine emanated from the chair. During an interview with Licensed Practical Nurse (LPN #1), on 02/26/2024 at approximately 5:25 PM, she stated a resident had soiled the chair, and she was storing it in the shower room until staff could clean it. The LPN stated the second shower room was used for the storage of clean supplies, such as PPE and briefs, and shared equipment, such as lifts and wheelchairs. She further stated she acknowledged concerns over placing a dirty chair in with clean supplies and storing dirty with clean could cause cross-contamination of supplies. Observation of the Laundry Room on 02/28/2024 at 10:15 AM, revealed laundry was delivered to the basement via a laundry chute located on the 300 Hall. The Environmental Services Director (EVS) opened the laundry chute and multiple bags of laundry dropped into a large laundry cart. The multiple bags dropped from the chute were not properly tied, which allowed multiple pieces of loose contaminated linen to come out of the chute and drop freely into the laundry cart. During the observation, the EVS touched multiple pieces of unbagged contaminated laundry without wearing proper PPE, including a gown and gloves, and failed to perform HH after rearranging the pile of soiled linen in the laundry cart. Observation of the Dirty Utility Room, located on the 100 Hall, on 02/28/2024 at 10:35 AM, revealed one (1) trash barrel and one (1) barrel for dirty linen. The dirty linen barrel was overflowing with bagged linen by almost half of the size of the barrel preventing a lid from being placed on top to cover the dirty linen. Three (3) of the bags observed were not tied securely, and contaminated linen was falling out onto the other bags. Observation of the Dirty Utility Room, located on the 300 Hall, on 02/28/2024 at 10:45 AM, revealed one (1) trash barrel and two (2) barrels for dirty linen. One (1) dirty linen barrel was overflowing with bagged linen hanging over the rim preventing a lid from being placed on top to cover the dirty linen. One (1) contaminated linen bag was not tied securely, and contaminated linen was falling out onto the other bags. During an interview with the EVS on 02/28/2024 at 10:00 AM, she stated she was newly hired and had only been on the job for (3) three weeks. She stated all staff should be educated on IPCP upon hire; however, she stated she had not received IPCP training from the facility upon hire. She stated following established IPCP was important to prevent the spread of germs throughout the facility. During a continued interview with the EVS on 02/28/2024 at 11:15 AM, she stated any dirty linens in the room should be placed in a bag, tied, and taken to the Dirty Utility Room. She stated staff members should deposit the soiled linen in the designated linen barrel and ensure that the lid was securely placed on top. She stated, once the barrel was full, the staff should transport the barrel to the laundry chute located on the 300 Hall and empty the contaminated linen down the chute. During an interview with the Regional EVS Resource Director on 02/28/2024 at 11:15 AM, she stated soiled linen should be removed from the dirty utility room when the barrel was full and taken to the laundry chute. She stated all linen should be placed in a plastic bag and tied closed, and the barrel should be transported through the facility with the lid on. She stated staff should never overfill the barrel. During an interview with the Administrator on 02/28/2024 at 11:15 AM, she stated staff should not allow dirty linen to pile up in the Dirty Utility Rooms. She stated used linen should be bagged and tied securely before exiting the resident's room or shower areas. Per the interview, the Administrator was unsure if there was a schedule to ensure that linen was transported routinely throughout the day to prevent linen from piling up. She stated staff was expected to keep the Dirty Utility Room free from loose linen and trash. She stated the lids should be kept on the barrels during storage and transporting of linen. She stated properly bagging and transporting linen was an important part of infection control. 1) a. Review of Resident #117's Admission Record revealed the facility admitted the resident on 02/12/2023 with diagnoses to include chronic obstructive pulmonary disease, cerebral infarction, and dementia. Per the resident's Annual MDS Assessment, dated 12/05/2023, the facility assessed the resident to have a BIMS score of fourteen (14) of fifteen (15), indicating an intact cognitive response. b. Review of Resident #154's Admission Record revealed the facility admitted the resident on 02/15/2024 with diagnoses to include chronic obstructive pulmonary disease, cerebral infarction, and dementia. Per the resident's Admission MDS Assessment, dated 02/17/2024, the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating an intact cognitive response. c. Review of Resident #31's Admission Record revealed the facility admitted the resident on 01/10/2024 with diagnoses to include acute kidney failure, type 2 diabetes, and a local infection of the skin and subcutaneous tissue. Per the resident's Admission MDS Assessment, dated 01/10/2024, the facility assessed the resident to have a BIMS score of 12 of 15, indicating moderate cognitive impairment. d. Review of Resident #114's Admission Record revealed the facility admitted the resident on 10/22/2022 with diagnoses to include type 2 diabetes mellitus and disorders involving the immune mechanism. Per Resident #114's Quarterly MDS Assessment, dated 01/20/2024, the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating an intact cognitive response. Observation of the 100 Hall on 02/26/2024 at 4:40 PM, revealed the Social Services Assistant placed call lights within reach of residents. The Social Services Assistant arranged the call light for Resident #117, and when doing so, touched the resident and the resident's immediate environment, including the call light, bed stand, and bed linens. She then went over to Resident #154 and adjusted his/her call light, touching the call light and bed linens. The Social Services Assistant then exited Room the residents' room, failing to perform hand hygiene (HH) between residents. She then walked into Residents #31 and #114's room and adjusted their call lights, touching the call light and bed linens for both residents. She did not perform HH between resident care or after exiting the room. During an interview with the Social Services Assistant on 02/26/2024 at 4:55 PM, she stated she did not perform HH between residents. She stated she had received education on infection prevention and control procedures (IPCP) upon hire. She stated it was important to perform hand hygiene before and after entering the room or when providing care to prevent the spread of infection. Observation of Shower room [ROOM NUMBER] in the 100 Hall, on 02/26/2024 at 5:17 PM, revealed a Hoyer lift with visible dirt, stains, and dust on the base, swivel bar, and the grab bars, which residents touched while being transferred. The lift was being stored with a sling attached to the hooks on the swivel bar. Observation of the 100 Hall Nurse's Station, on 02/28/2024 at 11:00 AM, revealed two Nurse on a Stick (NOAS) portable vital sign machines. Both machines had visible dirt, stains, and dust on the base. The electronic screens of the machines were covered in fingerprints. During an interview with SRNA/KMA #12 on 02/28/2024 at approximately 11:05 AM, she stated she was educated to perform hand hygiene (HH) before and after providing resident care. She stated she was also educated on how to don (put on) and doff (take off) personal protective equipment (PPE). She stated she used Sani-Cloth Germicidal Wipes to wipe down shared equipment such as the portable vital sign machine and shared blood pressure wrist cuffs. SRNA/KMA #12 stated she used one (1) wipe to clean the portable vital sign machine. She stated she did not use a barrier cloth to place the equipment after cleaning. She stated she was unsure of what dwell time meant, but she thought it was how long you let it dry. SRNA/KMA #12 had to reference the container to determine the dwell time for effective disinfection using Sani-Cloth Germicidal Wipes on shared equipment. Observation of State Registered Nurse Aide/Kentucky Medication Aide (SRNA/KMA) #18 performing daily vital sign monitoring, on 02/29/2024 at 8:15 AM, revealed SRNA/KMA #18 took the NOAS into Resident #117's room and obtained a blood pressure reading. Continued observation revealed without cleaning and sanitizing the NOAS and plastic blood pressure cuff, SRNA/KMA #18 rolled the NOAS over to Resident #154's bed and obtained the resident's vital signs. SRNA/KMA #18 left the room, pushed the NOAS to the nurse's station, placed the machine against the wall, and began to chart. SRNA/KMA #18 failed to clean or sanitize the shared equipment. During an interview with SRNA/KMA #18 on 02/29/2024 at 8:35 AM, he stated he had been educated and trained on infection prevention and control practices (IPCP) upon hire and through periodic in-services. He stated he did not clean or sanitize the shared equipment. He stated per policy, staff should clean and disinfect the equipment before and after using the equipment and between residents. He further stated it was important to clean and disinfect shared equipment to prevent the spread of infection. 2). a. Review of Resident #105's Admission Record revealed the facility admitted the resident on 01/15/2024, with diagnoses including metabolic encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection, and hemiplegia (partial paralysis) following cerebral infarction (stroke). Review of Resident #105's Admission Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed Resident #105 as having an indwelling catheter; always incontinent of bowel; and needing staff supervision for toileting hygiene. Observation on 02/26/2024 at 5:38 PM, revealed Resident #105's urinary drainage bag dragging on the floor underneath his/her wheelchair. An interview was attempted with Resident #105, at the time of observation; however, the resident declined to answer the State Survey Agency (SSA) Surveyor's questions. Observation on 02/27/2024 at 10:03 AM, and on 02/28/2024 at 2:39 PM and at 3:46 PM, revealed Resident #105's urinary drainage bag was dragging on the floor beneath his/her wheelchair. In an interview on 02/28/2024 at 3:01 PM, SRNA #3 stated she had not seen Resident #105's catheter bag dragging on the floor prior to the interview. She further stated keeping a resident's catheter bag off the floor was important to ensure it was kept clean. In an interview on 03/02/2024 at 11:15 AM, Licensed Practical Nurse (LPN) #7 stated Resident #105's catheter bag frequently dragged on the floor because he/she self-propelled his/her wheelchair around the facility and the bag easily became dislodged from where it was hung on the wheelchair frame. LPN #7 stated staff should reattach the drainage bag to the wheelchair when it fell off because allowing it to drag on the floor would place the resident at risk for a urinary tract infection. In continued interview, LPN #7 stated Resident #105 would benefit from a leg bag during the day to promote his/her mobility and prevent the bag from dragging on the floor. 2) b. Observation on 03/07/2024 at 9:11 AM, revealed SRNA #20 placed washcloths directly in the sink without using a basin. Continued observation revealed the sink drain did not have a cover, so the washcloths went partially down into the sink drain when staff wet them. Further observation revealed SRNA #20 applied soap to the washcloths from the sink and used those washcloths to cleanse Resident #105's catheter. In an interview on 03/07/2024 at 12:28 PM, SRNA #20 stated she had prior experience as an SRNA; however, had not received training on how to provide catheter care at the current facility. She stated no one at the facility had told her about the facility's resident care policies. SRNA #20 stated she usually would have used a basin to place the washcloths in, but could not find one, so she thought placing the washcloths in the sink would be acceptable. In further interview, she stated she had not thought about the bacteria that would be in the sink, especially in the drain. SRNA #20 further stated she might have been more careful if she had known Resident #105 had a history of urinary tract infections. In an interview on 03/08/2024 at 10:10 AM, Director of Nursing (DON) #1/Resource Nurse stated to use a washcloth that had been lying directly in the sink, without use of a basin, to cleanse a urinary catheter was an unacceptable practice by a staff member . In an interview on 03/08/2024 at 4:25 PM, the Administrator stated it was unacceptable for a staff member to use a washcloth that had been placed in the sink without a basin to cleanse a urinary catheter. She further stated that observation indicated a need for further training with staff. 3) Review of Resident #103's medical record revealed the facility admitted the resident on 02/27/2024, with diagnoses that included congestive heart failure, retention of urine, and type 2 diabetes mellitus. Review of Resident #103's Quarterly Minimum Data Set, dated dated [DATE], revealed the facility assessed Resident #103 with a BIMS score of nine out of fifteen indicating moderate cognitive impairment. Observation on 02/27/2024 at 10:51 AM revealed SRNA #1 removed Resident #103's suprapubic catheter drainage bag out of the dignity cover bag to show she had emptied the drainage bag. Continued observation revealed SRNA #1 did not wear gloves when handling the catheter tubing. Observation on 03/01/2024 at 8:08 AM revealed Resident #103 lying on his/her bed with his/her suprapubic catheter drainage bag touching the floor. Further observation revealed the catheter drainage bag was halfway out of the dignity bag and was also touching the floor. Observation on 03/01/2024 at 2:30 PM revealed SRNA #5 emptied Resident #103's catheter drainage bag. Continued observation revealed SRNA #5 donned gloves and placed an undated graduate urine collector directly on the floor without a barrier. Per observation, SRNA #5 performed hand hygiene (HH) and donned gloves. Continued observation revealed the SRNA took the drainage tube out of the pocket, held the drainage tube over the urine collector, and opened the valve to drain the urine. Observation revealed she clamped the valve; however, did not cleanse the end of the drainage tube before clamping it back. Further observation revealed SRNA #5 disposed of the urine in the urine collector into the toilet but did not rinse the collection container. In addition, the SRNA wiped the inside of the urine collector with a paper towel and placed it back into a plastic bag, which was hanging on the toilet. Observation on 03/03/2024 at 11:10 AM revealed Resident #103's suprapubic catheter drainage bag was not secured properly, as the bag was lying flat across the leg frame of the resident's bed. Continued observation revealed the urine flow was obstructed and was backing up into the drainage tubing because the bag was lying flat. Further observation revealed the entire length of the drainage tubing was filled with urine. Observation on 03/05/2024 at 7:46 AM, 8:01 AM, 8:16 AM, and 8:21 AM, revealed Resident #103's suprapubic catheter bag was lying on the floor under the resident's bed. During an interview with SRNA #5, on 02/29/2024 at 2:30 PM, she stated she had received infection control training upon hire. She stated she had not been trained to use a barrier pad on the floor when emptying catheter bags. Furthermore, she stated she did not know how often the graduated cylinders were changed, but she stated the night shift staff changed them. SRNA #5 stated further that she knows to use hand hygiene before donning gloves but does not know why she forgot before catheter care was provided to the resident. She stated that following infection prevention policies was important to prevent the spread of germs. During an interview with Licensed Practical Nurse/Unit Manager (LPN/UM) #1, on 03/03/2024 at 11:15 AM, she stated the catheter tubing should not have been lying on the floor as it could cause contamination and puts the resident at risk for infection. She further stated she would change the drainage bag and suprapubic catheter. During an interview with the DON/IP #1, on 03/08/2024 at 8:55 AM, she stated it was important for staff to practice hand hygiene when providing resident care. She also stated that staff were trained to place a paper towel on the floor before putting the graduated cylinder down. DON/IP #1 stated further that graduated cylinders should be rinsed, cleaned, and disinfected after use. In addition, all graduates should be labeled with the resident's name and date and were changed daily by the night shift. She stated following the facility's catheter care policy and procedures aids in preventing the spread of infection to the resident. During an interview with the Administrator, on 03/08/2024 at 4:45 PM, she stated it was her expectation that all direct care follow the facility's policies and procedures as they relate to catheter care. She stated it was important to prevent the spread of infection and communicable diseases. 4. Review of Resident #120's Admission Record revealed the facility admitted the resident on 07/17/2023 with diagnoses to include Alzheimer's disease, type 2 diabetes, and disorders involving the immune mechanism. Per the resident's Quarterly MDS Assessment, dated 12/20/2023, the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of three (3) of fifteen (15), indicating severe cognitive impairment. Observation of staff weighing a resident using a shared Hoyer lift on 03/02/2024 at 10:50 AM, revealed SRNA #15 and SRNA #17 took a Hoyer lift from the hallway and then got a sling for the lift from Shower room [ROOM NUMBER]. The lift had visible dirt, stains, and dust on the base, swivel bar, and grab bars. It was observed that the SRNAs failed to clean and disinfect the machine before using it on Resident #120. Further observation revealed, after leaving Resident #120's room, they pushed the Hoyer lift down the hall, removed the sling, and left the lift next to the Shower Room without cleaning or disinfecting it. Continued observations of SRNA #15 and SRNA #17, on 03/02/2024 at 10:50 AM, revealed the SRNAs failed to perform HH before they donned gloves to perform direct resident care on Resident #120. They weighed the resident using a Hoyer lift and then repositioned Resident #120 back into the bed. SRNA #15 and SRNA #17 doffed their gloves and did not perform HH before they exited the room. During an interview with SRNA #15 on 03/02/2024 at 11:10 AM, she stated she had received IPCP education and training under the former management. However, she also stated that she had not been assigned any new training by the current management. She stated she was not aware that the Hoyer lift had to be cleaned and disinfected after each use, and she thought that only changing the sling was sufficient. She stated it was important to perform hand hygiene before donning and after doffing gloves to prevent the spread of germs from resident-to-resident. During an interview with SRNA #17 on 03/02/2024 at approximately 11:15 AM, she stated she had received IPCP education upon hire under the former management. She stated shared equipment had to be cleaned and disinfected after each use. She stated each resident was given a clean sling for use during transfers. She further stated it was important to perform hand hygiene before putting on and after taking off gloves to prevent the spread of infection in the facility. 5. Review of Resident #24's Admission Record revealed the facility admitted the resident on 03/06/2023 with diagnoses to include chronic obstructive pulmonary disease, alcohol-induced chronic pancreatitis, and other specified disorders involving the immune mechanism. Per the resident's Annual Minimum Data Set (MDS) Assessment, dated 01/17/2024, the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 of 15, indicating an intact cognitive response. Observation during glucose monitoring of Resident #24 on 02/27/2024 at 4:05 PM, revealed Licensed Practical Nurse (LPN) #2 retrieved a worn, unsealed plastic Ziploc bag from the medication cart. The bag had Resident #24's name written on it and contained one (1) Assure Prism Blood Glucose Monitor (a device for measuring blood sugar levels), a bottle of test strips, alcohol wipes, lancets, a box of insulin glargine, and one (1) insulin pen. The bag also held three (3) of Resident #24's labeled insulin syringes. LPN #2 took the bag to Resident #24's room and placed it on the bedside table without using a barrier to cover the surface. She then performed hand hygiene, put on gloves, and conducted a fingerstick test. Continued observation on 02/27/2024 at 4:05 PM, revealed after LPN #2 performed the fingerstick procedure, she put the glucometer with the contaminated test strip on the bare bedside table. She then retrieved the insulin pen from the bag and administered insulin to Resident #24 without removing the contaminated gloves or performing hand hygiene. She returned the insulin pen and glucometer to the bag and left Resident #24's room without performing hand hygiene. LPN #2 then put the bag with Resident #24's insulin supplies, including the glucometer, back into the top drawer of the medication cart. She did not clean and disinfect the glucometer. During an interview on 02/27/2024 at 4:17 PM, LPN #2 stated, I should have cleaned the glucometer before placing it back into the bag. It's what I normally do. LPN #2 stated she normally would have followed proper infection control practices but stated, I was trained to do it that way by a UM [Unit Manager]. She stated she could not recall which UM had trained her to place everything back in the bag. She stated it was important to follow IPCP and clean and disinfect equipment to prevent contamination and the spread of disease. During an interview with the Interim Director of Nursing/Infection Preventionist (DON/IP) #1 on 03/05/2024 at 3:55 PM, she stated she had been in her position for two and one-half (2.5) weeks before the survey. She stated staff should have received training on IPCP. However, she stated she could not provide documentation on whether all current staff members had completed their training on IPCP provided by the current corporation. She stated the new company took ownership in October 2023. She further stated the facility followed IPCP guidelines as per the CDC. DON #1 stated it was her expectation that all staff members were responsible for infection control and must follow the facility's infection control policies and procedures. She stated having an infection control and prevention program was important to prevent infectious and communicable diseases. During additional interview with the Administrator on 03/08/2024 at 4:45 PM, she stated she had been in the position of Administrator since 12/2023. The Administrator stated when the facility changed ownership, many employees left, and she had been hiring new staff to replace them. She also explained that all staff members were provided with IPCP training upon hire and received education and training through online courses. Furthermore, she stated agency staff underwent training before starting their first shift. The Administrator stated it was her expectation that all staff was well-versed with the policies related to their job duties and adhered to all facility policies and procedures, including infection control. During continued interview with the Administrator on 03/08/2024 at 4:45 PM, she stated that DON/IP #1 was hired to provide interim leadership and oversee the infection prevention and control program at the facility when the former DON left. However, she stated that as the Administrator, I am responsible for everybody doing their job. The Administrator stated corporate leadership provided a Regional Resource Nurse to the facility to assist with providing education and guidance to nurse leadership and staff. According to the Administrator, the facility had appointed an Assistant Director of Nursing (ADON) to take over as the new Infection Preventionist. The Administrator stated it was her expectation that all staff members were responsible for infection control and must follow the facility's infection control policies and procedures. She stated it was important to prevent the spread of infection and communicable diseases.

Based on observation, interview, record review, and review of the facility's policy, it was determined, the facility failed to provide services with reasonable accommodation of resident needs and preferences for six (6) of one hundred and four (104) sampled residents (Residents #71, #101, #5, #105, #1 and #65). 1. On 01/02/2024, the facility was notified Resident #71's wheelchair brake was broken; however, the facility failed to repair his/her wheelchair in a timely manner, placing the resident at risk for falls during transfers. The facility provided Resident #71 an another wheelchair while waiting to have his/her assigned wheelchair repaired, which had brakes that failed to hold the wheelchair in place when applied during transfers. Resident #71 reported he/she did not feel safe transferring in and out of the wheelchair, and stated he/she was concerned a fall would cause him/her more of an injury to his/her already fractured hip. 2. On admission, the facility identified Resident #101 as a non-English speaking resident, with Cantonese as his/her preferred language. However, the facility failed to ensure staff were trained and used a Language Line to prevent communication barriers with Resident #101, for necessary assessments and person-centered care. 3. Observation revealed Residents #5's and #105's call lights were out of reach leaving them unable to use the call light to request assistance. 4. In interview, Resident #1 stated he/she vomited on his/her shoes and a new pair were needed. Resident #1 stated he/she wanted to go shopping to get the new shoes and other items. However, the facility failed to make arrangements for the resident. 5. In interview, Resident #65 stated he/she was hard of hearing and wore hearing aids. The resident stated he/she needed to go shopping or have someone obtain batteries for his/her hearing aids. The findings include: Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised March 2017, revealed the facility was to inform all residents and residents' representatives orally and in writing of the resident's rights while residing at the facility. Further review revealed the policy did not detail what resident's rights were, it only discussed how a resident could get their Residents Rights (which were posted) in the policy. 1. Review of Resident #71's Face Sheet revealed the facility admitted the resident on 11/13/2023, with diagnoses of fracture to the right femur and infection due to right hip prosthesis. Continued review revealed the facility admitted Resident #71 for rehabilitation services while awaiting a second hip surgery. Review of Resident #71's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15) which indicated the resident was cognitively intact. Further review revealed the facility also assessed Resident #71 to require supervision and touch assistance for toileting hygiene, sit to stand mobility, chair to bed to chair transfer and for using the toilet. In addition, the facility noted Resident #71 was wheelchair bound, awaiting hip surgery. Review of Resident #71's Comprehensive Care Plan focus for Activities of Daily Living (ADL), revealed the facility determined the resident had impaired physical functioning related to surgical incision to his/her right hip. Further review revealed on 11/07/2023, the facility care planned Resident #71 to require the assistance of one (1) staff for all ADL care. In interview on 03/01/2024 at 9:15 AM, Resident #71 stated he/she had concerns related to his/her wheelchair. The resident explained that the brakes were broken on his/her wheelchair, and a temporary replacement wheelchair was provided for him/her while the facility waited for parts. Resident #71 stated he/she was also concerned about the replacement wheelchair because the brakes did not hold on it either. The resident stated he/she was at the facility for rehabilitation services while awaiting surgery for his/her hip. The resident explained as long as he/she had a functional wheelchair he/she could transfer alone to the bathroom and that was very important. Resident #71 stated he/she could not take a chance of falling and getting hurt. In further interview, the resident stated staff said to call for help, but he/she could not wait sometimes to get to the bathroom and had to be able to go to the bathroom alone. In interview on 02/28/2024 at 2:05 PM, the Occupational Therapist (OT) explained she contacted maintenance several weeks ago about concerns regarding Resident #71's wheelchair. The OT stated she was told a part had been ordered and the facility was waiting for that part to arrive in order for the wheelchair to be repaired. She stated she checked daily with the Maintenance Director, and had been told the part had not arrived. The OT stated she was very concerned about Resident #71 not having his/her assigned wheelchair, as that could be very serious if the resident sustained a fall because of his/her hip injury. In an interview with the Maintenance Director on 02/28/2024 at 3:01 PM, she stated she was aware of the concerns about Resident #71's wheelchair. She stated she put an order in for the part. The Maintenance Director provided a Direct Supply order history which showed a replacement brake assembly, left side for a Panacea Standard & Lightweight Wheelchair was ordered on 01/02/2024. She stated she did not have an invoice to show the part was actually ordered and she had no way of knowing when the replacement parts would arrive. The Maintenance Director further stated she could not provide any record showing she had called to check on when the part would arrive. In an interview with Resident #71 on 02/29/2024 at 9:00 AM, the resident stated his/her wheelchair had been repaired and returned for use. Resident #71 stated he/she was very happy to have his/her wheelchair back, and he/she felt safer now. 2. Review of the facility's policy titled, Notice of Resident Rights and Responsibilities, revised March 2017, revealed if a resident spoke a foreign language not commonly spoken in the facility, staff were to use the Language Line for Resident's Rights to be read in his/her language. Review of the facility's policy titled, Translation and/or Interpretation of Facility Services, revised November 2020, revealed the facility's Language Access Program was to ensure residents with Limited English Proficiency (LP) had meaningful access to information and services provided by the facility. Per policy review, the LP Coordinator was to be the Social Services Director (SD) or designee. Continued review revealed the LP Coordinator was to complete the initial language assessment and ensure all staff were aware of what language the resident spoke. Policy review revealed when written translation of vital information (for the resident) was unavailable or impractical the facility was to attempt to provide oral translation of the vital information. Further review revealed the information should be provided in a timely manner and at no cost to the resident; through: a staff member trained and competent in the skill of interpreting; a staff interpreter; contracted interpreter services; a volunteer who was trained and competent in translation services; or via a telephone interpretation service. Additional policy review revealed (the facility's) Quality Assurance and Performance Improvement (QAPI) Committee should bi-annually assess the LP program and make changes as necessary. Continued review revealed all staff were to be trained upon hire and at least annually on how to provide language access services to LP residents. Review of Resident #101's Face Sheet, revealed the facility last admitted the resident on 10/22/2022, for a change in mental status. Continued review revealed the facility previously admitted Resident #101 on 02/24/2022, for diagnoses of calorie malnutrition, mild cognitive impairment and unspecified hearing loss in both ears. The facility diagnosed the resident with dementia on 02/21/2024. Review of Resident #101's Admission MDS assessment dated [DATE], revealed the facility failed to assess the resident with a BIMS' score to indicate his/her mental capacity. Further review of the MDS Assessment, Section A, revealed the facility failed to complete that section which identified Resident #101's language and desire for an interpreter. Review of Resident #101's Quarterly MDS assessment dated [DATE], revealed the facility failed to assess the resident's BIMS score, and no behaviors were noted. Continued review of the MDS Assessment revealed Section GG, which was related to assessment of the resident's Activities of Daily Living (ADL) level of care was not completed. Further MDS review revealed the facility failed to complete Section A, which assessed Resident #101's (preferred) language and desire for an interpreter. Review of Resident #101's Comprehensive Care Plan, related to communication revealed the facility was to ensure availability and functioning of adaptive resources/equipment specifically: a language line, message/communication board; cue cards; and to provide preferred (primary) language interpreter services such as a language line as indicated (10/26/2022). Review of Resident #101's progress notes dated from 02/25/2022 to 03/04/2024, revealed sixteen (16) times staff referred to the resident's language barriers as a reason for their inability to communicate with him/her and/or assess the resident. Review of the progress note dated 10/22/2022, revealed Licensed Practical Nurse (LPN) #14 noted the resident had a language deficit because he/she spoke very little English. Continued review revealed LPN #14 additionally documented Resident #101 had difficulty understanding others and being understood by others related to his/her language barrier. However, further review revealed no documented evidence any communication tools were used by the facility. Review of the facility's phone number list, revealed LPN #14 was no longer employed by the facility; and the phone number listed for the LPN was no longer in service. Review of Resident #101's progress note completed on 06/27/2023 by LPN #10, revealed she noted after a reported sexual incident involving the resident and another resident, the LPN documented a BIMS score of ninety-nine (99). Continued review revealed LPN #10 noted Resident #101's BIMS score was 99 because, We believe was due to the language barriers the resident had. Further review of the progress note revealed there was no documented evidence the nurse used a Language Line or any other communication tool in order to complete the assessment. Attempted interview with LPN #10 on 03/04/2024 at 9:00 AM and 03/05/2024 at 2:00 PM, was unsuccessful as she no longer worked at the facility, and a voice message with a call back phone number was left for her. Review of Resident #101's progress note completed by LPN #5 on 01/17/2024, revealed the facility found Resident #101 lying on the floor with a brief pulled up and another brief down around his/her ankles. Continued review revealed LPN #5 noted she was unable to discuss why Resident #101 had on two (2) briefs because of the language barrier. Further review revealed there was no documented evidence the nurse tried to use a Language Line or any other communication tool with the resident in attempts to communicate with him/her. In an interview with LPN #5 on 03/01/2024 at 8:50 AM, she stated she had worked with Resident #101 and when the resident first arrived at the facility she tried to use a Google translator application (app) to communicate with him/her; however, it had not worked out. She explained she was never informed of a Language Line she could call to get help communicating with the resident. LPN #5 also stated she had not been given any guidance on how to best communicate with residents who did not speak English as their first language. Review of Resident #101's nurse's note completed by Registered Nurse (RN) #2 dated 05/31/2023, revealed she noted the resident as unable to answer pain assessment questions after a fall due to language barriers. However, further review revealed no documented evidence the RN used a language line or any other tools to communicate with the resident. In an interview with RN #2 on 03/05/2024 at 2:20 PM, she explained she was never told about a phone number or provided any direction on how to call a Language Line to communicate with Resident #101. She said for basic needs it was not too hard to communicate with Resident #101. The RN stated she just offered the resident food. However, she further stated she could not explain how she assessed or determined Resident #101's medical needs, other than just did them like she would do for any cognitively impaired resident. Review of the Advanced Practice Registered Nurse (APRN) progress note dated 01/24/2023, revealed she had not assessed Resident #101's cognition because of language barriers. Further review revealed there was no documented evidence she attempted to use any type of communication tool, such as a language line to be able to successfully communicate with the resident. Review of Resident #101's APRN progress note dated 05/15/2023, revealed she noted the resident was very limited with the English language. Continued review revealed the APRN documented she had been unable to assess Resident #101's cognitive ability due to the language barrier. Further review revealed there was no documented evidence the APRN used a language line to communicate with the resident. Review of Resident #101's APRN progress notes, dated 11/01/2023, 11/03/2023, 12/27/2023, 01/06/2024, 01/31/2024, 02/16/2024, and 02/21/2024, revealed she noted she was unable to assess the resident's psychiatric orientation due to language barriers. Continued review revealed there was no documented evidence the APRN attempted to use a language line or any other communication tool to attempt to communicate with the resident. In an interview with APRN on 03/08/2024 at 10:30 AM, she stated she had worked at the facility for four (4) years and had provided care for Resident #101 during that time. She said she knew how to contact a language line; however, she stated she did not need a language line to communicate with the resident for his/her basic needs. The APRN stated she had no explanation for her notes in which she documented unable to assess the resident based on the language barrier. In an interview with the Director of Nursing (DON) on 03/07/2024 at 3:01 PM, she stated she was not aware of an interpreter line or service previously used by the facility. She explained she saw a sign (which said Interpreter Services) in the room where staff clocked in and the sign had recently been moved to the entrance so residents and visitors could see it. The DON stated the new owner of the facility had interpreter services and all staff were to be trained on it. The DON further stated all residents should have the appropriate assistive devices to aide in their care and those assistive devices should be provided as soon as possible. In an interview with the Administrator on 03/08/2024 at 4:35 PM, she stated staff should use interpreter services, if the need presented itself. She said, she was informed the Director of Social Services (DSS) attempted to use the interpreter services one (1) time when Resident #101 was first admitted ; however, the resident refused the services and therefore, they had not tried using it again. 46710 3. Review of the facility's policy titled, Answering the Call Light, revised 09/2022, revealed the facility was to ensure a resident's call light was to be accessible to the resident. a). Review of Resident #5's Admission Record revealed the facility admitted the resident on 11/10/2023, with diagnoses which included chenille (paralysis of one side of the body) following a cerebral infarction (stroke), epilepsy (seizure disorder), and need for assistance with personal care. Review of Resident #5's Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS score of eleven (11) out of a possible fifteen (15), indicating the resident was moderately cognitively impaired. Further MDS review revealed the facility assessed the resident as dependent on staff for transfers and toileting hygiene. Review of Resident #5's care plan dated 01/11/2024, revealed the facility identified the resident as visually impaired and at risk for falls. Continued review revealed the interventions included always keeping the resident's call light in reach. Observation on 03/02/2024 at 8:19 AM, revealed Resident #5 sitting in his/her wheelchair with the call light lying on his/her bed out of the resident's reach. Observation on 03/07/2024 at 9:11 AM, revealed the call light for Resident #5 was out of reach, lying on the floor. In an interview on 03/02/2024 at 8:31 AM, State Registered Nurse Aide (SRNA) #19 stated she had not noticed Resident #5's call light being out of his/her reach. SRNA #19 stated she would go fix it immediately because the resident needed the call light to alert staff if he/she needed anything. In an interview on 03/07/2024 at 12:28 PM, SRNA #20 stated she had not noticed the call light being out of reach of Resident #5 when she was in the room performing morning rounds around 9:00 AM that morning. She stated staff needed to ensure call lights were always in reach of each resident. b). Review of Resident #105's Admission Record revealed the facility admitted the resident on 01/15/2024 with diagnoses including metabolic Encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection, and chenille (partial paralysis) following cerebral infarction (stroke). Review of Resident #105's Admission MDS assessment dated [DATE], revealed the facility assessed the resident with a BIMS score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Continued review revealed the facility assessed Resident #105 as having an indwelling catheter, always incontinent of bowel, and needing staff supervision for toileting hygiene. Further review revealed the facility additionally assessed Resident #105 as needing staff supervision or touching assistance for transfers. Review of Resident #105's care plan dated 01/16/2024, revealed the facility care planned the resident as at risk for falls and dependent on staff for assistance with Activities of Daily Living (ADLs). Further review revealed the facility had not included interventions regarding Resident #105's use of the call light in his/her care plan. Observation on 03/07/2024 at 9:11 AM, revealed Resident #105's call light lying on the floor, out of reach of the resident. In an interview on 03/07/2024 at 12:28 PM, SRNA #20 stated she had not noticed Resident #105's call light being out of reach of the resident when in his/her room performing morning rounds that morning around 9:00 AM. SRNA #20 further stated staff needed to ensure residents' call lights were always in reach. In an interview on 03/08/2024 at 10:10 AM, DON #1/Resource Nurse stated call lights needed to be in reach for residents at all times. She further stated call lights were the mechanism residents used to call for staff assistance to get their needs met. In an interview on 03/08/2024 at 11:13 AM, DON #2 stated her expectation was for residents' call lights to always be in reach of residents at all times. In an interview on 03/08/2024 at 4:25 PM, the Administrator stated call lights should always be within reach of the resident. She further stated it was her expectation staff ensured the call light was in reach as the last thing they did before leaving the resident's room when finished providing care. 4. Record review revealed the facility admitted Resident #1 on 01/06/2021, with diagnoses to include Paranoid Schizophrenia, Bipolar Disorder, and Dependence on renal dialysis. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #1 to have a BIMS' score of ten (10) indicating the resident was moderately cognitively impaired. Review of the Annual MDS assessment dated [DATE] revealed the facility assessed that it was very important to Resident #1 to take care of his/her personal belongings. Observation of Resident on 02/29/2024 at 2:38 PM revealed the resident was lying on his/her bed. During interview with Resident #1 at the time of the observation, the resident stated she/he had not been able to go shopping for new shoes. Resident #1 said she/he vomited on her/his shoes and could no longer wear those shoes, and needed to go shopping to get new shoes. The resident further stated the facility used to provide shopping trips for its residents; however, they no longer provided shopping trips. 5. Record review revealed the facility admitted Resident #65 on 09/04/2021, with diagnoses to include morbid obesity, handsomely (medical condition involving the rapid dissolution of damaged or injured skeletal muscle), and need for assistance with personal care. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #65 to have a BIMS score of fifteen (15) out of fifteen (15) indicating she/he was cognitively intact. Review of Annual MDS assessment dated [DATE] revealed it was very important to go outside and participate in her/his favorite activities. In addition, further review revealed it was also very important for her/him to take care of personal items. Observation of Resident #65 on 02/29/2024 at 2:48 PM, revealed the resident was lying on his/her bed. During interview of Resident #65 at the time of the observation, she/he stated the facility used to take the residents shopping, but they no longer took residents shopping. Resident #65 stated she/he had hearing aides and needed batteries for the hearing aides in order to hear others. The resident stated she/he did not have family to go shopping for her/him. In addition, Resident #65 further stated she/he really liked peanut butter: however, he/she was not able to go to the store to purchase it. During interview with the Activities Director (AD) on 03/01/24 at 9:06 AM, he stated the facility's van was currently not working as the hydraulic pump was out of service. He stated he had not provided any outings for residents since October 2023. The AD stated he had residents who expressed interest in going on outings; however, it had been challenging as the facility did not have the means to take the residents on outings. He stated to supplement for those types of activities he had been trying to bring events into the facility. The AD stated staff had shopped for residents in the past, all the way up to October. He said when the facility's new company took over, staff stopped doing shopping for residents. The AD stated he was shopping eight (8) days a month now, and it was affecting his activities calendar. He stated shopping was overwhelming the activities department, as he was spending abut twenty-two (22) man hours per resident unit for the shopping for each unit. The AD stated activities staff had reached out to families and were attempting to provide iPhones and iPads, so they had alternative means of requiring resources for residents. . During interview with DON #1 on 03/08/2024 at 10:28 AM, she stated she was not aware that the activity department was no longer providing or able to go shopping for the residents. During interview with DON #2 on 03/08/2024 at 11:14 AM, she stated it was important for residents to be able to get items from outside the facility that were important to them. During interview with the Administrator on 03/08/2024 at 3:02 PM, she stated she had not been informed of any changes in the activity department.

Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment. Observations included a strong urine and feces odor throughout the facility; cracked and misshapen ceiling tiles; dirty air intake vents; dirty floors with stains; a loose and warped metal plate in the floor; and clean and dirty items stored together. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to a safe, clean, comfortable, and homelike environment. Review of the facility's policy titled, Homelike Environment, dated 2001 and revised February 2021, revealed that facility staff and management maximized, to the extent possible, the characteristics of the facility that reflected a personalized, homelike setting. These characteristics included: a clean, sanitary, and orderly environment, with pleasant neutral scents. Observation on 02/26/2024 at 4:40 PM upon entry into the facility, revealed there was a strong odor of urine and feces. When walking down the 100, 200, and 300 Hallways, Hallway 100 had the strongest smell of urine and feces. Observation revealed water stains on the ceilings on all three (3) hallways and in the entry way. The entry way had cracked and misshapen ceiling tiles. Air intake vents were dirty and discolored, and the floors were not clean in the hallways. Observation on 02/26/2024 at 5:03 PM through 5:15 PM, revealed the shared bathroom for room [ROOM NUMBER] had a lumpy brown-black object on the floor. Shared bathrooms for rooms 211, 212, 213, and 214 had the strong smell of urine, and the floors were not clean. Continued observation on 02/26/2024 at 6:05 PM revealed a red-brown stain on the wall between rooms [ROOM NUMBERS], near the handrail. Observation on 02/26/2024 at 4:49 PM and at 7:12 PM and on 02/28/2024 at 8:08 AM, revealed the second to last metal plate in the floor of the 100 Hallway was loose and warped, causing the corner to be bent upwards, creating a tripping hazard. The metal place also slid/moved when stepped on. In an interview on 02/26/2024 at 7:12 PM, State Registered Nurse Aide (SRNA) #1 stated she was worried that someone, either a staff member, visitor, or resident could trip over the loose metal plate. She stated she did not know if anyone had put in a work order for maintenance to repair it. SRNA #1 stated the plate had been loose and bent like that since at least 02/14/2024. In an interview on 03/03/2024 at 6:32 PM, Licensed Practical Nurse (LPN) #1 stated the metal plate was an access point to repair plumbing problems. The LPN stated she was aware the plate would slide out of place at times, but staff members did the best they could to keep everyone safe. She stated they notified maintenance when the plate slid out of place and needed to be repaired. In an interview on 03/07/2024 at 9:47 AM, the Maintenance Assistant stated the process for completing repairs at the facility was for staff to fill out a paper work order, or verbally tell him when something needed to be fixed. The Maintenance Assistant stated he was not aware of the warped, loose metal plate in the 100 Hallway until a couple days ago, when he replaced it with a thicker metal plate that would be less likely to [NAME] and screwed it in place so it would not shift when stepped on. In an interview on 03/08/2024 at 4:25 PM, the Administrator stated the metal plate on the 100 Hallway had not been previously repaired because staff just got used to it being like that and did not report it to maintenance. Observation on 02/27/2024 at 12:48 PM, revealed the floor in room [ROOM NUMBER] had trash that included: three (3) napkins, two (2) straw wrappers, and five to six (5-6) other small pieces of paper. It did not appear to have been cleaned. Observation on 02/28/2024 at 11:30 AM of the soiled utility room on the 100 Hallway, revealed both clean and dirty items stored together. Dirty items in the room included: two (2) cans with lids for placing dirty and soiled linens, which did not have lids. The bags were not tied up well to prevent the odor of urine and feces from emanating. A gown was thrown on the shelf that held the clean equipment/supplies. A suction pump, four (4) unused biohazard boxes, a cardboard box of biohazard bags, an easy air pump, an unopened bottle of sterile water for the humidification of oxygen were sitting on two (2) shelves. Interspersed on these two (2) shelves were cleaning supplies, a cup, and used bath supplies. Continued observation revealed a plastic two (2) drawer storage container, which contained masks, sat on the soiled floor, with one (1) side touching one (1) of the soiled linen containers. The two (2) cans that were for dirty linens were visibly soiled on the outside with brown stains, and the floor in the room was dirty with brown stains. In the dirty linen room on the 300 Hallway, clean equipment, such as oxygen concentrators and a feeding tube pump were stored along with the stained and dirty soiled linen cans and red biohazard cans. Observation on 02/28/2024 at 11:53 AM of the 300 Hallway, revealed a Hoyer Lift (mechanical lift that transferred a resident from one surface to another) that had brown staining on the bottom and where the sling hooks to the lift. The shower room floor on the 300 Hallway was visibly soiled. It contained dirty equipment, such as one (1) recliner, three (3) to four (4) bedside commodes that were soiled, a soiled Hoyer lift, and two (2) mats. Observation on 03/05/2024 at 10:27 AM in Resident #55's room revealed there was a hole in the ceiling over his/her bed. The hole had been poorly patched with a patch made of plastic/paper that did not fit completely over the hole. It was observed that no drywall mud had been placed over the patch, and the area had not been repainted. In an interview with Resident #4 on 03/08/2024 at 3:33 PM, the resident stated he/she felt the facility was not as clean as it could be. Resident #4 stated the bathroom could be cleaned more often and should be cleaned better. In an interview with State Registered Nurse Aide (SRNA) #14, SRNA #17, and SRNA #43 on 03/08/2024 at 3:58 PM, all stated they thought the facility was cleaner sometimes than it had been in the past, prior to the new owners taking over. SRNA #14 said the facility was still dirty, and prior to the new owners, the hallways and bathrooms were not cleaned, but now they were cleaned some of the time. All of the SRNAs stated dirty linens were taken out of the dirty linen room when the container was full. Further, they stated if they found blood, feces, urine, or other fluids on the floor or walls, they would put on personal protective equipment (PPE), clean it up, and call housekeeping. In an interview with Social Worker #18 on 02/28/2024 at 1:07 PM, she stated the first time she entered the facility, the smell of urine and feces were so potent that it made her want to vomit. She stated there was a drain snake in the hallway in a wheelchair, which remained there from November 16th through November 18th. She stated she visited Resident #149 daily in the week that he/she was admitted to the facility. Social worker #18 said the floors were extremely dirty, with food, debris, and napkins strewn down the hallway. In an interview with the Housekeeping Director and the Regional Housekeeping Director on 02/28/2024 at 11:15 AM, the Housekeeping Director (HD) stated she had worked at the facility for three (3) weeks. The RHD stated individual housekeeping staff members were assigned to areas. The HD stated she did a spot check of three (3) random rooms daily, and any concerns were written down and given to the housekeeping staff member to fix. She stated the staff member would then reclean any areas that were not cleaned well, and the HD rechecked to make sure the areas were clean. The HD stated that weekly she toured the entire facility to ensure that it was clean. Both the HD and the RHD stated housekeeping staff members were to clean residents' rooms as follows: sweep and mop the floors, dust, clean residents' bedside trays/carts, clean bathrooms (including sweeping and mopping the floors and wiping the walls), clean shower rooms, and clean common areas. The HD and RHD stated trash was taken out daily, but for some residents, if housekeeping knew they generated a lot of trash, it would be taken out twice daily. The HD and RHD stated the dining room was cleaned twice daily. In continued interview with the HD and RHD on 02/28/2024 at 11:15 AM, both stated there was no paper documentation of what was cleaned daily per each staff member and there was no daily cleaning log for housekeeping staff members. The RHD stated if a resident refused to allow housekeeping to clean his/her room, the housekeeper was to let their supervisor know. The RHD stated the housekeeping supervisor would talk with the nurse that was taking care of that patient (resident) to get the nurse's help with the resident allowing housekeeping to clean the room. The RHD stated if the resident continued to refuse, and it was affecting other residents, she would notify her supervisor at the corporate level, and they would get involved. The RHD stated that under no circumstances were the housekeepers to just go ahead and clean the room if the resident refused. The HD stated she did not know per policy how often handrails and walls were wiped down, but she expected the handrails to be cleaned daily and the walls in the hallways weekly. The HD stated the walls should be wiped in residents' rooms daily. The HD stated stripping, cleaning, and waxing floors was done per the pull schedule. The HD and RHD stated the pull schedule was when staff did a more thorough cleaning of a resident's room or area. In an interview with the Facility Maintenance Director (FMD) on 02/28/2024 at 2:15 PM, she stated there was a process for preventive maintenance for the building. She stated this process was to keep track of by the TELS (software) program. She stated this program told maintenance staff when to do upkeep and provided a place to record that the maintenance was performed. The FMD stated that repairs were triaged by severity, for instance a water leak was first fixed, and then the damaged ceiling tiles and drywall were fixed. The FMD stated that once the wet drywall was removed, it was then patched and painted with Kilz (to prevent mold from growing) before it was repainted. The FMD stated the metal plate in the floor of the 100 Hallway had to remain unsealed so that plumbing for the building could be accessed. In an interview with Director of Nursing (DON) #1 on 03/08/2024 at 10:10 AM, she stated she did not feel that a dirty facility that smelled of urine and feces and had observed blood, feces, or smashed bugs on the floor and wall constituted a safe, clean, comfortable, homelike environment. In an interview with the Administrator (ADM) and Regional [NAME] President of Operations (RVPO) on 03/06/2024 at 1:45 PM, both stated they were aware of the odors of urine and feces in the facility. Both stated they thought a facility that had an unpleasant odor, dirty patient rooms and bathrooms, and feces/blood on the wall, did not constitute a safe, clean, comfortable, homelike environment. Both stated that the smell was better than it was when corporate took over the facility in October 2023. During the interview, the VPO stated staff members were doing many things to address the smell and to clean the facility, such as replacing the exhaust fans throughout the building, replacing all mattresses, and encouraging residents to shower. The ADM stated these actions had not occurred under the old owners. The ADM stated she monitored the residents to make sure staff members were doing resident checks and brief changes. She stated she expected staff to check incontinent residents every two (2) hours and change them if they were soiled. The ADM stated she expected the walls and handrails to be wiped down daily. The RVPO stated the walls and ceilings were being repainted, which would seal in the odors they have absorbed over time. The RVPO stated that ceiling tiles would also be changed out. Both the ADM and the RVPO stated it was not common practice for maintenance to leave tools and other equipment such as a drain snake in the hallway. 46710

Based on observation, interview, record review, review of the facility's investigation reports, and review of the facility's policies, it was determined the facility failed to protect residents from abuse and neglect for eight (8) of one hundred and four (104) sampled residents (Residents #101, #112, #115, #152, #70, #88, #142, and #43). 1. Staff observed Residents #101 and #112 on two (2) separate occasions on 06/26/2023 engaged in sexual activity. Both residents were cognitively impaired and therefore unable to provide consent. 2. Resident #115 was verbally abused by a housekeeping staff who had not been trained on abuse on 03/27/2023. 3. Resident #152 was sent to hospital wearing two soiled briefs on 01/07/2024, indicating facility neglect. 4. On 12/31/2022, Resident #70 stated his/her roommate (Resident #88) had scratched him/her after both residents had a verbal argument over access to the bathroom. 5. On 04/03/2023, Resident #142 passed by Resident #43 in the 200 Hall and struck Resident #43 in the arm, with no apparent injuries. The findings include: Review of the facility's policy, Identify Types of Abuse, dated 04/2021, revealed in order to prevent abuse, staff education, training and support, and a facility-wide culture of compassion and caring was required. Also, in order for staff to prevent abuse, they must know how to identify abuse. Further review revealed abuse of any kind against residents was strictly prohibited. Continued review revealed physical abuse included, but was not limited to hitting, slapping, biting, punching, or kicking. Additional review revealed verbal abuse included any verbal, written, or gestured communication (including sounds) directed at a resident within hearing distance, regardless of his or her ability to comprehend or disability. Per the policy, sexual contact with a resident who lacked the cognitive ability to consent was considered non-consensual and therefore constituted abuse. The policy stated the resident's capacity to consent to sexual conduct was to be carefully evaluated as part of the initial assessment and care planning process. The policy stated the Interdisciplinary Team (IDT) was to consult with the ethics committee or legal counsel whenever there was a question of capacity to consent. Further, the resident's capacity to consent must be monitored and re-evaluated over time, based on changes to his/her physical, mental and/or psychosocial status. The policy identified neglect as having knowledge and ability to provide care and services, but choosing not to. Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 04/2021, revealed a facility-wide commitment to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including other residents. 1. In an interview with SRNA #7 on 03/01/2024 at 1:49 PM, she stated once she arrived for her shift at 7:00 AM on 06/26/2023, she was told by the off-going shift to watch Resident #101 and Resident #112 because they had showed sexual behavior toward each other in a room. She stated the two (2) residents had been separated at that time. SRNA #7 stated she went to locate the residents and that was when she found them in the dining room, seated next to each other. She stated Resident #101's genitalia was out of his/her pants, and Resident #112 had both hands on it, with his/her mouth open and moving toward the genitalia She also stated, Resident #101 and Resident #112 usually spent time together, often held hands as they walked together, watched movies together, and ate meals together. However, she stated she had not seen them do anything sexual until this date. She stated both residents were cognitively impaired and therefore were not allowed to engage in sexual activity of any kind. Review of the facility's Final Investigation Report, involving Residents #101 and #112, related to the incident on 06/26/2023, revealed a skin assessment was completed on the residents, and no issues were identified. Also, both residents were checked for a change in mood or behaviors, and none were noted. Review of the facility's Five Day Report, dated 06/29/2023, revealed Resident #101 and Resident #112 had been found together in bed, engaged in intimate activity, prior to the incident in the dining room. a. Review of Resident #101's Face Sheet, revealed the facility last admitted the resident on 10/22/2022 for rehabilitation for pneumonia, mild cognitive impairment of uncertain/unknown etiology and unspecified hearing loss. The facility identified a new diagnosis of unspecified dementia, mild with other behavioral disturbances on 02/21/2024. It was noted in the resident's file, he/she was non-English speaking. Review of Resident #101's Quarterly Minimum Data Set (MDS) Assessment, dated 05/01/2023, revealed no Brief Interview for Mental Status (BIMS) score was documented (due to language barrier and inability to determine), no behaviors noted, and the resident walked independently without assistance of staff or device. The MDS also revealed the resident required supervision for Activities of Daily Living (ADL) care, except for toileting transfer where it was noted the resident required substantial assistance. Review of Resident #101's Physician Orders revealed the facility started the resident on Depakote 125 milligrams (mg) three (3) times per day for dementia and Fluoxetine 20 mg, one (1) time daily for dementia on 02/22/2024. Review of Resident #101's miscellaneous records tab in the Electronic Medical Record (EMR), revealed no documented evidence psychiatric services followed up with the resident after the 06/26/2023 incident as noted in the facility's final investigative report. Review of Resident #101's Comprehensive Care Plan (CCP), initiated 06/27/2023, revealed the resident engaged in sexual behavior with another resident, and as a goal, the resident would not exhibit episodes of sexual behaviors with other residents through the next review date (initiated on 06/27/2023, and revised on 12/06/2023). Further review revealed interventions to approach the resident in a non-judgmental way; if in public area, provide privacy for the resident; distract and redirect to a positive activity as needed; and to encourage attendance of an activity of the resident's choice. Additionally, there were changes made to Resident #101's care plan on 02/13/2024 in which it was noted the resident touched self in sexual manner. The facility added an intervention of a room change on 02/14/2024. Observation of Resident #101 on 02/26/2024 at 5:00 PM, revealed the resident was very small in stature and was sleeping under the covers. Observation of Resident #101 on 02/28/2024 at 8:07 AM, revealed the resident was in bed sleeping, and staff helped the resident sit up to eat. However, the resident laid back down to go back to sleep. b. Review of Resident #112's Face Sheet revealed the facility admitted the resident on 08/02/2022 with diagnoses of dementia with agitation, dysphagia oral phase, and Alzheimer's (10/11/2022). Review of Resident #112's Quarterly Minimum Data Set (MDS) Assessment, dated 05/03/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of six (6) of fifteen (15), which indicated severe cognitive impairment. The resident was noted without behaviors during this assessment. He/She was assessed for partial/minimal assistance with toileting hygiene, maximum assistance for showering, supervision for upper/lower body dressing, and set-up/clean-up for all bed mobility. The resident was assessed to walk 150 feet independently. Review of Resident #112's miscellaneous section of the medical records, revealed the resident was seen by in-house psychiatric services on 07/07/2023; but, there was no mention of the incident on 06/26/2023. Review of Resident #112's Comprehensive Care Plan (CCP) revealed a focus area, initiated on 06/27/2023, in which the resident engaged in sexual touching with resident, had a BIMS score of six (6), and it was related to cognitive impairment. It also stated the resident required observation of these behaviors. The goal was the resident would have no further sexual behaviors with others as resident was unable to cognitively give consent (initiated 06/27/2023 and revised on 02/13/2024). The following interventions were established: alert the in-house psychiatric services about the incident, distract the resident and redirect to a positive activity as needed; if sexual behavior was noted, gently remove the resident from the area; be non-judgmental of behaviors and report to the Medical Director as needed; and offer to escort to activity programs of choice and a room change to another unit (initiated 06/27/2023). Observation of Resident #112 on 02/29/2024 at 8:00 AM, revealed the resident lying in his/her bed, eating chicken nuggets. The resident's wander guard (a device to prevent elopement) was present on the resident's ankle. At 8:03 AM, Resident #112 exited the room and headed toward the 200 Hall TV room. Observation of Resident #112 on 03/02/2024 at 7:55 AM, revealed the resident was seated on his/her bed. After a minute the resident exited his/her room and headed toward the 200 Hall Nurse's Station. The resident wandered down the 200 Hall to the dining room and turned around and headed back to the 200 Hall TV room, and he/she sat on the couch. The resident did not engage with anyone. In an interview with SRNA #41 on 03/07/2024 at 1:25 PM, she stated if she saw two (2) residents engaged in sexual activity, she would tell the nurse and have the nurse separate them. She stated sometimes residents could be aggressive. She stated staff would have to know which residents could or could not have sexual relationships because there were some residents who considered themselves girlfriend and boyfriend. She stated breaking up those sexual relationships could violate their rights. SRNA #41 stated residents who had dementia or another impairment would have to be assessed to determine if they could have sexual relationships. She also stated residents who could not consent would have to be provided appropriate supervision. In an interview with the Social Services Assistant on 02/29/2024 at 12:13 PM, she stated her experience in Long Term Care was all hands-on learning over the past year in her position. The Assistant stated, as part of her current job duties, she completed Sections A, B, C, D, E, Q and V of the Minimum Data Set. She also stated the facility used the Brief Interview for Mental Status (BIMS) score to determine if a resident could consent to sexual relationships or sexual activity of any kind. The Assistant stated any resident assessed with an eight (8) or below signified the resident had a severe cognitive impairment and therefore could not consent for sexual activity. In an interview with the Director of Social Services (DSS) on 03/01/2024 at 2:51 PM, she stated Resident #101 and Resident #112 walked around the facility and held hands, previously. She stated the two (2) residents were not required to have no contact. She stated Resident #112 had a state guardian, and the state guardian never said Resident #112 could not see Resident #101. The DSS stated she did not complete any type of assessment on residents to determine if the resident was able to consent to sexual activity. She stated she assessed residents for past trauma. The DSS stated she delegated much of her work to the Social Services Assistant. She stated the Assistant completed most of the required social services assessments on the residents. When asked if she met daily to get briefed by her assistant her answer was, We share an office. However, the DSS was not able to answer many of the questions asked and stated the Assistant completed those items. Attempted interview with Licensed Practical Nurse (LPN) #10 on 03/04/2024 at 3:00 PM. There was no answer, and a voice message was left. LPN #10 was the nurse on duty on 06/26/2023, but she no longer worked at the facility. Attempted interview with LPN #10 on 03/05/2024 at 2:15 PM. There was no answer, and a voice message was left. Attempted interview with LPN #10 on 03/07/2024 at 8:45 PM. There was no answer, and a voice message was left. In an interview with LPN #1 on 03/07/2024 at 2:18 PM, she stated residents with severe cognitive impairment could not consent or engage in sexual relationships. She stated if staff observed two (2) residents in such a position, the nurse would need to separate the residents and gently redirect the residents. LPN #1 stated staff would need to continue to watch the residents if they were together or just watch for them if they wandered the facility on their own. She stated Resident #101 and Resident #112 would still be allowed to eat dinner and walk together holding hands. LPN #1 expressed knowledge of Resident #112's previous history of high attention seeking behaviors toward male residents. LPN #1 stated she was not sure if Resident #112's attention seeking behaviors were on the care plan. Review of Resident #112's care plan, revealed he/she was not care planned for attention seeking behaviors with other residents. In an interview with Registered Nurse (RN) #2 on 03/05/2024 at 4:51 PM, she stated she could not recall a date, but it was about one (1) year ago, when she was given information during report about Resident #101 and Resident #112's sexual contact and told staff members they needed to keep an eye on them. She stated she was told they were caught in bed together. RN #2 stated Resident #101 at the time was at the far end of the hall, walked up and down the hall, and sat in the television room in the 300 Hall. She stated the resident kept to himself/herself, and she never witnessed him/her engage in any inappropriate behavior. She also stated Resident #112 wandered around, but she was unable to recall anything else about him/her. She also stated residents who had impaired cognitive functioning could not have sexual contact with another person. In an interview with the Advanced Practice Registered Nurse (APRN) on 03/07/2024 at 9:30 AM, she stated she would not have been involved in a case where two (2) residents with low cognitive functioning or no cognitive impairment were engaged in sexual activity unless there was a medical outcome of some sort. She stated that would be handled by the facility and/or psychiatric services. She stated she had never seen Resident #112 show any fluctuation in his/her mood. She stated the resident always had a flat affect, and he/she just smiled and nodded when spoken to. She stated in her professional opinion it would be very difficult to determine any type of psychosocial harm on Resident #112 because the resident's affect never changed. In an interview with the current Director of Nursing (DON) on 03/07/2024 at 3:01 PM, she stated residents who had impaired cognitive ability were not able to consent to sexual relationships, even with other residents with impaired cognitive ability. The DON stated there was no reason Resident #101 and Resident #112 could not continue their friendship of watching movies, eating dinner together, and holding hands. However, she stated the residents would need supervision to ensure they did not have sexual contact with each other. She stated the residents' representatives would have be to notified if that happened. In an interview with the Administrator on 03/08/2024 at 4:35 PM, she stated any resident with a low BIMS lacked the ability to consent to sexual relationships of any kind. She stated residents needed to be supervised to prevent them from engaging in inappropriate sexual encounters. The Administrator stated she expected any resident with a BIMS under twelve (12) to be assessed to determine if he/she was able to engage in sexual relationships. She also stated facility policies were expected to be followed, and any reports of abuse required complete investigations and reporting to the necessary state and law agencies. 46710 2. Review of Resident #115's Admission Record revealed the facility admitted the resident on 02/25/2023 with diagnoses including a history of traumatic brain injury, unspecified intellectual disabilities, and adjustment disorder with anxiety and depressed mood. Review of Resident #115's Quarterly Minimum Data Set (MDS) Assessment, dated 01/19/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as having unspecified intellectual disabilities. Review of Resident #115's care plan, revised 08/11/2023, revealed the facility assessed the resident as having aggressive behaviors toward staff. Interventions included adjusting care delivery based on the triggers of the resident's behavior and gently guiding the resident from the environment while speaking in a calm voice. Review of the facility's Investigation Report, dated 03/31/2023, revealed on 03/27/2023, Housekeeper #3 attempted to keep Resident #115 away from a resident with whom he/she had a previous altercation. Per record review, Resident #115 responded to the attempted redirection by calling Housekeeper #3 a racial slur. In further review, the investigation included written statements from staff, including Licensed Practical Nurse (LPN) #16, who revealed Housekeeper #3 threatened to hit the resident if he/she stated that word again. In an interview on 02/26/2024 at 6:12 PM, Resident #115 could not recall the event and denied any history of being verbally or physically abused in the facility. In an interview on 03/04/2024 at 5:44 PM, Housekeeper #3 stated she recalled Resident #115 calling her a racial slur. She stated she told another housekeeper, while standing in the hallway where the resident could hear, that the resident was lucky she did not hit him/her in the mouth. Per interview, Housekeeper #3 stated she knew she should not have stated that but had an emotional reaction to the disrespect of the racial slur. Housekeeper #3 stated the facility did not provide her with any training on how to handle residents who had aggressive verbal and physical behaviors. In an interview on 03/07/2024 at 2:23 PM, Licensed Practical Nurse (LPN) #16 stated she heard Resident #3 use a racial slur towards Housekeeper #3 and heard Housekeeper #3 state she would smack the resident in the mouth for saying that word. In further interview, LPN #16 stated Housekeeper #3 did not hit the resident, only threatened to do so. During an interview with SRNA #7 on 03/01/2024 at 1:03 PM, she stated she had often been called racial slurs and verbally threatened by residents, but she had learned to remove herself from those situations. In an interview on 03/08/2024 at 10:10 AM, the Director of Nursing (DON) #1/Resource Nurse stated she was not aware of the specifics of the abuse allegation involving Housekeeper #3 and Resident #115. She stated she expected staff to follow the care plan for residents who had behaviors to know how to respond. DON #1 stated she had talked to some staff members individually about verbally aggressive residents, particularly the use of racial slurs, but had not done a staff-wide education on how to handle those situations. DON #1 stated she did not know what training housekeeping staff had received regarding abuse prevention and handling residents with behaviors. In an interview on 03/08/2024 at 4:25 PM, the Administrator stated she was not working at the facility at the time of the event between Resident #115 and Housekeeper #3; however, she expected staff to handle their emotions, no matter what the residents said to them. She further stated she knew it was a common problem with Resident #3 and some others that had dementia, and the facility identified a need for crisis training. She stated crisis training had not yet been provided to staff. 28707 3. Review of the facility's policy, Activities of Daily Living (ADL), Supporting, revised March 2018, revealed appropriate care and services would be provided for residents who were unable to carry out ADLs independently, including appropriate support with hygiene and elimination. Review of Resident #152's Electronic Health Record (EHR) revealed the facility admitted the resident on 06/06/2023 with diagnoses to include dementia in other diseases classified elsewhere without behavioral disturbance, overactive bladder, and chronic pain syndrome. The facility assessed Resident #152, in a 12/14/2023 Quarterly Minimum Data Set (MDS) Assessment, as utilizing a wheelchair for mobility, requiring substantial/maximal assistance with toilet hygiene, and requiring substantial/maximal assistance with lower body dressing. The facility assessed the resident as having a score of zero (0) of fifteen (15) on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. The facility assessed the resident as having clear speech and being understood, while the resident was assessed with minimal hearing difficulty and sometimes understands others. The assessment also noted Resident #152 was at risk for pressure ulcer development. Review of Resident #152's Treatment Administration Record (TAR) for January 2024 revealed Resident #152 was last documented as being toileted on 01/07/2024 at 2:59 PM. Review of Resident #152's Progress Note, dated 01/07/2024 at 9:34 PM, revealed Resident #152 experienced an acute mental status change, with moaning, abdominal breathing, and unable to obtain a blood pressure. The note stated Resident #152 was sent to the emergency department. Review of Resident #152's Skin Check, dated 01/07/2024 at 10:00 PM, revealed the resident had an abrasion to the top of the right foot, with no other wounds noted. Review of Resident #152's hospital emergency department (ED) documentation revealed Resident #152 entered the ED on 01/07/2024 at 10:42 PM. The hospital Registered Nurse (RN) signed the note, on 01/08/2024 at 1:42 AM, which stated Resident #152 was unable to talk or communicate, wore two (2) briefs which were both saturated with urine, and had wounds to the buttocks. The nature of the wounds or severity was not revealed in the ED documentation. In an interview on 03/07/2024 at 2:43 PM with State Registered Nurse Aide (SRNA) #10, she stated she remembered working with Resident #152. She stated he/she had declined during the few months in the facility, and toward the end of his/her stay was quiet and not interacting much, which required more assistance. She stated Resident #152 had been getting aggressive, and two (2) staff would provide him/her care at that time. She stated she worked with Resident #152 from 7:00 AM until 3:00 PM on 01/07/2024, and there were two (2) other aides working. She stated she was able to provide appropriate care for Resident #152. She stated she ensured all her residents were cared for, as she knew there would only be two (2) aides after 3:00 PM to care for residents on the 100 Unit. She stated she would sometimes see residents double briefed when she started her shift in the mornings, and it could have been due to the previous night shift being short handed. She stated this did not happen a lot. On 01/07/2024, SRNA #10 stated there were thirty (30) something residents on the 100 Unit and quite a few two (2) assist residents. In an interview on 03/08/2024 at 6:27 AM with SRNA #24, she stated she had always worked third shift. SRNA #24 stated she remembered Resident #152, and he/she had declined a lot toward the end of his/her stay in the facility. SRNA #24 stated she was late to arrive the evening of 01/07/2024, arriving at approximately 8:15 PM, too late to receive report from the off-shift aide, and had been doing her rounds. She stated around 9:00 or 10:00 PM, the nurse asked if she had seen Resident #152, and she had not yet seen him/her. She stated she she went to check on Resident #152, and he/she was agitated, unlike anything she had previously seen with the resident. She stated she lifted the sheet up and cleaned the resident with a washcloth, cleaning his/her face and chest. She stated the resident did not appear to have more than one (1) brief on, but with his/her combativeness it would have been difficult to even get one (1) brief on the resident. SRNA #24 stated she was suspended because she was the last to provide care for Resident #152 when the allegation of the resident presenting to the hospital wearing more than one (1) brief was reported. SRNA #24 stated before the new company took over in October 2023, she would see residents double briefed all the time, particularly with Resident #30 being double briefed. In an interview on 03/07/2024 at 10:45 AM with Director of Nursing (DON) #1, she stated she had heard about the allegation of the resident having two (2) briefs on and being sent to the hospital. She stated she had no idea why a resident would be sent to the hospital double-briefed, and that was not something the facility condoned. In an interview on 03/08/2024 at 12:39 PM with the Administrator, she stated when Adult Protective Services (APS) came to the facility, she asked who made the allegation of Resident #152 presenting to hospital double briefed] and had a hard time believing it. She stated since she came to the facility in October 2023, she had been notorious about not ever sending a patient out without taking a look at them. She stated the resident needed to be appropriate from head to toe. The Administrator stated stated there had been a couple of issues she had with staff and felt it might have been a disgruntled staff that made the allegation. She stated she expected staff to do a head-to-toe assessment when residents left the facility and when they come back. The Administrator stated when she received that allegation, she opened an SRI (Serious Reportable Incident) on that and suspended the SRNA that had been responsible for providing Resident #152's care. 49360 4. Review of the Facility's Incident Report, dated 12/31/2022, revealed Resident #70 came to the nurse's station with scratches on his/her right arm and with scratches on his/her right side of the face. Continued review revealed Resident #70 stated his/her roommate (Resident #88) had scratched him/her after both residents had a verbal argument over access to the bathroom. Further review revealed Resident #70 was confused but aware that his/her roommate (Resident #88) needed to use the bathroom. However, Resident #70 refused to let Resident #88 have access to the bathroom as Resident #70 was using his/her bedside table (which was in front of the bathroom door) to arrange his/her flowers. Additional review of the report revealed Resident #70's scratches were cleaned with normal saline, antibiotic ointment was applied to the scratches, and his/her right forearm scratches were covered with a gauze dressing. Review of the facility's 5-day Incident Report, dated 01/04/2023, revealed the facility separated both residents immediately and moved Resident #70 to a different room, and the facility determined the allegation of resident-to-resident altercation was substantiated without significant harm. The facility determined this was an isolated event, as there was no history of physical aggression between the two (2) residents. a. Review of Resident #70's Admission Record revealed the facility admitted Resident #70 on 10/28/2019 with diagnoses to include chronic obstructive pulmonary disease (COPD), chronic kidney disease (Stage 3), and bipolar disorder. Review of Resident #70's Quarterly Minimum Data Set (MDS) Assessment, dated 11/16/2022, revealed Resident #70 had a Brief Interview for Mental Status (BIMS) score of eleven (11) of fifteen (15), which indicated cognition was moderately impaired. Review of Resident #70's Change in Condition Evaluation, dated 12/31/2022, revealed Resident #70 got verbally aggressive with his/her roommate, and the altercation escalated to physical actions. Continued review of the Change in Condition Evaluation revealed both residents were separated immediately, and Resident #70 was moved to another room. Review of Resident #70's Treatment Administration Record (TAR) revealed Resident #70 had treatment initiated to his/her right arm and right side of the face on 12/31/2022. It also revealed the treatment was completed on 01/05/2023, with no signs of infection or complications noted on the TAR. Review of Resident #70's Progress Notes, entered by Licensed Practical Nurse (LPN) #21 on 12/31/2022, revealed Resident #70 came to the nurse's station with scratches to his/her right arm and right side of the face. Continued review revealed the Physician, the Family, and the Director of Nursing (DON) were notified and treatment was initiated per the Physician's Order. Review of Resident #70's Comprehensive Care Plan (CCP), dated 02/15/2022, revealed Resident #70 was at risk for distressed/fluctuating mood symptoms related to a diagnosis of bipolar disorder with a goal to have improved mood state as evidenced by Resident #70 having a calm appearance and happier demeanor. Continued review of the CCP revealed Resident #70 had interventions for Social Services to visit to provide support as needed and to re-direct Resident #70's behaviors. Additionally, the interventions included to allow Resident #70 to have time for expression of feelings; and to provide empathy, encouragement, and reassurance. Furthermore, the facility would provide Resident #70 with opportunities for choice during care/activities to provide a sense of control. Review of Resident #70's Skin Check, entered by the Advanced Practice Registered Nurse (APRN) on 01/01/2023, revealed Resident #70 had a right outer forearm scratch with surrounding purpura which measured 1.6 centimeters by 1.9 centimeters. It also stated Resident #70's scratch on the right side of the face was fainter and did not need measurement obtained as the area was faded. Continued review revealed Resident #70 had a pain rating of three (3) out of ten (10) but was on routine pain medication. Review of Resident #70's Progress Note, entered by LPN #24 on 01/02/2023, revealed Resident #70 had zero (0) out of ten (10) pain. Observation of Resident #70 on 02/26/2024 at 6:37 PM, on 03/02/2024 at 8:09 AM, and on 03/06/2024 at 3:53 PM, revealed Resident #70 was pleasant and social with both staff and other residents. Continued observation revealed Resident #70 had no behaviors and no other altercations were observed in the facility. During an interview with Resident #70 on 02/27/2024 at 9:58 AM, Resident #70 stated he/she ran over Resident #88's toes with his/her wheelchair on accident, and Resident #88 scratched his/her right arm. Continued interview with Resident #70 revealed Resident #70 stated he/she was moved to another room, and he/she did not have any other incidents in the facility. b. Review of Resident #88's Admission Record revealed the facility admitted Resident #88 on 01/25/2021 with diagnoses to include intracranial abscess and granuloma, COPD, encephalopathy, and anxiety disorder. Review of Resident #88's Quarterly MDS Assessment, dated 12/30/2022, revealed Resident #88 rated a two (2) for Cognitive Skills for Daily Decision Making, which indicated Resident #88 was moderately impaired with poor decision making skills. Review of Resident #88's Progress Notes, entered by LPN #21 on 12/31/2022, revealed Resident #88 had no skin issues and no signs of pain after the incident with Resident #70. Observation of Resident #88 on 02/27/2024 at 10:58 AM, on 02/28/2024 at 8:42 AM, and on 03/03/2024 at 4:19 PM, revealed Resident #88 was pleasantly confused and not any behaviors or any other altercations in the facility were observed. The State Survey Agency (SSA) Surveyor attempted an interview on 02/27/2024 at 10:58 AM wi [TRUNCATED]

Based on interview, record review, review of the facility's incident report forms and policy, it was determined the facility failed to ensure residents remained free from misappropriation of property for six (6) of one hundred and four (104) sampled residents (Residents #11, #42, #65, #122, #148, and #150). Resident #127 took items belonging to the five (5) of the six (6) residents. 1. The facility identified Resident #127 as responsible for multiple allegations of misappropriation of other residents' property which included taking $100 from Resident #148 on [DATE], and $15 from the same resident on [DATE]; and taking $10 from Resident #65 on [DATE]. 2. On [DATE] at 7:00 AM, at shift change it was identified a blister pack containing thirteen (13) pills of Hydrocodone ,d+[DATE] mg and three (3) Gabapentin tablets of 100 mg were missing during the shift change narcotic count. The missing medications belonged to Resident #11 and Resident #150. 3. LPN #1 stated in interview Resident #127 came to her with an iPad and offered to sell it to her for ten dollars ($10.00). The LPN stated told the Administrator who identified the iPad as Resident #142's. 4. Additionally, the wallet and passport belonging to Resident #122 were reported as missing, and were located in Resident #127's room. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation, dated ,d+[DATE], revealed upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administration was responsible for determining what actions (if any) were needed for the protection of the residents. Review of Resident #127's clinical record revealed the facility admitted the resident on [DATE], with diagnoses to include bipolar disorder, schizophrenia, and chronic lung disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Resident #127 with a Brief Interview for Mental Status (BIMS) score of seven (7) out of fifteen (15) which indicated the resident was severely cognitively impaired. Review of the Admission MDS assessment dated [DATE], revealed the facility assessed the resident as independent for walking. Review of Resident #127's care plan dated [DATE], revealed the facility identified a focus for the resident noting he/she went into other residents' rooms and took the other residents' personal property and hid those items. Continued review revealed the goal was Resident #127 would not demonstrate episodes of theft by next review. Review of the care plan revealed interventions that included: increasing supervision; evaluating the need for a psychiatry/behavioral health consult; providing consistent, trusted caregivers, and structured daily routine when possible; removing the resident from the environment if needed by gently guiding the resident from the environment while speaking in a calm, reassuring voice; providing the resident with opportunities for choice during care/activities to provide her/him a sense of control; having Social Service visits to provide support, as needed; and informing the resident his/her behavior was not desirable, and explaining the legal consequences. Observation of Resident #127 on [DATE] at 9:45 AM revealed the resident sitting in a chair in front of the nurses' station on the one hundred (100) unit. During interview with Resident #127, at the time of the observation, the resident denied taking anything from another resident. 1(a). Review of Resident #148's clinical record revealed the facility admitted the resident on [DATE], and discharged him/her to the hospital on [DATE]. Further review revealed Resident #148 was transferred from the hospital to a hospice facility and expired while there. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #148 with a BIMS' score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of the facility's initial repot revealed on [DATE], Resident #148 informed staff he/she had three hundred (300) to four hundred (400.00) dollars ($) missing from his/her wallet. Per review, Resident #148 stated he/she noted the money missing from his/her wallet on the evening of [DATE]. Continued review revealed another resident, Resident #127 was noted to have one hundred dollars ($100.00) in his/her possession on [DATE], and admitted to taking money belonging to Resident #148. Further review revealed Resident #148 did not want to involve law enforcement. Additional review of the facility's initial report revealed Resident #148 also reported on [DATE], his/her white wallet which contained $15.00 was missing. Per review of the report, Resident #127 admitted to taking the money from Resident #148, and that information was reported to law enforcement on [DATE]. The State Survey Agency (SSA) attempted to retrieve the police report; however, the police responded that no report had been found involving Resident #148 missing money. Review of the facility's Five (5) Day Follow Up/Final Report dated [DATE], revealed Resident #127 admitted to taking Resident #148's money, and one hundred dollars ($100.00) in five dollar ($5.00) bills was found in her/his possession. Continued review of the Final Report revealed Resident #148 declined law enforcement involvement. Further review of the report revealed on the morning of [DATE], Resident #148 reported his/her white wallet with fifteen dollars ($15.00) was missing. Additional review revealed Resident #127 admitted to taking the money; and fifteen dollars ($15.00) was observed in her/his possession. The money was returned to Resident #148. During telephone interview with the emergency contact for Resident #148, his/her niece, on [DATE] at 10:10 AM, the niece stated Resident #148 had a wallet. She further stated she had taken Resident #148 about eighty dollars ($80.00) in five dollar ($5.00) bills. During interview on [DATE] at 2:15 PM, State Registered Nurse Aide (SRNA) #22, who worked on the unit where Resident #148 resided, stated she knew Resident #127 took items from other residents. SRNA #22 stated when staff saw Resident #127 with a bulge in his/her pocket they checked it out. SRNA #22 further stated Resident #127 admitted to taking other residents' items. During interview with Director of Nursing (DON) #2 on [DATE] at 2:17 PM, she stated a staff member came to her and reported Resident #127 was going in an out of other resident's rooms. She stated she interviewed staff and found that Resident #127 had a history of taking items that belonged to other residents. The DON stated she had started staff education on misappropriation. In interview with DON #1 on [DATE] at 11:14 AM, she stated she had been working at the facility for about two (2) months. She stated since her arrival she had completed staff education on abuse, and used the facility's abuse policy to educate the staff. DON #1 stated she was told by an SRNA that Resident #127 had been taking items from other residents. She stated the SRNA told her Resident #127 had been going into other residents' rooms, and the SRNA was concerned that Resident #127 might take something from the other residents. DON #1 stated she planned to improve the facility's staffing, so they would have enough staff to monitor Resident #127. She stated that currently she did not have any plans to prevent Resident #127 from taking items that belonged to other residents. DON #1 further stated she was planning on providing all residents with a lock box in their rooms to place their valuables. During interview with the current Administrator on [DATE] at 3:02 PM, she stated when a resident took items from another resident, the facility contacted the resident's guardian and replaced any missing items. The current Administrator stated she expected staff to notify her of any type of abuse, neglect or misappropriation. She further stated she had been informed of Resident #127 taking items from other residents, and the resident had been better since she had been at the facility. During interview with the previous Administrator on [DATE] at 1:02 PM, she stated she was aware of Resident #127 taking items from other residents. She stated she had the police involved to attempt in deterring Resident #127 from taking other residents' personal items. 1(b). Review of Resident #65's clinical record revealed the facility admitted the resident on [DATE], with diagnoses to include heart failure, morbid obesity, and chronic pain syndrome. Review of the Quarterly MDS assessment dated [DATE] for Resident #65 revealed the facility assessed the resident to have a BIMS' score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Further MDS review revealed the facility also assessed Resident #64 as mobile with use of a wheelchair. Observation of Resident #65 on [DATE] at 2:48 PM, revealed the resident lying on his/her bed. Further observation revealed Resident #65 showed the SSA Surveyor a key located in his/her wallet that went to the locked top drawer of his/her bedside table. During interview at the time of the observation, Resident #65 stated someone had taken a five dollar ($5.00) bill and five (5) one (1) dollars ($1.00) bills in change from his/her wallet. Resident #65 further stated the facility replaced the money. The resident further stated he/she only kept about' five dollars ($5.00) in his/her wallet at a time. Observation on [DATE] at 10:42 AM, Resident #127 revealed the resident lying on his/her bed. During interview with Resident #127, at the time of the observation, revealed the resident stated he/she had never taken money from another resident. Resident #127 further stated he/she might have borrowed money, but had never taken money for others. Review of the facility's initial report dated [DATE] at 6:55 AM, revealed the facility noted Resident #65 reported Resident #127 had stolen a five dollar ($5.00) bill and five dollars ($5.00) in change from her/him while in his/her (Resident #65's) room. Continued review revealed Resident #65 was offered a lock box, to place his/her wallet/purse inside the drawer for safe keeping. Further review revealed Resident #65 was responsible for himself/herself, and had a guardian who was contacted regarding the missing money. Record review revealed Resident #127 denied all allegations; however, due to his/her recent history of theft, the Administrator placed Resident #127 on one-to-one (1:1) supervision for observation of the resident. Additional review revealed Resident #65 was moved to a different hallway, and requested that the police not be contacted . Review of the facility's final investigation report dated [DATE], revealed it was documented that as a result of the investigation, it was determined the allegation was not verified and was inconclusive. Continued review revealed per the SRNA, who had been working at the time, Resident #127 was not seen in the room belonging to Resident #65. Based on Resident #127 having a history of theft however, the Administrator was inclined to believe something happened in Resident #65's room that morning. Review further revealed the facility would reimburse Resident #65's five-dollar ($5.00) bill and five dollars ($5.00) in change. 2. Review of the facility's policy titled, Medication Labeling and Storage, dated ,d+[DATE], revealed all medications were to be stored in a locked compartment and only authorized personnel were to have key access. Continued review revealed nursing staff were responsible for maintaining storage of medications, and when the medication cart was not in use and unattended, all compartments (containing medications) were to be locked. Additional review revealed controlled substances were to be separately locked in a permanently affixed compartment in which the quantity stored was minimal, in order to detect a missing dose quickly. Review of the facility's policy titled, Security of Medication Cart, dated ,d+[DATE], revealed the nurse was responsible for securing the medication cart during medication pass to prevent unauthorized entry. Further review revealed the medication cart must always be locked when out of the nurse's view, and when not in use, must be locked and parked at the nurses' station or inside the medication room. Review of the facility's policy titled, Controlled Substances, dated ,d+[DATE], revealed inventory of controlled substances were to be counted at the end of each shift, by the off going and on coming nurses. Continued review of the policy revealed any discrepancies occurring during the count were to be reported to the DON, who would then contact the Administrator and Pharmacist. Further review revealed any discrepancies were to be reviewed to assure any affected residents still received their medications and ensure the therapy goals were met. (a). Review of the clinical record for Resident #11 revealed the facility admitted the resident on [DATE], with diagnoses to include hemiplegia, muscle weakness, reduced mobility, and cerebral infarction. (b). Review of Resident #150's electronic medical record revealed the facility admitted the resident on [DATE], and discharged him/her on [DATE]. Further review revealed pertinent diagnoses included dislocation of right hip, anterior dislocation of left hip, and osteoarthritis. Review of the facility's initial incident report dated [DATE] at 10:45 AM, revealed during shift change the narcotic count was performed (as per policy) and LPN #23 noted a blister pack containing thirteen (13) Hydrocodone (narcotic pain medication) ,d+[DATE] milligrams (mgs) pills were missing, along with three (3) Gabapentin (an epilepsy medication also used for nerve pain) pills. Continued review revealed Resident #127 gave permission for his/her room to be searched and the empty blister pack was found in his/her bathroom, seven (7) whole pills and ten (10) half pills in a baggy were also found in the resident's room. Further review revealed Resident #127 was assessed and had normal vital signs, with Narcan (medication used to help people overdosing on an opioid) administered with minimal change, and the APRN ordered laboratory work for the resident. In review of the report, it was noted pharmacy was contacted to assist with the identification of the pills found during the search of Resident #127's room, and Resident #127 was placed on 1:1 supervision. Continued review of the report revealed Resident #127 had a reported BIMS' score of ten (10) out of fifteen (15) indicating moderate cognitive impairment, and was care planned for taking and hiding items which did not belong to him/her. Review of the initial facility report revealed notification of the incident was made to the Physician, APRN, city police department, Adult Protective Services (APS), and the Ombudsman. The facility began education with all nurses and Kentucky Medication Assistants (KMA) on [DATE]; however, the report did not specify what the education was regarding. Review of the facility's Final 5 Day Follow Up Report dated [DATE], revealed there had been no changes in mood or behavior for any of the involved residents whose medications were misappropriated, their vital signs remained stable, and there were no complaints of pain received. Continued review revealed the facility noted the family of Resident #11 and Resident #150 were notified on [DATE] at 10:00 AM, and a voice mail message was left with the State Guardian for Resident #127. Per review, the facility notified the city police department who filed a case, and the Pharmacist was notified by voice mail on [DATE] at 2:51 PM. Further review of the final report revealed the facility documented the missing medications belonging to Resident #11 and Resident #150, and the medications were replaced from the pharmacy at the facility's expense. Review further revealed the facility noted there were no visual or verbal cues indicating any psychosocial distress or harm for Resident #11 or Resident #150, and both denied experiencing any ill effects from missing their medications. In addition, record review revealed the facility documented agency night shift nurse, LPN #23 admitted to leaving the medication cart unlocked. Record review revealed the facility's findings revealed the medications were taken as a direct result of the nurse/medication aide failing to lock the medication cart. Observation, on [DATE] at 4:43 PM and at 6:20 PM, revealed a medication cart located by room [ROOM NUMBER] which was unlocked, with no staff observed near the medication cart. During the observation at 6:20 PM, Resident #127 was observed crouched down in front of the nurses' station on the 100 unit, looking at the unattended medication cart. Observation on [DATE] at 10:06 AM, and again on [DATE] at 8:45 AM, revealed Resident #127 once again crouched down in front of the nurses' station on the 100 unit, watching staff. During interview with LPN #1 on [DATE] at 2:40 PM, she stated she began her shift at 7:00 AM on [DATE], as the Unit Manager and was informed by staff narcotic medications had been found missing during the morning shift change narcotic count. She stated staff had immediately notified the DON, who notified the Administrator. LPN #1 stated staff found the blister pack for the missing Hydrocodone medication in the bathroom of Resident #127. She stated the Administrator notified the police, who came and took a report regarding the missing medication. LPN #1 stated the facility reordered Resident #11 and Resident #150's missing medications. Resident #11 nor Resident #150 missed any doses or experienced any ill effects from the event. LPN #1 stated Resident #127 had issues with taking items from others that do not belong to him/her. LPN #1 stated at the time the facility had been working at finding other placement for Resident #127 in a more appropriate place which had thus far been unsuccessful. She stated Resident #127 had been moved closer to the nurses' station where nurses and aides could keep eyes on him/her. LPN #1 stated Resident #127 would sit near the nurses' station and had been caught coming out of other residents' rooms with items not belonging to him/her. She stated Resident #127 had been found with items reported as missing by other residents. During interview with KMA #18 on [DATE] at 10:19 AM, he stated he had worked at the facility for about ten (10) years as a KMA, and could give narcotic medications unless they were ordered via suppository or gastric tube (g-tube). Observation at the time of the interview revealed KMA #18 demonstrated where narcotic medications were stored on the medication cart, and demonstrated how to unlock the cart, what drawer narcotics were stored in, and how the medication was accessed. Continued observation revealed KMA#18 demonstrated how the narcotic box inside the drawer was secured after access, and how to secure the drawer as well as the cart itself. He stated it was important to always lock and secure the medication cart every time you were done so that no one could access it while you were in a resident's room or away from the unit. KMA #18 stated he recalled an occurrence of a resident taking medications from the cart that lead to some staff education and taking a post test. He stated he did not work with the nurse involved; however, he was familiar with Resident #127, the resident that took the medications. KMA #18 stated Resident #127 stayed in the hallways and was known for taking things that did not belong to him/her. During interview with the Social Services Director (SSD) on [DATE] at 2:52 PM, she stated Resident #127 had numerous incidents with wandering in other residents' rooms and taking items that belonged to the other residents. She stated the facility had tried moving Resident #127's room multiple times; placed him/her on 1:1 observations, every fifteen (15) minute checks, all in attempts to decrease the resident's wandering and thefts. The SSD stated no intervention had worked thus far. She stated the police had been called on some occasions and they had taken a report, but to date no charges had been filed. The SSD stated she did not know why Resident #127 had not had any legal actions taken against him/her. She further stated currently she was attempting to find new placement for Resident #127; however, many facilities would not accept the resident until he/she could pass a swallow study. During interview with DON #1 on [DATE] at 10:28 AM, she stated she expected staff to be educated on medication administration during their orientation. She stated she expected all staff to do rounds to assure all medication carts were locked, and she randomly checked the medication carts. DON #1 stated there was a process in place to prevent residents from taking items that belonged to another resident. She further stated that process included the incident being reported and investigated and interventions put in place to prevent further incidents. DON #1 additionally stated all incidents were to be reported to her and the Administrator. During interview with the current Administrator on [DATE] at 3:02 PM ,she stated if a resident took something that belonged to another resident she notified the guardian and replaced the item. She stated since she had been at the facility she had provided training on abuse, which included misappropriation of resident property. The current Administrator stated she taught staff to immediately report any suspicion of abuse, within two (2) hours. She further stated she educated staff on the different types of abuse, to ensure residents were safe, and also taught staff on what 1:1 supervision entailed. During interview with the previous Administrator on [DATE] at 1:02 PM, she stated she was aware of Resident #127 taking items from other residents. She stated she had the police involved to attempt in deterring Resident #127 from taking items. 3. Review of the clinical record for Resident #42 revealed the facility admitted the resident on [DATE] with diagnoses that included quadriplegia, contracture's, and arthritis. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to have a BIMS' score of fifteen (15) of fifteen (15), which indicated he/she was cognitively intact. In interview on [DATE] at 2:56 PM, Resident #42 stated his/her iPad (a touchscreen tablet) had been taken, but was returned. The resident stated he/she was upset that the iPad was stolen from his/her. During interview with LPN #1 on [DATE] at 10:35 AM, she stated Resident #127 came to her with an iPad and offered to sell it to her for ten dollars ($10.00). She stated she immediately reported that information to the Administrator, who found the iPad which belonged to Resident #42. LPN #1 further stated the Administrator returned the iPad to Resident #42. During interview with the previous Administrator on [DATE] at 1:02 PM, she stated she was not aware of a missing iPad, and therefore, the facility had not reported or investigated the iPad being taken from Resident #42. 4. Review of the clinical record for Resident #122 revealed the facility admitted the resident on [DATE], with diagnoses that included dementia, and urinary retention. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #122 to have a BIMS score of thirteen (13) out of fifteen (15), indicating the resident was cognitively intact. On [DATE] at 2:46 PM, an interview was attempted with Resident #122; however, was unsuccessful as the resident thought the SSA Surveyor was a telephone repair person coming to repair his/her telephone. Resident #122 kept talking about the phone, and did not respond to the SSA Surveyor's questions. During interview with LPN #7 on [DATE] at 10:42 AM she stated she once saw Resident #127 go into his/her room looking suspicious however, did not recall the date of that observation. She stated she followed Resident #127 into his/her room and asked the resident if she/he had taken something that did not belong to him/her. LPN #7 stated Resident #127 looked at his/her bedside table, pointed to the bottom of it. She stated she looked under the bedside table and found a wallet and passport that belonged to Resident #122. LPN #7 further stated in the wallet was a credit card, and she immediately told the DON and Administrator and gave them the wallet and passport. During interview with the previous Administrator on [DATE] at 1:02 PM she stated she was aware of Resident #127 taking items from other residents. She stated she had the police involved to attempt in deterring the resident from taking items. She stated she was not aware of a wallet and passport being taken from Resident #122, and therefore, the facility had not reported or investigated the missing items taken from the resident. 50000

Based on observation, interview, record review, review of the facility's investigation reports, review of the 135DE Secure Care System Installation Manual, review of google.com/maps, and review of the facility's policy, it was determined the facility failed to ensure the residents' environment remained free of accident and hazards as possible and failed to identify, evaluate, and implement interventions to reduce hazards and risks for eleven (11) out of one hundred and four (104) sampled residents. The facility failed to have accurate Elopement Binders which had correct or thorough information for ten (10) residents who were at high risk for elopement (Residents #32, #43, #67, #75, #82, #88, #112, #115, #127, and #156). 2. The facility failed to provide appropriate supervision for two (2) residents to prevent elopement (Residents #63 and #112). 3. The facility failed to have an effective alarm system in place to allow for appropriate monitoring and supervision of wandering and elopement risk residents. The findings include: Review of the facility's policy, Elopement of Patient, revised [DATE], revealed the facility would assess each resident upon admission to determine if the resident was an elopement risk. Additionally, the resident would be reassessed on readmission, quarterly, and with a change in condition (CIC). Per the policy, residents determined to be an elopement risk would receive appropriate interventions to decrease that risk. Elopement was defined as any situation in which a patient left the premises or a safe area without the facility's knowledge and supervision. The policy stated the facility would have a binder located at designated areas with a picture of the resident and a completed Elopement Risk Identification Form for all residents at risk for elopement. Review of the 135DE Secure Care System, Installation Manual dated [DATE], revealed the system was not a substitute for monitoring by professional staff. Per the manual, Secure Care was designed to augment a facility's reasonable procedures for protecting residents. The manual also revealed the standard mode of operation for the exit system allowed free access of the door by nurse staff members and visitors but quietly locked the door when a transmitter (wander guard/bracelet) approached the exit door. The manual stated when the transmitter was removed from the area, the door unlocked, and access was again available to nurses, staff, and visitors. The manual stated, if a nurse staff member was required to escort a transmitter out of the protected area, an escort code could be entered into the Exit Panel keypad, which allowed both the nurse/staff member and the transmitter to pass through the perimeter without creating an alarm. 1. Review of the wander guard list provided by the facility on [DATE] revealed twenty-one (21) residents were on wander guard alerts at the time: Residents #8, #12, #32, #43, #48, #62, #63, #67, #75, #77, #82, #88, #101, #105, #112, #115, #118, #123, #127, #142, and #156. Review of the 100 Hall Elopement Binder on [DATE] at 11:02 AM, revealed Resident #127 was not listed in the book. Residents #32, #112, and #115 did not have the correct room number. Resident #156 did not have an elopement form. Review of the 200 Hall Elopement Binder on [DATE] at 11:15 PM, revealed Resident #32, #43, #67, #75, #82, #88, #112, #115, and #127 had the wrong room numbers on their forms. Review of the 300 Hall Elopement Binder on [DATE] at 1:00 PM, revealed Residents #32, #67, #75, #82, #88, #112, and #115 had the wrong room numbers in the book. Resident #127 was on the list but was not in the book, and Resident #156 was missing the elopement form. In an interview with Licensed Practical Nurse (LPN) #7 on [DATE] at 11:02 AM, she explained the purpose of the Elopement Binder was to inform staff what residents were at risk for wandering and elopements. She stated it was important that the binders were kept up-to-date because if someone was missing, the first thing staff was to do was grab the binder. She stated if the information in the binder was not up-to-date, it could delay locating the resident or starting the search. She stated she was not sure who was responsible for the upkeep of the binder to ensure it was accurate and current. In an interview with LPN #1 on [DATE] at 11:45 PM, as she took out documents and replaced documents in the elopement binder, she stated the elopement binder was used as a quick grab reference if there was a missing person alert called. She stated it would be important for the binder to be up-to-date so staff knew exactly which residents were an elopement risk or who wandered the facility. LPN #1 stated it was the responsibility of the Unit Manager to keep the binders updated. In an interview with the Administrator on [DATE] at 4:35 PM, she stated if there was an identified missing resident, each unit would bring their Elopement Binder and staff would start to look for the resident, throughout the facility and outside the building. She stated the Elopement Binder should be changed any time there was a change with the resident or if the resident no longer was an elopement risk. She stated she believed Social Services was responsible for the upkeep of the book, but she was not sure. 2. a. Review of Resident #63's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), epilepsy, and vascular dementia unspecified severity with agitation. Review of Resident #63's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident for partial to moderate assistance for toileting transfer, self-showering, upper/lower body dressing, putting on and taking off shoes, and ambulated independently without an assistive device. The facility assessed the resident was absent of any behaviors. Further review revealed staff did not complete a Brief Interview for Mental Status (BIMS) for the [DATE] MDS Assessment. However, the previous MDS (Annual), dated [DATE], revealed the facility assessed the resident with a BIMS of eleven (11) of fifteen (15), signifying moderate cognitive impairment. Review of Resident #63's Elopement Evaluation V2-V1, dated [DATE], revealed the resident was independently ambulatory and had a diagnosis of dementia. No other elopement identifiers were marked. However, the form lacked a section to identify if the resident was or was not an elopement risk. The same form was completed for Resident #63 on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Resident #63's electronic medical record (EMR) and Elopement Risk Assessments, revealed the facility failed to complete a quarterly Elopement Risk Assessment on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Additionally, the facility failed to complete an Elopement Risk Assessment upon the resident's readmission from the hospital after being gone for more than twenty-four (24) hours, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of Elopement Evaluation V2-V2, dated [DATE], for Resident #63, revealed the resident was identified as an Elopement Risk. This was a different version of the previous form, and this form had an area to identify with yes/no whether the resident was at risk for elopement. Review of Resident #63's Comprehensive Care Plan (CCP), initiated [DATE], revealed it had a focus area for elopement risk related to the resident's expressed desire to leave the facility prematurely, not medically ready for discharge. Interventions were for staff to monitor the nature and circumstances of attempted elopement; during specific activities and involvement with other residents, watch for exit seeking; encourage the resident to participate in activities; allow the resident to express his/her feelings; provide empathy and encouragement; familiarize resident with his/her belongings and surroundings; redirect the resident when near exits; and check wander guard for placement and operation ([DATE]). Additionally, staff was to use redirection techniques with television, snacks, and activities ([DATE]) and observe for risk factors and exit seeking behaviors ([DATE]). Review of the facility's investigation, dated [DATE], revealed the written statement from State Registered Nurse Aide (SRNA) #44 who reported after picking up breakfast trays on [DATE], Resident #63 went to the 100 Hall Nurse's Station and told staff he/she was going to leave, and they were holding him/her hostage and against his/her will. She noted Resident #63 stated he/she was going to call the police and file charges against them. She noted she went to get her supervisor, and the supervisor returned and talked to the resident for about twenty (20) minutes. SRNA #44 noted the resident seemed fine after that. However, she noted she heard a door alarm sound and checked the patio door off the courtyard. She noted she went to Resident #63's room, and he/she was not there. She then informed her supervisor the resident was missing. Continued review of the facility's investigation, dated [DATE], revealed the written statement by Licensed Practical Nurse (LPN) #17, who reported she was notified by SRNA #44 that she could not locate Resident #63 at approximately 11:30 AM. She noted she went to the door which had alarmed, looked outside, and did not see the resident. She reported staff searched the facility, and the resident was not located. She documented the resident was found by staff at a shopping mall parking lot nearby and returned to the facility by 11:40 AM. LPN #17 reported staff completed a skin assessment, vitals, and placed the resident on one-to-one (1:1) supervision. Review of the Maintenance Director's written statement about the [DATE] elopement of Resident #63, revealed she noted she arrived at the facility at 1:00 PM and was at the door the resident reportedly exited at 1:02 PM. In an interview with the Maintenance Director on [DATE] at 10:00 AM, she stated on [DATE], she was called to the facility after staff was unable to locate Resident #63 and arrived about forty-five (45) minutes later. She stated staff called and told her the alarms on the fire exit doors were not working. She explained, once she arrived on site, she checked all twelve (12) alarmed doors, and they were functioning properly. The Maintenance Director also reported this incident was the reason she put the locator alarm system in place, which showed what door alarmed and where in the facility, to allow staff to respond to the door that triggered. She stated the 135DE Door Guardian (wander guard) system was on two (2) doors, the main entrance and the dining room door to the smoking area. She stated the door Resident #63 exited out of did not have a 135DE Door Guardian on it, but the regular fire alarm sounded which had a low ring, and staff did not hear it. Review of google.com/maps on [DATE] at 5:00 PM, revealed from the facility to the shopping center parking lot in which the resident was found was a half mile away from the facility and was a (12) minute walk. Observation of Resident #63 on [DATE] at 5:00 PM, [DATE] at 9:00 AM, [DATE] at 3:00 PM, and [DATE] at 1:00 PM, revealed the resident was sleeping, with the covers over his/her head. In an observation and interview with Resident #63 on [DATE] at 8:20 AM, the resident was very pleasant and very confused. The resident stated he/she just woke up and did not know how long he/she had been in the facility. The resident believed he/she just arrived at the facility but had in fact been there since 2021. The resident stated he/she did not remember leaving the facility at any time. Resident #63 also stated, he/she was a very able-bodied person and could do what any other person his/her age could do. The resident stated he/she only needed help with oxygen. The resident also stated he/she did not know if he/she was able to leave the facility alone. The resident still had a wander guard bracelet on. Attempted interview with SRNA #44 on [DATE] at 10:00 AM, revealed the phone number provided was no longer in service. She was no longer employed by the facility. 2. b. Review of Resident #112's Face Sheet revealed the facility admitted the resident on [DATE] with diagnoses of dementia with agitation, dysphagia oral phase, and Alzheimer's ([DATE]). Review of Resident #112's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of eight (8) of fifteen (15), signifying severe cognitive impairment. The facility noted the resident was absent of any behaviors during this assessment. The MDS assessment revealed the resident was independent for all Activities of Daily Living (ADL), except for required supervision for showers. The resident was checked for elopement/wander alarm, but the wandering behavior section was not marked. Review of Resident #112's Comprehensive Care Plan (CCP) revealed the facility initiated an Elopement care plan, related to the resident's exit seeking behaviors and related to cognitive loss and dementia ([DATE]). The interventions were to monitor the nature and circumstances of exit seeking during activities, encourage the resident to participate in activities of choice, use and monitor security bracelet per protocol (Administrator stated they did not have a wander guard procedure/policy), divert the resident's attention by giving objects to hold, familiarize resident to his/her own belongings ([DATE]), as appropriate redirect resident if near exits or doorways, ensure supervision during smoke breaks ([DATE]), use wander guard as ordered ([DATE]), and staff were to observe for risk factors/triggers for exit seeking behaviors, increased wandering and to offer diversions ([DATE]). In an interview with the Administrator on [DATE] at 1:00 PM, she stated because of the ownership change which happened in [DATE], many documents and paperwork were taken out with them. She stated she would find what she could related to investigations from 2021 and 2022. Based on that information, it was determined some items from the investigations might be missing. Review of the facility's investigation into the elopement of Resident #112 on [DATE], revealed a written statement by Unknown Staff #1, which documented residents were outside of the facility, she left to use the bathroom, and when she returned, Resident #112 was outside with an aide. She noted, when the other therapist went out to help get the residents back in, I told the other therapist to make sure (Resident #112) came back in. She also noted, The therapist stated (he/she) was not out there with the new aide, stating (he/she) left. The staff member stated she went inside and told the Administrative Assistant at the front desk that physical therapy was outside, and she left. Review of a statement written by Unknown Staff #2, dated [DATE] (correct date), noted she was on the 200 Hall when a visitor asked to exit the door. The alarm was going off, there was a visitor in the lobby, and one (1) in the parking lot. She noted as the visitor walked out the door, she observed a resident walking in the parking lot. She stated she got the resident, returned him/her inside the facility, and reported to her nurse what happened. Review of a typed statement also dated [DATE], unknown author, noted a visitor was in the lobby, and he saw a resident push on the front door and exit. The statement noted the visitor alerted staff the resident had exited the building. It was noted the resident was brought back inside within thirty (30) seconds. Review of the facility's final report, undated, revealed, on [DATE], Resident #112 was discovered outside the facility and nearby the local golf course. The report stated the resident was outside the facility for approximately fifteen (15) minutes. The facility noted the resident stated he/she went for a walk. Per the report, the resident was placed on one-to-one (1:1) supervision upon return, and when the resident's wander guard was checked for proper operation, there was no wander guard on the resident. Also, the report stated the facility's findings revealed during a smoke break, Resident #112 went outside. It stated SRNA #2 observed the resident leaving the smoking area, and she thought the resident was allowed to come and go from the facility as he/she desired. The report revealed it was SRNA #2's first day working at the facility. However, the facility's investigation did not include a written statement from SRNA #2. The State Survey Agency (SSA) Surveyor attempted an interview with SRNA #2 on [DATE] at 1:00 PM, [DATE] at 10:00 AM, and [DATE] at 9:00 AM with voice messages left. However, SRNA #2 did not return the calls. In an interview with the Administrative Assistant (AA) on [DATE] at 9:43 AM, she stated she was not at work when Resident #112 eloped on [DATE]. However, she explained the resident would go to the front door and push on the keypad, but the resident also knew if he/she pushed the door it would eventually open. She stated many of the residents could read and knew the door stated to press and hold for fifteen (15) seconds and the door would open. The AA also stated if the front door did not close properly or if a person used their hand to make it close slowly, the door would not latch, and the alarm sounded. The AA reported she was not present when Resident #63 eloped either, but she knew the resident got out of the therapy door in the 100 Hall. In an interview with SRNA #41 on [DATE] at 12:49 PM, she stated it was her fourth (4th) day working at the facility. She stated when she joined the State Survey Agency (SSA) Surveyor, the alarm system to the facility was sounding, and she asked what the sound was. She stated she had asked other aides what the sound was and was told they did not know. The SRNA also stated she did not know it was an alarm the residents could set off exiting the building. SRNA #41 stated some exit seeking behaviors were if a resident constantly talked about leaving the facility, packed their bags, asked where their family was, and pulled on doors. She stated if she observed a resident with that behavior, she would redirect the resident and ask the resident to walk with her while she informed the nurse. She stated the nurse should then assess the resident and put an intervention in place. SRNA #41 stated the most important thing would be to keep eyes on the resident. In an interview with the Director of Nursing (DON) on [DATE] at 3:01 PM, she stated if staff noticed a resident was missing, staff was to immediately do a head count in their assigned area and start searching, room-by-room and any opening where a person could hide. She stated she was not sure of the exact procedure since the change in ownership. She explained she did not get her orientation/introduction because her first day on the job was the day after the SSA Surveyors entered the building. The DON stated if a resident was not found within fifteen (15) minutes, the police should be called. In an interview with the Administrator on [DATE] at 4:35 PM, she stated if staff members noticed a resident was missing, they were to call an elopement code, and all units were to bring their Elopement Binders to the center of the facility and search inside and outside the facility. She stated if the resident was not found within fifteen (15) to twenty (20) minutes, the police were to be called. She stated staff was expected to follow the facility's policy. The Administrator explained staff only had access to policies that were pertinent to their job duties. She stated if staff members wanted to request different policies, they could ask management and management would provide it for them to review, but they would not have full access to all policies. 3. Observation on [DATE] at 8:15 AM, revealed a very loud and piercing alarm sounded, and it was identified as the alarm to the door which exited to the smoking area. The door also had a wander guard alarm on it. The alarm sounded when a person with a wander guard was near the door, and if the door was held open too long. Observation on [DATE] at 8:16 AM, revealed the alarm sounded but there were not any smokers outside. In an interview with the Administrative Assistant (AA) on [DATE] at 8:16 AM, she stated the alarm triggered because of the weather: if it was windy outside or if it was too hot or cold outside. She explained there was an adjustment knob on the magnetic lock that required adjustment to ensure the door and the magnetic lock connected properly. The AA also stated staff used the door which exited to the smoking area to cut through the unit to get to the 300 Hall. Observation on [DATE] revealed the alarm sounded at 10:00 AM. The SSA Surveyor stood at the 200 Hall Nurse's Station, and the alarm was extremely loud in that area. The alarm sounded at 10:01 AM, for ten (10) seconds, 10:02 AM for ten (10) seconds, 10:14 AM for ten (10) seconds, 10:16 AM for ten (10) seconds, 10:17 AM for ten (10) seconds, 10:18 AM for twenty (20) seconds, again on 10:18 AM on/off, and 10:18 AM for thirty-five (35) seconds. Observation on [DATE] from 8:00 AM to 11:00 AM and 12:00 PM to 4:00 PM, revealed the door alarm sounded fifty-nine (59) times. Observation on [DATE] revealed the alarm sounded at 9:12 AM, on and off for five (5) seconds; 9:43 AM for fifteen (15) seconds; 9:49 AM for fifteen (15) seconds; 9:50 AM for five (5) seconds; 9:53 AM on and off for five (5) seconds; 9:54 AM on and off for five (5) seconds; and 10:24 AM on and off. Observation on [DATE], [DATE] and [DATE] revealed smoking times started at 9:30 AM, 1:30 PM, 5:30 PM, and 7:30 PM, until the three (3) units finished smoke break. During that time the alarm sounded while staff moved residents in and out of the facility. Observation on [DATE] at 1:35 PM, revealed three (3) staff seated at the 100 Hall Nurse's Station did not turn around and look at the annunciator when it was triggered as staff took residents out to smoke. The three (3) staff had their faces in the opposite direction the entire time the alarm sounded. Review of the Resident Council Meeting minutes, dated [DATE] at 12:42 PM, revealed since [DATE], there had been twelve (12) resident complaints about the volume of the alarm and the number of times the alarm sounded in a day. It was noted, one (1) resident would cry and yell, turn it off, and another resident complained it caused problems for his/her hearing aid. In an interview with State Registered Nurse Aide (SRNA) #8 on [DATE] at 12:50 PM, she stated the alarm sounded all the time, it was very loud, but staff got used to it. She stated even though the alarm sounded all the time, staff was still expected to check the box to find out which door triggered the alarm and check the door to ensure a resident had not exited the building. In an interview with SRNA #45 on [DATE] at 4:00 PM, he stated there were blue illuminators placed on the walls that went off when the alarms sounded, and based on their location, that identified which door triggered. They were placed at the front entrance. He stated other than that the annunciator at each nurse's station showed which door was triggered. He explained staff were expected to check the door that triggered the alarm. SRNA #45 stated he could see that the alarm sounding all the time could be a problem for keeping track of residents who wandered or were at risk for elopement. He stated, if a resident exited while the alarm was already triggered, staff could miss it. He stated the alarm sounded very often, and he could understand that all staff did not respond as expected. In an interview with Licensed Practical Nurse (LPN) #4 on [DATE] at 1:16 PM, she stated the alarm sounded many times a day, and it was very loud. She stated most of the time it sounded because it took too long for staff getting residents outside to smoke. She stated staff could enter a code to silence the alarm, but it still sounded because of the smokers with wander guards on. The stated LPN stated the wander guard triggered the alarm system too. LPN #4 stated the Administrative Assistant (AA) stationed at the front door monitored the alarm too. LPN #4 stated when the front door alarm sounded, the AA shut it off. In an interview with LPN #7 on [DATE] at 1:47 PM, she stated when the alarm sounded in the facility, all staff in that area were to respond to the alarm and see if a resident exited the building or tried to leave the building. In an interview with the Maintenance Director on [DATE] at 3:01 PM, she stated the alarm went off all day. She stated when Covid was in the building the residents smoked in the courtyard at the end of the 100 Hall. She stated at that time the alarm was not loud enough, and only therapy and maybe staff at the 100 Hall could hear when it sounded. She explained she was called on [DATE], when Resident #63 exited the building, and that was when the annunciator was put in. She explained the annunciator was a box which connected to the twelve (12) fire exit doors to the outside. The Maintenance Director stated the door that triggered lit up, and each of the nurse's stations could see which door had been set off. In continued interview with the Maintenance Director on [DATE] at 3:01 PM, she stated the alarm was too loud and she could probably adjust that. She stated the alarm had been discussed a lot, by staff and residents, for being too loud. She stated they needed the alarm system, but it was too loud. She stated she was not able to turn the sound volume down, and the alarm company had to do that. The Maintenance Director also stated the wander guards were part of the alarm system. The door to the smoking area had a wander guard alarm on it too. She explained the alarm could not be turned off while there was a wander guard close to the door. She stated most residents that went out to smoke had a wander guard and were in wheelchairs. She stated, while staff pushed them outside, there was no way to turn the alarm off. The Maintenance Director stated she checked the alarm function weekly to include the wander guard system. She stated sometimes the front door was too sensitive, and continued adjustments needed to be made, otherwise it could trigger from the dining room. The Maintenance Director stated she believed all staff members were expected to respond to the sounding alarm. She stated they could identify which alarm sounded by the light on the annunciator. Observation on [DATE] at 3:09 PM, revealed the facility changed the alarm sound. It was now a high pitched straight sound, and it rang far less than the previous alarm. In another interview with the Maintenance Director on [DATE] at 10:00 AM, she explained she removed the loud alarm box, and it lowered the sound of the alarm. She stated the annunciator would still work the same as before, it just was not as loud. In an interview with the Regional Maintenance Director on [DATE] at 9:00 AM, he stated he did not realize the volume of the alarm was such a big problem. He explained the system had been changed where staff who escorted residents out of the facility would have a code they could enter to temporarily pause the alarm. He stated this was so it would not trigger the entire time staff moved residents out/in who had on a wander guard system. Observation of the Maintenance Director on [DATE] at 3:00 PM, revealed she demonstrated how she did weekly checks on the alarm system and the wander guards. She had a handheld scanner, and when placed by the keypad at the door or by the wander guard, it presented a code to show if the system was working. Review of the maintenance log provided by the Maintenance Director for [DATE] to [DATE], revealed weekly door checks were completed and all doors were functioning as they should be. In an interview with the Administrator on [DATE] at 4:35 PM, she stated she could not answer the question of why the alarm system was not addressed. She stated the owner came to the facility, and the alarm was fixed. She stated the alarm would not be at the high volume any longer, but it would still go off. She stated the wander guard system would still trigger the alarm when smokers went outside, but staff members were now able to put in a code to mute the alarm while moving them in and out of the facility.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective antibiotic stewardship program to monitor antibiotic use as part of the overall infection prevention and control program (IPCP). Furthermore, the facility failed to incorporate monitoring and assessment of antibiotic use for five (5) of one hundred and four (104) sampled residents (Residents #20, #45 #71, #97, and #158). In addition, the facility failed to track antibiotic use in the facility and failed to report regularly on antibiotic use and resistance to the facility's leadership. The findings include: Review of the facility's policy, Antimicrobial Stewardship, dated December 2016, revealed antibiotics would be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the policy was to ensure that the antibiotic stewardship program was used to monitor the use of antibiotics. 1. Review of Resident #20's Admission record revealed the facility admitted the resident on 10/17/2019 with diagnoses to include congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD). Review of Resident #20's Annual Minimum Data Set (MDS) Assessment, dated 12/18/2023, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) of fifteen (15), indicating an intact cognitive response. The MDS assessment did not indicate the resident had a diagnosis of an infection. Review of Resident #20's Physician's Orders revealed an order, dated 03/05/2024, for Levaquin (antibiotic) Oral Tablet 750 milligrams (mg) administered once daily for five (5) days for pneumonia. However, the facility failed to provide evidence of antibiotic monitoring or infection control notes for Resident #20. Review of Resident #20's Medication Administration Record (MAR) and Progress Notes, dated from 03/05/2024 to 03/08/2024, revealed no monitoring or documentation of assessment related to antibiotic therapy or adverse reactions. 2. Review of Resident #45's Admission Record revealed the facility admitted the resident on 12/27/2021 with diagnoses to include COPD, type 2 diabetes mellitus, and acute and chronic respiratory failure. Review of Resident #45's Quarterly MDS Assessment, dated 01/15/2024, revealed the facility assessed the resident to have a BIMS score of fourteen (14) of fifteen (15), indicating an intact cognitive response. The MDS assessment did not indicate the resident had a diagnosis of an infection. Review of Resident #45's Physician's Orders, dated 02/25/2024, revealed an order for Cefuroxime (antibiotic) Oral Tablet 250 mg administered two times daily for ten (10) days to treat an urinary tract infection (UTI). Review of Resident #45's laboratory work revealed a urine culture and sensitivity was performed on 02/24/2024, which was positive for proteus mirabilis (a bacterium). However, the facility failed to provide evidence of antibiotic monitoring or infection control notes for Resident #45. Review of Resident #45's MAR and Progress Notes, dated from 02/25/2024 to 03/08/2024, revealed no monitoring or documentation of assessment related to antibiotic therapy or adverse reactions. 3. Review of Resident #71's Admission Record revealed the facility admitted the resident on 11/13/2023 with diagnoses to include type 2 diabetes mellitus, acute osteomyelitis, and infection and inflammatory reaction due to internal right hip prosthesis. Review of Resident #71's Quarterly MDS Assessment, dated 01/19/2024, revealed the facility had assessed the resident to have a BIMS score of fourteen (14) of fifteen (15), indicating an intact cognitive response. The MDS assessment showed that the resident had a diagnosis of a wound infection. Review of Resident #71's Physician's Orders revealed an order, dated 12/14/2023, for Levaquin (antibiotic) Oral Tablet 750 mg administered once daily for methicillin sensitive staphylococcus aureus (MSSA) bacteremia to be completed when the total hip replacement was completed. However, the facility failed to provide evidence of antibiotic monitoring or infection control notes for Resident #71. Review of Resident #71's MAR and Progress Notes, dated from 12/14/2023 to 03/08/2024, revealed no monitoring or documentation of assessment related to antibiotic therapy or adverse reactions. 4. Review of Resident #97's medical record revealed the facility admitted the resident on 12/22/2022 with diagnoses to include type 2 diabetes mellitus, CKD, and moderate protein-calorie malnutrition. Review of Resident #71's Quarterly MDS Assessment, dated 01/19/2024, revealed the facility assessed the resident to have a BIMS score of fifteen (15) of fifteen (15), indicating an intact cognitive response. The MDS assessment showed that the resident had an indwelling catheter and ostomy. Review of Resident #97's Physician's Orders revealed an order, dated 03/01/2024, for Amoxicillin (antibiotic) Oral Tablet 500 mg administered two (2) times daily for nineteen (19) administrations to treat a UTI. Review of Resident #97's laboratory work revealed a urine culture and sensitivity was performed on 02/27/2024, which was positive for pseudomonas aeruginosa and enterococcus faecalis (bacteria). However, the facility failed to provide evidence of antibiotic monitoring or infection control notes for Resident #97. Review of Resident #97's MAR and Progress Notes, dated from 02/27/2024 to 03/08/2024, revealed no monitoring or documentation of assessment related to antibiotic therapy or adverse reactions. 5. Review of Resident #158's Admission record revealed the facility admitted the resident on 03/05/2024 with diagnoses to include CHF, end-stage renal disease, and type 2 diabetes mellitus. An MDS assessment had not been completed. Review of Resident #158's Physician's Orders revealed an order, dated 03/06/2024, for Cefdinir (antibiotic) Oral Tablet 300 mg administered once daily for pneumonia for four (4) days. However, the facility failed to provide evidence of antibiotic monitoring or infection control notes for Resident #158. Review of Resident #158's MAR and Progress Notes, dated from 03/06/2024 to 03/08/2024, revealed no monitoring or documentation of assessment related to antibiotic therapy or adverse reactions. During an interview with the Advanced Practice Registered Nurse (APRN) on 03/05/2024 at 10:30 AM, she stated she worked under the former owners and had stayed on as a provider under the new leadership. She stated she did not have access to any medical records under the prior system. The APRN stated residents with infections were given the appropriate antibiotic. She stated she did not repeat lab work as the residents were assumed treated when the antibiotic was completed. During an interview with the former Assistant Director of Nursing/Infection Preventionist (ADON/IP) on 03/07/2024 at 2:23 PM, she stated through the recent transition of ownership in the facility, she became the Infection Prevention (IP) nurse. She stated that all staff members were trained in infection prevention and antibiotic stewardship. She stated as part of the training, nurses were instructed to keep track of the residents' progress and any adverse reactions in the progress notes while administering antibiotic therapy to residents. She stated they were also advised to inform the provider immediately if they encountered any adverse side effects from the antibiotic. She stated she maintained a binder to monitor antibiotic use in the facility. Upon resigning, she stated she handed over her documents to the current administration. During an interview with the Interim Director of Nursing/Infection Preventionist (DON/IP) #1 on 03/05/2024 at 3:44 PM, she stated she was brought in temporarily to assume the role of DON/IP after the former DON had resigned several weeks ago. She stated she had been at the facility for less than one (1) month. She stated due to the recent change in ownership and the resignation of the former DON, there was currently no antibiotic stewardship program in place at the facility. She stated the former DON was likely monitoring the antibiotic use at the facility, but she was unable to provide the State Survey Agency (SSA) Surveyor with any documentation regarding the frequency of monitoring and assessments related to antibiotic stewardship. During continued interview on 03/05/2024 at 3:44 PM with DON/IP #1, she stated during her tenure she had not been monitoring protocols or overseeing the system to monitor antibiotic use. Furthermore, she stated she had not collected or reported on data related to antibiotic usage and resistance. DON/IP #1 stated she had not documented any infection control notes. The DON/IP #1 stated that monitoring antibiotic use was important to ensure that those residents who required an antibiotic were prescribed the appropriate antibiotic and monitored for adverse side effects. During an interview with DON #2 on 03/08/2024 at 11:12 AM, she stated she had been in the position of DON for two (2) weeks. She stated the facility brought in a Regional Resource Nurse to train her in the new position as DON. She stated she identified issues concerning infection control, especially issues related to education and training. According to DON #2, the facility had hired an Assistant Director of Nursing (ADON) to take over as the new Infection Preventionist (IP). She stated as part of the new ADON/IP's duties, ADON/IP would oversee infection surveillance and antibiotic stewardship. DON #2 stated antibiotic stewardship was important to ensure residents with infections were treated appropriately, and signs and symptoms of infections were being assessed and monitored. During an interview with the Administrator on 03/08/2024 at 4:45 PM, she stated she had been in the position of Administrator since 12/2023. The Administrator stated it was her expectation that all staff was well-versed with the policies related to their job duties and adhered to all facility policies and procedures, including infection control. She stated DON/IP #1 was brought in to provide interim leadership and oversee the infection prevention and control program, including antibiotic stewardship after the former DON left. Additionally, she stated corporate leadership provided a Regional Resource Nurse to assist with providing education and guidance to nurse leadership and staff. According to the Administrator, they had appointed an ADON to take over as the new IP, and as part of her duties, she would oversee infection surveillance and antibiotic stewardship. She stated antibiotic stewardship was important for the treatment of infections to ensure that residents who required an antibiotic were prescribed the appropriate antibiotic and monitored for adverse side effects.

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system to ensure the Physician was notified when there was a significant change in condition and a need to alter treatment for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #110 was hospitalized , on [DATE], with Altered Mental Status, Condition Decline, and [CONDITION(S)]. Prior to the [DATE] acute care hospitalization , the resident was receiving Oxycodone with Acetaminophen (a narcotic opioid [MEDICATION(S)] given for moderate to severe pain) on a every six (6) hour schedule. Review of Resident #110 medical record revealed the resident returned from the hospital to the facility, on [DATE]. The resident's discharge medication and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Moreover, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However there was no documented evidence the Physician was notified that the order expired in three (3) days. Interviews with staff revealed Resident #110 continued to complain of pain. Interview with the resident revealed he/she was in constant pain and had made staff aware of his/her pain; however, no one was addressing the resident's pain. Interviews with Resident #110's Physician and Advanced Practice Registered Nurse (APRN) revealed they were aware the resident had chronic pain and had been on the narcotic [MEDICATION(S)]. However, they both stated they were unaware it had been discontinued as of [DATE]. In addition, the Physician stated he would have expected staff to notify him or the APRN that the resident was complaining of pain. Resident #110 was transferred to the Hospital Emergency Department (ED) on [DATE]. Review of the Admitting Physician's Note, dated [DATE], revealed the resident arrived at the ED in pain, lethargic, did not move his/her extremities, and moaned with discomfort. Per the ED record, the resident received [MEDICATION(S)] (an opioid narcotic). The facility's failure to have an effective system to ensure the Physician was notified when there was a significant change in condition and a need to alter treatment provided to residents who required such services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified in the area of 42 CFR 483.10 Resident Rights, on [DATE] and were determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Change in Condition: Notification Of, revised [DATE], revealed the center must immediately inform the resident, consult with the resident's Physician, and notify, consistent with his/her authority, the resident's Health Care Decision Maker (HCDM), where there was: a need to alter treatment significantly (that was, a need to discontinue or change from an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Review of the facility's policy titled, Physician/Advanced Practice Provider (APP) Notification, revised [DATE], revealed the requirement to communicate a change in the resident's condition to the Physician/APP and initiate interventions as needed or ordered. Review of the facility's policy titled, Resident Rights and Dignity, revised [DATE], revealed each resident would be cared for in a manner that promoted an enhanced quality of life, dignity, respect, and individuality. Review of Resident #110's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #110's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated he/she had mild cognitive impairment. Continued review revealed the facility assessed Resident #110 as having pain during this assessment period and had received scheduled or as needed (PRN) pain medication. Review of Resident #110's Comprehensive Care Plan (CCP), initiated on [DATE], revealed Resident #110 was at risk for alterations in comfort related to [CONDITION(S)], muscle weakness, right upper extremity [CONDITION(S)], contracture, [CONDITION(S)], obesity, and polyneuropathy. The goal was the resident would achieve an acceptable level of pain control. Further, interventions included but were not limited to, administer pain medication as ordered; elevate right upper extremities with pillow; observe pain characteristics: quality, severity, location, precipitating/relieving factors; medicate resident as ordered for pain and observe for effectiveness and side effects; report to Physician as indicated. Observation of Resident #110, on [DATE] at 9:05 AM, revealed the resident yelling for a nurse. Resident was moaning and groaning in pain. Further observation revealed, the resident was lying flat on his/her back, no pillow under the right arm. The resident's hands had contractures, and the resident was unable to use the call light related to his/her contractures. Per observation resident showed non-verbal ques of pain with grimacing. Further observation revealed no one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. However, there was no documented evidence the Physician was notified of the resident's complaints of pain. Interview with Resident #110, on [DATE] at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, on [DATE], he/she had not received pain medication as needed. Further interview revealed, the resident stated, I am miserable and I hurt all the time. Per interview the resident stated when he/she tells the nurse he/she was in pain, no one would help him/her. Review of Resident #110's Vital Sign Assessment, revealed, in the month of [DATE] the only pain assessments documented were on [DATE] at 1:00 PM, rated zero (0) out of ten (10), and on [DATE] at 10:00 PM, rated zero (0) out of ten (10), despite a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with State Registered Nurse Aide (SRNA) #11, on [DATE] at 1:50 PM, revealed Resident #110 hurt all the time, especially when he/she was moved. She stated the resident could not tolerate lying on his/her right side. Further interview revealed she would notify the nurse that the resident was in pain. Review of Resident #110's Hospital ED (emergency department) Admitting Physician Note, dated [DATE], revealed the resident arrived at the ED in pain lethargic, did not move his/her extremities, and moaned with discomfort. Per the ED record, [MEDICATION(S)] (an opioid narcotic [MEDICATION(S)] for acute pain) Injection four (4) mg was ordered and given. Review of Resident #110's Hospital ED Face Sheet, dated [DATE], revealed [MEDICATION(S)] Injection four (4) mg was added to the resident's hospital medications. Interview with Licensed Practical Nurse (LPN) #8, on [DATE] at 8:26 AM, revealed if a staff member reported to her that a resident was in pain, she would first review the orders and if a resident had unrelieved pain, the policy required the nurse to notify the Physician or APP (Advanced Practice Registered Nurse, APRN) to adjust the resident's pain medication regimen. However, she stated she could not recall notifying the Physician of the resident not having an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Agency LPN #9, on [DATE] at 2:15 PM, revealed Resident #110 had experienced a recent change in condition (CIC) resulting in a decline. In addition, LPN #9 stated she readmitted the resident on [DATE] and recalled seeing the order for the narcotics for only three (3) days; however, she did not notify the Physician or APRN, nor reconcile orders with the medications the resident was ordered prior to the hospital admission. She stated she just assumed the Physician at the hospital did not want the resident on the pain medicaton after three (3) days. Furthermore, she did not notify the Physician that the resident was complaining of pain because she felt like that was the norm for the resident. Interview with the Unit Manager (UM), on [DATE] at 1:49 PM, revealed it was the responsibility of the nurse assigned to the resident to notify the Physician or APRN of any change of condition. Further interview revealed they should document the change on a Change of Condition form in the resident's medical record. She further stated if it was not documented, then it did not happen. Interview with the Assistant Director of Nursing (ADON), on [DATE] at 4:40 PM, revealed she was not made aware that nursing staff failed to notify the Physician or the APRN to reorder the resident's scheduled narcotic pain medication after the three (3) day order had expired on [DATE]. Further interview revealed she was also not aware the resident was crying out in pain. She stated it was her expectation for staff to follow the policies and notify the Physician or APRN when there was a change in a resident's condition. However, there was no documented evidence the nursing staff notified the Physician that the resident was no longer on scheduled Oxycodone with Acetaminophen after returning from the hospital. Furthermore, there was no documented evidence the nursing staff notified the Physician of a CIC related to pain, according to facility policy. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 3:40 PM, revealed it was her expectation that nursing staff follow the facility's policies. The RCQS stated, with Resident #110's pain management, there was a communication breakdown because there was no documented evidence the nursing staff notified the Physician or the APRN of a CIC related to pain, according to facility policy. Interview with the APRN, on [DATE] at 2:30 PM, revealed she was aware the resident had chronic pain and mobility issues, used opioid medications, and took Oxycodone ,d+[DATE] mg (milligrams), one (1) tablet by mouth every six (6) hours, scheduled, prior to his/her admission to the hospital on [DATE]. Per interview, staff did not make her aware upon readmission of the order expiring in three (3) days. Per interview, if she had been made aware she would have reordered the medication. Further interview revealed, staff failed to notify her that the resident was in pain and was experiencing a change of condition. Interview with the Physician, on [DATE] at 10:15 AM, revealed it was his expectation for staff to notify him or the APRN if the resident was having a change of condition. Per interview, he was unaware the resident was in pain, and that the resident's pain medication order had expired. Interview with the Director of Nursing (DON), on [DATE] at 9:18 AM, revealed that follow-up on admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, the DON stated there was no documented evidence the nursing staff notified the Physician that the resident was no longer on scheduled Oxycodone, after returning from the hospital. In addition, she stated there was no documented evidence the nursing staff notified the Physician or APRN of a CIC related to pain. Per interview, it was her expectation for staff to follow the facility's policies. Interview with the Administrator, on [DATE] at 5:28 PM, revealed the Change in Condition/Notification of Change policy was expected to be followed to ensure the Physician was notified of changes in a resident's condition per policy guidelines. Additionally, she stated any significant change in a resident's condition was expected to be documented in the medical record. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. Newly hired staff and contracted staff were to be provided education and post-test during orientation by the DON, ADON, CQS, NPE, UM, and/or Licensed Nurse (LN). 4. Starting [DATE], clinical observation rounds will be conducted every shift, including interviews of ten (10) staff and five (5) residents who receive pain medication to identify any change in condition including a change in pain by the DON, ADON, UM, NPE, or LN to determine if residents have experienced a change in condition regarding pain. The Physician/NP were notified and the plan of care was reviewed to ensure it reflected the current needs of the resident daily until the Immediate Jeopardy is abated. 5. Starting [DATE], the Center Executive Director (CED) and/or LN would conduct ten (10) employee questionnaires daily to determine if staff were aware of the Center's process of the Stop and Watch Tool and reporting a change in condition, including reporting resident pain to a licensed nurse, to ensure prompt interventions when a resident experienced a change in condition, until the Immediate Jeopardy is abated. 6. The results of the observations, interviews, and audits will be reviewed daily by the CED or DON corrective actions taken upon discovery of deficiencies. 7. Beginning on [DATE], the DON, UM, ADON, NPE, CQS, and/or LNs initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition. 8. All admissions, readmissions, and residents with changes in respiratory status since [DATE] were reviewed on [DATE] by the DON, ADON, NPE, UM, and or LNs to determine if care plans reflected patient specific interventions to include interventions to monitor respiratory status to include residents with sleep apnea, [CONDITION(S)], acute [CONDITION(S)], and asthma. Areas of concern were corrected upon discovery. 9. On [DATE], the DON, UM, ADON, NPE and or CQS initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Revision of the care plan with all admissions, readmissions, and changes in respiratory status with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A post-test was administered at the time of the reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Licensed Nursing and Agency Licensed Nursing Staff not available will be provided reeducation, including a post-test, by the DON, UM, ADON, NPE, and/or Registered Nurse upon day of return to work before providing care. New licensed nursing hires and agency licensed nurses will be provided education and post-test during orientation by the DON, ADON, NPE and/or UM. 10. Care plan audits were completed for residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. Five (5) Licensed Nursing Staff interviews were completed by the CED, DON, UM, ADON, NPE, and/or CQS to determine if staff were aware of the process of a respiratory assessment when a resident's condition warranted the assessment and per the resident's plan of care will be conducted daily until the Immediate Jeopardy is abated. 12. The DON, UM, ADON, NPE, and/or CQS completed reeducation beginning on [DATE] with facility licensed staff to include agency staff on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plans with individualized person-centered interventions to include monitoring pain, administering pain medications as ordered, and utilizing and documenting pain scale assessments, and observe for non-verbal signs/symptoms of pain. A medication reconciliation process is in place to review discharge orders to current orders; (B) Physician/Mid-Level Provider Notification of Change in a resident's condition; and (C) Person Centered care plans regarding resident interventions for pain. A post-test was administered at the time of reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and or CQS to validate understanding. Facility licensed staff and agency staff not available will be provided reeducation including a post-test during orientation by the DON, ADON, NPE, UM, and/or LN, before allowed to work. 13. The CED and/or LN will conduct five (5) employee questionnaires daily to determine if staff were aware of the Center's process of reporting a change in condition including pain to a licensed nurse to ensure prompt intervention when a resident experienced a change in condition until Immediate Jeopardy is abated. 14. The UM's, ADON, NPE, and licensed nurses completed skin assessments on all residents on [DATE], to ensure residents, including residents with pressure ulcers, received care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 15. The CQS reeducated the Wound Nurse regarding the facility's policy, Wound Care, on [DATE]. A post-test was administered at the time of the reeducation to validate understanding. 16. The NPE, DON, UM's, and/or ADON reeducated all licensed staff, including agency staff, regarding the requirement that residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers, to include appropriate assessment of all wounds when a wound/abscess was identified, beginning on [DATE], with a posttest requiring 100% score to validate understanding. 17. The DON, ADON, NPE or UM will conduct observation rounds and treatment administration audits to ensure residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 18. Quality Assurance/Performance Improvement (QAPI) meetings are occurring daily (Monday-Friday) beginning [DATE] with the interdisciplinary team, which consists of the CED, DOB, ADON, NPE, UM's, MDS, Dietary Manager, Social Services, Business Office Manager, Environmental Services, Medical Records, Maintenance, Human Resources, Registered Dietician, Activities Director, Central Supply, and Director of Rehabilitation, until Immediate Jeopardy is abated. During QAPI meetings, the current status of the AoC is discussed, including review of the audit tools, findings, and any needed corrective action. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the facility's audit tool revealed the audits were reviewed, with all residents present as of [DATE]. Audits were conducted to determine the presence of pain, and the effectiveness of any pain medications ordered. Record review revealed nineteen (19) residents were identified with pain concerns, with most concerns identified consisting of pain medications not being effective, or not being effective for the length of time until the next dosage of pain medication was available. All of this information was emailed to the Nurse Practitioner (NP) by the CQS. Review of residents' medical records for residents identified, revealed residents had been reassessed by either the Physician or NP, with new orders provided as appropriate. 2. Review of nineteen (19) residents with identified pain issues revealed residents identified had been reassessed on [DATE] by the DON, UMs and/or Licensed Nurse (LN) to determine if a change in condition had occurred regarding pain. Interview with the NPE, on [DATE] at 1:30 PM, revealed, based on audits conducted by [DATE]; nineteen (19) residents were identified with pain issues. She revealed all residents had been reassessed, and staff were documenting changes in resident condition in nursing notes regarding effectiveness of pain medications. 3. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all facility staff were educated in person or over the phone regarding: (A) Change in condition; (B) Pain management; (C) Stop and Watch Tool; (D) Provider notification of change; and (E) Person-centered care plans. Review of documents titled Post Test, revealed staff completed testing covering all identified areas, to include changes in resident condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with Admissions personnel, on [DATE] at 8:20 AM, revealed she had been educated to monitor residents for any new or worsening pain or any change in activity or changes in resident condition, the resident care plan. Admissions personnel was to report to the nurse and DON. She stated she was in-serviced on the use of the Stop and Watch tool. Interview with Laundry personnel, on [DATE] at 8:30 AM, revealed Laundry staff had been educated to monitor residents for pain or change in condition and to notify the nurse if any occurs. Laundry staff was to observe for any lack of care for the residents. Per interview Laundry personnel were in-serviced on the Stop and Watch tool. Interview with Physical Therapy Assistant (PTA) #1, on [DATE] at 8:15 AM, revealed PTA#1 had been educated to monitor for new or worsening pain and if a resident was participating less in activities or had a change in condition to report this to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool. PTA #1 completed a posttest after the training. Interview with SRNA #8, on [DATE] at 8:35 AM and SRNA #27 at 8:45 AM, SRNA #25 at 8:50 AM and SRNA #28 at 9:00 AM revealed education was provided to monitor for any new or worsening pain, change in condition and the appropriate use of the resident's care plan. Any change was to be reported immediately to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool and had taken a posttest after the education. Interview with the Activities Director on [DATE] at 3:40 PM revealed she had been educated in the Stop and Watch tool and the importance of the resident's care plan. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. 4. Review of AoC Audit Tool - [DATE], dated [DATE] through [DATE], revealed the facility was conducting observation rounds of ten (10) staff and five (5) residents every shift. Continued review revealed residents were interviewed to ensure they were receiving pain medications, with any changes in condition noted, assessments completed, notifications made as appropriate, and care plans updated as appropriate. Review of the staff portion for licensed staff revealed licensed staff were interviewed regarding the process for respiratory treatment, the process for reporting changes in condition, awareness of notification of the Physician or NP regarding resident pain issues and awareness of the care plan reflecting resident needs. Review of the staff portion for non-licensed staff revealed they were interviewed regarding awareness of the Stop and Watch Tool reporting of changes in resident condition regarding pain, respiratory status, or skin issues. Interview with RN #4 on [DATE] at 12:00 PM revealed she had audited nineteen (19) residents with pain. A tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. Interview with SRNA #8, on [DATE] at 8:35 AM, revealed education was done to monitor for any new or worsening pain or change in condition. Any change was to be reported immediately to the nurse. Per interview, she had been questioned during management rounds related to monitoring for pain and reporting to nursing staff. Interview with the Activities Director, on [DATE] at 3:40 PM, revealed she had been educated in the 'Stop and Watch' tool. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. Per interview, she had been asked during management rounds regarding awareness of the Stop and Watch Tool. 5. Review of the facility's AoC binders revealed completed documentation labeled F580 Test 2 All Staff except LN, completed by facility staff covering topics such as the Stop and Watch Tool, changes in resident condition, and person-centered resident care. 6. Interview with the DON, on [DATE] at 9:18 AM, revealed she reviewed the results of observations, interviews, and audits daily, and she ensured there was additional follow-up as needed. She stated audits had increased staff education and were helping management ensure staff followed-up with everything. She stated management had identified a need for staff improvement on documentation. 7. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed Licensed Nurses attended or were educated in person or over the phone regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition, Review of documents titled Post Test revealed licensed nursing staff completed testing covering all identified areas, to include changes in residents' condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated to watch for any new or worsening pain, to implement a person centered care plan with individualized interventions, administer pain medications as ordered using the pain scale, pressure ulcers monitor and treatment and to notify the practitioner with all changes in resident conditions. Per interviews, a posttest to acknowledge understanding of the education was given. Interview with RN #4 on [DATE] at 12:00 PM revealed a tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. The education is to be ongoing. Staff were educated to be transparent and use open communication. RN#4 reported all staff were educated on notifying the practitioner if a resident was experiencing pain. For chronic pain, interventions were to be implemented. 8. Review of the facility's documentation revealed the NPE reviewed all residents on [DATE] that had been admitted , readmitted , or that had been identified with changes in respiratory status. The NPE identified any changes since [DATE], and ensured care plan changes were implemented as necessary. Interview with the NPE, on [DATE] at 1:30 PM, revealed she did review all residents on [DATE] that had been admitted , readmitted or identified with changes in respiratory status. 9. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all licensed nurses, to include agency nurses, were educated in person or over the phone regarding revision of resident care plans for all admissions, readmissions, and changes in respiratory status for residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Clinical Competency Validation Respiratory Assessment, revealed licensed nursing staff completed testing following education. Interview with RN #4 on [DATE], LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated related to the revision of the resident care plan for all admissions, readmissions and changes in respiratory status for residents. Per interviews, a posttest to acknowledge understanding of the education was given. 10. Review of the AoC Audit Tool - [DATE], revealed care plan audits were conducted on new admissions, readmissions, and change in condition residents, to include a change in respiratory status, and were ongoing as of [DATE]. 11. Continued review of the AoC Audit Tool - [DATE], revealed five (5) licensed staff were intervie [TRUNCATED]

Based on observation, interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure Comprehensive Care Plans (CCP) for chronic pain and pressure risk with individualized person-centered interventions were followed for four (1) of thirty (30) sampled residents, Resident #110, #114, #36 and #102. The facility identified Resident #110 as at risk for alterations in comfort related to [CONDITION(S)] (OA), muscle weakness, right upper extremity [CONDITION(S)], contracture, [CONDITION(S)], obesity, and polyneuropathy. Observation of Resident #110, on [DATE] at 9:05 AM, revealed the resident yelled for a nurse for appoximately two (2) minutes. No one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. Interview with Resident #110, on [DATE] at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, he/she had not received pain medication as needed. Resident #110's care plan, revised on [DATE], identified the resident as being at risk for pressure injuries. Interviews and record review revealed the facility failed to implement pressure sore interventions. Resident #110 developed an open right gluteal abscess 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. In addition, there was development of an unstageable sacral decubitus ulcer measuring 8.0 cm (length) by 2.0 cm (width). Furthermore, a Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infection from the right buttock ulcer. The facility's failure to have an effective system to ensure the facility developed care plans and implemented interventions in the care plans to address the resident's assessed needs, related to pain management and pressure ulcers, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], in the area of 42 CFR 483.21(b)(1) Comprehensive Resident Centered Care Plans, Develop and Implement Care Plans, and was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, revised [DATE], revealed Comprehensive Care Plans were developed to help the resident attain or maintain his/her highest practicable physical, mental and psychosocial well-being and included measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that were identified in the comprehensive assessments. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the care plan was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan, based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. The manual stated a well-developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. 1. Review of Resident #110's medical record revealed the resident was admitted by the facility, on [DATE]. The resident had current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed Resident #110 had been hospitalized , from [DATE] to [DATE], with [CONDITION(S)] and Acute Respiratory Failure. Review of Resident #110's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated he/she had mild cognitive impairment. Continued review revealed the facility assessed Resident #110 as having pain during this assessment period and had received scheduled or as needed (PRN) pain medication. Review of Resident #110's Comprehensive Care Plan (CCP), initiated on [DATE] and last reviewed on [DATE], revealed Resident #110 was at risk for alterations in comfort related to [CONDITION(S)] (OA), muscle weakness, right upper extremity [CONDITION(S)], contracture, [CONDITION(S)], obesity, and polyneuropathy. The goal was the resident would achieve an acceptable level of pain control. Further, interventions included but were not limited to, administer pain medication as ordered; elevate right upper extremities with pillow; observe pain characteristics: quality, severity, location, precipitating/relieving factors, medicate resident as ordered for pain, observe for effectiveness and side effects, and report to the Physician as indicated. Observation of Resident #110, on [DATE] at 9:05 AM, revealed the resident yelled for appoximately two (2) minutes. Resident was heard to moan and groan and observation of resident showed non-verbal ques of pain with grimacing. No one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. This surveyor went to the nursing station and made SRNA #11, aware that Resident needed assistance. SRNA #11 got up and went into the room. Interview with Resident #110, on [DATE] at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, he/she had not received pain medication as needed. Interview with the resident revealed that he/she was in pain. The resident stated, I'm miserable and I hurt. I hurt all the time. Interview with Agency LPN #9, on [DATE] at 2:15 PM and [DATE] at 8:15 AM, revealed all staff was to follow and implement the residents' CCP to ensure they were receiving ordered care. LPN #9 stated Resident #110 was uncomfortable with positioning and would not tolerate it well. She stated the resident would cry out in pain when turned. LPN #9's interview revealed the resident verbalization pain, but stated if the resident had pain it was Only when moved. Further stated, She/he says she's in pain but she isn't. She stated the resident was incontinent, obese, and needed frequent skin assessments. Review of the facility's Roster Matrix (a cumulative record of residents on the census, their care needs, and identified health conditions), dated [DATE], revealed no indication Resident #110 had any pressure ulcers. Further review of the Comprehensive Care Plan, last reviewed [DATE], revealed Resident #110 was at risk for skin breakdown as evidenced by moisture/excessive perspiration, limited mobility, diabetes mellitus, peripheral vascular disease, incontinence of bowel and bladder, medications, history of pressure ulcers, obesity, [CONDITION(S)], [CONDITION(S)], and an arterial ulcer to the right second digit. The goal was for the resident to show no signs of further skin breakdown. Further review revealed interventions were to apply barrier cream with each cleansing, assist with methods of reducing friction and shear, assist the resident with turning and repositioning every two (2) hours as tolerated, float heels while in bed as tolerated, provide a low air loss (LAL) mattress to the bed, perform Norton/Braden assessments per policy, observe skin risk factors per protocol, and observe for localized skin problems. Further review of the Comprehensive Care Plan, last reviewed [DATE], revealed Resident #110 was at risk for skin breakdown or had actual skin breakdown. The healing goals were: 1) the resident would remain free of skin tear and bruising; 2) show no signs of skin breakdown; 3) the skin tear/bruise would heal; and 4) the wound/skin impairment would heal. Further review revealed interventions were to pat skin when drying, provide treatment to skin tear per Physician order, observe for signs of infection, assist resident with turning and repositioning, observe skin for signs/symptoms of skin breakdown, evaluate localized skin problems, utilize devices to assist with turning/positioning to reduce friction and shear, weekly skin assessments by a licensed nurse, weekly wound assessment to include measurements and description of the wound, and provide wound related pain management intervention (i.e. premedicate before wound care). Further review of the Comprehensive Care Plan, last reviewed [DATE], revealed Resident #110 was incontinent of urine and was unable to participate cognitively or physically in a retraining program. The goals were to have incontinence care needs met by staff to maintain dignity and comfort, and to prevent incontinence related complications. Further review revealed interventions were to check and change every two (2) hours and as needed (PRN) and to observe for skin redness/irritation and report as indicated. Interview with Agency LPN #9, [DATE] at 8:15 AM, stated the wound on the hip was an abscess with drainage, and she performed a culture and sensitivity on the drainage during a dressing change. She stated the wound abscess was tiny. LPN #9 stated the area on the right buttocks was healed. Further review Resident #110's medical record revealed, on [DATE], Resident #110 was transferred to the hospital Emergency Department (ED) by Emergency Medical Services (EMS), and during the triage period, hospital staff and EMS identified a sacral wound. The hospital assessed the resident to have an open right gluteal abscess, 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. In addition, the record stated staff identified an unstageable sacral decubitus ulcer measuring 8.0 cm (length) by 2.0 cm (width). Furthermore, a Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infection from the right buttocks ulcer. Further review revealed a surgical consult revealed the abscess and sacral ulcer would require surgical debridement of necrotic tissue. Then, a palliative care (care primarily focused on alleviating pain) consult was requested by the provider because the patient has no quality of life. The resident was transferred back to the facility under Hospice Care on [DATE] and expired on [DATE]. Review of a Braden Scale (a scale used to determine the degree of risk a resident had for developing pressure ulcers) Assessment and Skin Check dated, [DATE] at 5:27 PM, revealed Resident #110's score as ten (10), which indicated high risk. Review of the Skin Check, dated [DATE], revealed the nurse identified wounds to the right, second toe; right buttocks; and forehead. Review of a CIC follow-up Progress Note, dated [DATE] at 9:43 AM, revealed Resident #110's skin was warm with one-plus (1+) pitting [CONDITION(S)] in bilateral feet. Review of the Skin Check, performed on [DATE] at 5:27 PM, revealed no documented assessment, skin injuries, or wounds. Review of the Skin Assessment Grid, dated [DATE], revealed the only remaining wounds documented as assessed, was the buttocks/right hip abscess. There was no documentation of the right first toe, second toe, or third toe. There was no documentation of the medial forehead wound. There was no documentation or description of an unstageable sacral decubitus ulcer. Interview with SRNA #18, on on [DATE] at 8:20 AM, revealed when aides found a skin issue on a resident, the process was to document the finding on the Skin Assessment sheet and make the nurse aware. She further stated it was important to follow the resident's CCP. Interview with SRNA #26, on [DATE] at 5:15 PM, revealed Resident #110 was a total assist, but not bedridden. She stated the resident did not refuse care, but she would have to be very gentle when providing care. She used a pillow for elevation of the right arm. However, the SSA Surveyor observations, on [DATE], revealed no pillow under the resident's right arm as directed by the resident's CCP. SRNA #26 further stated it was important to follow the resident's CCP so that residents' needs were met. She stated she had performed incontinent care for Resident #110, but she did not recall seeing a wound. Interview with Agency LPN #15, on [DATE] at 5:05 PM, revealed she cared for Resident #110. She stated he/she was bedridden and had skin breakdown in abdominal folds. She did not recall any other skin breakdown. She stated Resident #110 would occasionally not want to be changed. LPN #15 stated her focus was on acute residents, so the SRNA's were her eyes and ears to alert her to potential problems. She stated person-centered care plans should be implemented. Additional interview with LPN #9, on [DATE] at 11:13 AM, revealed Resident #110's right buttocks area had purulent drainage like an abscess. She stated she notified the Wound Care Nurse (WCN), obtained a wound culture and sensitivity, and notified the Physician for treatment orders. She stated she did not measure the wound and estimated it to be the size of a nickel. She stated no other skin issues were present. LPN #9 stated, on [DATE], the abscess was open and draining, and she had to pack it. She recalled the resident flinched during treatment and stated it was uncomfortable. She further stated that Resident #110 did not want to be disturbed. LPN #9 stated she did not document the resident's care or his/her verbal or non-verbal reactions to treatment. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110's had an abscess to the right buttock. Per interview, RN #3 stated SRNA's only changed the resident two (2) times or less a shift because it was too uncomfortable for the resident. RN #3 stated the resident's CCP should have be implemented. Interview with RN #2, Nurse Educator/Wound Care Nurse (WCN), on [DATE] at 9:00 AM, revealed she was following Resident #110 for a wound on the toe, forehead, and shearing on the right buttock; however, she was not following the resident's abdominal fold wounds. RN #2 stated the shearing wound on the right buttock was healed, but a new wound abscess was found on the right hip area. She stated that LPN #9 did culture and dress the wound. In addition, the WCN stated the resident would grimace and moan when touched, and staff had to be gentle and procede slowing during the resident's wound care treatments. She stated she did not document Resident #110's pain level or non-verbal cues. She further stated if there was an order to do so, she would generally premedicate residents prior to wound care. Per interview, she stated it was important to follow the resident's CCP. Furthermore, she stated she should have premedicated Resident #110, per the CCP. She stated it would have been important to prevent any additional discomfort to the resident. Continued interview with the WCN, on [DATE] at 9:00 AM, revealed it was her expectation that staff assessed skin, bathed, checked and changed, and turned the resident per the CCP. She stated the importance of CCP was to ensure the Resident #110 was turned a minimum of every two (2) hours, and if he/she required, more frequently to prevent pressure injuries. She stated CCP's should be personalized and updated. Further interview revealed there was currently no widespread education on newly identified skin issues. The WCN stated the facility process was to let Unit Managers know about new skin issues. She stated not all staff had been educated on Pressure Ulcer Prevention (PUP) and PUP protocols were not in place. The WCN stated the plan was to implement new training regarding the turn schedule so nursing staff and SRNA's were educated on the importance of turning residents. Additional interview with the WCN, on [DATE] at 4:35 PM, revealed Agency staff was trained prior to coming to the facility on basic resident care. She stated the facility had processes to ensure competencies, which were not yet in place, for new hires, but new hires were paired with a trainer for one (1) to two (2) days, which she did not think was an adequate period of time. In addition, the WCN stated, during orientation, new staff was educated about using the CCP to personalize care, and trainers reported if there were any issues with competencies. Per interview, she stated she relied on other staff to check that agency staff was competent. Furthermore, she stated there was no follow-up from the Educator to assure competent care was provided according to the CCP and facility policies. She stated her goal was to spend one-on-one time with all staff, but for right now the process is broken. Additional interview with the WCN, on [DATE] at 11:52 AM, revealed during the last treatment she did on Resident #110, she only concentrated on the abscess to the hip. She recalled documenting assessment findings on a piece of paper. She stated she received an order to pack the wound with [MEDICATION(S)] covered gauze. Per interview, she stated the wound was an abscess and not something that could be staged. She stated she did not measure the wound, and per policy, no photographs were obtained. The WCN stated a full skin assessment was not done. Further interviewed revealed she focused on the acute areas of skin breakdown, and nurses did a weekly skin assessment. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 03:40 PM, revealed it was her expectation that nursing staff utilize skilled charting to document She stated, If it was not charted, it didn't happen. RCQS stated, Stated there is a breakdown in communication. here was no documented evidence the nursing followed the resident's care plan, according to facility policy. Interview with the Director of Nursing (DON), on [DATE] at 9:18 AM, revealed it was her expectation staff followed the resident's CCP, and if a resident had a pressure injury, it should be addressed in the CPC. She stated she expected nursing staff to provide the correct level of care per the person-centered care plan and as ordered by the Physician. Further interview revealed full skin assessments should be completed by nursing staff when weekly skin assessments were due. Per interview, the DON stated all residents at risk for skin breakdown should be checked, changed, and turned every two (2) hours. The DON stated SRNA's should notify the nurse of any change in the resident's condition. 2. Based on observation, interview, and record review, it was determined the facility failed to follow the individualized care plan relating to bathing and grooming of Resident #114. Record review revealed the facility admitted Resident #114 on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) exam score of eight (8) of fifteen (15), and determined the resident to be moderately cognitively impaired. Review of Resident #114 Comprehensive Care Plan, last reviewed on [DATE], revealed the resident required assistance with, and was dependent for Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to Limited Mobility, Cognitive Loss and Behaviors, [CONDITION(S)], and Left Above-Knee Amputation (LAKA), with the goal that ADL care needs will be anticipated and met throughout the next review period. Target date was [DATE]. Interventions included providing Resident #114 with extensive assist for toileting, dressing, and bathing. Observation of Resident #114, on [DATE] at around 2:00 PM, revealed Resident #114 lying in bed with a urinal containing urine hanging on his bed rail. There was an odor detected coming from the resident's side of the room. Resident #114 also had a full beard, and his clothes and hair were disheveled. Attempts to have a conversation with Resident #114 regarding his care needs were unsuccessful. He commented that he liked pretty women. Interview with the Manager on 200 Hall (LPN #1), on [DATE] at 2:15 PM, revealed residents received showers on a routine assigned schedule and as often as staff deemed necessary. In addition, the manager stated the nurse aides complete shower sheets when showers were given to their assigned residents. The shower sheets were placed in a shower book at the nurses' station. Resident #114 was assigned to receive a shower on Tuesdays and Fridays during the evening shift. Continued interview with LPN #1 (Unit Manager), revealed that based on the shower sheets in the book, she could not determine when the last time Resident #114 received a shower, or that ADL care needs were being provided as per care plan. Observation of the Shower Binder, on [DATE] at 2:30 PM, located at the nurses' station, revealed Resident #114 did not have any shower sheets in the book for April. Interview with the manager again revealed she did not know why the sheets were not in the book. She stated that this was a new process, and she realized the process needed improvement. Continued interview revealed that perhaps the sheets were removed and sent to medical records already, and she would check to find out. However, no sheets were located in medical records. Interview with SRNA #22, on [DATE] at 9:00 AM, employed sixteen (16) years, revealed she usually worked weekends from 7 AM-11 PM on the 200 Hall. On a good day, staffing was four (4) nurse aides; today, there were three aides working the 200 Hall. Continued interview revealed each aide was assigned two to three showers each. During the shower, the nurse aide noted any skin issues and reported any findings to the nurse. Afterward, a shower sheet was completed, and placed in the shower binder located at the nurses' station. If the shower sheet was not found in the shower book, either the nurse aide did not do the shower, or the aide failed to complete the sheet; The nurse was supposed to verify that the nurse aide conducted the shower by checking the shower sheets. She stated that the facility has been in a staffing crisis lately, and most of the staff are Agency. Interview with SRNA #19 on [DATE] at 9:30 AM, employed [AGE] years at the facility, revealed she primarily works weekends on the 300 Hall and works typically with three to four aides. She revealed she normally was assigned two showers on her shift. She said the aides completed the shower sheets and reported any skin issues to the nurse; they then put the sheets in the shower book. Continued interview revealed that she would assume it was not done if she did not see the shower sheet in the book. Interview with LPN #11, on [DATE] at 8:49 AM, employed seventeen (17) years, revealed that aides were responsible for performing resident's showers on the days the showers were due. Aides bring the shower sheets to the nurse upon completion. The aides were supposed to inform nurses if the resident refuses their shower. The nurse would then go to the resident and try to convince the resident to take a shower. If the resident continued to refuse a shower, it should be documented in the medical record. Interview again with LPN #1, on [DATE] at approximately 10:00 AM, revealed Resident #114 received a good shower last evening. She revealed more attention would be given to make sure resident's care plans were implemented as outlined in their individualized care plan. 3. Record review revealed the facility admitted Resident #36 on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Annual Minimum Data Set (MDS), dated [DATE], revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) exam score of three (3) of fifteen (15), and determined the resident to be moderately cognitively impaired. The resident required one person physical assist with mobility and extensive assistance with transfers due to impairment on one side. In addition, the resident was dependent for toileting, hygiene, and requires substantial/maximum assistance with shower/bath. Resident #36 was incontinent of urine. Review of Resident #36's Comprehensive Care Plan (CCP), last reviewed on [DATE], revealed the resident required extensive to dependent care for all Activities of Daily Living (ADL) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to Anoxia and [CONDITION(S)]. Review of Resident #36's CCP, last reviewed on [DATE], revealed the resident required extensive to dependent care for all Activities of Daily Living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to Anoxia and [CONDITION(S)]. The goal of Resident #36 ADL care was to maintain the highest capable level of ADL ability throughout the next review period. Initiated date was [DATE]. Target date was [DATE]. Interventions included providing extensive assist for personal hygiene (grooming), and bathing. Review of Resident #36's CCP, last reviewed on [DATE], revealed the resident was at risk for skin breakdown as evidenced by incontinence, limited mobility, [CONDITION(S)], and cognitive loss and decreased safety awareness, convulsions, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal of Resident #36 interventions were the resident would not show signs of skin breakdown for the next ninety (90) days. Initiated date was [DATE]. Target date was [DATE]. Interventions included applying barrier cream with each cleansing, assist resident with repositioning, observe for localized skin problems, observe for skin risk factors per protocol, observe skin conditions with ADL care, observe skin for signs/symptoms of skin breakdown, provide pericare/incontinence care as needed, perform a weekly skin assessment by a licensed nurse. Observation of Resident #36, on [DATE] at 9:30 AM, revealed the resident to have greasy, uncombed hair. The Resident's had food stuck between his/her teeth and they appeared dirty. Resident #36 reported to SSA Surveyor that he/she was in pain. Resident #36 pointed to the groin area and stated, It hurts and [CONDITION(S)]. Observation noted a strong smell of urine. Resident stated he/she was wet, and the brief under slacks appeared saturated. When asked how often he/she was changed during the day, Resident #36 replied, he/she sat in the wheelchair and was not changed until he/she was put back to bed. SSA Surveyor reported Resident #36's condition to the Unit Manager, LPN #6. Medical Records review, on [DATE] at 11:10 AM, revealed a Skin Assessment was performed after SSA Surveyor alerted nursing staff that the resident was wet and uncomfortable. On [DATE] at 2:12 PM, LPN #9 documented a red fungal rash to vaginal folds. Continued review of medical records revealed a Nursing Note, dated [DATE] at 2:25 PM, for a change in condition (CIC). Review of the CIC notes revealed, LPN #9 assessed Resident #36 as having a rash area covering vaginal labias. The physician was notified and new orders received. Observation, on [DATE] at 4:00 PM, of perineal care on Resident #36, revealed labial area was excoriated with a small amount of thick, white drainage note. Observation on [DATE] at 8:30 AM, revealed Resident #36 sitting in his/her in room in a wheelchair. Resident #36 pointed to his/her groin. Per interview, Resident stated he/she had not been changed. Resident stated he/she was wet. Observation revealed a strong smell of urine and briefs were full. SSA Surveyor asked if the staff changed his/her briefs when asked, he/she replied, Not very much. When asked if staff takes him/her to the bathroom during the day, he/she stated, No. I sit all day. The resident began to cry. Staff came in and changed the resident. Review of the 300 Hall Shower Binder, on [DATE] at 2:50 PM, located at the nurses' station, revealed Resident #36 had only two (2) document shower sheets, dated [DATE] and [DATE]. There was no document evidence Resident #36 received his/her showers as care planned and per facility policy for resident to receive a bath/shower at least twice weekly. Interview with the Unit Clerk, SRNA #11, on [DATE] at 1:50 PM, revealed she did not know why the sheets were not in the book. She stated the nurse was responsible for making sure the shower or bed bath was completed, and should sign each shower sheet when the shower wa completed. She stated aides do a skin check with each change. Continued interview revealed Resident #36 was changed in the morning, per the Care Plan, then changed and repositioned every two (2) hours thereafter on even hours. However, further interview revealed, Resident #36 was placed in his/her wheelchair after breakfast and not changed until after lunch. Interview with SRNA #19, on [DATE] at 3:43 PM, revealed she worked the 300 Unit. She stated the facility was frequently short staffed. Per interview, SRNA #19 stated she did not have enough time on some days to do job. On days when there were not enough aides, she revealed she tried to check and change each residents every two (2) hours. SRNA #19 stated, however, check and change were usually done every three (3) hours. She state aides completed shower sheets, documented skin issues, and reported to the nurse to sign. Continued interview revealed that she would assume it was not done if shower sheet were not in the shower binder. On [DATE] at 2:15 PM,Interview with LPN #9, revealed showers were given every two (2) days. The policy was for the aide to report to the nurse, if a resident refused a shower so the nurse could talk with the resident. If the resident refused a second time, the Unit Manager would speak to and educate the resident on the benefits of taking regular showers. If after a third refusal, the nurse was to document the refusal on the shower sheet, and as a nursing note. LPN #9 stated that was not always the case, and shower sheets were not always completed. Interview with RN #2, Nurse Educator/Wound Care Nurse, on [DATE] at 9:00 AM revealed incontinent residents should be checked and changed every two (2) hours. RN #2 stated the importance of following the Care Plan (CP) was to ensure the Resident was turned minimally every two (2) hours, and if they require, [TRUNCATED]

Based on interview, record review, review of the facility's policy, and review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual Version 3.0, it was determined the facility failed to ensure Comprehensive Care Plans (CCP) were reviewed and revised to address the need for additional interventions to monitor and maintain sufficient respiratory status for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110, on [DATE] with current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #110 had been hospitalized , from [DATE] to [DATE] with [CONDITION(S)] and Acute Respiratory Failure. In addition, Resident #110 had been sent to the hospital Emergency Department (ED), on [DATE], for [CONDITION(S)] and was returned to the facility five (5) hours later, on [DATE]. However, there was no documented evidence the facility identified the resident's risks and revised the Comprehensive Care Plan (CCP) to give direction for staff to monitor and maintain sufficient respiratory status for the resident. On [DATE], Resident #110 experienced a change in condition (CIC) with his/her respiratory status. Resident #110 was transferred to the hospital's ED (Emergency Department), on [DATE] at 5:52 PM, via Emergency Medical Services (EMS) and was admitted . Resident #110 presented to the ED in pain, lethargic and moaning with diminished lung sounds bilaterally (both sides), bilateral upper and lower extremity swelling and [CONDITION(S)], febrile, and with an altered mental status. Resident #110 returned to the facility under Hospice Care, on [DATE], and expired on [DATE]. The facility's failure to revise the resident's care plan to address the resident's respiratory status has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE] in the area of 42 CFR 483.21(b)(2) Comprehensive Resident Centered Care Plans, Timing and Revision of Care Plans, and was determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Refer to F695 The findings include: Review of the facility's policy titled, Person-Centered Care Plan, revised [DATE], revealed Comprehensive Care Plans were developed to help the resident attain or maintain his/her highest practicable physical, mental and psychosocial well-being and included measurable objectives and timetables to meet a resident's medical, nursing, nutrition, and mental and psychosocial needs that were identified in the comprehensive assessments. Review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, dated [DATE], revealed the care plan must be reviewed and revised periodically, and the services provided or arranged should be consistent with each resident's written plan of care. Continued review of the manual, revealed the care plan was driven, not only by identified resident issues and/or conditions, but also by a resident's unique characteristics, strengths, and needs. Furthermore, a care plan, based on a thorough assessment and effective clinical decision making, was compatible with current standards of clinical practice that provided a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. The manual stated a well-developed and executed assessment and care plan re-evaluated the resident's status at prescribed intervals (quarterly, annually, or if a significant change in status occurred) using the RAI and then modified the individualized care plan as appropriate and necessary. Record review revealed the facility admitted Resident #110 on [DATE]. The resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed, Resident #110 had been hospitalized , from [DATE] to [DATE], with [CONDITION(S)] and Acute Respiratory Failure. Review of Resident #110's CCP, initiated on [DATE], revealed a focus of the resident was at risk for the potential alteration in fluid balance and he/she was at risk for fluid volume excess because of Heart Failure and Chronic Kidney Disease. The goal revealed the resident would not experience any signs/symptoms of fluid overload as evidenced by the absence of peripheral [CONDITION(S)] and dyspnea. Continued review of the CCP revealed interventions, initiated on [DATE], included staff was to observe for symptoms of [CONDITION(S)], shortness of air (SOA) and weight gain. Further review revealed the CCP was not revised when the resident experienced a change in condition on [DATE]. Continued review of Resident #110's CCP, initiated on [DATE], revealed the resident was at risk for complications related to OSA, [CONDITION(S)], Asthma, and Dysphagia. The goal stated the resident would not have sign/symptoms of respiratory distress or aspiration. Further review of the CCP revealed some interventions were to administer aerosol medications as ordered/indicated; administer [CONDITION(S)] as ordered; observe and report SpO2 (blood oxygen saturation) levels via pulse oximetry as ordered and as needed; and observe respiratory rate, signs/symptoms of dyspnea, abnormal breath sounds, cyanosis, and use of accessory muscles. Review of Resident #110's hospital records, dated [DATE], revealed the resident was admitted to the hospital, on [DATE], for [CONDITION(S)] and acute respiratory failure. Resident #110 was discharged from the hospital and returned to the facility on [DATE]. However, there was no documented evidence the CCP was revised to address the resident's respiratory status. Further review of Resident #110's medical record revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the record showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview with Resident #110, on [DATE] at 9:20 AM, revealed the resident in bed lying on his/her left side with his/her heels pressed against the mattress. There was generalized [CONDITION(S)] observed over the lower extremities, bilateral hands, and upper extremities; the left hand had an indentation where it rested against the bed. Further observation revealed the resident was on two (2) liters/minute of oxygen via nasal cannula, but the oxygen tubing was not labeled with a date or initialed. Additional observation showed the resident's [CONDITION(S)] mask and tubing were on the floor. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110 was in no respiratory distress throughout the evening of [DATE], until about 5:30 AM on [DATE]. Continued interview revealed at 6:30 AM, a State Registered Nurse Aide (SRNA) observed the resident with thick phlegm coming from the mouth. RN #3 stated she notified the Physician. Per interview, the Physician examined the resident that morning and ordered lab work and a chest x-ray. Further interview revealed she did not update the care plan, and she left for the day. However, she stated any licensed nurse could update care plans. RN #3 stated the care plan should have been revised to include increased monitoring for Resident #110 when he/she had the change of condition. Interview with the Physician, on [DATE] at 10:12 AM, revealed he examined Resident #110 on the morning of [DATE]. Per interview, he assessed the resident with fluid overload caused by his/her recent intravenous (IV) antibiotic therapy, and it was his intent to [MEDICATION(S)] (remove fluid) the resident. The Physician stated he gave a verbal order to the Director of Nursing (DON) directly to place an indwelling catheter, give one (1) dose of [MEDICATION(S)] (a diuretic used to remove excess fluid from the body) sixty (60) mg IV (intravenous), monitor lung sounds, and document strict I&O's (fluid intake and output). The Physician stated he gave the order specifically to the DON because, as an RN (Registered Nurse), she was the only nurse in the building, who could push IV [MEDICATION(S)]. Additionally, he stated he ordered strict I&O's and the monitoring of the resident's lung sounds to assess the resident's response to the treatment. However review of the resident's CCP revealed no documented evidence the care plan was revised to reflect these new orders. Continued review of Resident #110's Nursing Progress Note, dated [DATE] at 3:09 PM, revealed the first CIC follow-up note by LPN #9. The note stated the resident's condition had declined, and the Physician was notified. Furthermore, the note stated new orders were received to continue to hold PO (oral) medications, insert a Foley catheter for strict I&O's, and provide comfort care; there was not a specific time given for receipt of the orders. However, the resident's CCP was not revised to reflect these changes to the resident's plan of care. Interview with Agency State Registered Nurse Aide (SRNA) #21, on [DATE] at 3:04 PM, revealed she was assigned to Resident #110 on [DATE]. Per interview, she stated that when she cared for the resident, he/she was crying and complained of having no air (SOA). Per interview, SRNA #21 stated she reported this to the nurse, but did not recall if the nurse assessed the resident. She further stated no one made her aware of any revisions to the resident's care plan. She stated all she knew was the resident was sent to the hospital later that day. Review of Resident #110's Hospital ED Admitting Physician Note, dated [DATE], revealed the resident arrived at the ED in pain, lethargic, did not move his/her extremities, and moaned with discomfort. Resident #110 was admitted to the hospital with diminished lung sounds bilaterally (both sides), bilateral upper and lower extremity swelling and [CONDITION(S)], febrile, and with an altered mental status. Resident #110 returned to the facility under Hospice Care, on [DATE], and expired on [DATE]. Interview with LPN #9, on [DATE] at 8:15 AM, revealed she was assigned to Resident #110, on [DATE] from 6:00 AM to 6:00 PM. She stated the resident was noted to have a CIC during the night shift, which was documented and reported to her at shift change. LPN # 9 stated she was up and down the hall ensuring the resident was responsive, and she monitored his/her vital signs throughout the day. However, she stated she did not revise the care plan to include increased monitoring and to include strict intake and outputs, as ordered by the Physician. She further stated she should have updated the care plan, so Resident #110 could obtain the best possible outcome and so all staff would know how to care for the resident. Telephone Interview with the Minimum Data Set (MDS) Coordinator, [DATE] at 4:20 PM, revealed every nurse had the ability to access and update the CCP, and she would expect to see updates on acute changes as they happened. Interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on [DATE] at 10:00 AM, revealed she was made aware of the change of condition with Resident #110 on the morning of [DATE]. She stated she expected the care plans to be revised according to the resident's condition to prevent further decline. She further stated the care plans must be accurate in order for all staff to know what care needs were to be provided. Interview with the DON, on [DATE] at 9:15 AM, revealed it was her expectation that nursing staff provide the correct level of care per the care plan and as ordered by the Physician. Per interview, it was the DON's expectation that nurses did resident assessments and charted accordingly. She further stated it was her expectation for the care plans to be revised to reflect the resident's plan of care. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 3:40 PM, revealed it was her expectation that care plans were updated, when there was a CIC. Furthermore, nursing staff was to assess the resident as ordered and as in the CCP. Interview with the Administrator, on [DATE] at 2:15 PM, revealed it was her expectation for care plans to be revised when there was a change of condition. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. Newly hired staff and contracted staff were to be provided education and post-test during orientation by the DON, ADON, CQS, NPE, UM, and/or Licensed Nurse (LN). 4. Starting [DATE], clinical observation rounds will be conducted every shift, including interviews of ten (10) staff and five (5) residents who receive pain medication to identify any change in condition including a change in pain by the DON, ADON, UM, NPE, or LN to determine if residents have experienced a change in condition regarding pain. The Physician/NP were notified and the plan of care was reviewed to ensure it reflected the current needs of the resident daily until the Immediate Jeopardy is abated. 5. Starting [DATE], the Center Executive Director (CED) and/or LN would conduct ten (10) employee questionnaires daily to determine if staff were aware of the Center's process of the Stop and Watch Tool and reporting a change in condition, including reporting resident pain to a licensed nurse, to ensure prompt interventions when a resident experienced a change in condition, until the Immediate Jeopardy is abated. 6. The results of the observations, interviews, and audits will be reviewed daily by the CED or DON corrective actions taken upon discovery of deficiencies. 7. Beginning on [DATE], the DON, UM, ADON, NPE, CQS, and/or LNs initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition. 8. All admissions, readmissions, and residents with changes in respiratory status since [DATE] were reviewed on [DATE] by the DON, ADON, NPE, UM, and or LNs to determine if care plans reflected patient specific interventions to include interventions to monitor respiratory status to include residents with sleep apnea, [CONDITION(S)], acute respiratory failure, and asthma. Areas of concern were corrected upon discovery. 9. On [DATE], the DON, UM, ADON, NPE and or CQS initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Revision of the care plan with all admissions, readmissions, and changes in respiratory status with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A post-test was administered at the time of the reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Licensed Nursing and Agency Licensed Nursing Staff not available will be provided reeducation, including a post-test, by the DON, UM, ADON, NPE, and/or Registered Nurse upon day of return to work before providing care. New licensed nursing hires and agency licensed nurses will be provided education and post-test during orientation by the DON, ADON, NPE and/or UM. 10. Care plan audits were completed for residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. Five (5) Licensed Nursing Staff interviews were completed by the CED, DON, UM, ADON, NPE, and/or CQS to determine if staff were aware of the process of a respiratory assessment when a resident's condition warranted the assessment and per the resident's plan of care will be conducted daily until the Immediate Jeopardy is abated. 12. The DON, UM, ADON, NPE, and/or CQS completed reeducation beginning on [DATE] with facility licensed staff to include agency staff on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plans with individualized person-centered interventions to include monitoring pain, administering pain medications as ordered, and utilizing and documenting pain scale assessments, and observe for non-verbal signs/symptoms of pain. A medication reconciliation process is in place to review discharge orders to current orders; (B) Physician/Mid-Level Provider Notification of Change in a resident's condition; and (C) Person Centered care plans regarding resident interventions for pain. A post-test was administered at the time of reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and or CQS to validate understanding. Facility licensed staff and agency staff not available will be provided reeducation including a post-test during orientation by the DON, ADON, NPE, UM, and/or LN, before allowed to work. 13. The CED and/or LN will conduct five (5) employee questionnaires daily to determine if staff were aware of the Center's process of reporting a change in condition including pain to a licensed nurse to ensure prompt intervention when a resident experienced a change in condition until Immediate Jeopardy is abated. 14. The UM's, ADON, NPE, and licensed nurses completed skin assessments on all residents on [DATE], to ensure residents, including residents with pressure ulcers, received care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 15. The CQS reeducated the Wound Nurse regarding the facility's policy, Wound Care, on [DATE]. A post-test was administered at the time of the reeducation to validate understanding. 16. The NPE, DON, UM's, and/or ADON reeducated all licensed staff, including agency staff, regarding the requirement that residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers, to include appropriate assessment of all wounds when a wound/abscess was identified, beginning on [DATE], with a posttest requiring 100% score to validate understanding. 17. The DON, ADON, NPE or UM will conduct observation rounds and treatment administration audits to ensure residents with pressure ulcers receive care to promote healing and prevent additional pressure ulcers as per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 18. Quality Assurance/Performance Improvement (QAPI) meetings are occurring daily (Monday-Friday) beginning [DATE] with the interdisciplinary team, which consists of the CED, DOB, ADON, NPE, UM's, MDS, Dietary Manager, Social Services, Business Office Manager, Environmental Services, Medical Records, Maintenance, Human Resources, Registered Dietician, Activities Director, Central Supply, and Director of Rehabilitation, until Immediate Jeopardy is abated. During QAPI meetings, the current status of the AoC is discussed, including review of the audit tools, findings, and any needed corrective action. The State Survey Agency validated the implementation of the facility's AoC as follows: 1. Review of the facility's audit tool revealed the audits were reviewed, with all residents present as of [DATE]. Audits were conducted to determine the presence of pain, and the effectiveness of any pain medications ordered. Record review revealed nineteen (19) residents were identified with pain concerns, with most concerns identified consisting of pain medications not being effective, or not being effective for the length of time until the next dosage of pain medication was available. All of this information was emailed to the Nurse Practitioner (NP) by the CQS. Review of residents' medical records for residents identified, revealed residents had been reassessed by either the Physician or NP, with new orders provided as appropriate. 2. Review of nineteen (19) residents with identified pain issues revealed residents identified had been reassessed on [DATE] by the DON, UMs and/or Licensed Nurse (LN) to determine if a change in condition had occurred regarding pain. Interview with the NPE, on [DATE] at 1:30 PM, revealed, based on audits conducted by [DATE]; nineteen (19) residents were identified with pain issues. She revealed all residents had been reassessed, and staff were documenting changes in resident condition in nursing notes regarding effectiveness of pain medications. 3. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all facility staff were educated in person or over the phone regarding: (A) Change in condition; (B) Pain management; (C) Stop and Watch Tool; (D) Provider notification of change; and (E) Person-centered care plans. Review of documents titled Post Test, revealed staff completed testing covering all identified areas, to include changes in resident condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with Admissions personnel, on [DATE] at 8:20 AM, revealed she had been educated to monitor residents for any new or worsening pain or any change in activity or changes in resident condition, the resident care plan. Admissions personnel was to report to the nurse and DON. She stated she was in-serviced on the use of the Stop and Watch tool. Interview with Laundry personnel, on [DATE] at 8:30 AM, revealed Laundry staff had been educated to monitor residents for pain or change in condition and to notify the nurse if any occurs. Laundry staff was to observe for any lack of care for the residents. Per interview Laundry personnel were in-serviced on the Stop and Watch tool. Interview with Physical Therapy Assistant (PTA) #1, on [DATE] at 8:15 AM, revealed PTA#1 had been educated to monitor for new or worsening pain and if a resident was participating less in activities or had a change in condition to report this to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool. PTA #1 completed a posttest after the training. Interview with SRNA #8, on [DATE] at 8:35 AM and SRNA #27 at 8:45 AM, SRNA #25 at 8:50 AM and SRNA #28 at 9:00 AM revealed education was provided to monitor for any new or worsening pain, change in condition and the appropriate use of the resident's care plan. Any change was to be reported immediately to the nurse. Per interview, they had been in-serviced on the Stop and Watch tool and had taken a posttest after the education. Interview with the Activities Director on [DATE] at 3:40 PM revealed she had been educated in the Stop and Watch tool and the importance of the resident's care plan. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. 4. Review of AoC Audit Tool - [DATE], dated [DATE] through [DATE], revealed the facility was conducting observation rounds of ten (10) staff and five (5) residents every shift. Continued review revealed residents were interviewed to ensure they were receiving pain medications, with any changes in condition noted, assessments completed, notifications made as appropriate, and care plans updated as appropriate. Review of the staff portion for licensed staff revealed licensed staff were interviewed regarding the process for respiratory treatment, the process for reporting changes in condition, awareness of notification of the Physician or NP regarding resident pain issues and awareness of the care plan reflecting resident needs. Review of the staff portion for non-licensed staff revealed they were interviewed regarding awareness of the Stop and Watch Tool reporting of changes in resident condition regarding pain, respiratory status, or skin issues. Interview with RN #4 on [DATE] at 12:00 PM revealed she had audited nineteen (19) residents with pain. A tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. Interview with SRNA #8, on [DATE] at 8:35 AM, revealed education was done to monitor for any new or worsening pain or change in condition. Any change was to be reported immediately to the nurse. Per interview, she had been questioned during management rounds related to monitoring for pain and reporting to nursing staff. Interview with the Activities Director, on [DATE] at 3:40 PM, revealed she had been educated in the 'Stop and Watch' tool. She stated she was to watch for any new or worsening pain, or if a resident was participating less in activities. She stated she was to document and notify the nurse. Per interview, she had been asked during management rounds regarding awareness of the Stop and Watch Tool. 5. Review of the facility's AoC binders revealed completed documentation labeled F580 Test 2 All Staff except LN, completed by facility staff covering topics such as the Stop and Watch Tool, changes in resident condition, and person-centered resident care. 6. Interview with the DON, on [DATE] at 9:18 AM, revealed she reviewed the results of observations, interviews, and audits daily, and she ensured there was additional follow-up as needed. She stated audits had increased staff education and were helping management ensure staff followed-up with everything. She stated management had identified a need for staff improvement on documentation. 7. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed Licensed Nurses attended or were educated in person or over the phone regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition, Review of documents titled Post Test revealed licensed nursing staff completed testing covering all identified areas, to include changes in residents' condition, management of resident pain, Stop and Watch Tool, provider notification of change, and person-centered care plans. Interview with LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated to watch for any new or worsening pain, to implement a person centered care plan with individualized interventions, administer pain medications as ordered using the pain scale, pressure ulcers monitor and treatment and to notify the practitioner with all changes in resident conditions. Per interviews, a posttest to acknowledge understanding of the education was given. Interview with RN #4 on [DATE] at 12:00 PM revealed a tool called 'Stop and Watch' was used to educate staff on pain. All staff were educated and all tours of duty were included to assure no staff were missed. The education is to be ongoing. Staff were educated to be transparent and use open communication. RN#4 reported all staff were educated on notifying the practitioner if a resident was experiencing pain. For chronic pain, interventions were to be implemented. 8. Review of the facility's documentation revealed the NPE reviewed all residents on [DATE] that had been admitted , readmitted , or that had been identified with changes in respiratory status. The NPE identified any changes since [DATE], and ensured care plan changes were implemented as necessary. Interview with the NPE, on [DATE] at 1:30 PM, revealed she did review all residents on [DATE] that had been admitted , readmitted or identified with changes in respiratory status. 9. Review of the facility's In-Service Sign In Sheets, dated [DATE] through [DATE], revealed all licensed nurses, to include agency nurses, were educated in person or over the phone regarding revision of resident care plans for all admissions, readmissions, and changes in respiratory status for residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Clinical Competency Validation Respiratory Assessment, revealed licensed nursing staff completed testing following education. Interview with RN #4 on [DATE], LPN #17, on [DATE] at 8:49 AM and with LPN #10 on [DATE] at 8:05 AM, LPN #3 at 9:05 AM and LPN #6 at 9:10 AM, revealed they had been educated related to the revision of the resident care plan for all admissions, readmissions and changes in respiratory status for residents. Per interviews, a posttest to acknowledge understanding of the education was given. 10. Review of the AoC Audit Tool - [DATE], revealed care plan audits were conducted on new admissions, readmissions, and change in conditio [TRUNCATED]

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure the discharge summary process included reconciliation of all pre-discharge medications with the resident's post-discharge medications, both prescription and over-the-counter, and the resident was discharged with the correct medications for one (1) of thirty (30) sampled residents (Resident #81). The facility admitted Resident #81, on 03/12/2021, for short-term rehabilitation. On 05/05/2021, the Physician ordered to discharge Resident #81 home with medications. Licensed Practical Nurse (LPN) #3, Resident #81's nurse, reviewed the Discharge Instructions/Summary with Resident #81, and sent his/her medications from the medication cart home with the resident on 05/05/2021. On 05/07/2021, Resident #81 informed a family member that the medications he/she received from the facility at discharge included a medication that he/she did not take, [MEDICATION(S)] (an antipsychotic used to treat [CONDITION(S)] and other psychiatric disorders). The resident sent the family member a picture of a medication box that was labeled [MEDICATION(S)] 0.25 milligram (mg), with Resident #80's name on it. Resident #81 stated he/she took two (2) doses of [MEDICATION(S)] 0.25 mg and experienced lethargy, mental status changes, dizziness, and difficulty with memory after taking the medication. The facility's Pharmacist stated the medication, [MEDICATION(S)] (generic name [MEDICATION(S)]) could pose a moderate risk of interaction with the other prescribed medications for Resident #81. Resident #81's Attending Physician stated Resident #81 was a high-risk resident, and if the [MEDICATION(S)] had been taken at a higher dosage than 0.25 milligrams per day, it could cause increased sedation and a heart arrhythmia. The facility's failure to have an effective system in place to ensure each resident received the correct medications during medication reconciliation in the discharge summary process has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified, in the area of 42 CFR 483.21(c)(2) Comprehensive Resident Centered Care Plan, Discharge Summary, on 05/14/2021 and was determined to exist on 05/05/2021 and is ongoing. The findings include: Review of the facility's policy titled, Discharge Planning Process, review date 02/01/2019, revealed the discharge summary should include a reconciliation of all pre-discharge medications with the patient's (resident's) post-discharge medications (both prescription and over-the-counter). No further details were found in the policy regarding medication reconciliation. Review of Resident #81's medical record revealed the resident was admitted to the facility, on 03/12/2021, for short-term rehabilitation upon discharge from an acute care hospital episode for Alcoholic [CONDITION(S)] with Ascites, Generalized Weakness, Difficulty with Walking, and Chronic Pancreatitis. Review of Resident #81's initial Minimum Data Set (MDS) Assessment, dated 03/18/2021, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) out of fifteen (15), indicating the resident was cognitively intact. Review of Resident #81's initial care plan indicated the need for assistance with Activities of Daily Living (ADLs) including bathing, grooming, personal hygiene, dressing, transfers, locomotion and toileting related to a recent hospitalization resulting in fatigue. Discharge documents showed the need for a rolling walker for ambulation and independence in all ADLs. Further review of the record revealed initial medication orders, dated 03/12/2021, as well as changes to the orders, as indicated, throughout the course of Resident #81's stay at the facility. However, the record revealed no order for [MEDICATION(S)] at any time during the course of care for Resident #81. In addition, the record revealed the Physician ordered Resident #81 to be discharged home with medications, on 05/05/2021. Continued review revealed the resident was discharged per the order by LPN #3. However, there was no documented evidence of specific reconciliation of medications on the Order Summary, which was supposed to include all discharge medications and directions for administration. Further, the paper copies of Resident #81's record, kept in the hardback chart at the Nurse's Station revealed an Order Summary, including the form Medication List, but the form was blank. There was no documented list of Resident #81's discharge medications for review. Interview with Resident #81's Family Member, on 05/11/2021 at 2:12 PM, revealed, on 05/07/2021, Resident #81 called to inform her that he/she had discovered a medication box that was given to him/her from the facility. The Family Member stated Resident #81 told her the box contained a medication that was not ordered for him/her. She stated the box had thirty (30) pills of [MEDICATION(S)] 0.25 mg, take one (1) tablet daily. In addition, the resident told the Family Member the box was labeled with Resident #80's name, and he/she had taken two (2) doses. She stated Resident #81 reported to her that after taking the [MEDICATION(S)] tablets, he/she was feeling lethargic, had mental status changes, dizziness, difficulty with memory, some disorientation, and was very upset because he/she could not process thoughts or finish a sentence. The Family Member stated Resident #81 felt so bad that he/she was not able to visit with her, on 05/07/2021 or 05/08/2021; and, the resident was scheduled to see his/her primary care provider, on 05/11/2021 or 05/12/2021. Per interview, Resident #81 took photos of the medication box labeled with Resident #80's name and forwarded it to her. The Family Member stated she verified the picture of the medication box in Resident #81's possession that had Resident #80's name and was labeled [MEDICATION(S)] 0.25 mg, take one (1) tablet daily. Review of Resident #80's medical record revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with LPN #3, on 05/12/2021 at 10:20 AM, revealed when a nurse discharged a resident, they sent what was in the resident's medication drawer with the resident. LPN #3 stated the actual medication boxes were sent home with the resident. Further interview revealed the face sheet and medication list were printed, and the nurse used them to instruct the resident on the discharge medications prior to his/her departure. Additional interview with LPN #3, on 05/12/2021 at 4:00 PM, revealed she discharged Resident #81, sometime after 10:00 AM on 05/05/2021. LPN #3 stated she and Resident #81 went over the medication list together with education on his/her medications. She stated, for Resident #81, she printed the facesheet and the order summary, which included all of the resident's medications and how to take them. LPN #3 stated she had been over the whole process in her memory and did not know how Resident #81 received Resident #80's medication, other than human error. She also stated that prior to Covid, the Pharmacy came through at regular intervals and reviewed all medications and stocked the medication carts. However, with current Covid restrictions, LPN #3 stated Pharmacy depended on nursing to report medication needs. Continued interview on 05/12/2021 at 4:00 PM, with LPN #3 revealed since Resident #80 was transferred from another unit in the facility, there initially must have been enough medications from his/her previous order to provide the [MEDICATION(S)] he/she was ordered. Review of the medication cart showed a newly delivered box of [MEDICATION(S)] ([MEDICATION(S)]) as of 05/12/2021 for Resident #80. Interview with LPN #2, on 05/12/2021 at 10:00 AM, revealed that a resident who was to be discharged received a discharge summary with upcoming appointments, a printed medication list, and a summary of care at the facility. He/she stated, We are allowed to send any non-narcotic medications home with the resident and, narcotics if there was a specific order for it. The resident would be asked about pain medication availability already at home. Residents are discharged with medications in the original boxes. Telephone interview with the Pharmacist in charge, on 05/13/2021 at 9:09 AM, revealed that the Pharmacy was not involved with discharge medications. The Pharmacist stated additional drowsiness, lethargy, and inability to concentrate would be likely side effects of [MEDICATION(S)] use, in combination with Resident #81's own medication regimen and/or heavy alcohol use. Interview with Resident #81's Attending Physician, on 05/13/2021 at 1:20 PM, revealed he was not knowledgeable of the discharge process, but he expected the process to be managed safely, which included sending the correct discharge medications home with the resident. The Physician stated Resident #81 was a high risk for medication administration due to potential side effects; consequently, he stated he always weighed the risk of the medication versus the benefit before prescribing medications for Resident #81. In addition, the Physician stated there would probably be no serious adverse reactions from Resident #81 taking [MEDICATION(S)], with his/her other medications, if he/she only took it for two (2) days as reported, but if it were taken longer or abused, there could be increased lethargy and even a heart arrhythmia (abnormal heart rhythm). Interview with the Director of Nursing (DON), on 05/14/2021 at 9:18 AM, revealed with a resident to be discharged , the nurse would go over information about his/her care needs and what medications went home with the resident; the resident would receive whatever medications the doctor ordered. In addition, the resident signed the care summary and a copy went in the hard chart. Per interview, with medication reconciliation, she expected the nurse to compare the written list, prescription by prescription, with the actual medications to be sent home. She stated the facility followed these recommendations from Pharmacy about how the nursing staff should manage the discharge process for medications. The DON stated, in the incident with Resident #81 where an incorrect medication was sent home with the resident, the only answer she had was it involved human error. Furthermore, she stated the discharge education given to a resident was computer generated and was based on previously entered information for the resident. Interview with the Administrator, on 05/12/2021 at 2:20 PM, revealed she expected at discharge, the nurse would provide a list of medications and would go over those with the resident prior to discharge. She stated there should be printed copies, one (1) given to the resident, and one (1) placed in the resident's hard copy chart. The Administrator stated the nurse would gather the resident's medications and give them to the resident at departure. She further stated that medications were supposed to be in order in the medication cart by resident room, and she expected each resident's medications to be in the correct slot. In addition, the Administrator stated she expected nurses to reconcile the physical medication with the printed list.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure skin assessments were completed to identify/monitor for skin breakdown along pressure ulcer prevention interventions according to standards of practice to prevent further decline for one (1) of thirty (30) sampled residents, Resident #110. On [DATE], Resident #110 was transferred to the hospital by Emergency Medical Services (EMS) and during the triage period hospital staff and EMS identified a sacral wound. The hospital assessed the resident to have an open right gluteal abscess measuring three (3.0) centimeters (cm) and draining copious amounts of purulent material. There was an unstageable sacral decubitus ulcer measuring eight (8.0) cm (length) by two (2.0) cm (width). Surgical consult revealed the abscess and sacral ulcer would require surgical debridement of necrotic tissue. Review of Infectious Disease (ID) Consult, on [DATE], revealed ID was consulted for evaluation of [CONDITION(S)] and antibiotic management. Possible causes for the infectious etiology included Bacteremia and soft tissue infection from right buttocks ulcer. A Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infections. Wound culture of right buttock showing gram negative rods. Review of the facility's Skin Assessment Grids, revealed the Wound Nurse assessed Resident #110's wounds on [DATE] and identified a new Right Hip/Buttock Abscess that measured 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. However, interview and record review revealed the Wound Nurse nor other nursing staff had not identified the unstageable sacral decubitus ulcer that was assessed and identified during hospital triage. Review of the Acute Care Hospital record, dated [DATE], revealed a palliative care (treatment focused on prevention of suffering and improving quality of life) consult was requested on [DATE]. Continued review revealed the provider noted, Patient has no quality of life. Review of the Nurses Notes, dated [DATE], revealed the resident was readmitted back to the facility under Hospice Care, on [DATE], and later expired on [DATE]. The facility's failure to provide care consistent with professional standards of practice, to care for and prevent pressure ulcers has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE], in the area of 42 CFR 483.25(b)(1) Quality of Care, Treatment/Services to Prevent/Heal Pressure Ulcers, and were determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Skin Integrity Management revised on [DATE], revealed the purpose was to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Per the policy, staff was to continually observe and monitor residents for changes and implement revisions to the plan of care. Nursing staff was to follow Standards of Practice, which included: 1) Review pre-admission information to plan for resident's needs; 2) Complete comprehensive evaluation of the resident upon admission/readmission; 3) Identify resident's skin integrity status and need for prevention interventions or treatment modalities through review of all assessment information; 4) Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated; 5) Review co-morbid conditions that may affect healing; 6) Notify Dietician and Rehabilitation Services as indicated; 7) Notify Physician/Advance Practice Provider (APP); Review care plan weekly and revise as indicated; 8) Document daily monitoring of ulcer site, with or without dressing. Daily monitoring should include status of dressing, status of tissue surrounding dressing, and adequate control of wound pain. On [DATE] at 9:05 AM, observation of Resident #110, revealed the resident yelled for a nurse, moaned and groaned as if in pain. Further observation revealed the resident was lying flat on his/her back, no pillow under the right arm, as per the care plan. In addition, the resident did not have the care planned boots on his/her feet, the residents' hands had contractures, and the resident was unable to use the call light related to his/her contractures. Per observation, the resident showed non-verbal cues of pain with grimacing. No one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. Further observation revealed the resident smelled of the strong odor of urine. Observation of Resident #110, on [DATE] at 1:15 PM, approximately four (4) hours later, revealed the resident lying in the same position as earlier, however there was a pillow under his/her right arm. Interview with Resident #110, on [DATE] at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility since the last readmission, on [DATE], he/she had not received pain medication as needed. Further interview revealed, the resident stated I am miserable and I hurt all the time. Per interview, the resident stated when he/she told the nurse he/she was in pain, no one would help him/her. Resident #110 stated he/she was unable to turn and reposition related to the amount of pain he/she was experiencing. He/she was unaware of the last time he/she had been changed and stated he/she was wet and smelled. The resident further stated it hurt to be touched. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110 used to get showers, and now, she was unaware of the last shower the resident had taken. She stated the resident refused showers because he/she was in too much pain to move. Interview with LPN #13, on [DATE] at 3:55 PM, revealed she cared for Resident #110. She stated the facility policy was to check User Defined Assessments (UDA) in the Electronic Health Record (EHR), which directed/prompted nursing staff when to assess residents. LPN #13 stated nurses charted by exception, except with change in condition. She stated UDA had a Change in Condition/Situation, Background, Assessment, and Recommendation (CIC/SBAR) alert, which prompted the user to follow-up. She stated some sections of the EHR would not allow for free-hand charting, but nursing could use the progress note section. LPN #13 stated it was important to do resident assessments and document to ensure quality care. Interview with LPN #11, on [DATE] at 8:49 AM, revealed resident weekly skin assessments were assigned to each nurse. She stated the nurses routinely has two (2) to three (3) assessments per shift. Skin assessments were documented in the medical record. Further interview revealed, the Wound Care physician came weekly and reviewed findings. She stated staff looked for skin issues during routine care and showers/baths. Further interview revealed Resident #110 was being followed by Wound Care every week for skin issues. Record review revealed the facility admitted Resident #110 on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Social Services Assessment, dated [DATE], revealed Resident #110 scored an eleven (11) on the Brief Interview for Mental Status (BIMS) evaluation. Further review revealed the resident was able to express ideas and wants and was able to understand verbal content. Review of the Quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed the facility assessed Resident #110's Functional Abilities as needing substantial/maximal assistance. Resident was dependent on staff to roll left and right in the bed. Further review revealed the resident had one (1) Stage 2 ulcer, one (1) venous and arterial ulcer, and was receiving pressure ulcer/injury care. Review of the Braden Scale for Predicting Pressure Sore Risk, dated [DATE], revealed the facility assessed Resident #110 to be a severe risk for skin breakdown, with a score of eight (8). Review of the Comprehensive Care Plan (CCP), last updated [DATE], revealed Resident #110 was at risk for skin breakdown as evidenced by moisture/excessive perspiration limited mobility, Diabetes, Peripheral Vascular Disease, incontinence of bowel and bladder, medications, history of pressure ulcers, obesity, [CONDITION(S)], arterial ulcer to right second digit. The goals were to show no signs of further skin breakdown. Further review revealed interventions directed staff to apply barrier cream with each cleansing, assist with methods of reducing friction and shear, assist the resident with turning and repositioning every two (2) hours as tolerated. In addition, staff were to float resident's heels while in bed as tolerated, provide a low air loss (LAL) mattress to bed, perform Norton/Braden assessments per policy, observe skin risk factors per protocol, and observe for localized skin problems. Further review revealed, Resident #110 was at risk for skin breakdown or had actual skin breakdown. The healing goals were: 1) the resident would remain free of skin tear and bruising; 3) show no signs of skin breakdown; 3) the skin tear/bruise would heal; and 4) the wound/skin impairment would heal. Further review revealed interventions to pat skin when drying, provide treatment to skin tear per physician order, observe for signs of infection, assist resident with turning and repositioning, observe skin for signs/symptoms of skin breakdown, evaluate localized skin problems, utilize devices to assist with turning/positioning to reduce friction and shear, weekly skin assessments by licensed nurse, weekly wound assessment to include measurements and description of wound, and provide wound related pain management intervention (i.e. pre-medicate). Continued review of the CCP, last updated [DATE], revealed Resident #110 was incontinent of urine and was unable to participate cognitively or physically in a retraining program. The goals were to have incontinence care needs met by staff to maintain dignity and comfort, and to prevent incontinence related complications. Further review revealed interventions were to check and change every two (2) hours and as needed (PRN), observe for skin redness/irritation and report as indicated, observe for odor, color, consistency, and amount, use absorbent products PRN. Review of the Specialty Physician's Wound Evaluation and Management Summary, revealed the Wound Physician assessed Resident #110's wounds, on [DATE], and it identified a shear wound to the Right Buttock which measured 0.2 cm (length) by 0.3 cm (width) by 0.2 cm (depth), with light serous exudate, twenty percent (20%) slough, one hundred percent (100%) granulation tissue. Abnormal granulation present within wound margins. Wound progress improved. The summary stated to apply a Primary dressing and [MEDICATION(S)] once daily for thirty (30) days; Secondary dressing - apply gauze island once daily for sixteen (16) days; Apply House barrier cream to Peri-wound three (3) times daily for twenty-three (23) days. Off-load wound; reposition per facility protocol; turn side to side and front to back in bed every one to two hours if able. Review of the Specialty Physician's Wound Evaluation and Management Summary, revealed the Wound Physician assessed Resident #110's wounds, on [DATE], and it identified a shear wound to the Right Buttock - 0.4 cm (length) by 0.6 cm (width) by 0.2 cm (depth), with light serous exudate, twenty percent (20%) slough, eighty percent (80%) granulation tissue. Wound progress deteriorated. Treatment: Primary dressing - [MEDICATION(S)] apply once daily for twenty (23) days; Secondary dressing - apply gauze island once daily for nine (9) days; Apply House barrier cream to Peri-wound three (3) times daily for sixteen (16) days. Off-load wound; reposition per facility protocol; turn side to side and front to back in bed every ,d+[DATE] hours if able. Review of the Specialty Physician's Wound Evaluation and Progress Note, revealed the [DATE] visit was rescheduled. Review of the Specialty Physician's Progress Note, revealed the [DATE] visit was rescheduled due to Resident #110 hospitalization unrelated to wounds. Review of a Nursing Note, dated [DATE] at 5:27 PM, revealed Resident #110 was readmitted to the facility after a hospitalization for [CONDITION(S)] and Acute Respiratory Failure, from [DATE] to [DATE]. Review of skin check, dated [DATE], revealed the nurse identified the following skin injury/wounds: Mild bruising from intravenous (IV) to right upper chest and hands from hospital stay. Other wounds included an old, healed right buttocks scar; and scab areas to toes on right foot. No further descriptions were documented. Review of a Change in Condition (CIC) note, dated [DATE] at 1:35 AM, revealed a skin check was performed and noted the previously identified right buttock wound with treatment in place. The note did not include a description of the wound or surrounding tissue. However, the CIC note did include new orders to apply Z-Guard. Review of the Specialty Physician's Wound Evaluation and Management Summary, revealed the Wound Physician assessed Resident #110's wounds, on [DATE], and it stated the shear wound to the Right Buttock was resolved. The summary directed staff to continue to off-load wound; reposition per facility protocol; turn side to side and front to back in bed every ,d+[DATE] hours if able. A Braden Scale Assessment and Skin Check dated, [DATE] at 5:27 PM, revealed Resident #110's score as ten (10), indicating the resident was at high risk for pressure ulcer development. Review of Skin Check revealed the nurse identified wounds, including one to the Right Buttock. Review of the Specialty Physician's Progress Note, revealed the [DATE] visit was rescheduled. Review of Nursing Progress Notes, dated [DATE] at 7:00 PM, revealed Resident #110 was sent to the local emergency room for evaluation related to generalized peripheral [CONDITION(S)] and inability to obtain a blood pressure. Review of CIC follow-up Progress Note, dated [DATE] at 9:43 AM, revealed Resident #110's skin was warm with one-plus (1+) pitting [CONDITION(S)] in bilateral feet. Review revealed no evidence nursing assessed the resident for pressure wounds after identification of CIC. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 8:15 AM, revealed she readmitted the resident on [DATE], however she failed to assess the residents skin as per policy. Review of Nursing Skin Assessment Note, dated [DATE], revealed nursing failed to assess Resident #110's skin, per policy, as evidenced by the form/document being blank. Interview with LPN #9, on [DATE] at 8:15 AM, revealed she could not recall not documenting skin assessments for Resident #110 that she was assigned to perform. She stated there were times she was unable to get assessments completed on her shifts. Review of the facility's Skin Assessment Grids, revealed the Wound Nurse assessed Resident #110's wounds on [DATE] and identified a new Buttocks Right/Hip Abscess that measured 2.0 cm (length) by 3.0 cm (width) by 0.4 cm (depth), with hard surrounding tissue and moderate amounts of purulent drainage. The Skin Assessment Grid had no identification or assessment of the sacral area. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] TAR, revealed staff continued to cleanse Right Buttocks area with wound wash, pat dry, and apply [MEDICATION(S)] Wound/Burn Dressing Gel every day shift, except for [DATE] and [DATE], for shearing from start date of [DATE] until the end date of the order on [DATE], even though the wound was documented as resolved from the Specialty Physician's Wound Evaluation and Management Summary, dated [DATE]. Review of Late Entry Progress Note, dated [DATE] at 3:00 PM, revealed a change in condition (CIC) related to a skin wound or ulcer. Resident #110's vital signs were obtained and were the following: oral temperature was 97.8 degrees Fahrenheit (ºF), respirations 18 breaths per minute; pulse was 62 beats per minute and regular; blood pressure was ,d+[DATE], and oxygen saturation 98%. The resident's blood sugar was 190. The CIC note did not contain an assessment or identfication of a sacral wound. Review of Late Entry Progress Note, dated [DATE] at 11:45 PM, revealed nursing performed a skin check and identified the previous right buttock wound. However, there was no description of the wound or surrounding tissue. Review of the Nurses Progress note, dated [DATE], revealed a nickel size wound abscess to right buttocks with thick white exudate. Further review revealed there were no measurements obtained. Additional review of the note revealed new orders received to: obtain wound culture; clean site with wound cleanser; pack opening with non-medicated [MEDICATION(S)] gauze with [MEDICATION(S)]; and dry dressing BID. Interview with LPN #9, on [DATE] at 8:15 AM, revealed she assessed the resident's hip wound as an abscess, on [DATE]. She stated she did not measure the abscess; she only performed a swab of the abscess to send for culture and sensitivity. Further interview revealed the facility's policy prohibited her from taking pictures of the wound. Review of Progress Notes, dated [DATE] at 3:09 PM, revealed a decline in Resident #110's health. Resident #110's vital signs were obtained and were the following: oral temperature: 99.3 ºF; respirations 22; pulse 59 and regular; blood pressure ,d+[DATE], and oxygen saturation: 98%. Per the note, the Physician was notified and new orders were received to hold oral medications. Further review of the Progress Notes, dated [DATE] at 7:31 PM, revealed after further monitoring and review of Resident #110's declining condition, a new order was received to transport the resident to the Emergency Department (ED). Emergency Medical Services (EMS) was dispatched at 5:52 PM. Review of the EMS Run Sheet, dated [DATE] at 6:04 PM, revealed that no nurse was present in the resident's room, and no transfer information was available from the facility when Resident #110 was picked up for transport to the hospital ED. Further review revealed EMS crew stated the resident was alert to pain and felt warm. A temperature of 103.0 degrees Fahrenheit (ºF) was obtained while still in the facility. Review of ED Notes, dated [DATE] at 6:19 PM, revealed Resident #110 presented to the ED with [CONDITION(S)] (A-fib), generalized swelling, a fever of 101.6 degrees Fahrenheit, altered mental status, diminished lung sounds bilaterally, and faint heart tones. Lab results revealed an elevated White Blood Count (WBC) at 15.7 (reference range is 3.7 - 10.3 x 10(3)/mcl. X-ray results were positive for bilateral parenchymal opacities, which could represent [CONDITION(S)] or infection and computed tomography (CT) results showed bilateral pleural effusion. Further review revealed, Resident #110 was admitted to the hospital, on [DATE], with diagnoses, which included [CONDITION(S)], Unstageable Pressure Ulcer of Sacral Region and Right Gluteal Abscess, Morbid Obesity, and Healthcare Associated Pneumonia (HCAP). Continued review of ED Physician notes, dated [DATE], revealed Resident #110 met the criteria for [CONDITION(S)]. Wound cultures were obtained from the sacral decubitus ulcer and the right gluteal abscess. Review of Surgical Consult, dated [DATE], revealed a stat consult was requested to evaluate Resident #110's wounds. Per the notes, the resident's right gluteal abscess was actively draining, likely with necrotic tissue in the base, which could use further opening and debridement. Further review of the progress note revealed the resident had an unstageable sacral decubitus ulcer measuring 8 cm (length) by 2 cm (width), which required surgical debridement. The provider wrote, Patient has no quality of life. Review of Infectious Disease (ID) Consult, on [DATE], revealed ID was consulted for evaluation of [CONDITION(S)] and antibiotic management; possible causes for the infectious etiology included Bacteremia, HCAP, and soft tissue infection from right buttock ulcer. A Computed Tomography (CT) of the pelvis showed a chronic calcified posterior right gluteal region hematoma in the surrounding soft tissue infiltration indicating possible soft tissue infections. Wound culture of right buttock showing gram negative rods. Interview with State Registered Nurse Aide (SRNA) #18, on [DATE] at 8:20 AM, revealed when aides found a skin issue on a resident, the process was to document the findings on the Skin Assessment sheet, and make the nurse aware. She further stated residents were assessed every Friday by the Wound Care Nurse. She further stated Resident #110 had some areas on her toes, abdominal folds and right buttock. She stated the resident was being followed by wound care. Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 8:15 AM, revealed she was assigned to Resident #110, on [DATE]. She stated Registered Nurse (RN) #3 observed a CIC in the resident during the night shift. RN #3 documented the CIC and reported the resident's condition to her at shift change. LPN # 9 stated she was up and down the hall insuring he/she was responsive, and monitored vital signs throughout the day. LPN #9 stated vital signs were within normal limits, and the plan was to wait for labs to see what to do next; however, she added Resident #110 did not improve, was not verbally responsive, and his/her temperature was elevated. The Physician was notified, and new orders were received to send the Resident to the ED. EMS was dispatched and Resident was transferred to the hospital's ED via EMS at 5:52 PM. Interview with SRNA #19, on [DATE] at 3:43 PM, revealed she cared for Resident #110 and stated, I try to check and change residents every two hours, but it's usually more like every three hours. Further interview revealed when she was providing care to the resident on [DATE] she noticed the area to the residents right hip she notified the nurse on duty. She stated the area was red and open with white drainage coming out of area. SRNA #19 stated she did not observe the resident's buttocks, because once she identified the right hip wound she stopped providing care and got the nurse. Interview with Agency LPN #9, on [DATE] at 8:15 AM, revealed Resident #110 was incontinent, obese, and needed frequent skin assessments. LPN #9 identified the wound on the hip as an, abscess with drainage, on [DATE], and stated she performed a culture and sensitivity on the drainage during a dressing change. She stated the wound abscess was tiny. She stated she did not perform an additional skin assessment once the area to right hip was located, she only assessed that area, she did not look any further on the resident's sacral area. She stated the plan was to wait for labs to see what to do next; however, she added Resident #110 did not improve, was not verbally responsive, and his/her temperature was elevated. LPN #9 stated the resident was uncomfortable with positioning and would not tolerate it well. She stated the resident would cry out in pain when turned. The Physician was notified, and new orders were received to send the resident to the ED. Further interview with LPN #9, on [DATE] at 11:13 AM, revealed Resident #110's right buttock area had purulent drainage like an abscess. She stated she notified the Wound Care Nurse, obtained a wound culture, and notified the Physician for treatment orders. She stated she did not measure the wound and estimated it to be the size of a nickel. Further interview revealed she monitored the wound for drainage and checked for further deterioration during dressing changes, and charted when care was completed. Per interview, she stated no other skin issues were present. LPN #9 stated, on [DATE], the abscess was open and draining, and she had to pack it. She recalled that he/she flinched during treatment and stated it was uncomfortable. She further stated, Resident #110 didn't want to be bothered. LPN #9 stated she did not the document care or the resident's verbal or non-verbal reactions to treatment. Interview with Agency LPN #15, on [DATE] at 5:05 PM, revealed she cared for Resident #110. She stated he/she was bedridden and had skin breakdown in abdominal folds. She did not recall Resident #110 having any other skin breakdown and stated the SRNA's were her eyes and ears regarding identifying new skin issues. Interview with RN #3, on [DATE] at 8:30 AM, revealed wound shear on Resident #110's right buttock had healed; however, the resident did have an abscess to right buttock. RN #3 stated she did not do a full skin assessment because she only treated the wound areas she was assigned. RN #3 stated, Aides changed Resident #110 no more than two times a shift due to it being too uncomfortable for the resident. Interview with RN #2, Nurse Educator/Wound Care Nurse, on [DATE] at 9:00 AM, revealed nursing had identified a new wound abscess to Resident #110's right hip area. She stated, LPN #9 did the culture and dressing. She stated resident would, grimace and moan when touched, and staff had to go very slowly, and gently during the resident's wound care treatments. She stated staff nurses would follow-up with Resident #110's weekly skin checks and he/she was followed by the Wound Care Physician. She stated Wound Care Physician rescheduled in-house appointments with Resident #110 due to his/her hospitalization . She could not recall why the wound consult visit on [DATE] was rescheduled. RN #2 stated she notified the physician about the new abscess. RN #2 was not aware Resident was refusing care. Per interview, he/she was care planned (CP) to be turned per facility schedule. She stated it was her expectation that staff assess skin and turn resident per the CP. Further interview revealed there was currently no widespread education on newly identified skin issues. She stated the facility process was to let Unit Managers know about new skin issues. She stated not all staff had been education on Pressure Ulcer Prevention (PUP) and PUP protocols were not in place. RN #2 stated the plan was to implement new education regarding turn schedule. Subsequent interview with RN #2, on [DATE] at 4:35 PM revealed that Agency staff was trained prior to coming to facility on basic resident care. She stated the facility had processes to ensure competencies, which were not yet in place, for new hires. New hires were paired with a trainer for one to two days, which she stated, Personally, I don't believe that was enough time. Trainers report if there were any issues with competencies. She relied on other staff to check that staff was competent. There was no follow-up from the Educator to assure competent care was provided according facility policies. She stated that her goal was to spend one-on-one time with all staff, but for right now, The process is broken. Additional interview with RN #2, on [DATE] at 11:52 AM, revealed during Resident #110's last treatment, done on [DATE], she only concentrated on the abscess to the hip. She recalled documenting her assessment on a piece of paper and was did not recall she failed to document her assessment in the chart. She received an order to pack with [MEDICATION(S)] covered gauze. She stated the wound was an abscess and not something that could be staged. She stated she did not measure the wound, as directed per the policy. RN #2 stated, We didn't do a full skin assessment. Further interview revealed it was her process to focus on the acute area, and nurses did a weekly skin assessment. Interview with Assistant Director of Nursing (ADON), on [DATE] at 4:40 PM, revealed it was her expectation that nurses assess and document what they did. She stated, If you didn't document, it didn't happen. She further stated nursing staff should fully assess using the CIC Tool. She stated she was aware of Resident #110's abscess and knew it was assessed by the Wound Care Nurse. ADON stated it was not an expectation that nursing did a full skin assessment when made aware of a new skin condition; however, she stated it would be important to fully exam the entire area to determine full extent of wound. Interview with the Director of Nursing (DON), on [DATE] at 9:18 AM, revealed it was her expectation staff followed the resident's comprehensive care plan, and care plans should be updated if any type of pressure injury was found. It was the DON's expectation that nursing staff provide the correct level of care per the care plan and as ordered by the physician Further interview revealed it was her expectation that full skin assessments were completed by nursing staff when weekly skin assessment were due. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 3:40 PM, revealed it was her expectation that staff followed care plans, and updated as needed, when there was a CIC or a new pressure/wound was identified. Furthermore, nursing staff was to assess the resident and chart findings. She stated, If it was not charted, it didn't happen. The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. Newly hired staff and contracted staff were to be provided education and post [TRUNCATED]

Based on observation, interview, record review and review of the facility's policies, it was determined the facility failed to have an effective system to ensure residents' respiratory care needs were consistently met for one (1) of thirty (30) sampled residents (Resident #110). The facility admitted Resident #110 on [DATE]. The resident had current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #110 had been hospitalized , from [DATE] to [DATE] with [CONDITION(S)] and Acute Respiratory Failure. In addition, Resident #110 had been sent to the hospital Emergency Department (ED), on [DATE], for [CONDITION(S)] and returned to the facility five (5) hours later, on [DATE]. On [DATE], Resident #110 experienced a change in condition (CIC) with his/her respiratory status. Interview and record review revealed nursing staff did not implement respiratory care interventions for the resident on [DATE], as ordered by the Physician. Nursing staff failed to administer the resident's ordered [MEDICATION(S)] (a diuretic used to remove excess fluid from the body) sixty (60) mg intravenously (IV), monitor lung sounds; failed to perform strict fluid intake and output (I&O), and, failed to monitor the resident for his/her deteriorating condition. Record review and interview revealed staff failed to notify the Physician that Resident #110 refused to wear his/her mask that delivered Bi-level Positive Airway Pressure ([CONDITION(S)]), a mask with tubing attached to a machine that delivered bi-level positive airway pressure while sleeping to keep the airway open and improve oxygenation, used to treat OSA) at night. Resident #110 was transferred to the hospital's ED (Emergency Department), on [DATE] at 5:52 PM, via Emergency Medical Services (EMS) and was admitted . According to the hospital ED records, the resident arrived lethargic and moaning with diminished lung sounds bilaterally (both sides), bilateral upper and lower extremity swelling and [CONDITION(S)], febrile, and with an altered mental status. Resident #110 returned to the facility under Hospice Care, on [DATE], and expired on [DATE]. The facility's failure to provide respiratory care to meet the needs of the resident, has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE], in the area of 42 CFR 483.25(i) Quality of Care, Respiratory Care, and determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Respiratory Management, revised on [DATE], revealed the purpose of the policy was to provide appropriate respiratory services. Further review revealed residents would be assessed for the need for respiratory services as part of the nursing assessment process. If respiratory care was needed it would be performed by a licensed nurse who had been trained. Furthermore, the nurse would consult with the Physician/Advanced Practice Provider (APP) when a resident was not responding to treatment provided by nursing; or, a resident's condition worsened. Review of the facility's policy titled, Bi-level Positive Airway Pressure, revised [DATE], revealed this treatment was used and provided via a mask connected to a machine that delivered positive airway pressure therapy for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's policy titled, Change in Condition (CIC): Notification Of, revised on [DATE], revealed the facility must immediately consult with the resident's Physician and notify him/her when there was a need to change an existing form of treatment or start a new form of treatment. Review of the facility's policy titled, Physician/Advanced Practice Provider (APP) Notification, revised on [DATE], revealed if the resident had a CIC, the Physician or APP must be notified to address new or changed interventions as needed. Per policy, if a resident had a CIC, a licensed nurse must observe and collect information about the resident's condition and report these findings to the Physician or APP (Advanced Practice Registered Nurse/APRN). Review of the facility's policy titled, Nursing Documentation, revised on [DATE], revealed the purpose of nursing documentation was to communicate the resident's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. Further review revealed the resident's record would specify what nursing interventions were performed. Review of the facility's policy titled, Assessment: Nursing, revised on [DATE], revealed the purpose of a nursing assessment was to determine the resident's condition and clinical needs. Further review revealed the assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff on all shifts. Per facility policy, the Physician or APRN was to be notified of all CIC assessment results. Review of the facility's policy titled, Intake and Output, revised on [DATE], revealed the purpose was to ensure nursing staff recorded total fluid intake and output to track the resident's fluid balance. Per policy, nursing staff was to record all intake amounts including fluids taken by mouth and the amount of IV (intravenous) fluids infused; and nursing staff was to record all output amounts including urine in milliliters (ml). Further review of the policy revealed intake and output (I&O) totals were to be recorded in the resident's medical record. Review of the facility's policy titled, Taking Medication and Treatment Orders, revised on [DATE], revealed verbal orders were given face-to-face to a nurse by a practitioner who was in the facility, and verbal orders were not an accepted standard of practice and could only be used in an emergency situation. Continued review revealed the person taking the orders could only take the order from a credentialed physician or other authorized practitioner, as allowed by state regulations. Further review of the policy revealed the person obtaining orders must document verbal orders, with the prescriber's name and title, name and title of the person receiving the order, date, month, year, and time. The prescriber's signature must be obtained per state regulation. Review of Resident #110's medical record revealed the facility admitted the resident, on [DATE]. Further review revealed the resident had current diagnoses, which included Obstructive Sleep Apnea (OSA), Chronic Obstructive Pulmonary Disease ([CONDITION(S)]), Asthma, Dysphagia, Heart Failure (HF), and Chronic Kidney Disease (CKD). Review of Resident #110's Social Services Assessment, dated [DATE], revealed the resident scored an eleven (11) out of fifteen (15) on the Brief Interview for Mental Status (BIMS) evaluation, indicating the resident was cognitively intact. Further review revealed the resident was able to express ideas and wants, and was able to understand verbal content. Review of Resident #110's Plan of Care (POC), initiated on [DATE], revealed the resident was at risk for complications related to OSA, [CONDITION(S)], Asthma, and Dysphagia. The goal stated the resident would not have signs/symptoms of respiratory distress or aspiration. Further review of the POC revealed interventions included to administer aerosol medications as ordered/indicated; administer [CONDITION(S)] as ordered; observe and report SpO2 (blood oxygen saturation) levels via pulse oximetry as ordered and as needed; and observe respiratory rate, signs/symptoms of dyspnea, abnormal breath sounds, cyanosis, and use of accessory muscles. Continued review of the care plan revealed the resident had the potential for alteration in fluid balance and impaired renal function with interventions to include observing for symptoms of [CONDITION(S)], shortness of air (SOA), and weight gain. Review of Resident #110's Nursing Notes, dated [DATE] at 8:59 AM, revealed the resident was tachycardia, pulse one-hundred eighty (180) beats/minute; 02 sat 89% with 02/NC at two (2) liters per minute. Further review revealed Resident #110 complained of left sided chest pain. Resident denied nausea/vomiting, his/her skin was warm and dry to touch. But the resident stated he/she was feeling hot during night hours. Continued review revealed the resident was alert, oriented, and verbally responsive x 2; with no difficulty in breathing; and, the resident denied shortness of breath. The APRN was notified with new orders to send the resident to the emergency room . Review of Resident #110's hospital records, dated [DATE], revealed the resident was admitted to the hospital, on [DATE], for [CONDITION(S)] (widespread infection) and acute respiratory failure. Resident #110 was discharged from the hospital and returned to the facility on [DATE]. Review of Resident #110's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the order stated for the resident to use two (2) liters of oxygen, via nasal cannula, every shift to keep oxygen levels above ninety (90) percent. Continued review revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident #110's medical record revealed a Treatment Order, dated [DATE], to change oxygen tubing weekly, and label each component with date and initials, every day shift, every Thursday. Review of Resident #110's Nursing Notes, dated [DATE] at 7:00 PM, revealed the on call APRN was notifie of resident's generalized peripheral [CONDITION(S)] and not being able to obtain a blood pressure on the resident. Further review revealed new orders obtain to send the resident to the emergency room for furrther evaluation. Review of Resident #110's hospital records, dated [DATE], revealed the resident was sent to the ED, on [DATE], for [CONDITION(S)] and lab tests. The resident returned to the facility on [DATE], after spending approximately five (5) hours in the ED as an outpatient. Observation and interview with Resident #110, on [DATE] at 9:20 AM, revealed the resident in bed lying on his/her left side with his/her legs crossed, one over the other, with his/her heels pressed against the mattress. There was generalized [CONDITION(S)] observed over the lower extremities, bilateral hands, and upper extremities; the left hand had an indentation where it rested against the bed. Further observation revealed the resident was on two (2) liters/minute of oxygen via nasal cannula, but the oxygen tubing was not labeled with a date or initialed, which was not according to the treatment order. Additional observation revealed the resident's [CONDITION(S)] mask and tubing were on the floor, and the resident stated, My life is miserable. Record review revealed Resident #110's lung sounds were assessed on [DATE] at 6:00 AM. However, there was no documented evidence that nursing monitored the resident's lung sounds throughout the day to assess for the resident's worsening condition. Further review revealed there was no documented evidence the nurses assessed an apical pulse on the resident even though the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Licensed Practical Nurse (LPN) #9, on [DATE] at 8:15 AM, revealed Resident #110 routinely refused his/her [CONDITION(S)] treatment. She stated nurses should document refusals on the MAR (Medication Administration Record). Per interview, she could not recall if the Physician was aware of the resident's repeated refusals to wear the [CONDITION(S)]. Record review revealed no documentation of notification to the Physician of the resident's refusal to wear the [CONDITION(S)]. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110 refused the [CONDITION(S)] and wanted it off most nights because it was noisy and interfered with sleep. She stated she did not recall if the Physician had been notified of the resident's refusal to wear [CONDITION(S)]. Interview with the Physician, on [DATE] at 9:23 AM, revealed the nurses did not make him aware of Resident #110's non-compliance with wearing the [CONDITION(S)] at night. He further stated it would have helped the resident with his/her respiratory illness. Record review revealed Resident #110 refused to wear the [CONDITION(S)] on ten (10) out of twenty (20) nights in the month of [DATE]. However, there was no documented evidence nursing staff provided encouragement and education related to the refusal of care related to wearing the [CONDITION(S)] at night. Continued review of Resident #110's Nursing Progress Note, dated [DATE] at 6:05 AM, revealed Registered Nurse (RN) #3 observed Resident #110 with frothy, thick mucous in his/her mouth and throat. RN #3 noted the resident's oxygen saturation (SpO2) was ninety-two (92) percent on two (2) liters/minute of oxygen via nasal cannula. Per the Note, a nursing assessment at 6:00 AM, revealed the resident had abnormal lung sounds (rales, rhonchi, wheezing) and complained of chest pain. Further review revealed the assessment of the resident showed a resting pulse rate of one-hundred fifteen (115) beats per minute (BPM), respirations of eighteen (18) per minute, temperature of 97.6 degrees Fahrenheit, and a blood pressure (BP) of ,d+[DATE] millimeters of mercury (mmHg). The note stated Resident #110 was not wearing his/her [CONDITION(S)]. In addition, the note stated RN #3 notified the Physician of Resident #110's condition and new orders were given for lab work and a chest x-ray. Continued interview with RN #3, on [DATE] at 8:30 AM, revealed Resident #110 was normal until about 5:30 AM, and at 6:30 AM, a State Registered Nurse Aide (SRNA) observed the resident with thick phlegm coming from his/her mouth. RN #3 stated she notified the Physician. Per interview, the Physician examined the resident that morning and ordered lab work and a chest x-ray. Interview with the Physician, on [DATE] at 10:12 AM, revealed he examined Resident #110 on the morning of [DATE]. Per interview, he assessed the resident with fluid overload caused by his/her recent IV antibiotic therapy, and it was his intent to [MEDICATION(S)] (remove fluid) the resident. The Physician stated he gave a verbal order to the Director of Nursing (DON) directly to place an indwelling Foley (brand of indwelling catheter) catheter, give one (1) dose of [MEDICATION(S)] sixty (60) mg IV, monitor lung sounds, and document strict I&O's. The Physician stated he gave the order specifically to the DON because, as an RN, she was the only nurse in the building, who could push IV [MEDICATION(S)]. Additionally, he stated he ordered strict I&O's and the monitoring of the resident's lung sounds to assess the resident's response to the treatment. Further, the Physician stated a staff nurse informed him that following the ordered treatment, Resident #110 was diuresed of approximately two (2) liters of fluid. Per interview, when the resident's condition did not improve, he transferred him/her to the ED for more aggressive measures. Record review revealed Resident #110 was transferred to the hospital, via EMS, on [DATE] at 5:52 PM. Interview with the DON, on [DATE] at 9:15 AM, revealed she assessed Resident #110, on [DATE], in the morning, and told the unit LPN to call the doctor to send the resident out. She stated she documented the assessment; in addition, she stated, according to the facility's policy verbal orders were given in emergency situations by the Physician to an RN. Per interview, the facility's policy dictated that verbal orders were transcribed on an order sheet and signed by the Physician. When asked if she had ever taken a verbal order from a Physician, she replied, No. When asked if [MEDICATION(S)] had been taken out of the emergency box (e-Box), she replied, No. The DON further stated that no one gave Resident #110 [MEDICATION(S)] IV on [DATE], as ordered. She stated the unit LPN was given the order to give [MEDICATION(S)]. In addition, the DON stated the Physician also gave the unit LPN verbal orders to place an indwelling Foley catheter, monitor lung sounds, and document strict I&O's. The DON indicated she first heard about the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional interviews with the DON on [DATE] at 9:15 AM and review of the resident's records revealed no documented physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] &Os, or to provide comfort care. Furthermore, continued review of the Nursing Progress Notes, dated [DATE], revealed no documented nursing assessment by the DON, as stated per interview. Continued review of Resident #110's Nursing Progress Note, dated [DATE] at 3:09 PM, revealed the first CIC follow-up note by LPN #9. The note stated the resident's condition had declined, and the Physician was notified. Furthermore, the note stated new orders were received to continue to hold PO (oral) medications, insert a Foley catheter for strict I&O's, and provide comfort care. However, there was not a specfic time given for receipt of the orders. Interview with LPN #9, on [DATE] at 8:15 AM, revealed RN #3 observed a CIC in Resident #110 during the night shift, which was documented and reported to her at shift change. LPN # 9 stated she was up and down the hall ensuring the resident was responsive and monitored his/her vital signs throughout the day. LPN #9 stated the plan was to wait for lab results to see what to do next; however, she added Resident #110 did not improve, was not verbally responsive, and his/her temperature was elevated. LPN #9 stated the Physician gave orders regarding Resident #110 to the DON, not the LPN's on the unit. In addition, she stated she was not aware whether or not the resident had received [MEDICATION(S)] sixty (60) mg IV or that the Physician wanted the resident diuresed. She stated she did not perform any IV diuresis, but a catheter was placed in the morning to monitor strict I&O's and for comfort care. She recalled the resident's urine output was about fourteen hundred (1400) ml's. Per interview, she stated she did not document any I&Os, was unaware of any chest pain for the resident, and did not document any abnormal lung sounds because they were clear based on the night shift nurse's finding. According to LPN #9, around 11:00 AM, Resident #110 complained he/she could not swallow, so the Physician ordered nothing by mouth and to hold oral medications. The LPN stated Resident #110 was very edematous. She stated she assessed the resident and auscultated clear lung sounds; however, she did not document her assessment. LPN #9 stated the assessment should have been documented to keep an accurate record of the resident's condition. Further interview revealed LPN #9 continued to monitor the resident's mental status, provide comfort care, and monitor his/her status of distress for a further decline in condition. Again, LPN #9 revealed she did not document the assessments and stated the facility needed a better tool for documentation because it could be overwhelming. She recalled she documented a general note later in the afternoon. LPN #9 stated the resident required a higher level of care, which the facility could not provide, and she wanted the resident sent to the hospital. She stated the UM called the Physician, and she received an order to transfer the resident to the hospital. Record review revealed there were no documented assessments for lung sounds, strict I&Os or monitoring of Resident #110's condition, on [DATE] from 6:00 AM to 3:09 PM to ensure the resident's care needs were identified. In addition, there was no documented evidence LPN #9 performed the ordered care. Interview with the Pharmacist on, [DATE] at 3:31 PM, revealed if a needed medication was not on hand, it was pulled from the e-Box. Per interview, two (2) vials of [MEDICATION(S)] (forty) 40 mg were kept in the e-Box, and to audit what was used from the e-Box, nursing staff must fill out a requisition form and fax it to Pharmacy. According to the Pharmacist, the Pharmacy delivered the facility an e-Box, on [DATE], and picked it up, on [DATE]. The Pharmacist stated the e-Box was missing two (2) [MEDICATION(S)] (forty) 40 mg/4 ml vials; however, Pharmacy did not receive a faxed inventory form requesting replacement. However, interview with the DON revealed she did not administer the [MEDICATION(S)]. Review of the Hospital Emergency Department (ED) Notes, dated [DATE] at 6:19 PM, revealed Resident #110 presented to the ED with [CONDITION(S)], Generalized [CONDITION(S)], Altered Mental Status, a fever of 101.6 degrees Fahrenheit, diminished lung sounds bilaterally, and faint heart tones. Lab results revealed an elevated White Blood Cell (WBC) count at 15.7 (reference range is 3.7 to 10.3). Further review revealed chest x-ray results were positive for bilateral parenchymal opacities, which could represent [CONDITION(S)] or infection, and the computed tomography (CT) results of the lungs showed bilateral pleural effusions. Review of the Hospital History and Physical (H&P) for Resident #110, dated [DATE] at 11:19 PM, revealed Resident #110's principal problems were [CONDITION(S)] (widespread infection of the blood stream), [CONDITION(S)], Healthcare-Associated Pneumonia (HCAP), [CONDITION(S)], and Cor Pulmonale (an abnormal enlargement of the right side of the heart as a result of lung disease). A broad spectrum antibiotic and diuretic were ordered. Interview with Agency State Registered Nurse Aide (SRNA) #21, on [DATE] at 3:04 PM, revealed she had cared for Resident #110 and stated he/she required total assist for everything due to contractures. SRNA #21 stated Resident #110 usually had swollen extremities. She stated that when she cared for the resident recently, he/she was crying, complained of no air, and slept all day. Per interview, SRNA #21 stated that she reported the resident's condition to the nurse but did not recall if the nurse assessed the resident. Interview with Agency LPN #10, on [DATE] at 9:40 AM, revealed she was aware Resident #110 had bilateral [CONDITION(S)] in all extremities. However, there was no documented evidence that nursing staff assessed the resident's [CONDITION(S)] during the skin assessment on [DATE]. Interview with the Assistant Director of Nursing/Infection Preventionist (ADON/IP), on [DATE]at 10:00 AM, revealed resident assessments should be completed and documented according to policy. She stated it was her expectation that if a resident had a change of condition related to respiratory, that an assessment should be completed and documented in the clinical record. Further, the ADON stated the provider was to be notified. Continued interview with the DON, on [DATE] at 9:15 AM, revealed she expected nursing staff to provide the correct level of care. Per interview, it was the DON's expectation that nurses did resident assessments and charted accordingly. Interview with the RCQS, on [DATE] at 3:40 PM, revealed it was her expectation that when a resident had a change of condition, it was her expectation for it to be documented in the resident's clinical record; furthermore she expected the staff to follow the resident's plan of care and notify the Physician. Furthermore, nursing staff was to assess the resident and document the results. Interview with Administrator, on [DATE] at 2:15 PM, revealed it was her expectation for staff to follow the facility's policy related to assessments and follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility provided an acceptable credible Allegation of Compliance (AoC) on [DATE] alleging removal of the Immediate Jeopardy on [DATE]. Review of the AoC revealed the facility implemented the following: 1. An audit was conducted by the Assistant Director of Nursing (ADON), Nurse Practice Educator (NPE), and Unit Managers (UM) between [DATE] and [DATE] to determine if residents had pain, had pain medications ordered, if pain medications were effective, and if pain was not relieved. The Physician/Advanced Registered Nurse Practitioner (ARNP) were notified of unrelieved complaints of pain with new orders obtained if applicable. 2. Nineteen (19) of nineteen (19) residents identified with pain issues were reassessed on [DATE] by the Director of Nursing (DON), UM's, and/or Licensed Nurse (LN) Nurse Practitioner and/or Physician to determine if a change in condition had occurred regarding pain. Areas of concern were corrected upon discovery. 3. The DON, UM, ADON, NPE, and/or Clinical Quality Specialist (CQS) initiated reeducation, beginning on [DATE], with all facility staff to include contracted staff on the facility's policy and procedures regarding: (A) Change in Condition; (B) Pain Management, including observations; (C) Stop and Watch Tool; (D) Physician/Mid-Level Provider Notification of Change in a Resident's condition; and (E) Person Centered Care Plan. A post-test was administered at the time of the reeducation that required a passing score of 100% that will be graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Facility staff and agency staff not available during the reeducation and post-test were to be provided reeducation including a post-test by the DON, UM, ADON, NPE, and/or CQS upon day of return to work prior to providing care. Newly hired staff and contracted staff were to be provided education and post-test during orientation by the DON, ADON, CQS, NPE, UM, and/or Licensed Nurse (LN). 4. Starting [DATE], clinical observation rounds will be conducted every shift, including interviews of ten (10) staff and five (5) residents who receive pain medication to identify any change in condition including a change in pain by the DON, ADON, UM, NPE, or LN to determine if residents have experienced a change in condition regarding pain. The Physician/NP were notified and the plan of care was reviewed to ensure it reflected the current needs of the resident daily until the Immediate Jeopardy is abated. 5. Starting [DATE], the Center Executive Director (CED) and/or LN would conduct ten (10) employee questionnaires daily to determine if staff were aware of the Center's process of the Stop and Watch Tool and reporting a change in condition, including reporting resident pain to a licensed nurse, to ensure prompt interventions when a resident experienced a change in condition, until the Immediate Jeopardy is abated. 6. The results of the observations, interviews, and audits will be reviewed daily by the CED or DON corrective actions taken upon discovery of deficiencies. 7. Beginning on [DATE], the DON, UM, ADON, NPE, CQS, and/or LNs initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plan with individualized person centered interventions to include monitoring pain, administering pain medications as ordered, utilizing and documenting the pain scale, and observing for non-verbal signs/symptoms of pain; (B) Pressure Ulcer prevention to include developing/implementing the care plan; (C) Person-centered care plans; and (D) Physician/Mid-Level Provider Notification of Change in a resident's condition. 8. All admissions, readmissions, and residents with changes in respiratory status since [DATE] were reviewed on [DATE] by the DON, ADON, NPE, UM, and or LNs to determine if care plans reflected patient specific interventions to include interventions to monitor respiratory status to include residents with sleep apnea, [CONDITION(S)], acute respiratory failure, and asthma. Areas of concern were corrected upon discovery. 9. On [DATE], the DON, UM, ADON, NPE and or CQS initiated reeducation with all licensed nurses and agency nurses on the facility's policy and procedures regarding: (A) Revision of the care plan with all admissions, readmissions, and changes in respiratory status with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A post-test was administered at the time of the reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and/or CQS to validate understanding. Licensed Nursing and Agency Licensed Nursing Staff not available will be provided reeducation, including a post-test, by the DON, UM, ADON, NPE, and/or Registered Nurse upon day of return to work before providing care. New licensed nursing hires and agency licensed nurses will be provided education and post-test during orientation by the DON, ADON, NPE and/or UM. 10. Care plan audits were completed for residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 11. Five (5) Licensed Nursing Staff interviews were completed by the CED, DON, UM, ADON, NPE, and/or CQS to determine if staff were aware of the process of a respiratory assessment when a resident's condition warranted the assessment and per the resident's plan of care will be conducted daily until the Immediate Jeopardy is abated. 12. The DON, UM, ADON, NPE, and/or CQS completed reeducation beginning on [DATE] with facility licensed staff to include agency staff on the facility's policy and procedures regarding: (A) Pain management to include implementing person-centered care plans with individualized person-centered interventions to include monitoring pain, administering pain medications as ordered, and utilizing and documenting pain scale assessments, and observe for non-verbal signs/symptoms of pain. A medication reconciliation process is in place to review discharge orders to current orders; (B) Physician/Mid-Level Provider Notification of Change in a resident's condition; and (C) Person Centered care plans regarding resident interventions for pain. A post-test was administered at the time of reeducation that required a passing score of 100% that was graded by the DON, UM, ADON, NPE, and or CQS to validate understanding. Facility licensed staff and agency staff not available will be provided reeducation including a post-test during orientation by the DON, ADON, NPE, UM, and/or LN, before allowed to work. 13. The CED and/or LN will conduct five (5) employee questionnaires daily to determine if staff were aware of the Center's process of reporting a change in condition including pain to a licensed nurse to ensure prompt intervention when a resident experienced a change in condition until Immediate Jeopardy is abated. 14. The UM's, ADON, NPE, and licensed nurses completed skin assessments on all residents on [DATE], to ensure residents, including residents with pressure ulcers, received care per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 15. T [TRUNCATED]

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure pain management was provided to residents who required such services. The facility failed to ensure pain medication was available to the resident per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility admitted Resident #110, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #110 was hospitalized , on [DATE], with Altered Mental Status, Condition Decline, and [CONDITION(S)]. Prior to the [DATE] acute care hospitalization , the resident was receiving Oxycodone with Acetaminophen (a narcotic opioid pain reliever given for moderate to severe pain) on a every six (6) hour schedule. When Resident #110 returned from the hospital to the facility, on [DATE], the resident's discharge medication and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Moreover, the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The nursing staff at the facility failed to notify the Physician or the Advanced Practice Registered Nurse (APRN) to reorder the resident's scheduled narcotic pain medication after the three (3) day order had expired on [DATE]. Interviews with staff revealed Resident #110 continued to complain of pain; interview with the resident revealed he/she was in constant pain and had made staff aware of his/her pain. Interviews with Resident #110's Physician and APRN revealed both were aware the resident had chronic pain and had been on the narcotic pain reliever. However, both stated they were unaware it had been discontinued as of [DATE]. The Physician and APRN stated, if they had known Resident #110 had stopped receiving the scheduled narcotic pain medication, they would have reordered it. In addition, the Physician stated he would have expected staff to notify him or the APRN that the order had expired. The facility's failure to have an effective system in place to ensure pain management was provided to residents who required such services has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on [DATE], in the area of 42 CFR 483.25(k) Quality of Care, Pain Management, and were determined to exist on [DATE]. The facility provided an acceptable Allegation of Compliance (AoC) on [DATE], with the facility alleging removal of the Immediate Jeopardy on [DATE]. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on [DATE], prior to exit on [DATE], with the remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Pain Management, revised [DATE], revealed each resident would have an individualized, interdisciplinary care plan which would be developed to address and treat his/her pain to maintain the highest possible level of comfort. Additionally, a licensed nurse should conduct a pain assessment and reassessment. The resident would be reassessed upon admission/readmission, quarterly, and with change in condition (CIC) or change in pain status. Further, the policy stated the care plan would be evaluated for effectiveness, and revised until satisfactory pain management was achieved. Per policy, at a minimum of daily, patients would be evaluated for the presence of pain by making an inquiry of the resident or by observing for signs of pain; residents who had unstable pain management would be indicated on the twenty-four (24) hour Summary Report. In addition, staff would report any observation or communication of pain to the nurse responsible for that resident. The policy stated the attending physician or APRN would be consulted as indicated. Per policy, the nurse would document on the Medication Administration Record (MAR) when an as needed (PRN) pain medication was administered. Further, the nurse would monitor the resident to evaluate the efficacy of the interventions. Review of the facility's policy titled, Change in Condition: Notification Of, revised on [DATE], revealed the facility must immediately notify and consult with the resident's physician when there was a need to change an existing form of treatment or to commence a new form of treatment. Review of the facility's policy titled, Assessment: Nursing, revised on [DATE], revealed the purpose of a nursing assessment was to determine the resident's condition and clinical needs. Further review revealed the assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff on all shifts. Per policy, the physician or APRN was to be notified of all change in condition (CIC) assessment results. Review of the facility's policy titled, Nursing Documentation, revised on [DATE], revealed the purpose of nursing documentation was to communicate the resident's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. Further review revealed the resident's record specified what nursing interventions were performed. Review of Resident #110's medical record revealed the facility admitted the resident, on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #110's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed that on the Pain Assessment Interview, the resident self-reported to have had constant pain within the last five (5) days, making it hard for him/her to sleep. Furthermore, he/she rated the experienced pain at a two (2) out of ten (10), with ten (10) being the worst. Further review revealed Resident #110's score on the Brief Interview for Mental Status (BIMS) was nine (9), indicating the resident was cognitively intact. Review of Resident #110's MAR, dated ,d+[DATE], revealed the resident was receiving Oxycodone ,d+[DATE] mg (milligrams), one (1) tablet by mouth every six (6) hours, routinely scheduled and not as needed (PRN). Review of Resident #110's Hospital Discharge Summary, dated [DATE], revealed the resident was discharged with Oxycodone/Acetaminophen ,d+[DATE] mg (milligrams), one (1) tablet by mouth every six (6) hours PRN for acute pain, for up to three (3) days, expiring after [DATE]. Further review revealed during the month of [DATE], the resident received as needed, every four (4) hours, Acetaminophen (a non-narcotic pain reliever for mild pain) 325 milligrams (mg), two (2) tablets, on [DATE] at 4:33 AM and at 9:11 AM, both documented as being effective. Per the record, Acetaminophen was again administered to the resident, on [DATE] at 1:00 AM, and, on [DATE] at 4:56 AM. Further, with these administrations, there was no documentation of level of pain, source, or type of pain the resident was experiencing. Review of Resident #110's Care Plan, last reviewed on [DATE], revealed the resident was at risk for alteration in comfort related to [CONDITION(S)] (OA), muscle weakness, right upper extremity [CONDITION(S)], contractures, [CONDITION(S)], obesity, and polyneuropathy. The care plan goal was to achieve an acceptable level of pain control. Further review revealed pain interventions included: 1) observe for pain, and attempt non-pharmacological interventions to alleviate pain, and document effectiveness; 2) observe pain characteristics: quality, severity, location, and precipitating/relieving factors; 3) utilize the pain scale for assessment; 4) medicate as ordered for pain, observe for effectiveness and side effects, and report to physician as indicated; 5) observe for non-verbal signs/symptoms of pain; 6) complete pain assessment per protocol; 7) assist to a position of comfort, utilizing pillows as appropriate position devices as needed; 8) observe for change in mood or mental status; and 9) observe for behavioral symptoms for underlying cause, e.g. pain. Observation of Resident #110, on [DATE] at 9:05 AM, revealed the resident yelled for a nurse. Resident was moaning and groaning in pain. Per observation resident showed non-verbal ques of pain with grimacing. No one responded to the resident until the State Survey Agency (SSA) Surveyor alerted staff that the resident needed assistance. However, there was no documented evidence the Physician was notified of the resident's complaints of pain. Additional observation of Resident #110, on [DATE] at 9:20 AM, revealed the resident in bed lying on his/her left side with his/her legs crossed, one over the other, and his/her heels pressed against the mattress; shiny bilateral hands with contractures; and generalized [CONDITION(S)] was noted over the lower extremities, bilateral hands, and upper extremities. Further observation revealed the resident presented with oily, uncombed hair, and he/she smelled of urine. Interview with Resident #110 revealed he/she communicated verbally, his/her speech was clear, and he/she was able to understand and be understood when speaking. Continued observation revealed the resident's right arm was hanging at the right side of the bed and was not supported with a pillow as noted in the plan of care. In addition, the resident did not have an adaptive call bell equipment as care planned and required for use with the resident's bilateral hand contractures; the resident yelled for staff every time assistance was needed. The SSA Surveyor pressed the call bell to get staff to assist the resident; however, after five (5) minutes, the SSA Surveyor notified State Registered Nurse Aide (SRNA) #11 (the only staff available at the Nurse's Station) that the resident was in pain and needed a nurse immediately. Interview with Resident #110, on [DATE] at 9:20 AM, revealed staff did not address his/her chronic pain, and while the resident had resided at the facility, he/she had not received pain medication as needed. The resident stated his/her current level of pain was a ten (10), using a scale of one (1) to ten (10) with ten (10) being the worst pain. Additionally, the resident stated that his/her chronic and uncontrolled pain had prevented his/her mobility. Per interview, the resident stated activities of daily living (ADL's) produced increased pain, and at times, the pain was unbearable. The resident stated due to his/her pain, he/she could no longer transfer to a wheelchair and was bedridden, rendering him/her unable to participate in activities. Further interview revealed, the resident stated I am miserable and I hurt all the time. Per interview the resident stated when he/she told the nurse they wee in pain, no one would help him/her. Interview with the Activity Assistant (AA), on [DATE] at 11:10 AM, revealed Resident #110 was unable to attend group activities and was sleeping a lot more. The AA stated the resident used to get up in a wheelchair and go to Bingo, but had not recently been able to do so due to pain issues. Review of Resident #110's Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed that on the Pain Assessment Interview, the resident self-reported to have had constant pain within the last five (5) days, making it hard for him/her to sleep. Furthermore, he/she rated the experienced pain at a two (2) out of ten (10), with ten (10) being the worst. Resident #110's score on the Brief Interview for Mental Status (BIMS) was nine (9), indicating the resident was cognitively intact. Review of Resident #110's MAR, dated ,d+[DATE], revealed the resident was receiving Oxycodone ,d+[DATE] mg (milligrams), one (1) tablet by mouth every six (6) hours, routinely scheduled and not as needed (PRN). Review of Resident #110's Hospital Discharge Summary, dated [DATE], revealed the resident was discharged with Oxycodone/Acetaminophen ,d+[DATE] mg (milligrams), one (1) tablet by mouth every six (6) hours PRN for acute pain, for up to three (3) days, expiring after [DATE]. Review of Resident #110's Social Services Assessment, dated [DATE], revealed the resident scored an eleven (11) out of fifteen (15) on the Brief Interview for Mental Status (BIMS) evaluation, indicating the resident was cognitively intact. Further review revealed the resident was able to express ideas and wants, and was able to understand verbal content. Review of Resident #110's Quarterly MDS Assessment, dated [DATE], revealed, on the Pain Assessment Interview, the resident self-reported to have had constant pain within the last five (5) days, making it hard for him/her to sleep. Furthermore, he/she rated the experienced pain at an eight (8) out of ten (10), with ten (10) being the worst. There was no documented evidence the nursing staff notified Resident #110's Physician of a CIC (change in condition) related to increased pain because the pain level had increased from a rating of two (2), on [DATE], or followed the resident's care plan related to pain, according to the facility's policy. Furthermore, review of the resident's MAR, revealed the resident did not have an opioid/narcotic pain reliever ordered after [DATE]. Review of Resident #110's Change of Condition Transfer Form to the acute care hospital, dated [DATE], revealed the resident was sent to the ED, on [DATE], for generalized [CONDITION(S)], [CONDITION(S)], and anemia; the resident remained in the ED for approximately five (5) hours. The transfer form, completed by Licensed Practical Nurse (LPN) #13, revealed a numerical pain level of zero (0) out of ten (10) was documented on the MAR for Resident #110, on [DATE] at 10:00 PM. Review of the residents MAR revealed no documented evenidence of a numberical pain assessement since [DATE]. Therefore, Resident #110 had gone nine (9) days without a documented pain assessment on the MAR. Per the facility policy nursing staff would evaluate for the presence of pain daily. However, review of Resident #110's Vital Sign Assessment, revealed, in the month of [DATE] the only pain assessment documented was on [DATE] at 1:00 PM and [DATE] at 10:00 PM. The resident's pain was rated for the 1:00 PM and 10:00 PM assessments was zero (0) out of ten (10). Review of Resident #110's Situation, Background, Assessment, and Recommendation (SBAR) Note, dated [DATE] at 6:00 AM, revealed the resident's CIC evaluation. Resident #110 complained of chest pain. Vital signs included: pulse of one-hundred fifteen (115) beats per minute (BPM), respirations of eighteen (18) per minute, and blood pressure (BP) of ,d+[DATE] mmHg (millimeters of mercury). The SBAR showed there was no documented evidence, per the Care Plan directives, that staff evaluated the intensity, location, and duration of the chest pain; utilized the pain scale; observed or evaluated non-verbal signs/symptoms of pain; or provided medication to the resident to relieve pain. Resident #110 was sent to a local hospital Emergency Department (ED) and was admitted as an inpatient. Review of Resident #110's Hospital ED Admitting Physician Note, dated [DATE], revealed the resident arrived at the ED lethargic, did not move his/her extremities, and moaned with discomfort. Per the ED record, [MEDICATION(S)] (an opioid narcotic pain reliever for acute pain) Injection four (4) mg was ordered and given. Review of Resident #110's Hospital ED Face Sheet, dated [DATE], revealed [MEDICATION(S)] Injection four (4) mg was added to the resident's hospital medications. Review of Resident #110's Hospital ED Advanced Practice Provider (APP) note, dated [DATE] at 6:19 PM, revealed the resident presented with pain upon arrival to the hospital and moaned with discomfort. Review of Resident #110's Hospital History and Physical (H&P), dated [DATE] at 11:19 PM, revealed the resident experienced pain upon arrival to the hospital. The ED Hospitalist documented the resident had a large ulcer on his/her sacrum that was painful. Review of Resident #110's Hospital Palliative Care APP's note, dated [DATE] at 3:28 PM, revealed the resident presented with several wounds and a painful large wound. Further review of the Palliative Care Note revealed Resident #110 had been ordered [MEDICATION(S)] four (4) mg intravenous (IV) every three (3) hours PRN related to wound pain. Interview with State Registered Nurse Aide (SRNA) #11, on [DATE] at 1:50 PM, revealed Resident #110 hurt all the time, especially when he/she was moved. She stated the resident could not tolerate lying on his/her right side. SRNA #11 stated the resident had a hand touch call light (required only a touch to call the nurse). However, the SSA Surveyor observed, on [DATE] at 9:20 AM, the resident did not have an adaptive hand touch call light. Interview with Agency SRNA #21, on [DATE] at 3:04 PM, revealed Resident #110 yelled when he/she needed help and was a total assist for everything, including feeding, changing, and turning due to contractures and chronic pain in both hands. SRNA #21 stated, You can barely touch the resident, and (he/she) will scream out in pain. Per interview, she stated Resident #110 was in chronic pain and usually had bilateral [CONDITION(S)] in all extremities. SRNA #21 stated she would report Resident #110's pain to the nurses. Interview with SRNA #19, on [DATE] at 1:43 PM, revealed she had cared for Resident #110. SRNA #19 stated Resident #110 complained of chronic pain in his/her right arm and would scream out in pain when touched, moved, or when checked for incontinence or when change in clothing was performed. She stated when residents complained of pain, staff repositioned them, provided comfort measures, and if unrelieved, informed the nurse. SRNA #19 stated if something further needed to be done, the aides could go directly to the Unit Manager. In addition, SRNA #19 stated she would and did report Resident #110's pain to the nurses. Interview with Registered Nurse (RN) #3, on [DATE] at 8:30 AM, revealed Resident #110 did not complain, but if he/she needed assistance he/she would yell out for staff instead of using the call light. RN #3 stated she relied on the SRNA's to alert her about a resident's pain status, and it was important for SRNA's to tell nurses if residents were in pain so the Physician or APRN could get something ordered. Further interview revealed RN #3 utilized a numerical pain scale with alert residents, and a non-verbal scale if a resident was crying, moaning, or was unable to verbalize pain. Interview with LPN #13, on [DATE] at 3:55 PM, revealed she worked with Resident #110 and stated that he/she suffered from chronic pain, especially in the right arm. LPN #13 stated she would expect to see a pain level assessed if the resident was verbal, and if nonverbal, she would expect the nurse to assess for nonverbal cues. She stated she relied on aides to alert her to any CIC they saw in a resident, but she did not recall aides alerting her to Resident #110's pain. LPN #13 stated Resident #110 was getting scheduled pain medication prior to his/her [DATE] admission to the hospital. Per interview, upon readmission to the facility from the hospital, nurses completed a medication reconciliation and then would review the orders with the Physician or the APRN to determine new orders. In addition, she stated the resident would continue on hospital discharge orders until seen by the Physician or APRN. Furthermore, LPN #13 stated any resident that was on a scheduled narcotic pain medication and was sent back from the hospital with it ordered on an as needed (PRN) basis, should have the order clarified with the Physician or the APRN. Per interview, LPN #13 stated she would have questioned why Resident #110 was sent back to the facility on a three (3) day supply of narcotics after being on scheduled narcotics prior to admission. However, LPN #13 stated an agency nurse probably would not have questioned the order because he/she would not be as familiar with the residents. Additionally, LPN #13 stated the nurses were responsible for readmission assessments, which included observing for signs and symptoms of pain. She stated it was not good nursing practice to fail to do this, and it was important to do resident assessments and accurate documentation to ensure quality care was given. Telephone interview with Agency LPN #14, on [DATE] at 10:26 AM, revealed she worked all units and had cared for Resident #110 four (4) or five (5) times. Per interview, LPN #14 stated Resident #110 complained of pain anytime he/she was asked. LPN #14 recalled the last time she was assigned to him/her, there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed she did not notify the Physician or APRN about continuing the medication because she assumed it would be addressed due to the resident's need for it related to chronic pain. Interview with the Unit Manager (UM), on [DATE] at 1:49 PM, revealed upon admission or readmission, it was the responsibility of the UM to reconcile hospital discharge orders and inform the on-call physician for review. She stated the UM then faxed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, the UM updated the Care Plan and documented in the Nursing Progress Notes of the admission or readmission. The UM stated she then notified the staff nurse on the unit of his/her assignment to the resident. Interview with Agency LPN #10, on [DATE] at 9:40 AM, revealed she was aware of Resident #110's chronic pain. LPN #10 stated, (He/she) complains of pain with every change. She stated the resident did not open the left hand due to pain. Additionally, LPN #10 stated Resident #110 had bilateral [CONDITION(S)] in all extremities. Additional interview with Agency LPN #10, on [DATE] at 1:49 PM, revealed she did not recall that she updated Resident #110's Quarterly MDS Pain Assessment Interview, on [DATE], in which she documented Resident #110's self-reported pain as constant, moderate pain and rated it at an eight (8) out of ten (10) with ten (10) being the worst. LPN #10 stated if the resident reported pain and rated it as an eight (8), an assessment and administration of pain medication would be indicated. However, LPN #10 stated she did not know Resident #110 was not being given medication for his/her chronic pain and thought he/she was receiving scheduled narcotics. Furthermore, LPN #10 stated no one had followed-up on Resident #110's discharge orders and medication reconciliation, upon the resident's readmission on [DATE]. LPN #10 stated the importance of medication reconciliation, follow-up, and assessment was to make sure the resident was comfortable and his/her needs were being met. Interview with the Nurse Educator/Wound Care Nurse, RN #2, on [DATE] at 9:00 AM, revealed she was following Resident #110 for wounds on his/her toe, forehead, and shearing on the right buttock. Per interview, RN #2 stated she would have to be very gentle with Resident #110 when moving the resident's extremities to perform wound care because of his/her issues related to chronic pain. Furthermore, RN #2 stated Resident #110, when touched, would moan and grimace. RN #2 stated she did not document Resident #110's non-verbal pain response to care and treatments or his/her pain level. Further interview revealed if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN #2 did not recall providing pain medication to Resident #110 prior to wound care treatments. Interview with the ADON (Assistant Director of Nursing), on [DATE] at 4:40 PM, revealed she was not made aware that nursing staff failed to notify the Physician or the APRN to reorder the resident's scheduled narcotic pain medication after the three (3) day order had expired on [DATE]. She stated all readmissions were reviewed in clinical meetings, but she did not recall reviewing Resident #110's hospital discharge orders. Per interview, it was the ADON's expectation that nursing staff clarified orders with the provider, so the correct orders were followed. Furthermore, she stated she expected nurses to assess and document resident's assessments, using the numerical pain scale of one (1) to ten (10) with ten (10) being the worst pain, and for nonverbal residents, using the Morse Pain Scale (uses faces to mimic pain levels). The ADON stated it was important to use the pain scale to understand better a person's pain and to measure the effectiveness of treatment. In addition, the ADON stated she expected nursing staff to assess pain according to what the resident self-reported and to never assume the degree to which a resident was in pain because it could harm residents, stating Pain is what the resident says it is. Per interview, it was the ADON's expectation that nursing staff would notify the Physician or APRN for a resident's unresolved pain or clarification of orders should there be any question regarding a resident's care to ensure the resident was comfortable and correct care was being given. However, record review revealed there was no documented evidence the nursing staff notified the Physician that the resident was no longer on schedule Oxycodone with Acetaminophen after returning from the hospital. Furthermore, there was no documented evidence that the nursing staff notified the Physician of a CIC related to pain, according to facility policy. Interview with the Regional Clinical Quality Specialist (RCQS), on [DATE] at 3:40 PM, revealed it was her expectation that nursing staff utilized skilled charting to document the resident's pain level using a scale of one (1) to ten (10) with ten (10) being the worst pain, as well as assess for nonverbal pain cues. Per interview, it was important to assess, using a pain scale, to indicate the resident's response to questions about pain to determine treatment and alleviate suffering. The RCQS stated staff should not assume a resident's tolerance of pain, and pain was what the resident considered as pain. Per interview, she was not aware Resident #110 was not receiving scheduled pain medication. Furthermore, she stated nursing staff was to reassess the resident's pain level after administration of pain medications for effectiveness and document its effectiveness on the Medical Administration Record (MAR). The RCQS stated, with Resident #110's pain management, there was a communication breakdown because there was no documented evidence the nursing staff notified the Physician or the APRN of a CIC related to pain, according to facility policy. Further interview with the RCQS, revealed the DON reviewed each resident's pain level scores; if the resident was rated at a 0, she did not follow-up with the resident. Additional interview with the RCQS, on [DATE] at 5:06 PM, revealed it was the nurse's responsibility to ensure medications were verified with the Admitting/Readmitting Physician and necessary prescriptions were obtained and sent to the Pharmacy. Per interview, after an admission/readmission, it was also the Unit Manager's responsibility to contact the on-call provider for necessary prescriptions. The RCQS stated it was important that residents received ordered pain medication to ensure optimum care, effective treatment, and control of pain, according to facility policy. Interview with the APRN, on [DATE] at 2:30 PM, revealed she was aware the resident had chronic pain and mobility issues, used opioid medications and took Oxycodone ,d+[DATE] mg (milligrams), one (1) tablet by mouth every six (6) hours, scheduled, prior to his/her admission to the hospital on [DATE]. However, nursing staff did not make her aware the Oxycodone ,d+[DATE] mg, one (1) tablet by mouth every six (6) hours as needed for pain was only prescribed for three (3) days and was PRN. She stated Resident #110 had chronic pain and that most recently in the last months, she changed the resident's pain medication from PRN to scheduled, four (4) times a day for better pain control. Per interview, if she had known, she would have ordered to continue the scheduled Oxycodone ,d+[DATE] mg four (4) times a day. However, record review revealed no documented evidence the nursing staff notified the APRN that the resident was no longer on scheduled Oxycodone after returning from the hospital. Furthermore, there was no documented evidence the nursing staff notified the APRN of a CIC related to pain, or followed the resident's care plan related to pain, according to facility policy. She further stated it was her expectation for staff to inform her if there was a discrepancy with orders. The APRN stated she would have ensured Resident #110 had his/her pain medication. Interview with the Physician, on [DATE] at 10:15 AM, revealed he was aware the resident was receiving Tylenol for pain; however, he was not aware the Oxycodone ,d+[DATE] mg four (4) times a day, scheduled, had not been renewed after a three (3) day prescription from the acute care facility. He stated he would have expected staff to notify him or the APRN that the order had expired. Per interview, expiring medications were put into a book that was on each unit, which he or the APRN reviewed on each visit to the facility. However, the Physician stated there were no view alerts to let the providers know if a medication was expiring, the nursing staff was responsible for the alert. Further interview revealed, before reducing a narcotic that the resident had taken for a period of time, he looked at the duration the resident had been on the narcotic and could gradually decrease the frequency or the dosage given. He stated, in reducing narcotic pain medication, or at any time, he depended on nurses to inform him if a resident was having or continued to have pain or had increasing pain. There was no documented evidence the nursing staff notified the Physician the resident was no longer on scheduled Oxycodone after he/she returned from the hospital. Interview with the Director of Nursing (DON), on [DATE] at 9:18 AM, revealed residents with pain should have a pain assessment completed; the pain assessment was triggered in the Electronic Medical Record (EMR) and alerted the nurse to assess and document interventions. The DON stated it was important to assess, using a pain scale, to indicate the resident's response to questions about pain to address and treat the resident appropriately. Regarding resident admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she expected nurses to assess for pain when a resident returned from the hospital, and if a resident had a complaint of pain, the nurse would discuss his/her assessment with the Physician, who would follow-up, possibly with new orders. The DON stated that follow-up on admission/readmission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per interview, the DON stated there was no documented evidence the nursing staff notified the Physician that the resident was no longer on scheduled Oxycodone, after returning from the hospital. Interview with the Administrator, on [DATE] at 5:28 PM, revealed she expected residents with pain to have pain management per standards of practice; pain should be assessed and documented when noted. Continued

Based on observation, interview, record review, review of the facility's Policies, and review of the facility's Investigation, it was determined the facility failed to develop and implement a Baseline Care Plan for each resident that includes instructions needed to provide effective and person-centered care for one (1) of eight (8) sample residents (Resident #1). Although Resident #1 was assessed by the facility on admission as requiring supervision with smoking, there was no documented evidence the Baseline Care Plan was developed with interventions for supervised smoking. In addition, the facility failed to assess the resident for elopement risk upon admission, therefore they did not develop a Baseline Care Plan with interventions for supervision and monitoring related to risk for elopement, due to the resident's severe cognitive impairment. On 06/13/19 at approximately 12:30 AM, State Registered Nursing Assistant (SRNA) #5 assisted Resident #1 with leaving the building to smoke by entering the code into the keypad allowing the resident to exit the front door. SRNA #5 was unaware of the resident's supervision level and asked SRNA #1 if the resident could leave the building unsupervised to smoke. Although neither SRNA #5 nor SRNA #1 knew Resident #1's supervision level, the resident was allowed outside with no supervision. At approximately 12:35 AM, Resident #3 reported to LPN #1, he/she witnessed Resident #1 leaving the property. Resident #1 wandered approximately two tenths (0.2) of a mile off the property grounds and was located at the local Fire Department at approximately 8:15 AM. The Fire Department then transported Resident #1 to the local Hospital Emergency Department related to his/her abrasions and injury to the right hand. The Hospital ED Note revealed Resident #1 sustained Abrasions to the Right Elbow and Knee; and Traumatic Petechia to the right portion of the Scalp. Additionally, the X-Ray of the resident's Right Hand revealed Comminuted Fractures to the Fifth Finger and Fracture to the Middle Finger of the Right Hand. Resident #1 returned to the facility on [DATE] at 1:00 PM, with a Splint on the right hand. (Refer to F-689) The facility's failure to have an effective system in place to ensure each resident's Baseline Care plan was developed and implemented related to providing increased supervision for at risk residents has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) was identified on 06/21/19 and determined to exist on 06/13/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/28/19, alleging removal of the Immediate Jeopardy on 06/25/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/25/19, prior to exit on 06/28/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility Person Centered Care Plan Policy, effective revised 03/01/18, revealed the center must develop and implement a Baseline Person Centered Care Plan within forty-eight (48) hours for each resident that includes instructions needed to provide effective and person centered care that meet professional standards of quality of care and must include the minimum healthcare information necessary to take care of the resident. Review of the facility Elopement of a Patient Policy, revised 05/15/14, revealed residents will be evaluated for elopement risk upon admission, re-admission, quarterly and with change in condition as part of the nursing assessment process, with those identified as a risk receiving appropriate interventions to reduce risk and minimize injury. Continued review revealed the facility should complete an Elopement Evaluation, with individual risk factors and patterns identified and address within the care plan. Review of the facility Smoking: Resident Policy, revised 12/15/11, revealed for Residential Facilities that allow smoking, smoking will be permitted in designated areas only with residents who wish to smoke. Residents will be assessed upon admission, annually or per state regulation and with change of condition for the ability to smoke safely and if necessary, will be supervised. Review of Resident #1's Clinical Record revealed the facility admitted the resident on 06/03/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing Assessment, dated 06/03/19 at 2:00 PM, signed by LPN #6, revealed the resident was admitted from the hospital by wheelchair for long term care placement related to a [DIAGNOSES REDACTED].#1's admission and orders were verified. Review of the Smoking Risk Evaluation, dated 06/04/19 at 2:00 PM, signed by LPN #6, revealed Resident #1 was assessed to need supervision with smoking related to poor memory, and unable to demonstrate the location of the smoking areas. However, further record review revealed there was no documented evidence LPN #6 completed an Elopement Evaluation on Resident #1 upon admission, as per Policy. Review of the Baseline Care Plan, revealed a problem initiated 06/04/19, revealing the resident had the potential for adjustment issues related to new placement. The goal, which was initiated 06/04/19, revealed the resident would demonstrate increased involvement in establishing social connections. The interventions included: allow the resident opportunities for choice during care/other/ activities to provide a sense of control; and provide psychosocial support as needed. However, there was no documented evidence of interventions to address the need for supervision while smoking. In addition, there was no documented evidence of the supervision level required to keep the resident safe. The Kardex (Nurse Aide Care Plan) which was in effect upon Resident #1's admission, prior to 06/13/19 was requested; however, this document was computerized and did not indicate the dates interventions were initiated. Phone interview with LPN #6, on 06/20/19 at 6:45 PM, revealed she did recall going over the Admission Assessments during orientation; however, she thought the Unit Manager, was to complete the Elopement Risk Assessment upon a resident's admission. She further stated it would be important to complete an Elopement Risk Assessment on all new admissions to ensure the Baseline Care Plan addressed interventions to be implemented to keep residents safe who were at risk for elopement. Additional interview with LPN #6, revealed she should have ensured Resident #1's Baseline Care Plan was developed with interventions to be implemented related to the resident's need for supervision while smoking as per the Smoking Risk Evaluation, she completed on admission. Further interview revealed she should have ensured Resident #1's Baseline Care Plan was developed with interventions related to the need for supervision due to the resident's cognitive status and [DIAGNOSES REDACTED].#6 stated either the Admission Nurse or the Unit Manager could initiate the Baseline Care Plan. Review of the Admission Minimum Data Set (MDS) Assessment, dated 06/10/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of five (5) out of fifteen (15), indicating the resident was severely cognitively impaired. However, there was no documented evidence the facility ensured Resident #1's Baseline Care Plan was developed with interventions related to the resident's severe cognitive impairment. Review of the facility's Long Term Care Facility-Self Reported Incident Form -Five (5) day Follow Up/Final Report, and attachment dated 06/17/19, signed by the Center Executive Director (CED), revealed on 06/13/19 at 12:30 AM, a SRNA responded to an alarming front door, and Resident #1 and another resident (Resident #2) were noted to be at the front door. Although SRNA was not sure if Resident #1 was allowed to be out unsupervised, Resident #1 insisted on going out with the other resident who was going off the property to smoke. Further review revealed the SRNA immediately reported Resident #1 had gone outside to the Charge Nurse (Licensed Practical Nurse #1). The Charge Nurse and the SRNA were then notified at 12:35 AM by another resident (Resident #3) that Resident #1 had left the independent smoking area, which was located just off the facility property and had walked up the road. The SRNA and the Charge Nurse went outside to look for Resident #1, circled the parking lot and went up the sidewalks and up the road. However, staff was unable to find Resident #1 and the Charge Nurse then went back into the building and asked all units to perform a complete head count. Per the Incident Form, the Charge Nurse again went outside to look for the resident using her vehicle and was unable to locate the resident. Subsequently the Charge Nurse contacted the Manager on Duty, the local authorities, and the Center Executive Director at an unspecified time. Per the Incident Form, Resident #1 was located on the property of the local Fire Department four tenths (0.4) of a mile from the facility. The Fire Department expressed Resident #1 was in stable condition, but they were taking him/her to the local hospital to be checked out. Additional review of the Incident Report revealed Resident #1 returned to the facility on [DATE] at 1:00 PM. Review of the Hospital Emergency (ER) Department Notes, dated 06/13/19, revealed Resident #1 presented to the ER after a fall and injury to the right hand. Per the Notes, the resident stated he/she fell down a hill and complained of right hand pain. According to the Note, there was swelling and ecchymosis of the lateral right hand and the patient would not flex or extend the right fifth digit. X-Ray of the right hand performed 06/13/19, revealed, Findings: Comminuted Fracture of Proximal Aspect of the Fifth Proximal Phalanx; and [MEDICAL CONDITION] Aspect of the Second Middle Phalanx, which was also suspected to be Comminuted. Per the Note, an Ulnar Gutter Splint was applied, and [MEDICATION NAME] (narcotic pain medication) provided and will follow up with Orthopedist. Interview on 06/20/19 at 11:17 AM, with SRNA #5, revealed on 06/13/19 at 12:30 AM, she was working the night shift when she observed Resident #1 and Resident #2 at the front door asking to go out to smoke. She further stated she did not know if Resident #1 was allowed to go outside to smoke independently so she asked SRNA #1, who was coming towards the front door. Per interview, SRNA #1 was not sure if Resident #1 was allowed to go outside by himself/herself to smoke, but by then Resident #1 had already left the building. SRNA #5 stated SRNA #1 then went to check with the Nurse on the 100 Unit about Resident #1's supervision level. Additional interview with SRNA #5, revealed there was a sign out book at the nurse's station and in the front of the book was a list of residents who could smoke unsupervised. She further stated staff were to check the smoke list and the Elopement Binder before residents could go outside independently to smoke to ensure they were assessed as able to go outside to smoke by themselves. Further interview revealed the SRNAs did have a Kardex (Nurse Aide Care Plans) to review related to residents' supervision level as well; however, she did not check the Kardex, nor did she check the Elopement Binder or the sign out book smoker list prior to Resident #1 being allowed to go outside unsupervised on 06/13/19. Interview with SRNA #1, on 06/19/19 at 8:48 PM, revealed on the morning of 06/13/19, she heard the front door alarm between 12:00 AM and 12:30 AM and saw Resident #1 and Resident #2 going out the front door at that time. SRNA #1 stated she knew Resident #2 was able to leave the facility unsupervised to smoke, but was not sure of Resident #1's supervision level for smoking or leaving the facility. She stated she asked Resident #1 if he/she could leave the building unsupervised, but the resident did not answer. Further interview with SRNA #1, revealed she then left the front of the building and went to the Unit 100 nurses station to ask LPN #1 if Resident #1 could go outside to smoke unsupervised, and the nurse stated she was unsure. Per interview, LPN #1 could not find the sign out book to see if the resident was on the list to be able to go outside to smoke unsupervised. SRNA #1 stated interventions from the Care Plan were also on the Kardex for the SRNAs to use as a guide; however, she did not think to check the Kardex for the resident's supervision level. Interview with LPN #1, on 06/20/19 at 2:45 PM, revealed she was the nurse in charge of the 100 Unit on 06/13/19, when SRNA #1 came to the nurse's station around 12:30 AM, while she was counting medications with the pharmacy representative and notified her Resident #1 went outside unsupervised to smoke. Per interview, SRNA #1 questioned if the resident needed to be supervised when outside smoking. Interview revealed she told SRNA #1 she was not sure if Resident #1 was allowed to smoke outside unsupervised and she was unable to find the sign out book with the list of residents who could smoke unsupervised. Interview with the 100 Unit Manager, on 06/19/19 at 5:30 PM, and on 06/27/19 at 3:45 PM, revealed Resident #1 resided on the 100 Unit at the time of he/she eloped. Per interview, staff failed to complete an Elopement Risk Evaluation for Resident #1 upon admission, and therefore the Baseline Care Plan did not address the need for supervision when going outside related to the resident's cognitive impairment. She further stated, although the Smoking Evaluation was completed for Resident #1 upon admission, the Baseline Care Plan was not developed with interventions to be implemented for supervision while smoking. She stated it was her responsibility to review the admission paperwork within twenty-four (24) to forty-eight (48) hours to ensure the assessments, admission paperwork, and Baseline Care Plans were complete; however, she failed to do this for Resident #1. Per interview, residents who were at risk for elopement or who needed supervision for smoking should be care planned for those safety interventions on the Baseline Care Plan in order for the staff involved in the residents' care to have access to this information. Interview with the MDS Coordinator, on 06/28/19 at 10:15 AM, revealed it was important for the Admission Nurse or the Unit Managers to complete the Smoking Assessments and Elopement Risk Evaluations for new admissions in order identify the resident's risk factors and develop the Baseline Care Plan. Per interview, the Baseline Care Plan was an important tool for staff as it provided guidance on how to deliver care to the residents. She stated once interventions were developed on the Baseline Care Plan the interventions were automatically pulled over into the Kardex for the SRNAs to utilize in providing care. Per interview, Resident #1's Baseline Care Plan should have been developed and implemented with interventions related to smoking supervision. Further interview revealed the resident's Baseline Care Plan also should have been developed related to supervision needed to keep the resident safe related to his/her cognitive status. Interview with the Assistant Director of Nursing, (ADON), on 06/27/19 at 2:00 PM and on 06/28/19 at 10:00 AM, revealed she assisted with training nurses and SRNAs on the facility policies and procedures on hire and during the year. She stated she also trained nurses during orientation on admission procedures to include Admission Assessments, Smoking Assessments, Elopement Risk Assessments and Baseline Care Plans. Per interview, nurses sign a checklist after orientation to indicate they understand and have been trained related to these procedures. Further interview revealed Resident #1's Elopement Risk Evaluation was not completed on admission; however, the resident's BIMs score was low on admission, and therefore the Baseline Care Plan should have addressed the resident's need for supervision related to his/her cognitive status. She further stated the resident's Baseline Care Plan did not address the need for smoking supervision, even though the Smoking Assessment on admission revealed the resident required supervision with smoking. Interview with the Medical Director (MD), on 06/20/19 at 11:43 AM, revealed she was informed Resident #1 eloped after the resident was found on the morning of 06/13/19. Further interview revealed it was important to ensure both the Elopement Risk Evaluations and Smoking Assessments were completed on admission. Per interview, Resident #1's needs related to smoking supervision and supervision when going outside should have been addressed on the Baseline Care Plan. Interview with the Center Nurse Executive (CNE), on 06/21/19 at 3:30 PM, revealed staff failed to complete an Elopement Risk Assessment for Resident #1 upon admission and therefore did not identify the resident's risk for elopement related to the resident's cognitive status. She stated the 100 Unit Manager missed this with her audits. Further interview revealed the Smoking Evaluation completed on admission revealed the resident required supervision with smoking. However, she stated the resident's Baseline Care Plan was not developed and implemented related to the need for supervision with smoking. Further interview revealed the resident's Baseline Care Plan was not developed and implemented related to the need for supervision related to impaired cognitive status. Interview with the Center Executive Director, on 06/21/19 at 3:45, revealed it was her expectation for staff to follow the facility's policies and procedures related to accurately completing all admission paper work for new admissions to include Smoking Evaluations, Elopement Risk Evaluations and Baseline Care Plans. Per interview, it was important for any risks identified on the smoking and elopement assessments to be addressed on the Baseline Care Plan. Additional interview revealed the Baseline Care Plan needed to be developed with interventions to keep the residents safe and this information needed to be communicated to the staff involved with the resident's care. Additional interview revealed Resident #1's Baseline Care Plan was not developed and implemented with instructions to keep the resident safe. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/28/19, with the facility alleging removal of the Immediate Jeopardy on 06/25/19. Review of the AoC revealed the facility implemented the following: 1. On 06/13/19 at 1:00 PM, Resident #1 returned to the facility from the Hospital Emergency Department by Emergency Medical Services (EMS). On 06/13/19, Resident #1's Elopement and Smoking Evaluations were completed by the Unit Manager and Resident #1's Care Plan was updated by Social Services and the Unit Manager to reflect the resident's safety/supervision needs. 2. On 06/13/19, an Ad Hoc Quality Assurance Performance Improvement (QAPI) Committee meeting was held with members including the Center Executive Director (CED), Center Nurse Executive (CNE), Assistant Director of Nursing (ADON), Unit Manager (UM), Clinical Reimbursement Coordinator (CRC), Business office Director, Maintenance Director, Social Service Personnel, Guest Services, Director of Rehab, Clinical Quality Specialist (CQS), Dietician, Housekeeping Supervisor and Medical Director. Recommendations were discussed regarding the action plan including audits; visual audits; re-education and compliance monitors for residents at risk for elopement; elopement policy; elopement re-education to take place; elopement evaluations; care plans that were to be completed; tasks for checking doors; and running elopement drills. 3. An Elopement drill was conducted on first (1st) shift on 06/13/19 at 12:12 PM, followed by elopement drills across all shifts. Re-education and corrective action was completed upon discovery provided by the CNE, CED, ADON, Unit Managers and members of the QAPI Committee and Charge Nurses. Elopement drills included total facility participation including a head count of residents to determine all residents were in the facility. 4. Unit Managers re-assessed all smoking residents for smoking needs on 06/13/19. Thirty-six (36) of one hundred and thirty-three (133) residents were identified as smokers. 5. Unit Managers re-assessed all in house residents for elopement risks and five (5) residents were identified as at risk for elopement on 06/13/19 and 06/14/19. 6. Visual audits of all five (5) residents at risk for elopement to be completed daily by the CED, CNE, ADON, and Guest Services Director, starting 06/13/19. 7. The CRCs updated the Care Plans as needed related to elopement risk on 06/13/19 and 06/14/19. Kardexes were audited with corrective action taken on 06/14/19 by the CNE to ensure all Kardexes identified the elopement risk residents. 8. Doors checks to determine all doors were secured and functioning properly to prevent resident entrance to unsupervised areas was completed by the Maintenance Director on 06/13/19 and again on 06/14/19. All Doors and alarms were functioning properly. 9. Door Audits and alarm audits will be completed by the Maintenance Director weekly for one (1) month and then monthly thereafter, with immediate corrective action upon discovery of malfunction. 10. All Elopement Binders were reviewed on 06/14/19, by the Assistant Director of Nursing (ADON), to determine residents at risk for elopement had current information and current photos present. 11. Smoking Binders and Elopement Binders will be reviewed daily for two (2) weeks by the CNE, ADON and /or Unit Manager with each new admission or re-admission, and weekly thereafter, with immediate corrective actions upon discovery. 12. The CNE and CED were re-educated on the elopement policy and procedures by the CQS with a post- test and passing score of 100% on 06/13/19. 13. Re-education began on 06/13/19, with all staff including contracted staff, related to the elopement policy and location of listing of residents appropriate to sign themselves out with post- test of a passing score of 100% required to validate understanding. This education was presented by the Nurse Practice Educator (NPE)/ ADON, CNE or Unit Managers. The education included: staff was not to assist a resident with exiting the building without first verifying the resident was permitted via the provided list of residents who could sign out independently. One hundred twenty-five (125) out of one hundred thirty-seven (137) employees received the education/post-test as of 06/14/19. Staff who did not receive the education including staff on Family Medical Leave (FML), PRN (as needed) staff, staff on vacation, and contract staff will receive education and post-test prior to starting their next shift presented by the CNE, Resource Nurse, Unit Managers and/or Licensed Nurses with post-test to validate understanding and a passing score of 100 % required. All newly hired employees and contract employees will receive elopement education and complete post-test during orientation by the CNE, Unit Manager and or Licensed Nurse. 14. Elopement drills will be conducted across all shifts daily for two (2) weeks including weekends, three (3) times a per week for two (2) weeks, weekly for eight (8) weeks, every other week for eight (8) weeks, monthly for one (1) month, then as determined by the QAPI committee. 15. The CED, and CNE will review results of the elopement audits/drills, and visual audits of residents determined to be at risk for elopement to ensure they are not exiting the facility without supervision daily. Staff interviews and visual audits that staff are following care plans with regards to care planned smoking and/or elopement supervisory needs will be reviewed daily by the CED, CNE, the ADON. 16. On 06/24/19, the Ad Hoc QAPI Committee including the CED, CNE, ADON, Unit Manager, CRC, Business Office Manager, Guest Services, Director of Rehab, Clinical Quality Specialist (CQS), Dietician, Housekeeping Supervisor and Medical Director completed recommendations for the action plan including audits, re-education, and compliance monitors to ensure Baseline Care Plans were completed and accurately reflect the supervision needs of residents who smoke or are at risk for elopement. 17. Re-education began on 06/24/19, by the CNE, Unit Manager or ADON for licensed staff, including contracted licensed staff, related to the Care Plan policy including Baseline Care Plan; and need for a Smoking Evaluation and Elopement Risk Evaluation when completing the Baseline Care Plan. Education was provided to twenty-six (26) of thirty-three (33) licensed staff with a post-test and passing score of 100%. Licensed staff and contract licensed employees not available will be provided re-education and complete post-test upon return to work before providing resident care by the CNE, ADON or Unit Manager. All remaining licensed nurses who were on FML, or PRN staff would receive education and post-test prior to starting their next scheduled shift, by the CED or the ADON. All newly hired employees and contract employees (licensed staff) will have Care Plan and Baseline Care Plan education and complete post-test with a passing score of 100% during orientation by the CNE, Unit Manager and/or ADON. 18. All new admission and re-admission Care Plans will be audited by the CNE, CRC, ADON, Unit Managers or Licensed Nurses to ensure Baseline Care Plans address health and safety concerns, including information obtained from Smoking and Elopement Evaluations, to meet resident needs across all shifts daily for two (2) weeks including weekends, three (3) times a week for two (2) weeks, weekly for eight (8) weeks, every other week for eight (8) weeks, monthly for one (1) month, then as determined by the QAPI committee. 19. Interviews with five (5) random staff members on each shift regarding interventions/supervision status on Care Plans and Baseline Care Plans regarding residents who smoke or are at risk for elopement will be completed by the CNE, CED, Charge Nurses, Unit Managers and Manager on Duty for two (2) weeks including weekends, three (3) times a week for two (2) weeks, weekly for eight (8) weeks, every other week for eight (8) weeks, monthly for one (1) month, then as determined by the QAPI committee. 20. Trends identified from audits will be reported monthly for six (6) months to the QAPI committee. The State Agency validated the implementation of the facility's AoC as follows: 1. Review of Resident #1's Progress Note, dated 06/13/19 at 3:34 PM, revealed the resident returned to the facility per stretcher. Review of Resident #1's Smoking Evaluation, dated 06/13/19 at 12:59 PM, completed by the 100 Unit Manager, revealed the resident required supervision with smoking related to poor memory and was unable to demonstrate the location of designated smoking areas. Review of Resident #1's Elopement Evaluation, dated 06/13/19 at 12:54 PM, completed by the 100 Unit Manager, revealed the resident was at risk for elopement related to a history of elopement; history of wandering; had expressed the desire to leave; was unable to locate significant landmarks without assistance; and had impulsiveness. Review of Resident #1's Comprehensive Care Plan initiated 06/13/19, revealed the resident was at risk for elopement related to cognitive loss and [MEDICAL CONDITION]. The goal stated the resident would not attempt to leave the facility. There were several interventions including Wanderguard. Interview with the 100 Unit Manager, on 06/27/19 at 3:05 PM, revealed she and Social Services completed Resident #1's Smoking Evaluation on 06/13/19 and the resident was assessed as requiring supervised smoking. Further review revealed on that date she also completed Resident #1's Elopement Evaluation, revealing the resident was at further risk for elopement. Continued interview revealed she initiated the resident's Comprehensive Care Plan related to the resident being at risk for elopement on 06/13/19. 2. Review of the QAPI signature page validated the Committee met on 06/13/19 with the CED, CNE, Unit Managers, ADON, CRC, Business office Director, Guest Services, Medical Director, Director of Rehabilitation, Clinical Quality Specialist, Dietician, and Housekeeping Supervisor in attendance Interviews with the Medical Director on 06/20/19 at 10:15 PM; Unit Manager for the 100 Unit on 06/27/19 at 3:05 PM; ADON on 06/28/19 at 10:00 AM; Business office Director on 06/28/18 at 11:00 AM; Guest Services on 06/28/19 at 11:15 AM; CNE on 06/28/19 at 11:35 AM; and CED on 06/28/19 at 12:50 PM; verified a QAPI Committee meeting was held on 06/13/19 and there was discussion related to the action plan including audits; visual audits; re-education and compliance monitors for residents at risk for elopement; elopement policy; elopement re-education to take place; elopement evaluations; care plans that were to be completed; tasks for checking doors; and running elopement drills. 3. Review of the Elopement Drill Forms dated 06/13/19, revealed elopement drills were conducted on 06/13/19 at 12:12 PM, and also Elopement Drills were conducted on 06/13/19 on 2nd (second) and 3rd (third) shifts. 4. Record review revealed Smoking Evaluations were completed on 06/13/19 for all residents identified by the facility as smokers. Review of the Smoking Evaluations completed 06/13/19, revealed thirty-six (36) residents received Evaluations on that date by the Unit Managers. Interview with the 300 Unit Manager, on 06/27/19 at 2:45 PM, and the 100 Unit Manager on 06/28/19 at 3:05 PM, revealed on 06/13/19, they completed Smoking Evaluations for all residents who smoked. 5. Review of the Elopement Evaluations revealed all residents received a new Elopement Evaluation on 06/13/19 and 06/14/19. Interview with the 300 Unit Manager on 06/27/19 at 2:45 PM, and the 100 Unit Manager on 06/28/19 at 3:05 PM, revealed they completed the Elopement Evaluations for all residents on 06/13/19 and 06/14/19. 6. Review of the audits, revealed visual audits were completed daily from 06/15/19 through 06/27/19. Interview with Guest Services on 06/28/19 at 11:15 AM; CNE on 06/28/19 at 11:35 AM; and the CED on 06/28/19 at 12:50 PM; revealed elopement visual audits were performed daily from 06/15/19 through 06/25/19, to ensure the residents were in the building and not attempting to leave the building. 7. Review of the five (5) residents' Care Plans who were identified as elopement risk, revealed there was Care Plans in place related to elopement, and this was verified on 06/27/19. Resident #1's Care Plan was updated related to elopement on 06/13/19. Review of the Kardexes for the five (5) residents who the facility identified as at risk for elopement, revealed the Kardexes had interventions in place in an attempt to prevent elopement. Interview with the CRC, on 06/28/19 at 10:15 AM, revealed she verified the elopement Care Plans were in place for the five residents assessed to be at risk for elopement on 06/13/19, and the 100 Unit Manager initiated Resident #13's elopement Care Plan on 06/13/19. Interview with the CNE, on 06/28/19 at 11:35 AM, revealed she reviewed all Kardexes on 06/14/19, to ensure residents at risk for elopement had interventions as necessary to prevent elopement. 8. Review of the Maintenance TELS Log revealed doors were checked and functioning on 06/13/19 and again on 06/14/19, by the Maintenance Director. Interview with the Maintenance Director, on 06/27/19 at 10:15 AM, revealed he did check all doors and alarms to ensure they were functioning properly on 06/13/19 and 06/14/19, with no concerns noted. 9. Review on 06/27/19 of the Maintenance T

Based on observation, interview, record review, review of the facility's Policies, and review of the facility's Investigation, it was determined the facility failed to have an effective system to ensure each resident received adequate supervision and monitoring to prevent elopement for one (1) of eight (8) sampled residents (Resident #1). The facility admitted Resident #1 on 06/03/19, with a [DIAGNOSES REDACTED]. A Smoking Evaluation completed 06/04/19, revealed the resident required supervision with smoking. However, the facility failed to assess the resident for elopement risk upon admission, as per policy. On 06/13/19 at approximately 12:30 AM, State Registered Nursing Assistant (SRNA) #5 punched in the code on the keypad to the front door, with SRNA #1 present, allowing Resident #1 to propel self outside in the wheelchair unsupervised to smoke. However, neither SRNA #5 or SRNA #1 knew whether Resident #1 required supervision with smoking nor did they know if the resident was safe to go outside without being accompanied by staff. SRNA #1 returned to the 100 Unit where Resident #1 resided to ask Licensed Practical Nurse (LPN) #1 for Resident #1's supervision level; however, LPN #1 was counting medications with the pharmacy representative and afterwards was unable to find the sign out book which contained the list of residents who were allowed to smoke unsupervised, allowing for a delay in monitoring/supervising Resident #1. At approximately 12:35 AM, Resident #3 reported to LPN #1, he/she saw Resident #1 leaving the facility property. Resident #1 wandered approximately two tenths (0.2) of a mile off the property grounds and was found at the local Fire Department at approximately 8:15 AM. The Fire Department administered first aid and transported Resident #1 to the local Hospital Emergency Department. The Hospital ED Note revealed the resident had Abrasions to the Right Elbow and Knee and Traumatic Petechia to the right portion of the Scalp. In addition, the X-Ray of the resident's Right Hand revealed Comminuted Fractures to the Fifth Finger and Fracture to the Middle Finger of the Right Hand. Resident #1 returned to the facility on [DATE] at 1:00 PM, with a Splint on the right hand. Review of the local weather history revealed the temperature was between fifty-nine (59) and sixty-three (63) degrees Fahrenheit and partly cloudy on 06/13/19 and sunrise was at 6:12 AM, during the hours the resident was missing from the facility. The facility's failure to have an effective system in place to ensure each resident received adequate supervision to prevent elopement has caused or is likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 06/21/19 and determined to exist on 06/13/19. The facility provided an acceptable credible Allegation of Compliance (AoC) on 06/28/19, alleging removal of the Immediate Jeopardy on 06/25/19. The State Survey Agency validated removal of the Immediate Jeopardy as alleged on 06/25/19, prior to exit on 06/28/19, with remaining non-compliance at a Scope and Severity of a D while the facility develops and implements a Plan of Correction and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's Elopement of a Patient Policy, revised 05/15/14, revealed residents will be evaluated for elopement risk upon admission, re-admission, quarterly and with change in condition as part of the nursing assessment process, with those identified as a risk receiving appropriate interventions to reduce risk and minimize injury. Continued review revealed the facility should complete an Elopement Evaluation, with individual risk factors and patterns identified and addressed within the care plan. The facility should obtain a current photograph of the resident if risk factors were identified and an Elopement Risk Identification form should be filled out and placed in the Elopement Binder which should be easily accessible to staff. Further review of the Policy, revealed if there is a witnessed elopement, or if staff witness a confused resident or an identified elopement risk resident attempting to leave the center, staff will leave as appropriate to redirect the resident to a safe area and prevent elopement. If the resident cannot be redirected, staff will alert other staff members to notify the supervisor and stay with the resident until he/she is safely returned to the center. Per Policy, if the resident is not found after the search of the center grounds and perimeter, the facility will notify law enforcement. The Supervisor should be notified the resident is missing, then the Center Executive Director (CED) and Center Nurse Executive (CNE), with the supervisor notifying the family. Continued review of the Policy, revealed the facility's Safety Committee will review the incident of elopement and conduct a root cause analysis, correct systems to prevent future incidents and forward the information to the Quality Improvement Committee for further discussion. Sign in/out records will be maintained and used whenever a resident leaves the center grounds alone, with family or with recreational staff and staff will be trained on the Center's door security system and required response to sounding alarm. Additional review of the Policy, revealed Elopement drills will be conducted at a minimum of twice a year and documented on the Elopement Drill Documentation Form or in TELS, with Elopement Drills reviewed by the safety committee. System improvements will be made on the drill results. Review of the Elopement Drill Documentation Form, dated 2006, revealed the steps included: Nurse alerts all staff of missing patient with an announcement code, Medical Alert: activating Missing Patient protocols, patient last seen (location); and each unit sends a person to the unit that announced the code to learn the name and description of the missing patient. Each unit charge nurse directs in house staff to search room to room and all areas of the Center, patient rooms, closets, under beds, shower rooms, utility rooms, offices, dining rooms, stairwells, laundry, kitchen, bathrooms lounges, courtyards and employee lounges. In addition, staff was to search outside building perimeter and grounds; and report all search findings to the person in charge of the Center immediately. Review of the facility Smoking: Resident Policy, revised 12/15/11, revealed for Residential Facilities that allow smoking, smoking will be permitted in designated areas only with residents who wish to smoke. Residents will be assessed upon admission, annually or per state regulation and with change of condition for the ability to smoke safely and if necessary, will be supervised. Further review of the Policy, revealed supervised smoking is defined, as the observer must be in the direct area of the smoker, within eye contact, and able to respond to emergency situations. Review of the facility Electronic Medical Record Training document, undated, revealed facility nurses would be trained to complete Admission Assessments to include Smoking Evaluations, Elopement Evaluations, Bed Rail Evaluations, Skin Assessments, Fall Risk Assessments, and Nutrition Assessments on all new admissions. Review of Resident #1's Medical Record revealed the facility admitted the resident on 06/03/19 with [DIAGNOSES REDACTED]. Review of Resident #1's Admission Nursing Assessment, dated 06/03/19 at 2:00 PM, signed by LPN #6, revealed the resident was admitted from the hospital by wheelchair for long term care placement related to [MEDICAL CONDITION]. Per the Nursing Assessment, the Physician was notified of Resident #1's admission and orders were verified. Review of the Smoking Risk Evaluation, dated 06/04/19 at 2:00 PM, signed by LPN #6, revealed Resident #1 was assessed to need supervision with smoking. The risk factors included poor memory, and unable to demonstrate the location of the smoking areas. However, further record review revealed there was no documented evidence LPN #6 completed an Elopement Evaluation on Resident #1 upon admission. Review of the Baseline Care Plan, revealed a focus problem initiated 06/04/19, stating the resident had the potential for adjustment issues related to new placement. The goal initiated 06/04/19, revealed the resident would demonstrate increased involvement in establishing social connections. The interventions included: allow resident opportunities for choice during care/other/ activities to provide a sense of control; and provide psychosocial support as needed. However, there was no documented evidence of interventions to address the need for supervision while smoking; nor was there documented evidence of the supervision level required to keep the resident safe. Phone interview with LPN #6, on 06/20/19 at 6:45 PM, revealed, although her signature was on Resident #1's Admission Assessment, she did not remember completing the information and she was no longer employed by the facility as of a week ago. Continued interview revealed she did remember receiving education related to the Admission Assessments during orientation; however, she thought the Unit Manager, was to complete the Elopement Risk Assessment upon a resident's admission. Per interview, it would be important to complete an Elopement Risk Assessment on all new admissions to ensure their Baseline Care Plan had sufficient information to keep residents safe. Review of LPN #6's Training Record, dated 09/18/18, revealed she had received education related to completing an Elopement Evaluation on all new admissions. Interview with the 100 Unit Manager, on 06/19/19 at 5:30 PM and on 06/27/19 at 3:45 PM, revealed staff failed to complete an Elopement Risk Evaluation for Resident #1 upon admission. Per interview, she was to review the admission paperwork within twenty-four (24) to forty-eight (48) hours to ensure the assessments and admission paperwork were complete and to evaluate if the resident had any further safety needs; however, she failed to do this for Resident #1. Review of Resident #1's Admission Minimum Data Set (MDS) Assessment, dated 06/10/19, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) Score of five (5) out of fifteen (15), indicating the resident was severely cognitively impaired. Continued review revealed the facility assessed the resident as having no behavioral symptoms, which included not rejecting care and not wandering. Review of the facility's Long Term Care Facility-Self Reported Incident Form -Five (5) day Follow Up/Final Report, and attached Investigation dated 06/17/19, signed by the CED, revealed on 06/13/19 at 12:30 AM, the SRNA responded to an alarming front door, and Resident #1 and another resident (Resident #2) were noted to be at the front door. The SRNA was not sure if Resident #1 was allowed to be out unsupervised. Resident #1 insisted on going out with the other resident who was going off the property to smoke. Per the Incident Form, the SRNA immediately reported Resident #1 had gone outside to the Charge Nurse (LPN #1). The Charge Nurse and the SRNA were notified at 12:35 AM by another resident (Resident #3) that Resident #1 had left the independent smoking area, which was located just off the facility property and had walked up the road. The SRNA and the Charge Nurse went outside to look for the resident, circled the parking lot and went up the sidewalks and up the road. Staff was unable to find Resident #1 and the Charge Nurse then went back into the building and asked all units to perform a complete head count. Per the Incident Form, the Charge Nurse then went back outside to look for the resident using her vehicle and was unable to locate the resident. The Charge Nurse then contacted the Manager on Duty, the local authorities, and the CED at an unspecified time. Per the Incident Form, Resident #1 was found on the property of the local Fire Department four tenths (0.4) of a mile from the facility. The Fire Department expressed the resident was in stable condition, but they were taking him/her to the local hospital to be checked out. Further review of the Incident Form, revealed Resident #1 returned to the facility on [DATE] at 1:00 PM. An Elopement Evaluation was completed; a new BIMS was completed and the resident scored a seven (7) out of fifteen (15), indicating the resident was severely cognitively impaired. A Wanderguard Roam Alert Bracelet was initiated for the safety of the resident as an elopement precaution. Review of the local weather history revealed the temperature was between fifty-nine (59) and sixty-three (63) degrees Fahrenheit and partly cloudy on 06/13/19 and sunrise was at 6:12 AM. Review of the Police Department Records, dated 06/13/19 and 06/14/19, revealed the police were dispatched to the facility on [DATE] at 01:11 AM. Upon arrival to the scene, the Sergeant was advised by the facility, Resident #1 went outside in his/her wheelchair to smoke with another resident at approximately 12:30 AM, and about fifteen (15) minutes later, the other resident came back inside, but Resident #1 did not. At that time, a nurse went outside to look for Resident #1, when another resident informed the nurse he/she had seen Resident #1 walking North on Woodspoint Drive, pushing his/her wheelchair in front of him/her. Several officers canvassed the surrounding area looking for Resident #1; however, the resident was not found. When the Sergeant returned to the facility, the Sergeant advised the facility the resident had not been missing for twenty-four (24) hours and based on the conversations with staff and witnesses the resident did not appear to be in poor mental or physical health or a victim of foul play, thus would not qualify for a Critical Missing Person Report at that time. Per the Police Department Records, the officers involved were not given any information about the resident to make him/her a critically missing person, such as having a state guardian, or cognitive impairment. Continued review of the Police Department Records, revealed on 06/13/19 at 8:20 AM, the Police Department was asked to contact the facility's Center Nurse Executive (CNE). The facility's CNE was contacted and advised the officer the Police had responded to a missing resident call at the facility on 06/13/19 at about 12:30 AM, and the officers searched the area and were unable to locate the resident; and left the scene without taking a Missing Person Report. After speaking to the facility's CNE, the officer contacted the Police Lieutenant for recommendations regarding completing a Missing Person Report for Resident #1. While the officer and the Lieutenant were speaking, the facility CNE contacted the Police Department again to inform them Resident #1 had been found by the local Fire Department in a ravine near the fire station and was being transported to the local hospital. Additional review of the Police Department Records, revealed during a later conversation with the facility's Center Executive Director (CED), the Sergeant was informed Resident #1 was not permitted to leave the building unsupervised due to suffering a [MEDICAL CONDITION] by a Self-Inflicted Gun Shot Wound to the Head in 2004, which was the reason he/she was placed in the care of the facility. The facility's CED confirmed to the Sergeant the resident had remained missing the entire night on 06/13/19 from 12:30 AM until 8:15 AM, when the resident was found in the ravine directly behind the firehouse and transported to the local hospital for an injury to his/her right hand. Interview with the Police Department Captain, on 06/25/19 at 9:02 AM, revealed the call came in to the department related to the missing resident on 06/13/19 at 1:10 AM, and officers were dispatched to the property at 1:11 AM. Per interview, the officers arrived at the property at 1:15 AM and stayed until 1:41 AM. He stated the officers were told Resident #1 did not have any mental impairments, and was only at the facility for rehabilitation, a [MEDICAL CONDITION] disorder, and alcohol withdrawal. Continued interview revealed the facility called the Police Department the morning of 06/13/19 at 8:20 AM for additional information, and at that time Police were told Resident #1 was able to leave the facility freely, but had some minor cognitive issues only. Additional interview with the Police Department Captain, revealed the facility called on 06/13/19 around 8:50 AM and informed the Police, Resident #1 had been located behind the local Fire Department. He stated during a later interview with the CED of the facility, the Police Sergeant was told Resident #1 was not able to leave the facility freely and did have severe cognitive impairment from a [MEDICAL CONDITION] secondary to a Self-Inflicted Gunshot Wound to the Head. The Police Captain stated if the correct information related to the resident's medical history, [DIAGNOSES REDACTED]. Review of the Fire and Emergency Medical Services (EMS) Report, dated 06/13/19, revealed the Fire Department performed a patient assessment on Resident #1 on 06/13/19 at 8:31 AM, and his/her vital signs were assessed as heart rate 108 (normal heart rate for an adult is 60-100 beats per minute); respiratory rate 18 (normal respiration rate in an adult is 12-20 breaths per minute), and blood pressure 158/126 (normal adult blood pressure for an adult is below 120/80). Per the Report, the resident was assessed as verbally confused, cried but was consolable, and was localizing pain to the right dorsal hand. The Glasgow Coma Scale (neurological scale used to assess conscious state of a person) was a thirteen (13), indicating a mild [MEDICAL CONDITION]. Per the Report, the Fire Department was contacted when construction workers alerted them someone was at the bottom of the hill behind the Fire Department on 06/13/19 at 8:15 AM. The Captain on shift notified dispatch and the squad dispatched to find Resident #1 sitting on the ground behind the Fire Department. Resident #1 stated he/she fell out of his/her wheelchair and rolled to the bottom of the hill. Resident #1 complained his/her right hand was hurting, and the resident was moved to his/her wheelchair and walked up the hill with a four (4) point carry. The Captain on duty called the facility on 06/13/19 at 8:30 AM, and was told by facility staff, the resident had been missing for two (2) hours. Per the Report, Resident #1 was then transported to a local hospital with verbal report given to hospital nursing staff. Interview with the Fire Department Captain, on 06/20/19 at 6:30 PM, revealed it was reported to him on 06/13/19 at approximately 8:10 AM, by two (2) construction workers from the hotel next door to the Fire Department, that someone was trying to climb up the hill behind the Fire Department. Per interview, he and other members of the Fire Department then went behind the station and found Resident #1 toward the bottom of the hill and the resident's wheelchair at the top of the hill behind the fire station. Per interview, the firemen assisted Resident #1 into the fire station, and provided him/her with first aid as he/she had some abrasions and had an injury to his/her right hand. The Captain stated Resident #1 was able to state his/her name and verbalized he/she had fallen out of his/her wheelchair and had been out on the hill for hours. Per interview, the Captain called the facility, who stated the resident had been missing for a few hours. The Captain stated he informed the facility they would be transporting the resident to a local hospital for evaluation related to his/her injuries. Per interview, Resident #1 was transported to a local hospital at 8:30 AM. Review of the Hospital Emergency Department (ED) Notes, dated 06/13/19, revealed Resident #1 presented to the ED after a fall and injury to the right hand. Per the Note, the resident stated he/she fell down a hill and complained of right hand pain. The resident had Abrasions of the Right Elbow and Knee, Traumatic Petechia to the right portion of the Scalp, and there was swelling and ecchymosis of the lateral right hand and patient would not flex or extend right fifth digit. An X-Ray of the right hand performed 06/13/19, revealed, Findings: Comminuted Fracture of Proximal Aspect of the Fifth Proximal Phalanx; and [MEDICAL CONDITION] Aspect of the Second Middle Phalanx which was also suspected to be Comminuted. Continued review of the Note, revealed an Ulnar Gutter Splint was applied, [MEDICATION NAME] (narcotic pain medication) was provided and the resident was to follow up with the Orthopedist. Observation on 06/19/19 11:00 AM, of the elopement route, revealed Resident #1 would have ambulated from the 100 Unit Hallway passing the main dining room and the receptionist desk to the front door. The resident would have continued to ambulate through the facility parking lot to a two (2) lane road with a sidewalk. Further observation revealed there was construction on the road leading to the Fire Department, making it a one (1) lane road with traffic going in two (2) directions and a temporary steel plate in the road that had the potential to impede the resident if he/she used the road and not the sidewalk. The facility was noted to be two tenths (0.2) of a mile from the local Fire Department where the resident was located. Observation of Resident #1, on 06/19/19 at 1:00 PM, revealed the resident had a cast to the right hand/arm, and was wearing a Wanderguard/Roam Alert bracelet to the left ankle. Interview was attempted during the observation and the resident stated he/she did not recall how his/her hand had been hurt nor did he/she recall leaving the building on 06/13/19. Observation of Resident #1, on 06/20/19 at 10:30 AM, revealed the resident had a cast to the right hand/arm, and was wearing a Wanderguard/Roam Alert bracelet to the left ankle. Follow-up interview with Resident #1, during the observation, revealed he/she left the building on 06/13/19 and hurt his/hand when he/she fell out of his/her wheelchair behind the Fire Department. Resident #1 stated his/her hand really hurt and he/she did not want to do that again. Interview on 06/21/19 at 9:51 AM with Resident #3, assessed by the facility to have a BIMS score of fourteen (14), out of fifteen (15) indicating the resident was cognitively intact, revealed on 06/13/19 about 12:35 AM, he/she was outside on the bench just off the property, by the bus stop smoking and saw a resident pushing a wheelchair and walking on the road instead of the sidewalk. Resident #3 stated he/she did not know the resident's name but knew he/she was from the 100 Unit. Per interview, Resident #3 went back into the facility and informed the nurse and the aide on the 100 Unit about the resident leaving the immediate vicinity. Resident #3 stated there was no staff outside looking for the resident prior to the time he/she informed staff of the resident walking down the road. Per interview, staff did not know this resident had left the facility until he/she informed them, and at that point, staff began looking for the resident. Interview with SRNA #5, on 06/20/19 at 11:17 AM, revealed on 06/13/19 at 12:30 AM, she was working the night shift when Resident #1 and Resident #2 were observed to be at the front door asking to go out to smoke. Per interview, she opened the front door by punching the keypad code. Continued interview revealed SRNA #5 did not know if Resident #1 was allowed to go outside to smoke independently so she asked SRNA #1, who was coming towards the front door. Per interview SRNA #1 was not sure if Resident #1 could go out to smoke unsupervised. Per interview, Resident #1 had already left the building when SRNA #1 stated she would check with the nurse on the 100 Unit about Resident #1's supervision level. SRNA #5 stated she went back to the 200 Unit where she was working. Per interview, about thirty (30) to forty (40) minutes later she was told by LPN #2, who worked the 200 Unit, Resident #3 saw Resident #1 leave the property and go down the road. SRNA #5 stated she and SRNA #1 searched inside the facility and searched the grounds of the facility for Resident #1, and could not locate the resident. Continued interview with SRNA #5, revealed there was a sign out book at the nurse's station with a list in the front of the book, that showed which residents could go outside to smoke independently and the residents were supposed to sign before they went outside and have staff verify they had signed themselves out. However, she stated staff did not normally check to see if the residents signed the book before allowing the residents to go outside to smoke through the front door, which required a code to be punched into a keypad for the door to open. She further stated there was an Elopement Binder that was also to be checked before residents were allowed to go outside to smoke by themselves, but staff did not usually check this Elopement Binder because staff already knew which residents could go outside to smoke independently. Per interview, Resident #1 should not have been allowed to leave the building without supervision since she and SRNA #1 did not know if the resident was safe to go outside alone or if the resident was allowed to smoke unsupervised. Interview with SRNA #1, on 06/19/19 at 8:48 PM, revealed she worked on the 100 Unit where Resident #1 resided, and on 06/13/19, she heard the front door alarm between 12:00 AM and 12:30 AM. Per interview, she saw Resident #1 and Resident #2 going out the front door at that time. SRNA #1 stated she knew Resident #2 was able to leave the facility unsupervised to smoke, but was unsure of Resident #1's supervision level for smoking or leaving the facility. Per interview, she asked Resident #1 if he/she could leave the building unsupervised, but the resident did not answer. SRNA #1 stated she left the front of the building and went to the 100 Unit nurse's station to ask LPN #1 if Resident #1 could go outside to smoke unsupervised, and the nurse stated she was unsure. Per interview, LPN #1 could not find the sign out book to see if the resident was on the smoking list to be able to go outside to smoke unsupervised. Continued interview revealed shortly after she spoke with LPN #1, Resident #3 informed SRNA#1 and LPN #1 he/she had seen Resident #1 going off the property, and the resident was in the road pushing his/her wheelchair toward the gas station. Per interview, LPN #1 and SRNA #1 then went outside to look for Resident #1 around the boundary of the property and staff checked all the rooms in the facility and were unable to find the resident. Interview with LPN #1, on 06/20/19 at 2:45 PM, revealed she was the nurse in charge of the 100 Unit on 06/13/19, when SRNA #1 came to the nurse's station around 12:30 AM, while she was counting medications with the pharmacy representative and informed her Resident #1 went outside unsupervised to smoke. Per interview, SRNA #1 asked if the resident needed to be supervised when outside smoking. LPN #1 stated she told SRNA #1 to give her a minute to finish with pharmacy and she put the medications in the medication room. Per interview, LPN #1 told SRNA #1 she was not sure if Resident #1 was allowed to smoke outside unsupervised and she was unable to find the sign out book with the list of residents who could smoke unsupervised. Additional interview revealed at approximately 12:35 AM, Resident #3 came to the nurse's station and informed her and SRNA #1 he/she had seen a resident walking in the road past the bus stop by the facility pushing his/her wheelchair and the resident left the property. Further interview revealed SRNA#1 and LPN #1 proceeded to exit the building at 12:35 AM and walk around the property, but could not find Resident #1. LPN #1 stated she and SRNA #1 went back inside at that point and alerted the other units to the missing resident, and gave them a description of the resident. She stated they did not have a photograph of the resident in the hard chart, and the computer was down so she could not access the picture of the resident in the computer to give to staff on other units. Per interview, the resident had not been identified as at risk for elopement prior to 06/13/19, and therefore the resident's picture was not in the Elopement Binder. LPN #1 stated she went back to the 100 Unit and called the 100 Unit Manager, who was the Manager on Duty, to notify her of the missing resident. Per interview, the 100 Unit Manager told LPN #1 to have the staff search outside again and she would call LPN #1 back. LPN #1 stated at that point she and some other staff got in their cars and began to search. Per interview, it was about 1:00 AM when she called the 100 Unit Manager and about 1:05 AM when the Unit Manager called her back and instructed her to call the local Police. Further interview with LPN #1, revealed she called the local Police Department at 1:05 AM, who arrived at the facility shortly afterward. Per interview, LPN #1 helped the police conduct a search through the building upon arrival; however, Resident #1 was not found. She stated the Police Department could not file a police report because the resident did not have mental issues. Per interview, she did not realize after review of Resident #1's hard chart medical record, that the resident was diagnosed with [REDACTED]. Assessment. Per interview, she had not received proper training related to what to do if there was an elopement. (However, LPN #1 signed orientation training related to the facility elopement procedures presented by the Assistant Director of Nursing (ADON) on 12/06/18). Interview with SRNA #4, on 06/19/19 at 11:55 AM, revealed she no longer worked at the facility, but was working on the 300 Unit on 06/13/19, when she was informed by the nurse on her unit a little after midnight, that Resident #1 had eloped. Per interview, the search for the resident was very unorganized, as there was nothing announced over the intercom related to a missing person, and there was no picture of the resident available. Per interview, SRNA #4 helped search the perimeter of the facility property for about thirty (30) minutes and then went back inside the building to finish rounds. Continued interview revealed the Police later arrived and searched the building and the resident could not be located. Per interview, smokers were supposed to sign out before leaving the building to smoke if they were assessed to be able to smoke independently, and staff were to ensure they signed out each time they left the building. Interview with LPN #2, on 06/20/19 at 9:18 PM, revealed on 06/13/19 sometime after midnight, while he was working on the 200 Unit, the nurse from the 100 Unit told him a resident was missing, and the resident was wearing a black shirt and pushing a wheelchair. Continued interview revealed a headcount was done on his unit, and then LPN #2 searched the grounds of the facility, around the building, and then came back in the building after being unable to locate the missing resident. Per interview, LPN #2 was not sure what time he came back in the building, but he was aware the Police were called afterwards. Interview with LPN #5, on 06/20/19 at 11:15 AM, revealed she regularly worked on the 100 Unit, where Resident #1 resided. Per interview, LPN #5 received a call from the 100 Unit Manager, at 5:00 AM on 06/13/19, and was informed Resident #1 was missing. Per interview, since she had worked the night before until 11:26 PM, she was asked when she last saw Resident #1. Per interview, she told the 100 Unit Manager she had last seen Resident #1 on 06/12/19 about 10:30 PM in the

Based on interview, record review, and review of facility Policies, it was determined the facility failed to ensure the Comprehensive Care Plan was revised in order to ensure proper transfer technique for one (1) of thirty-one (31) sampled residents (Resident #10). Resident #10's Discharge Summary from Occupational Therapy, dated 12/06/17, revealed the resident did not achieve his/her goal of independent use of a slide board and required physical assistance from staff during transfer using a slide board. Although the Comprehensive Care Plan was revised on 12/07/17, with an intervention to use the Slide Board for all Transfers, the revised intervention did not include instruction related to the resident requiring physical assist (contact guard assist) and a gait belt with the the slide board transfer. On 02/10/18 at approximately 2:55 PM, Resident #10 was transferred per the slide board by Contract State Registered Nurse Aide (SRNA) #1, without using a gait belt or Contact Guard transfer method as recommended by Occupational Therapy, and the resident slid off the slide board onto the floor. Resident #10 later complained of right leg pain and the night shift nurse assessed the resident to have a large knot to the anterior right knee, below the patella. Resident #10 was transferred to the Hospital emergency room (ER) on 02/11/18 at 12:10 AM, and was diagnosed with [REDACTED]. (Refer to F-689) The findings include: Review of the facility Person Centered Care Plan, Policy, revised 03/01/18, revealed the Care Plan would be reviewed and revised by the Interdisciplinary Team. Per Policy, the Purpose of the Care Plan was to attain or maintain the patient's highest practicable physical, mental, and psychosocial well-being; to promote positive communication between patient, resident representative, and team; to ensure communication; and to optimize clinical outcomes. Review of Resident #10's clinical record revealed the facility admitted the resident on 10/27/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/04/17, revealed the facility assessed Resident #10 as cognitively intact with a Brief Interview for Mental Status (BIMS) Score of fifteen (15) out of fifteen (15). Further review revealed the facility assessed the resident as requiring two (2) person assist for bed mobility and transfers; and as having no falls since admission or since prior assessment; and as using a wheelchair for a mobility device. Review of the Occupational Therapy Discharge Summary, dated 12/06/17, revealed Resident #10 did not achieve his/her goal of independent use of a slide board for transfers. Further review of the Summary, revealed the resident could use that method of transfer, but required physical assistance from staff during the transfer using a slide board. Review of the Comprehensive Care Plan initiated 03/20/17, revealed Resident #10 was at risk for falls related to limited mobility, incontinence, debility, medication use, muscle weakness, and History of [MEDICAL CONDITION] Tibia. The goal revealed the resident would have no further falls with injury. An intervention to use the Slide Board for all Transfers was initiated on 12/07/17 by Licensed Practical Nurse (LPN) #3; however, there was no instruction related to the resident requiring physical assist (contact guard assist) with the the slide board transfer and no instruction related to using a gait belt with the slide board transfer. Interview on 03/29/18 at 12:49 PM, with the 100 Unit Manager, over the unit in which Resident #10 resided, revealed the Kardex was the tool provided for the Nurse Aides to use as a reference for providing care. Per interview, Resident #10's Kardex which was in place on 02/10/18, was not available for review, due to once they were updated, they were deleted from the electronic system and the hard copy was discarded. Review of the physician's orders [REDACTED]. This order was signed off by Licensed Practical Nurse (LPN) #3. Review of Resident #10's Interdisciplinary Progress Note (IPN), dated 02/10/18 at 2:50 PM, signed by LPN #3, revealed the resident stopped her in the hallway requesting she assess his/her left leg for a scratch. Per the IPN, LPN #3 examined Resident #10's left leg and did not observe a cut or any abnormality. The IPN revealed Resident #10 told LPN #3 he/she slid off the slide board when SRNA #1 was transferring him/her from the bed to the motorized chair. Further review of the IPN, revealed LPN #3 spoke with SRNA #1 and SRNA #2, and they both stated Resident #10 did not fall, but instead the resident's left side was in the motorized chair, when he/she started to slide. The IPN stated, SRNA #1 was yelling for SRNA #2, who was not present in Resident #10's room, to come into the room and help her. Per review of the IPN, revealed both SRNA #1 and SRNA #2 stated Resident #10 did not fall, and did not bump or hit anything. Review of Resident #10's Progress Note dated 02/11/18 at 3:46 AM, revealed at the start of the shift the resident called the nurse to his/her room related to right knee pain and was observed to be shaking. Per the Note, the assessment of the resident's right knee revealed a large knot to the anterior right knee just below the patella. Per the Note, the resident reported he/she had sustained a fall during a transfer using a slide board earlier that day about 2:30 PM. Further review revealed the resident was assessed by the nurse, vital signs were obtained and recorded, and the resident was transported per 911 Ambulance to the emergency roiagnom on [DATE] at 12:10 AM, for evaluation and treatment. Review of the Hospital Emergency Department (ED) Notes, dated 02/11/18, revealed Resident #10 was received in the ED on 02/11/18 at 12:18 AM, and was treated for [REDACTED]. The Radiology Findings revealed: Impression of right leg and X-Ray suggested Displaced Avulsion Fracture of Tibia Tuberosity with soft tissue swelling. The ED Notes stated the resident was given pain relief medication; a right posterior long leg splint was placed; and the resident was discharged back to the facility. Interview with Resident #10, on 03/26/18 at 10:25 AM, revealed SRNA #1 attempted to transfer him/her from the bed to the motorized chair using a slide board on 02/10/18 at approximately 2:30 PM. He/she stated the bed was elevated too high and not level with the seat of the motorized chair, and this placed the slide board in a downward direction. Per interview, Resident #10 told the SRNA the slide board was not in the correct position; however, she continued with the transfer and did not lower the bed. Per interview, prior to the transfer, the SRNA was not close to him/her and did not have her hands on his/her back as he/she positioned self on the slide. Further interview revealed as he/she positioned self onto the slide board, he/she slid down the slide board quickly and fell on to the floor, with his/her right leg bending backwards underneath his/her body. Per interview, SRNA #1 left Resident #10 alone on the floor and returned with SRNA #2, who lifted the resident from the floor to the seat of his/her motorized chair. Resident #10 revealed a nurse had not assessed him/her prior to SRNA #2 lifting the resident from the floor into the chair. The resident stated he/she did not complain of pain at that time. Interview on 03/28/18 at 3:24 PM, with SRNA #1, revealed she was a contract employee with the facility since (MONTH) (YEAR). SRNA #1 stated she worked the day shift (7:00 AM-3:00 PM) on 02/10/18, and was assigned to Resident #10. She further stated Resident #10 requested to be transferred from the bed to his/her motorized chair after lunch that day. Per interview, this was the first occasion SRNA #1 had provided care for Resident #10 and she was not familiar with the resident's transfer method. She revealed the resident refused to be transferred by a mechanical lift, and instead requested to use the slide board. Per interview, she had not been trained to use the slide board with this resident, and did not recall checking the resident's Kardex for guidance prior to the transfer. She stated she proceeded to position Resident #10's motorized chair parallel to the bed. She further stated she then placed the slide board in position to transfer Resident #10, stating the slide board was level between the bed and the chair. Further interview revealed SRNA#1 did not use a gait belt for the transfer, but placed her arms in front and behind the resident without touching the resident. She described the resident's fall as a slide, with the resident landing with his/her buttocks on the foot rest of the motorized chair. SRNA #1 further revealed she did not consider the incident a fall because the resident had not landed on the floor, but on the foot rest of the motorized chair. Additional interview with SRNA#1, revealed she left the resident alone in the room after the incident and searched for Resident #10's nurse (LPN #3) to inform her of the incident. Per interview, she located LPN #3 in the Dining Room working with another resident's intravenous (IV) line, and she did not notify the nurse because the nurse was busy. She stated she located SRNA #2 in the hallway and requested her assistance. SRNA #1 further revealed Resident #10 may have been on the floor when she returned to his/her room. Per interview, SRNA #1 and SRNA #2 lifted Resident #10 from the floor into his/her motorized chair. SRNA #1 stated she left the facility at the end of her work shift on 02/10/18, without informing LPN #3, of the resident's fall. SRNA #1 further stated the next day, LPN #3 requested her to write a statement describing the incident. Interview with SRNA #2, on 03/28/18 at 12:18 PM, revealed she was a contract employee with the facility since (MONTH) (YEAR), and had worked as an SRNA for various facilities the past eight (8) years. SRNA #2 revealed on 02/10/18, SRNA #1 asked her how Resident #10 was to be transferred and she instructed SRNA #1 to use a slide board. She stated she offered her assistance if SRNA #1 needed help. Per interview, SRNA #1 came to her later and requested help to get Resident #10 off the floor. Per interview, when she went to Resident #10's room, she found the resident lying on the floor near his/her motorized chair. She stated the resident's legs were crossed and under the motorized chair, and the resident's head was positioned toward the head of the bed. SRNA #2 stated she assumed the resident's nurse had been notified of the fall by SRNA #1, and she proceeded to manually lift the resident from the floor to the motorized chair by herself, using a gait belt. Continued interview with SRNA #2, revealed she was aware Resident #10 was to be transferred with a slide board a the time of the incident, and she always used a gait belt and placed her hand on the resident's back while transferring the resident with the slide board. She confirmed she was not assigned to care for Resident #10 that day and was not present during the resident's fall. Interview on 03/29/18 at 1:30 PM with LPN #3, revealed she worked the day shift on 02/10/18 and was assigned to Resident #10, but she was not informed of the resident's fall on that date. She revealed the next day (02/11/18) she arrived to work around 6:30 AM and observed an ambulance unloading Resident #10. Per interview, she asked the third shift nurse (LPN #4) why the resident was returning via ambulance and was informed of the resident's trip to the local emergency room , and that the resident had sustained a fracture to the right leg as a result of a transfer incident on 02/10/18. Continued interview revealed after she was notified of the resident's injury, she asked SRNA #1 and #2 what had happened the previous day and instructed them to complete written reports related to the incident. Per interview, she was told by SRNA #1, the resident did not sustain a fall. However, she stated she told SRNA #1 the resident had a fractured leg, so something happened. Additional interview with LPN #3, revealed she was the nurse who received the physician's orders [REDACTED]. She stated she updated the Care Plan and Kardex to reflect the use of the slide board on the date the physician's orders [REDACTED]. Phone interview with Registered Nurse (RN) #2, on 03/28/18 at 9:35 AM, revealed he was a contract employee with the facility who was working the afternoon and evening of 02/10/18 and was the nurse assigned to Resident #10. Per interview, Resident #10 complained of right leg pain upon the resident's return from his/her Occupational Therapy session. He stated he assessed the resident's right leg and saw no bruising or swelling. He further revealed he applied ice to the resident's right knee area and administered medication for pain. RN #2 stated Resident #10 told him he/she had slid off the slide board during a transfer from the bed to the motorized chair earlier that day. LPN #4 further revealed he did not receive any information in shift report from the day shift nurse who was assigned to the resident related to the resident sustaining a fall. However, he stated he reported the fall incident as explained to him by Resident #10 to the oncoming nurse and also informed the oncoming nurse of the resident's complaints of pain and what interventions he had provided. Phone interview with LPN #4, on 03/28/18 at 3:10 PM, revealed she was assigned to Resident #10 for the night shift from 02/10/18 to the morning of 02/11/18. She stated she received report from RN #2 regarding Resident #10's fall, right knee pain, and medications and ice used for treatment; however, there was no right leg swelling reported. Continued interview revealed the resident called LPN #4 to his/her room early in the shift for right knee pain, and she assessed the resident who was observed to be shaking, and had right knee swelling. Per interview, Resident #10 requested transport to the emergency room for evaluation, and this was immediately facilitated by LPN #4. Per interview, Resident #10 returned to the facility near the end of LPN #4's shift wearing a right leg splint immobilizing his/her knee, with new orders for more frequent pain medication. Interview on 03/29/18 at 8:33 AM, with the Director of Rehabilitation (DOR), revealed not all nursing staff had been trained on the use of a slide board to transfer Resident #10 prior to the resident's fall on 02/10/18. She stated therapy had been working with the resident and he/she wanted to use the slide board for transfers, and on 12/07/17, a telephone order was obtained to discontinue the use of the mechanical lift and instead use a slide board for all transfers. Per interview, Resident #10 was discharged from Occupational Therapy on 12/06/17, and she verbally notified the nurses and SRNAs of the need to transfer the resident with a slide board and contact guard, meaning staff's hands had to be touching the resident's back, as well as use of a gait belt. She stated the communication process when a resident was discharged from therapy was verbal instruction to the nursing staff, with no revision of the Care Plan completed by therapy for discharge instructions. She verified at the time of the resident's fall on 02/10/18, the resident was to be transferred with a slide board using contact guard, and a gait belt. Interview with the MDS Coordinator on 03/29/18 at 1:12 PM, revealed the MDS nurses revised Care Plans with the Admission, Quarterly, Annual and Significant Change MDS Assessments; however, the floor nurses were responsible for updating the Care Plan with any changes between Assessments. Interview on 03/28/18 at 3:43 PM, with the DON, revealed she assisted with the Fall Investigation regarding the fall Resident #10 sustained on 02/10/18. She stated the fall occurred near shift change at approximately 2:55 PM. She further stated as part of the investigation, she interviewed SRNA #1 and was told the resident did not fall, but rather landed in his/her motorized chair, then slid onto the foot rest. Continued interview with the DON, revealed she interviewed Resident #10 who told her he/she slid off the slide board and started hurting later. Per interview, the DON reviewed the resident's care plan which stated the resident was to be transferred by slide board, but did not have specific instructions on how much assistance the resident needed with the slide board transfer, or instructions to use the gait belt with the slide board transfer. She revealed during the investigation she identified the Comprehensive Care Plan was not specific related to instructions for slide board transfers. Interview on 03/29/18 at 2:45 PM, with the Administrator, revealed it was her expectation staff revise Care Plans as per Policy, and to ensure the safety of the residents.

Based on interview, record review, review of the Incident Report, review of the facility Investigation, and review of facility Policies, it was determined the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for one (1) of thirty-one (31) sampled residents (Resident #10). On 02/10/18 at approximately 2:55 PM, Resident #10 was transferred per the slide board by Contract State Registered Nurse Aide (SRNA) #1, who had not been trained by the facility on how to transfer the resident using a slide board. SRNA #1 transferred the resident without using a gait belt or Contact Guard transfer method as recommended by Occupational Therapy, and the resident slid off the slide board onto the floor. SRNA #1 failed to notify the nurse of the resident's fall in order for the resident to be assessed for pain or injury, and instead asked SRNA #2 to help her assist the resident off the floor and into the motorized chair. Resident #10 later complained of right leg pain and was assessed by the night shift nurse to have a large knot to the anterior right knee, below the patella and was transferred to the Hospital emergency room (ER) on 02/11/18 at 12:10 AM. Resident #10 was diagnosed with [REDACTED]. The findings include: Review of the facility Safe Resident Handling/Transfer Equipment Policy, revised 05/15/17, revealed patients would be assessed to determine the appropriate equipment to be used. Further review of the Policy, revealed staff would be trained in the use of each type of equipment (slide boards or mechanical lift). Per Policy, a slide board could be used for patients who were able to independently transfer and rehabilitation services would provide patient and/or caregiver training. Review of the facility Falls Management Policy, revised 03/15/16, revealed patients would be assessed for falls risk as part of the nursing assessment process and those determined to be at risk would receive appropriate interventions to reduce risk and minimize injury. Further review revealed the purpose of the Policy was to reduce the risk for falls and minimize the actual occurrence of falls. After a fall, the Accident/Incident Report would be completed and documented as a new event in the Risk Management System (RMS), on a Change of Condition Note. An Investigation would be conducted using the Fall Investigation/QA and other appropriate tools in the RMS. The Care Plan would be updated to reflect new interventions and an interdisciplinary team meeting would be conducted within seventy-two (72) hours of the fall. Further review of the Policy, revealed the facility's Executive Director/Administrator and Nurse Executive/DON would conduct a post-fall review. Review of Resident #10's medical record revealed the facility admitted the resident on 10/27/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 12/04/17, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) Score of fifteen (15) out of fifteen (15) indicating the resident was cognitively intact. Further review revealed the facility assessed Resident #10 as requiring two (2) person assist for bed mobility and transfers; and as having no falls since admission or since prior assessment; and as using a wheelchair for a mobility device. Review of the Fall Risk Assessment Scoring Report dated 12/02/17, revealed the facility assessed the resident to score a six (6) for fall risk, and per the scale, a score of twelve (12) was considered to be at high risk for falls. Review of the Occupational Therapy Discharge Summary, dated 12/06/17, revealed Resident#10 did not achieve the goal of independent use of a slide board for transfers. Per the Summary, the resident could use that method of transfer, but required physical assistance from staff during the transfer using a slide board. Review of the Comprehensive Care Plan initiated on 03/20/17, revealed the resident was at risk for falls related to limited mobility, incontinence, debility, medication use, muscle weakness, and Fracture to the Left Tibia. The goal stated the resident would have no further falls with injury. An intervention for Slide Board for all Transfers was initiated on 12/07/17 by Licensed Practical Nurse (LPN) #3; however, there was no instruction related to the resident requiring physical assist (contact guard assist) with the the slide board transfer and no instruction related to using a gait belt with the slide board transfer. Interview on 03/29/18 at 12:49 PM, with the 100 Unit Manager, over the unit in which Resident #10 resided, revealed the Kardex was a tool provided for the Nurse Aides to use as a reference for providing care. She stated the nurses could add care plan interventions to the Nurse Aide's electronic Kardex, and there was also a hard-copy in a binder at the Nurse's Station for all nurse aides to review. Per interview, Resident #10's Kardex which was in place on 02/10/18, was not available for review, due to once they were updated, they were deleted from the electronic system and the hard copy was discarded. Review of a physician's orders [REDACTED]. This order was received by Licensed Practical Nurse (LPN) #3. Review of the Interdisciplinary Progress Note (IPN), dated 02/10/18 at 2:50 PM, completed by Licensed Practical Nurse (LPN) #3, revealed Resident #10 stopped her in the hallway requesting she assess his/her left leg for a scratch. Per the IPN, LPN #3 examined Resident #10's left leg and did not observe a cut or any abnormality. The IPN stated Resident #10 told LPN #3 he/she slid off the slide board when State Registered Nursing Aide (SRNA) #1 was transferring him/her from the bed to the motorized chair. Further review of the IPN, revealed LPN #3 spoke with SRNA #1 and SRNA #2, who both stated Resident #10 did not fall, but instead the resident's left side was in the motorized chair, when he/she started to slide. Per the IPN, SRNA #1 was yelling for SRNA #2, who was not present in Resident #10's room, to come into the room and help her. Further review of the IPN, revealed both SRNA #1 and SRNA #2 stated Resident #10 did not fall, and did not bump or hit anything. Review of the Progress Note dated 02/11/18 at 3:46 AM, revealed at the start of the shift Resident #10 called the nurse to his/her room, and was observed shaking with complained of right knee pain. Per the Note, the nurse's assessment of the resident's right knee revealed a large knot to the anterior right knee just below the patella. The Note stated the resident reported he/she had sustained a fall during a transfer using a slide board earlier that day about 2:30 PM. Additional review revealed the resident was assessed by the nurse, vital signs were obtained and recorded, and the resident was transported per 911 Ambulance to the emergency roiagnom on [DATE] at 12:10 AM, for evaluation and treatment. Continued review of the Note, revealed notifications were made to the Facility Physician and report was called to the Hospital emergency room . Review of the Hospital Emergency Department Notes, dated 02/11/18, revealed Resident #10 was received in the Emergency Department (ED) on 02/11/18 at 12:18 AM, and treated for [REDACTED]. The Impression of right leg and X-Ray suggested Displaced Avulsion Fracture of Tibia Tuberosity with soft tissue swelling. The Notes stated the resident was given pain relief medication; a right posterior long leg splint was placed; and the resident was discharged back to the facility. Review of the Fall Incident Report, undated, revealed the Preparer of the Report was Licensed Practical Nurse (LPN) #3. Per the Report, the Date and Time of the incident was 2:55 PM on 02/10/18; the Event was resident lowered to the floor; and the Injury Sustained was a Fracture. Per the Report, LPN #3 was walking back from the Dining Room (on 02/10/18) when Resident #10 stopped her in the hallway and asked her to look at his/her left leg while sitting in his/her electric wheelchair. LPN #3 looked at the left lower extremity and didn't see anything and told the resident there was nothing there. She documented she saw light colored spots of skin on the left knee area where there used to be scabs. Further review of the Report, revealed the resident told LPN #3 that SRNA #1 had to have SRNA #2 help her get him/her over from the slide board because she couldn't do it. LPN #1 documented she went to the desk and asked what had happened to the two (2) SRNAs and they stated the resident did not fall, that the left side of his/her body was in the chair and the resident started to slide so SRNA #1 and SRNA #2 pulled the resident up to the chair. Review of the Fall Investigation attached to the Incident Report, undated, with no name or signature of preparer, revealed the fall was Self Reported by the resident and the resident explained he/did not hit his/her head. The Preventative Measures in place prior to the fall were primarily to ensure nonskid footwear-socks were applied. The Activity during the incident was getting in/out of bed. Per the Investigation, the event was related to lifting, transferring, turning, and /or repositioning the resident. The Investigation stated the resident had previously been assessed for the use of Safe Resident Handling (mechanical lift) and assistive devices assigned to the resident included a slide board which was used at the time of the event. The Description of the Event stated: the resident was lowered to the floor and was transported to the Hospital at 12:10 AM on 02/11/18 by 911 Ambulance call. The Physician and Resident Representative were notified. Interventions implemented after the fall included: Resident was sent to Emergency Department for evaluation; a new order was initiated for NWB (Non-Weight-Bearing) status; transfer changed to total mechanical lift x two (2) staff; follow-up with Orthopedic Physician; and Physical Therapy/Occupational Therapy evaluation to treat as necessary. The Root Cause Analysis Conclusion: revealed the resident began to slide off the slide board during transfer and fell on to his/her foot rests, hitting his/her knee. The Corrective Actions taken: revealed the resident's transfer status changed back to mechanical lift with the resident referred to therapy for treatment. Review of the Change in Condition document, dated 02/11/18 prepared by the Director of Nursing (DON), revealed an incident investigation was performed regarding Resident #10's fall on 02/10/18. Resident #10 stated SRNA #1 and SRNA #2 assisted him/her back into bed because SRNA #1 was unable to do so alone. Additional review revealed SRNA #1 stated the resident slid from the slide board to the foot rest when attempting to transfer. SRNA #1 stated she attempted to notify the resident's nurse; however, the nurse was hanging an Intravenous (IV) bag and was busy. According to the Note, SRNA #2 assisted the resident up and assumed a nurse had already assessed the resident. Further review revealed LPN #3 stated the resident asked her to look at his/her left leg to examine a scratch; however, no scratch was observed. The document stated, LPN #3 asked SRNA #1 and SRNA #2 if anything had happened, and they denied anything had occurred. However, on 02/11/18 SRNA #2 reported Resident #10 had sustained a fall on 02/10/18, and she had removed the resident from the floor. This was not reported until the morning of 02/11/18. Additional review revealed the DON reviewed the care plan to verify the use of the slide board for transfers was initiated as an intervention on 12/07/17 and that these interventions were included in the SRNA Kardex. Further review revealed the only actions taken by the DON was to educate SRNA #1 on notifying the nurse prior to moving a resident after a fall. Interview, on 03/26/18 at 10:25 AM, with Resident #10, revealed SRNA #1 attempted to transfer him/her from the bed to the motorized chair using a slide board on 02/10/18 at approximately 2:30 PM. The resident stated the bed was elevated too high and not level with the seat of the motorized chair, and this placed the slide board in a downward direction. Per interview, the resident told the SRNA the slide board was not in the correct position; however, she continued with the transfer and did not lower the bed. The resident stated prior to the transfer, the SRNA was not close to him/her and did not have her hands on his/her back as he/she positioned self on the slide. Per interview as he/she positioned self onto the slide board, he/she slid down the slide board quickly and fell on to the floor, with his/her right leg bending backwards underneath his/her body. Further interview revealed SRNA #1 left Resident #10 alone on the floor and returned with SRNA #2, who lifted the resident from the floor to the seat of his/her motorized chair. Resident #10 stated a nurse had not assessed him/her prior to SRNA #2 lifting the resident from the floor into the chair. Per interview, he/she did not complain of pain at that time. Interview with SRNA #1, on 03/28/18 at 3:24 PM, revealed she was a contract employee with the facility since (MONTH) (YEAR). SRNA #1 stated she was working the day shift (7:00 AM-3:00 PM) on 02/10/18, and was responsible for Resident #10's direct care. She stated Resident #10 requested to be transferred from the bed to his/her motorized chair after lunch that day. The SRNA revealed this was the first occasion SRNA #1 had provided care for Resident #10 and she was not familiar with the resident's transfer method. She stated the resident refused to be transferred by a mechanical lift, and instead requested to use the slide board. SRNA #1 further stated she had not been trained to use the slide board with this resident, and did not recall checking the resident's Kardex for guidance prior to the transfer. Per interview, she proceeded to position Resident #10's motorized chair parallel to the bed. She stated she then placed the slide board in position to transfer the resident, stating the slide board was level between the bed and the chair. Continued interview revealed SRNA#1 did not use a gait belt for the transfer, but placed her arms in front and behind the resident without touching the resident. She described Resident #10's fall as a slide, with the resident landing with his/her buttocks on the foot rest of the motorized chair. SRNA #1 further stated she did not consider the incident a fall because the resident had not landed on the floor, but on the foot rest of the motorized chair. SRNA #1 could not remember where the resident's legs or head were located after the fall. Further interview with SRNA#1, revealed she left the resident alone in the room after the incident because she was scared and panicked. She stated she searched for Resident #10's nurse (LPN #3) to inform her of the incident; however, the nurse was found in the Dining Room working with another resident's intravenous (IV) line. SRNA #1 stated she did not notify the nurse because the nurse was busy and instead located SRNA #2 in the hallway and requested her assistance. SRNA #1 further stated Resident #10 may have been on the floor when she returned to his/her room. Per interview, she and SRNA #2 lifted Resident #10 from the floor into his/her motorized chair. SRNA #1 revealed she left the facility at the end of her work shift on 02/10/18, without informing LPN #3, of the resident's fall. Per interview, the resident was not assessed by the nurse after the incident during her shift. SRNA #1 stated the next day, LPN #3 requested her to write a statement describing the incident. She stated she was not interviewed by the Director of Nursing (DON) or administrative staff, regarding the incident. Interview with SRNA #2, on 03/28/18 at 12:18 PM, revealed she was a contract employee with the facility since (MONTH) (YEAR), and had worked as an SRNA for various facilities for eight (8) years. SRNA #2 stated on 02/10/18, SRNA #1 asked her how Resident #10 was to be transferred and she instructed SRNA #1 to use a slide board. She stated she offered her assistance if SRNA #1 determined she needed help. She further stated SRNA #1 came to her later and requested help to get Resident #10 off the floor. Per interview, she asked SRNA #1 why the resident was on the floor and was told, I don't know, just help me. She stated she went to Resident #10's room and found the resident lying on the floor near his/her motorized chair. Per interview, the resident's legs were crossed and under the motorized chair, and the resident's head was positioned toward the head of the bed. SRNA #2 stated she assumed the resident's nurse had been notified of the fall by SRNA #1, and she manually lifted the resident from the floor to the motorized chair by herself, using a gait belt. SRNA #2 stated Resident #10 did not complain of pain at that time. Continued interview with SRNA #2, revealed after the transfer, she asked SRNA #1 what the nurse said about the resident and she was then informed by SRNA #1 that the nurse had not yet been notified of Resident #10's fall. Per interview, she was aware Resident #10 was transferred with a slide board and she always used a gait belt and placed her hand on the resident's back while transferring the resident with the slide board. She confirmed she was not assigned to care for Resident #10 that day and was not present during the resident's fall. Interview on 03/29/18 at 1:30 PM with LPN #3, revealed she worked the day shift on 02/10/18 and was assigned to Resident #10, but she was not informed of the resident's fall on that date prior to the end of her work shift. She stated the next day (02/11/18) she arrived to work around 6:30 AM and observed an ambulance unloading Resident #10. She stated she asked the third shift nurse (LPN #4) why the resident was returning via ambulance and was told of the resident's trip to the local emergency room . She stated she was then informed the resident had sustained a fracture to the right leg as a result of a transfer incident on 02/10/18. Further interview revealed after she was notified of the resident's injury, she then asked SRNA #1 and #2 what had happened the previous day and instructed them to complete written reports related to the incident. She stated she was told by SRNA #1, the resident did not sustain a fall. She further stated she then told SRNA #1 the resident had a fractured leg, so something happened. Per interview, she was told by the DON she had to complete the Fall Incident Report. She stated at the time of documentation of the Fall Incident Report, she was unaware the resident actually sustained a fall, and thought the resident was lowered to the floor. Continued interview with LPN #3, revealed she was the nurse who received the telephone order to change the resident's transfer method from a mechanical lift to the slide board in (MONTH) (YEAR). She stated she had updated the Care Plan and Kardex to reflect the use of the slide board on the date the physician's orders [REDACTED]. However, she stated she failed to document on the Care Plan and Kardex, physical assistance from staff and a gait belt was needed to transfer the resident using the slide board. Phone interview with Registered Nurse (RN) #2, on 03/28/18 at 9:35 AM, revealed he was a contract employee with the facility who was working the afternoon and evening of 02/10/18 and was assigned to Resident #10. Interview revealed Resident #10 complained of right leg pain upon the resident's return from his/her Occupational Therapy session. He stated he assessed the resident's right leg and found no bruising or swelling. He further stated he applied ice to the resident's right knee area and administered medication for pain. Per interview the resident requested pain medication later in the evening for continued complaints of right leg pain. The nurse stated Resident #10 told him he/she had slid off the slide board during a transfer from the bed to the motorized chair earlier that day. LPN #4 further stated he did not receive any information in shift report from the day shift nurse who was assigned to the resident related to the resident sustaining a fall. He stated he reported the fall incident as explained to him by Resident #10 to the oncoming nurse and also informed the oncoming nurse of the resident's complaints of pain and what interventions he had provided. Review of the PRN Pain Management Flow Sheet and Medication Administration Record [REDACTED]. Per the MAR, the resident received [MEDICATION NAME] 5 milligram (mg) by mouth on 02/10/18 at 4:15 PM, and [MEDICATION NAME] 5 mg on 02/10/18 at 9:38 PM. Phone interview with LPN #4, on 03/28/18 at 3:10 PM, revealed she had worked at the facility for fifteen (15) years, and was assigned to Resident #10 for the night shift from 02/10/18 to the morning of 02/11/18. She stated she received report from RN #2 regarding Resident #10's fall, right knee pain, and medications and ice used for treatment, with no right leg swelling reported. Additional interview revealed the resident called LPN #4 to his/her room early in the shift for right knee pain, and she assessed Resident #10 who was observed to be shaking, and had right knee swelling. Interview further revealed Resident #10 requested transport to the emergency room for evaluation, and this was immediately facilitated by LPN #4. Continued interview revealed Resident #10 returned to the facility near the end of LPN #4's shift wearing a right leg splint immobilizing his/her knee, with new orders for more frequent pain medication. Interview on 03/29/18 at 8:33 AM, with the Director of Rehabilitation (DOR), revealed not all nursing staff had been trained on the use of a slide board with Resident #10 prior to the resident's fall on 02/10/18. She further stated therapy had been working with the resident and he/she had wanted to use the slide board for transfers, and on 12/07/17, a telephone order was obtained to discontinue the use of the mechanical lift and instead use a slide board for all transfers. Per interview the resident was discharged from Occupational Therapy on 12/06/17, and she verbally notified the nurses and SRNAs of the need to transfer the resident with a slide board and contact guard meaning staff's hands had to be touching the resident's back, as well as use of a gait belt. Per interview, at the time of the resident's fall on 02/10/18, the resident was to be transferred with a slide board using contact guard, and a gait belt. Further interview with the DOR, revealed Resident #10 was receiving Occupational Therapy again during the timeframe in which he/she sustained the fall, and on 02/10/18 the resident completed upper body exercises with no complaints of pain. Per interview, the resident reported SRNA#1 had positioned the bed higher than the motorized chair earlier in the day and he/she slid from the slide board onto the floor and sustained a fall. She stated she informed LPN #3 after Resident #10 informed her of this on 02/10/18. The DOR stated Resident #10 was alert and oriented to person, place and time, and seemed able to recall the incident accurately. She further stated after this fall where the resident sustained [REDACTED]. Continued interview revealed once the Orthopedic physician cleared the resident for therapy (last week) and she began working with him/her on transfers with the slide board again. She stated a gait belt should always be used with this resident during a slide board transfer and the staff should always have hands touching the resident. Further interview revealed contract staff were monitored with random observations completed by the staff nurses and herself to ensure appropriate care was given. Interview with the Nurse Educator, on 03/29/18 at 10:18 AM, revealed she provided all new hire orientation training, including nurses and aides. Per interview, different methods for resident transfers would be included in this education. She stated all clinical staff employed by the facility received a Competency Skills packet during orientation that must be completed during the training process of seven (7) to ten (10) days, and they also worked with a preceptor for several days, depending on the individual's experience. However, per interview, contract staff were not required to complete orientation or competency demonstration, as she considered them to be trained and experienced prior to their date of hire. Additional interview revealed no education regarding slide board transfer was provided during orientation for contract staff and the contract staff did not receive training with a preceptor on the floor. Further interview with the Nurse Educator, revealed all new hires, including contract hires, were required to study the Genesis Corporate Safety Training Manual, which included a Section titled, Musculoskeletal Disorder Prevention with a Sub-Section titled, Resident Transfer, and to view the Safe Resident Handling, slide PowerPoint presentation. Review of a checklist the Nurse Educator provided, revealed SRNA #1 had signed she completed the Musculoskeletal Disorder Prevention module of the Genesis Safety Training Manual with the Safe Handling Presentation, on 01/17/18; and SRNA #2 had signed as completing the module on 12/19/2017. However, the Musculoskeletal Disorder Prevention training did not include specific training on slide board transfers. Review of the Genesis Safety Training Manual, undated, under the section titled, Musculoskeletal Disorder Prevention, revealed the facility had implemented a Safe Resident Handling Program to reduce the chance of injury to both residents and employees. Employees responsible for hands-on resident care would be orientated to the program. If a resident was in need of transfer and staff had not been trained in that method of transfer, the employee was to locate a supervisor to ensure proper procedures and equipment were used for the safety of employee and the resident. Review of a document titled, Safe Resident Handling, a twenty-four (24) slide PowerPoint presentation, revealed caregivers must be aware of the specific lift types/brands available in the center, and safe resident handling impacted moving a resident to/from bed/chair. Further review of the Power Point, revealed an assessment of lift/transfer/repositioning of a resident should be completed upon admission/re-admission, quarterly, and with a significant change. This assessment included the need for gait belt or repositioning devices, and a consistent method of communicating the lift/transfer needs of the patient would be selected. However, the only mention of a slide board was to say the slide board was an approved method of transfer. The training module did not include how to transfer a resident with a slide board. Interview on 03/28/18 at 3:43 PM, with the DON, revealed she assisted with the Fall Investigation regarding the fall Resident #10 sustained on 02/10/18. She stated the fall occurred near shift change at approximately 2:55 PM. She further stated the first-shift nurse (LPN #3) completed the Incident Report on 02/11/18. Per interview, as part of the investigation, she interviewed SRNA #1 and was told the resident did not fall, but rather landed in his/her motorized chair, then slid onto the foot rest. The DON stated SRNA #1 admitted she left the resident in the room alone after the fall. Per interview, SRNA #1 told the DON, she did not notify the nurse of the fall, but instead requested the assistance of SRNA #2 to assist the resident back into the motorized chair. The DON further stated she was upset because SRNA #1 had left Resident #10 alone and did not report the incident to the nurse. She stated SRNA #2 should not have picked up the resident and assisted him/her into the motorized chair without an assessment by a nurse. Further interview with the DON, revealed she interviewed Resident #10 who told her he/she slid off the slide board and started hurting later. The DON stated she did not ask Resident #10 if he/she had fallen onto the floor, and where he/she had landed. Per interview, the DON reviewed the resident's care plan which stated the resident was to be transferred by slide board, but did not have specific instructions on how much assistance the resident needed with the slide board transfer, or instructions to use a gait belt with the slide board transfer. She revealed she was aware Resident #10 experienced a balance deficit, and sometimes experienced dizziness after his/her [MEDICAL TREATMENT] treatments. The DON stated she had counseled both SRNAs regarding their responses to the incident. Per interview, she had conferred with the therapy department and the Nurse Educator and they could not find any evidence where SRNA #1 and SRNA #2 had been trained on the use of the slide board for this resident. The DON stated she identified failures related to this fall incident which included: SRNA #1 failed to report the fall to the nurse, and therefore the resident was not assessed for injuries and was moved without assessment; no training was given to the SRNAs regarding the use of the slide board; a gait belt was not used for the slide board transfer; and the Care Plan was not specific related to instructions for slide board transfers. Interview on 03/29/18 at 2:45 PM, with the Administrator, who had been in the Administrator role for one (1) week, revealed it was her expectation staff follow facility Policies for resident safety and to prevent accidents. Per interview, staff were to be trained and knowledgeable of proper transfer techniques and follow Therapy recommendations.

Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure services were provided in accordance with each resident's written Plan of Care. There was no documented evidence the resident's care plans were implemented to ensure resident's achieved acceptable level of pain control as evidenced by the facility's failure to medicate residents as ordered for pain, report to the physician if pain medications were unavailable, complete pain assessments, and assess and document effectiveness of pain medications for thirteen (13) of twenty four (24) sampled residents (Residents #2, #4, #6, #8, #10, #12, #13, #15, #16, #17, #19, #20 and #21). (Refer to F157, F309 and F425) In addition, Resident #10's Care Plan was not followed related to the administration of intravenous antibiotic as ordered for wound infection secondary to lumbar laminectomy. Resident #6's Care Plan was not followed related to ensuring the resident received thickened liquids as per the diet order. The findings include: Review of the facility policy titled, NSG 102 Care Plans, revised 01/02/14, revealed the purpose of the Care Plan was to provide necessary care and services to attain or maintain the patient's needs and goals as identified in the Assessment Process. 1. Review of Resident #10's medical record revealed the facility admitted the resident on 02/26/16 with the following Diagnoses: [REDACTED]. The Minimum Data Set (MDS) Assessment had not been completed due to the resident being a recent admission. Review of the Brief Interview for Mental Status (BIMS) List provided by the facility revealed the facility assessed Resident #10 as having a BIMs score of fifteen (15) out of fifteen (15) indicating no cognitive impairment, date unknown of the BIMS assessment. Resident #10's Interim Care Plan, dated 02/26/16, revealed the resident was at risk for alteration in comfort related to acute pain, chronic pain, and surgical-post-op. The care plan goal stated the resident would achieve acceptable level of pain control. The interventions included: evaluate for pain characteristics, quality, severity, location, precipitating/relieving factors; utilize the pain scale; advise resident to request pain medication before pain becomes severe; medicate resident as ordered for pain; monitor for effectiveness, monitor for side effects, and report to the physician as indicated. However, interview and record review revealed this care plan was not implemented related to administration of medications as ordered, notification to the Physician as indicated, assessing for pain and monitoring for the effectiveness of the pain medication. Further review of Resident #10's Interim Care Plan dated 02/26/16, revealed the resident exhibited or was at risk for complications of infection related to wound infection due to lumbar laminectomy. The care plan goal stated the resident would remain free of complications/infection for thirty-six (36) days. The interventions included assist with handwashing, encourage fluids, and administer [MEDICATION NAME] medication as ordered. However, this Care Plan was not implemented related to the administration of [MEDICATION NAME] as ordered. Review of Resident #10's Hospital Discharge Summary, dated 02/26/16, revealed the resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication used to treat moderate to moderately severe pain) 10/325 milligrams (mg) one (1) to two (2) tablets every four (4) hours as needed for pain. Per the Summary, Resident #10 received his/her last dose on 02/26/16 at 3:00 PM and the next dose was scheduled on 02/26/16 after 7:00 PM as needed (PRN). The Hospital Discharge Summary further revealed the resident received the last dose of [MEDICATION NAME] (antibiotic medication) two (2) Grams (G) in [MEDICATION NAME] 5% (five percent) intravenously on 02/26/16 at 1:34 PM and was scheduled for the next dose on 02/26/16 at 10:00 PM. Review of Resident #10's Facility Physician Order Sheet and Interim Plan of Care, dated 02/26/16, revealed orders for [MEDICATION NAME] 10/325 mg one (1) or two (2) every four (4) hours PRN for pain and [MEDICATION NAME] 2 G in D5W- 1GM/50 ML (two grams in [MEDICATION NAME] 5% water one gram/ fifty milliliters) every eight (8) hours for thirty-six (36) days. Review of the Fax Confirmation Sheet revealed orders for the [MEDICATION NAME] and the [MEDICATION NAME] were faxed to the pharmacy on 02/26/16 at 8:10 PM, and a prescription for [MEDICATION NAME]-[MEDICATION NAME], dated 02/26/16, was faxed to the Pharmacy on 02/26/16 at 6:52 PM. Review of Licensed Practical Nurse (LPN) #2's, Nurse's Notes, dated 02/26/16 at 10:35 PM, revealed the resident was upset his/her medications were not at the facility and the resident had arrived at the facility around 5:00 PM. Interview on 03/01/16 at 12:00 PM with Resident #10, revealed he/she was admitted to the facility on Friday, 02/26/16, and suffered in pain for approximately twelve and a half (12 ½) hours without pain medication. Resident #10 revealed the last time he/she received pain medication from the hospital was at 3:00 PM on 02/26/16 and he/she did not receive another dose of pain medication until approximately 3:30 AM on 02/27/16, although he/she repeatedly requested the pain medication. Further interview with Resident #10, revealed he/she missed two (2) doses of intravenous antibiotic after admission to the facility which was ordered for the infection in his/her spine. Resident #10 revealed the last dose of antibiotic received at the hospital was on 02/26/16 at 2:00 PM, and he/she did not receive the antibiotic until 02/27/16. Interview with Licensed Practical Nurse (LPN) #4, on 03/02/16 at 7:15 PM, who worked on the 100 wing, revealed she was assigned to the resident on 02/26/16 from 11:00 PM to 7:00 AM. LPN #4 revealed Resident #10 told her, when she reported to work at 11:00 PM, he/she was in pain, and the resident continuously asked when his/her medication would be there. LPN #4 revealed the resident's [MEDICATION NAME] did not arrive to the facility until between 2:00 AM and 3:00 AM on 02/27/16, and she administered the medication to Resident #10 as soon as it arrived. Further interview with LPN #4, revealed the facility had an Emergency Box (E-Box), but the dosage of [MEDICATION NAME] the resident was ordered was not on the Emergency Box List, thus the facility did not have the medication to provide for the resident. LPN #4 revealed she should have addressed the resident's pain by contacting the resident's Physician and calling pharmacy to see if anything could have been given to the resident from the E-Box. Interview on 03/02/16 at 10:55 PM, and 03/04/16 at 9:30 AM, with LPN #9/Unit Manager of Unit 100 where Resident #10 was admitted on [DATE] revealed if the facility did not have the pain medication and the resident was complaining of pain, the nurse should have notified the Physician to obtain a one (1) time order for pain medication to be given to Resident #10 from the E-Box. Continued interview with LPN #4, on 03/02/16 at 7:15 PM, revealed she did not administer Resident #10's antibiotic because it was noted on the MAR, the resident's antibiotic was not due to start on her shift, adding per the MAR indicated [REDACTED]. Further interview revealed she did not check the Physician's orders to verify when the medication was to start. Further interview with LPN #9/Unit Manager, on 03/02/16 at 10:55 PM, and 03/04/16 at 9:30 AM, revealed she was notified the morning of 02/27/16 the antibiotic was not delivered with the resident's other medications. LPN #9 further stated the nurse should have called the pharmacy to get the medication delivered to the facility stat and the physician should have been called to see if another antibiotic could have been given until the medication arrived. Review of the Narcotic sign-out sheet revealed the resident received his/her medication five (5) times on 02/27/16; at 3:30 AM, 8:45 AM, 2:00 PM, 6:00 PM, and 10:00 PM. However, review of the resident's PRN Pain Management Flow Sheet revealed there was no documented evidence the resident was assessed for his/her pain level before the administration of his/her pain medication or after to determine the effectiveness of the medication as per the Care Plan, other than the one (1) time assessment on 02/27/16 at 3:30 AM. Review of the Narcotic sign-out sheet revealed the resident took his/her [MEDICATION NAME] four (4) times on 02/28/16, and was administered two (2) tablets at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM. However, there was no documented evidence the resident's pain level was assessed before or after the pain medication was administered to determine the effectiveness of the medication as per the Care Plan. Review of the Narcotic sign-out sheet revealed the resident was given [MEDICATION NAME] 10/325 two (2) tablets five (5) times on 02/29/16, at 4:00 AM, 9:30 AM, 1:00 PM, 5:00 PM, and 9:00 PM. However, review of the PRN Pain Management Flow Sheet for 02/29/16, revealed no documented evidence the resident was assessed prior to administration of his/her medication or after administration of the medication to determine if the medication was effective as per the Care Plan. Interview with LPN #1 on 03/04/16 at 3:27 PM, who worked on the 100 Wing, revealed he had worked with Resident #10 once and was knowledgeable about his/her care. He stated while he did not document the resident's pain level the resident expressed his/her pain was at a level of eight (8) out of ten (10) at the time he was assigned on 02/29/16 from 7:00 AM to 3:00 PM. Review of the Physicians Orders dated March 2016 revealed orders for [MEDICATION NAME] 10-325 mg one (1) tablet every four (4) hours as needed for mild pain; and [MEDICATION NAME] 10-325 mg two (2) tablets by mouth every four (4) hours as needed for severe pain. Continued interview with Resident #10 on 03/01/16 at 12:00 PM revealed he/she had to take half of of the usual dose of PRN [MEDICATION NAME] because staff told him/her that they ran out of his/her [MEDICATION NAME] and he/she wandered how they could have run out of the medication. Review of LPN #9's Late Entry Nurse's Notes dated 03/02/16 at 11:17 AM, revealed on 03/01/16 at 4:00 PM a call was placed to the facility's Pharmacy requesting to know where Resident #10's pain medication was. Per the Note, the LPN was told the medication was on its way and left the Pharmacy at 1:30 PM. LPN #9 documented offering the resident a Tylenol ([MEDICATION NAME] for mild pain), however the resident declined. Review of Resident #10's Prescriptions delivered to the facility, dated March 2016, revealed [MEDICATION NAME] ([MEDICATION NAME]) left the Pharmacy at 12:08 PM on 03/01/16. Interview with the Pharmacist/General Manager on 03/04/16 at 6:25 PM, revealed the [MEDICATION NAME] arrived to the facility on [DATE] at 4:30 PM. Review of Resident #10's Narcotic Sign-Out Sheet revealed the resident had been receiving [MEDICATION NAME] 10-325, two (2) tablets from 02/27/16 through 02/29/16 and per the Sheet, on 02/29/16 at 9:00 PM after administering two (2) tablets, there was only two (2) tablets left. Further review of the Narcotic Sign out Sheet revealed on 03/01/16 the resident only received one (1) tablet for the next two (2) doses at 3:00 AM, and at 10:30 AM, and then the resident did not receive another dose of [MEDICATION NAME] until 03/01/16 at 6:15 PM, when the resident received (2) tablets after the medication was delivered from the pharmacy. This was a time span of almost eight (8) hours the resident went without the [MEDICATION NAME] pain medication from 10:30 AM until 6:15 PM. Continued interview with LPN #9/Unit Manager on 03/02/16 at 10:55 PM, revealed she became aware Resident #10's had run out of [MEDICATION NAME] on 03/01/16 and called the pharmacy on 03/01/16 at 1:30 PM to find out where the resident's pain medication was, and was told the medication was en route. LPN #9/Unit Manager revealed the resident's medication arrived to the facility around 4:25 PM on 03/01/16, at which time she administered the pain medication to the resident. Further interview on 03/02/16 at 10:55 PM with LPN #9/Unit Manager, revealed the resident received only one (1) [MEDICATION NAME] 10/325 mg tablet at 3:00 AM and one (1) tablet at 10:30 AM, on 03/01/16; however, the resident had a history of [REDACTED]. LPN #9/Unit Manager, revealed although the resident normally would receive the medication about every four (4) hours, the medication was unavailable and after the 03/01/16 dose at 10:30 AM of one (1) tablet, the resident did not receive another tablet until 6:15 PM when the resident received two (2) tablets, which was almost eight (8) hours later. Per interview the resident was without his/her [MEDICATION NAME] normal dose of two (2) [MEDICATION NAME] every four (4) hours for approximately fifteen (15) hours, until his/her Pain Medication arrived from Pharmacy, from 03/01/16 at 3:00 AM until 03/01/16 until 6:15 PM. Continued review of the Narcotic Sign-Out Sheets revealed Resident #10 received his/her medications four (4) times on 03/01/16, four (4) times on 03/02/16 and once on 03/02/15 (per sequential order of times and dates, should have been written as 03/03/16 on the Narcotic sign out book). However, review of the PRN Pain Management Flow Sheet for March 2016, revealed the resident was not assessed for his/her pain level prior to the administration of his/her medication or for the effectiveness of the medication for the month of March 2016 as per the Care Plan. Interview with the Director of Nursing (DON), on 03/03/16 at 3:20 PM revealed staff should have been more proactive to ensure Resident #10 received pain medication and antibiotics as ordered on admission on 02/26/16. She stated, staff should have contacted the resident's physician to determine if another pain medication or antibiotic medication could have been administered to the resident until the residents medications were received from pharmacy because the Physician may have recommended something the facility already had in the E-Box. Also, she stated the narcotic pain medications should have been ordered in time for the pharmacy to re-fill them and if this did not happen, pharmacy should have been notified for immediate delivery. Interview on 03/04/16 at 12:06 PM with the Assistant Director of Nursing (ADON), in the absence of the DON, revealed her staff should have followed Resident #10's care plan related to pain to ensure medications were administered as ordered, the Physician was notified if there was concern with availability of medications and assessing the resident for pain as per policy. 2. Review of Resident #12 's medical record revealed the facility admitted the resident on 04/14/15, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 02/07/16, revealed the facility assessed Resident #12 to have a BIMS score of thirteen (13) out of fifteen (15) which indicated the resident was cognitively intact. Continued review of the MDS revealed the facility assessed the resident to have frequent severe pain. Review of Resident #12's Comprehensive Care Plan, dated 01/13/16, revealed a problem of exhibiting or at risk for alteration in comfort related to Chronic Pain, and Arthritis. The care plan goal stated the resident would achieve acceptable level of pain control. The interventions included evaluating pain characteristics of quality, severity, location, and precipitating/relieving factors. Further review revealed interventions to utilize the pain scale and to observe the effectiveness of the Pain Medication. However, interview and record review revealed Resident #12's Care Plan was not followed related to administration of medications as ordered and notification to physician for concerns. Review of Resident #12's Order Summary Report (Physician's Orders), dated 03/02/16 revealed orders including [MEDICATION NAME] Tablet ([MEDICATION NAME]-[MEDICATION NAME])10-325 MG every six (6) hours PRN. Review of Resident #12's February 2016 Narcotic Sign Out Sheets revealed on 02/12/16 at 6:30 AM, the resident received the last dose of [MEDICATION NAME] pain medication. Continued review revealed the resident did not receive [MEDICATION NAME] from 02/12/16 at 6:30 AM until 02/15/16 at 8:40 AM, three (3) days later when thirty (30) [MEDICATION NAME] tablets were delivered. Interview, on 03/04/16 at 6:40 PM, with Resident #12 revealed on more than one occasion he/she had been in pain and asked for pain medication, only to be told he/she did not have any pain medication and it was on order. Resident #12 further stated the last time he/she ran out of medication, the resident's pain was an eight (8) out of ten (10) with ten (10) being the most severe pain. Resident #12 revealed he/she had to go without pain medication for an entire weekend. Furthermore, Resident #12 revealed he/she was not always asked what his/her pain level was before receiving or after receiving pain medication. Interview and medical record review, on 03/04/16 at 5:05 PM, with Licensed Practical Nurse (LPN) #7 revealed Resident #12 received his/her last dose of [MEDICATION NAME] pain medication on 02/12/16 at 6:30 AM. LPN #7 further stated on the morning of 02/15/16 she received shift report from the night shift nurse, and it was reported to her Resident #12 had been requesting pain medication over the weekend and he/she was out, but it would arrive that morning. Post survey phone interview on 3/14/16 at 1:30 PM, with LPN #13, revealed she was assigned to Resident #12 on 02/12/16 on the 3:00 PM to 11:30 PM shift, and she recalled a nurse on the prior shift had called the Physician for a prescription because in this instance the resident needed a new prescription for the [MEDICATION NAME] refill. She stated she didn't remember the resident asking for pain medication during that shift. Post survey phone interview with Registered Nurse (RN) #5, on 3/14/16 2:35 PM, revealed on 02/13/16 on the 3:00 PM to 11:00 PM shift, Resident #12 asked for a [MEDICATION NAME] about 8:00 PM during her medication pass and when she realized there was no [MEDICATION NAME] available to administer, she offered Tylenol ([MEDICATION NAME] for mild pain) which the resident refused. She further revealed she called pharmacy and was informed a prescription was needed for the refill of [MEDICATION NAME]. She stated she didn't notify the Physician of the need for the [MEDICATION NAME] prescription. Further interview with RN #5, revealed she should have notified the Physician Resident #12 was out of pain medication and a one (1) time order could have been written for a medication from the E-Box or a three (3) day supply of pain medication could haven been requested with the Physician giving a verbal prescription to pharmacy. However, she revealed the resident was not grimacing or showing outward signs of pain, and she passed the information on in report related to not having the narcotic medication available for Resident #12. Post survey phone interview with the DON on 03/14/16 at 3:00 PM, revealed after reviewing Resident #12's medical record she confirmed Resident #12 was without pain medication for three (3) days from 02/12/16 until 02/15/16. She further stated, she did not see documentation of the resident complaining of pain or of not receiving pain medication in the Nurse's Notes; however, she stated she could not find where a pain assessment had been done during the three (3) days, of not receiving the [MEDICATION NAME]. Per interview the Physician should have been notified of the resident running out of medication and a one (1) time stat order for something which was available in the E- Box could have been ordered and administered and also the physician could have called pharmacy and authorize a prescription until the medication was delivered. 3. Review of Resident #4's medical record revealed the facility admitted the resident on 09/25/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #4 to have a BIMS score of fifteen (15), indicating the resident was cognitively intact. The MDS further revealed the facility assessed the resident as almost constantly in pain in the last five (5) days making it difficult for the resident to sleep at night and limiting his/her day-to-day activities. Continued review of the MDS, revealed the resident rated his/her pain level at a ten (10), on a scale of one (1) to ten (10) with ten (10) being the worst pain. Review of Resident #4's Comprehensive Care Plan, initiated 09/27/15, revealed the resident exhibited or was at risk for alteration in comfort related to Chronic Pain, and [MEDICAL CONDITION]. The care plan goal stated the resident would achieve acceptable level of pain control. The interventions included: evaluate pain characteristics; quality, severity, location, precipitating/relieving factors; utilize the pain scale; advise the resident to request pain medication before the pain became severe; monitor the frequency of episodes of breakthrough pain to determine the need for pain medication adjustment; monitor for non-verbal signs/symptoms of pain and medicate as ordered; and complete pain assessment per protocol. However, record review revealed the resident's pain was not assessed and monitored per the Plan of Care. Review of Resident #4's March 2016 Physician's Orders, revealed the resident was prescribed [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) one (1) tablet to be given by mouth every six (6) hours PRN for moderate pain and two (2) tablets by mouth every six (6) hours PRN for severe pain. Review of the Narcotic Sign-Out Sheet revealed [MEDICATION NAME] was signed out fifty-two (52) times between 02/02/16 and 03/02/16. However, there was no documented evidence of the PRN Pain Evaluation Flow Sheet being completed to assess the resident's pain level prior to administering the medication nor after administration of the medication to assess the effectiveness of the medication as per the care plan. 4. Review of Resident #16's medical record revealed the facility admitted the resident on 12/23/14 with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS Assessment, dated 12/08/15, revealed the facility assessed Resident #16 to have a BIMS score of fifteen (15), indicating the resident was cognitively intact. Further review of the MDS revealed the facility assessed the resident to have pain frequently within the last five (5) days making it hard for him/her to sleep at night and limiting his/her day-to-day activities. Further review revealed Resident #16 rated his/her pain on a scale of zero (0) to ten (10) over the past five (5) days and the resident stated nine (9), with a score of ten (10) being the worst pain. Review of Resident #16's Comprehensive Care Plan, initiated on 02/20/14, revealed the resident was at risk for alteration in comfort related to a [DIAGNOSES REDACTED]. The interventions revealed: evaluate pain characteristics, quality, severity, location, precipitating/relieving factors; utilize pain scale; advise the resident to request pain medication before pain becomes severe; medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects; report to physician as indicated; observe frequency of episodes of breakthrough pain to determine the need for pain medication adjustment; observe for non-verbal signs/symptoms of pain and medicate as ordered; and complete pain assessment per protocol. However, record review revealed the resident's pain was not assessed and monitored per the Plan of Care. Review of Resident #16's Physician Orders for March 2016 revealed orders for [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]-narcotic pain medication) one (1) tablet by mouth every four (4) hours as needed for pain. Review of Resident #16's Narcotic Sign-Out Sheet revealed the medication was signed out sixty-four (64) times between 02/01/16 and 03/02/16. However, there was no documented evidence the resident's PRN Pain Evaluation Flow Sheet was completed to assess the resident's pain level prior to administering the pain medication nor after administration of the pain medication to monitor the effectiveness of the pain medication as per the care plan. 5. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 02/02/16, revealed the facility assessed Resident #19's BIMS as a fifteen (15) out of fifteen (15) indicating no cognitive impairment. Further review, revealed the facility assessed Resident #19 as having occasional pain with the numeric rating of a seven (7) out of ten (10), with zero (0) being no pain and ten (10) being the worst pain. Review of Resident #19's Comprehensive Care Plan with an initiated problem date of 10/24/14, revealed the resident was at risk for alteration in comfort related to Neuropathic Pain and [MEDICAL CONDITION]. The care plan goal stated the resident would achieve an acceptable level of pain control. Review of the interventions revealed: staff was to evaluate pain characteristics,quality, severity, location, precipitating/relieving factors; medicate resident as ordered for pain; observe for effectiveness and side effects and report to physician as indicated; complete pain assessment per protocol; and utilize the pain scale. However, record review revealed the resident's pain was not assessed and monitored per the Plan of Care. Review of the Order Summary Report (Physician's Orders) Active Orders as of 03/03/16 revealed orders for [MEDICATION NAME] Tablet (An opoid combination narcotic medication to treat moderate to severe pain) 5-325 Milligrams (MG) to be administered PRN for pain. Review of the Narcotic Sign-out Sheet for Resident #19's [MEDICATION NAME] Tablet revealed six (6) doses of the [MEDICATION NAME] Tablet were signed out for Resident #19 on 02/07/16, one (1) dose was signed out on 02/17/16, one (1) dose was signed out on 02/20/16 and one (1) dose was signed out on 02/26/16. However, review of Resident #19's PRN Pain Management Flow Sheet for February 2016, revealed no documented evidence of an assessment of the resident's pain level prior to the administration of the pain medication nor after administration to reassess for effectiveness of the pain medication as per the care plan. 6. Review of Resident #20's medical record revealed the facility admitted the resident on 02/26/16 with [DIAGNOSES REDACTED]. Review of the Order Summary Report (Physician's Orders) dated 02/26/16 revealed orders for [MEDICATION NAME] Tablet (A narcotic-like pain reliever to treat moderate to severe pain.) 50 MG every six (6) hours PRN for pain. Review of the Comprehensive Care Plan, dated 02/26/16, revealed Resident #20 was at resident was at risk for alteration in comfort related to chronic pain. The care plan goal stated the resident would achieve acceptable level of pain control, and the interventions included: evaluate pain characteristics for quality, severity, location, and precipitating/reliving factors; utilize pain scale; and complete pain assessment per protocol. However, record review revealed the resident's pain was not consistently assessed and monitored per the Plan of Care. Review of the Narcotics Sign-out Sheet for Resident #20 for [MEDICATION NAME] administered February 2016, revealed the facility staff documented seven (7) occasions the medication was administered to Resident #20: two (2) doses signed out on 02/27/16, three (3) doses signed out on 02/28/16 and two (2) doses signed out on 02/29/16. However, the care plan was not followed as there was only one (1) dose documented on the PRN Pain Management Flow Sheet with the appropriate pain assessment which was on 02/28/16 at 5:30 AM. 7. Review of Resident #21's medical record revealed the facility admitted the resident on 11/17/15 with [DIAGNOSES REDACTED]. Review of Resident #21's Quarterly MDS Assessment, dated 01/13/16, revealed the facility assessed the resident to be in almost constant pain. Review of Resident #21's Order Summary Report (Physician's Orders) dated March 2016, revealed orders for [MEDICATION NAME]-50 Patch (a [MEDICATION NAME] formulation of [MEDICATION NAME] used for the management of persistent, moderate to severe chronic pain, around the clock opoid [MEDICATION NAME]) one (1) patch every seventy-two (72) hours. Review of the Comprehensive Care Plan, effective date 11/17/15, revealed the resident had a problem of alteration in comfort due to [MEDICAL CONDITION] Disease with [MEDICAL CONDITION] and Muscle Spasms. The care plan goal stated Resident #21 would achieve acceptable level of pain control. The interventions included: evaluating pain characteristics, utilizing pain scale, medicating as ordered for pain and observing for effectiveness of medication. Further review revealed staff was to observe for non-verbal signs/symptoms of pain, and complete pain assessment per protocol. However, record review revealed the resident's pain was not assessed and monitored per the Plan of Care. Review of the Controlled Drug Record (Narcotic Sign Out Sheet) revealed the [MEDICATION NAME]-50 was signed out for Resident #21 ten (10) times between 02/08/16 and 03/02/16; however, there was no documented evidence of a Pain Evaluation completed for the [MEDICATION NAME]-50 Patch for February 2016 or March 2016 as per the care plan. 8. Review of Resident #8's medical record revealed the facility admitted the resident on 08/20/14 for palliative care and Hospice care after a rapid decline in health at home. The resident's [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE], revealed the the facility assessed Resident #8 as having unclear speech, as independent with decisions, and as having no long or short term memory loss. Further review of the MDS revealed the facility assessed Resident #8 as having constant pain on at a level of ten (10) with ten (10) being the worst pain on a scale of one (1) to ten (10). Review of the Comprehensive Care Plan, effective 08/21/14, revealed Resident #8 was at risk for alteration in comfort related to chronic pain. The care plan goal revealed Resident #8's pain medication would be effective one (1) hour after receiving the medication. The interventions included: evaluate pain characteristics, including quality, severity, location, and precipitating/relieving factors; utilize pain scale; medicate resident as ordered for pain; monitor for effectiveness and side effects; and observe for non-verbal signs and symptoms of pain and medicate as ordered. However, record review revealed the resident's pain was not consistently assessed and monitored per the Plan of Care. Review of Physicians Orders dated February 2016 and March 2016, revealed Resident #8 was ordered the following pain medications: [REDACTED]

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to provide the necessary care and services to obtain or maintain the highest practical and highest well-being for thirteen (13) of twenty four (24) sampled residents (Residents #2, #4, #6, #8, #10, #12, #13, #15, #16, #17, #19, #20 and #21). The facility failed to implement policies regarding assessing and documenting the residents' pain presence on the Medication Administration Record (MAR) and failed to assess the effectiveness of PRN (as needed) medications on the PRN Pain Management Flow Sheet on the back of the MAR. The facility failed to consistently document the administration of narcotic pain medication on the MAR; therefore, residents' physicians were not aware of the amount of PRN pain medication residents were requesting and receiving. In addition, the facility failed to ensure Resident #10 received an antibiotic timely. Resident #10 who was admitted to the facility on [DATE] after being hospitalized for [REDACTED]. The resident received his/her last dose of [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] -narcotic pain medication used to treat moderate to moderately severe pain) at the hospital on [DATE] at 3:00 PM and the medication was ordered every four (4) hours PRN (as needed), meaning the resident was due to receive another PRN dose of pain medication at 7:00 PM, if needed. Resident #10 arrived at the facility on 02/26/16 at approximately 5:00 PM, and although the resident complained of pain and requested the pain medication, the resident did not receive his/her pain medication until 02/27/16 at 3:30 AM, eight and a half (8 1/2) hours after the medication was requested. Concurrently, Resident #10 did not receive the antibiotic timely to treat Discitis/Oste[DIAGNOSES REDACTED] (bone infection) as ordered. physician's orders [REDACTED]. The resident received his/her last dose of antibiotic on 02/26/16 at 1:34 PM at the hospital; however, did not receive the medication at the facility until 02/27/16 at 2:00 PM. This caused the resident to miss two (2) doses of antibiotics. Substandard Quality of Care with actual harm was identified related to the facility's systemic failure to assess and monitor residents' pain. The findings include: Review of the facility's policy titled, Pain Management, with a revision date of 01/02/14, revealed the purpose of the policy was to maintain the highest possible level of comfort for the residents by providing a system to identify, assess, treat, and evaluate pain. Continued review of the policy revealed staff would notify the physician/mid-level provider as appropriate and obtain treatment orders as indicated. Per policy, an individualized, interdisciplinary care plan would be developed and include pharmacological and non-pharmacological approaches and at a minimum of daily, residents would be evaluated for the presence of pain by making an inquiry of the resident or by observing for signs of pain. Continued review revealed staff would document the residents' pain presence on the Medication Administration Record (MAR). Per policy, if PRN (as needed) medications were given, staff would document on the PRN Pain Management Flow Sheet on the back of the MAR. Patients receiving interventions for pain will be monitored for the effectiveness and side effects in providing pain relief. Document effectiveness of PRN medications, ineffectiveness of routine or PRN medications including interventions, follow up, and physician/mid-level provider notification, side effects if present, and non-pharmacological interventions and effectiveness. Review of the facility's policy, titled, NSG305 Medication Administration: General, revision date 07/01/15, revealed staff would monitor the patient for adverse reactions and effectiveness of medication and staff would document the administration of medication on the Medication Administration Record (MAR) including the resident's response to medication, and effectiveness of as needed (PRN) medications. 1. Review of Resident #10's medical record revealed the facility admitted the resident on 02/26/16 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment had not been completed due to being a recent admission. Review of the Brief Interview for Mental Status (BIMS) List provided by the facility revealed the facility assessed the resident as having a BIMs score of fifteen (15) out of fifteen (15) indicating no cognitive impairment, date unknown of the BIMS assessment. Review of Resident #10's Interim Care Plan, dated 02/26/16, revealed the resident was at risk for alteration in comfort related to acute pain, chronic pain, and surgical-post-op. The goal stated the resident would achieve acceptable level of pain control. The interventions included: evaluate for pain characteristics, quality, severity, location, precipitating/relieving factors; utilize the pain scale; advise resident to request pain medication before pain becomes severe; medicate resident as ordered for pain; monitor for effectiveness, monitor for side effects; and, report to the physician as indicated. Review of Resident #10's Interim Care Plan dated 02/26/16, revealed the resident exhibited or was at risk for complications of infection related to wound infection secondary to lumbar laminectomy. The goal stated the resident would remain free of complications/infection for thirty-six (36) days. The interventions included assist with handwashing, encourage fluids, and administer [MEDICATION NAME] medication as ordered. Review of Resident #10's Hospital Discharge Summary, dated 02/26/16, revealed the resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] -narcotic pain medication used to treat moderate to moderately severe pain) 10-325 milligrams (mg) one (1) to two (2) tablets by mouth every four (4) hours as needed for pain. Per the Summary, the resident received his/her last dose on 02/26/16 at 3:00 PM and the next dose was scheduled on 02/26/16 after 7:00 PM PRN. Continued review of the Hospital Discharge Summary revealed the resident received the last dose of [MEDICATION NAME] (antibiotic medication) two (2) Grams (G) in [MEDICATION NAME] 5% (five percent) intravenously on 02/26/16 at 1:34 PM and was scheduled for the next dose on 02/26/16 at 10:00 PM. Review of Resident #10's Physician order [REDACTED]. Review of the facility's Fax Confirmation Sheet revealed orders for the [MEDICATION NAME] and the [MEDICATION NAME] was faxed to the pharmacy on 02/26/16 at 8:10 PM. Continued review revealed a prescription for [MEDICATION NAME]-[MEDICATION NAME], dated 02/26/16, was faxed to the Pharmacy on 02/26/16 at 6:52 PM. Review of the MAR dated February 2016, revealed the resident did not receive the [MEDICATION NAME] pain medication from the time of admission at approximately 5:00 PM until 02/27/16 at 3:30 AM, when it was documented the resident received [MEDICATION NAME] 10/325 mg two (2) tablets. Also, review of the MAR, revealed the resident did not receive the first dose of intravenous [MEDICATION NAME] antibiotic until 02/27/16 at 2:00 PM, although the antibiotic was scheduled every eight (8) hours and should have been administered on 02/26/16 at 10:00 PM, and 02/26/16 at 6:00 PM. Review of Resident #10's Pharmacy Connection, Proof of Delivery, printed on 03/02/16, revealed the resident's [MEDICATION NAME]/[MEDICATION NAME] thirty (30) tablets were delivered to the facility at 3:31 AM on 02/27/16. Further review of the Pharmacy Connection, Proof of Delivery, printed on 03/02/16, revealed the resident's [MEDICATION NAME] Sodium-[MEDICATION NAME] 2 GM/100 ML was delivered and received by the facility on 02/27/16 at 1:45 PM. Review of Licensed Practical Nurse (LPN) #2's, Nurse's Notes, dated 02/26/16 at 10:35 PM, revealed the resident was upset his/her medications were not at the facility and the resident had arrived at the facility around 5:00 PM. Interview with Resident #10, on 03/01/16 at 12:00 PM, revealed he/she was admitted to the facility on Friday, 02/26/16, and was told by staff he/she was a late admission. Continued interview revealed he/she suffered in pain for approximately twelve and a half (12 ½) hours. Resident #10 stated the last time he/she received medication from the hospital was at 3:00 PM on 02/26/16 and he/she did not receive another dose of medication to treat his/her pain until approximately 3:30 AM on 02/27/16, although he/she repeatedly asked for the pain medication. Further interview with Resident #10, revealed he/she was on an antibiotic for his/her spine. He/she stated the last dose of antibiotic received at the hospital was on 02/26/16 at 2:00 PM, and he/she missed two (2) doses of antibiotics after arrival at the facility on 02/26/16 due to the pharmacy thinking he/she had an allergic reaction to the medication. Interview with Licensed Practical Nurse (LPN) #2, on 03/02/16 at 10:51 AM and 03/04/16 at 10:57 AM, who worked on the 100 wing where Resident #10 resided, revealed she was Resident #10's admitting nurse and was assigned to the resident on 02/26/16 from admission until she left work which was about 7:00 PM. Further interview revealed the delivery and administration of medication was not a concern on her shift because to her knowledge the resident just received his/her medications before leaving the hospital and the medications would have been delivered after her shift. Continued interview with LPN #2, revealed if Resident #10's pain medications were not delivered timely, he/she could have been given the [MEDICATION NAME] in the Emergency Box (E-Box) from the 200 Wing because the facility had access to the E-Box for pain medication if the pharmacy ran late in delivering medications. She stated LPN #4, should have notified the Physician for a verbal order for the [MEDICATION NAME] dosage in the E-Box. LPN #2 stated at times there was a delay in pharmacy getting the medications to the facility. LPN #2 further stated she did not assess the resident for pain throughout her shift or ask the resident if he/she was in pain, adding, I use to work at a prison so I did not want to put the idea in his/her head that he/she needed pain medication. Further interview with LPN #2, revealed if a resident had an uncommon antibiotic, then pharmacy would be notified to have the medication delivered stat. She revealed she received a telephone call the day the resident was admitted , on 02/26/16, from Pharmacy and they were concerned about the resident's allergy to [MEDICATION NAME], wondering if the resident should have the intravenous antibiotic. LPN #2 stated she told the pharmacist it should not have been a concern since the resident came from the hospital on the antibiotic. LPN #2 stated she verified with Resident #10 he/she was not allergic to the antibiotic around 7:00 PM when she was getting off work. Further interview with LPN #2 revealed there would have been nothing in the E-Box to give the resident for the antibiotic and the facility would have had to wait on Pharmacy. She stated LPN #4 relieved her the night of 02/26/16. Interview with Licensed Practical Nurse (LPN) #4 on 03/02/16 at 7:15 PM, who worked on the 100 wing, and was assigned to the resident on 02/26/16 from 11:00 PM to 7:00 AM, revealed during the admission process, all the residents physician's orders [REDACTED]. LPN #4 revealed Resident #10 told her, when she reported to work at 11:00 PM, he/she was in pain. LPN #4 stated the resident would continuously ask when his/her medication would be there and she advised the resident his/her medication had not arrived and she would give him/her the medication as soon as it arrived. Per the PRN Pain Management Flow Sheet the resident was assessed for pain on 02/27/16 at 3:30 AM which was described as an eight (8) on a scale of one (1) to ten (10), with eight (8) being severe/horrible pain. Per the PRN Pain Management Flow Sheet the resident received two (2) tabs of [MEDICATION NAME] 10/325 mg at the time of the pain assessment, and another pain assessment on 02/27/16 at 4:30 AM, revealed the resident was rated as having a pain level of one (1) meaning mild pain. Further interview with LPN #4 revealed the resident's [MEDICATION NAME] arrived at the facility between 2:00 AM and 3:00 AM on 02/27/16. LPN #4 revealed she immediately administered Resident #10's pain medication when it arrived from pharmacy, adding it was very important the resident received his/her pain medication because the resident was in pain. LPN #4, revealed the facility had an E-Box, but the dosage of [MEDICATION NAME] the resident was taking was not on the Emergency Box List, thus the facility did not have the medication to provide for the resident. LPN #4 revealed she should have addressed the resident's pain by contacting the resident's Physician and calling pharmacy to see if anything could have been given to the resident from the E-Box. Further interview with LPN #4, revealed she did not follow up on Resident #10's antibiotic because the MAR had been transcribed incorrectly by LPN #2. She stated per the MAR, the medication administration times were marked out with x's for 02/26/16 and 02/27/16 at 6:00 AM, 2:00 PM, and 10:00 PM, and should have indicated the medication was to start on 02/16/16 at 10:00 PM as per orders. She further stated if she had checked the orders she would have realized pharmacy needed to be notified the medication was unavailable for administration. She stated the nurse before her, LPN #2 should have ensured the MAR was filled out correctly. LPN #4 revealed it was important for Resident #10 to receive his/her doses of antibiotic as ordered because the purpose of the antibiotic was to treat the infection. Interview with the facility's Pharmacist/General Manager, on 03/04/16 at 6:25 PM, revealed the pharmacy received Resident #10's physician's orders [REDACTED]. He revealed there was a delay in the resident's medication because the pharmacist filling the order asked the facility to clarify the resident's allergy for the antibiotic and this was not clarified until 7:10 PM on the same day. The General Manager revealed the medication was then sent on the next run, which was on 02/27/16 at 12:00 AM. He stated the resident's pain medication arrived to the facility at 3:31 AM; however, the resident's antibiotic was not on that run because the information about the resident's allergy was not communicated to the intravenous (IV) department. Further interview with the General Manager revealed the delay occurred in his department because of miscommunication. Interview on 03/04/16 at 5:23 PM, with State Registered Nursing Assistant (SRNA) #4, who worked on the 100 wing, where Resident #10 was admitted , revealed she was assigned to the resident the day of admission, 02/26/16. Continued interview with SRNA #4 revealed the resident reported to her, he/she was in pain the first day of admission. SRNA #4 stated to her knowledge, there was a mix up with pharmacy. Further interview with SRNA #4 revealed the resident was upset because he/she kept requesting his/her pain medications, adding the resident pressed his/her light every hour to check on his/her pain medications on 02/26/16. SRNA #4, further revealed, when a resident could not have anything to relieve his/her pain, it could be mentally and physically harmful to the resident. Interview with SRNA #5, on 03/04/16 at 5:39 PM, who worked on the 100 wing, revealed she worked with Resident #10 from 3:00 PM to 11:00 PM, the day the resident was admitted . She stated the first day the resident came in to the facility he/she expressed his/her back was hurting and needed assistance to the bathroom. SRNA #5 stated she recalled the resident continuously asking if his/her pain medication came in that day. Interview with LPN #9/Unit Manager on 03/02/16 at 10:55 PM and 03/04/16 at 9:30 AM, revealed she was the Unit manager for the unit where Resident #10 was admitted on [DATE]. She stated she was responsible for ensuring the new admissions physician's orders [REDACTED].#10's physician's orders [REDACTED]. LPN #9 revealed if the facility did not have the pain medication and the resident was complaining of pain, the nurse should have notified the Physician to obtain a one (1) time order for something to be given to Resident #10 from the E-Box. Further interview with LPN #9/Unit Manager, revealed she received a phone call at home the morning of 02/27/16 from LPN #10 who informed her when she signed for the residents medications on 02/27/16 from pharmacy, the antibiotic was not included with the resident's other medications. LPN #9 stated, LPN #10 should have called the pharmacy to get the antibiotic medication delivered to the facility stat and the physician should have been called to see if another antibiotic could have been given until the medication arrived. Further interview, revealed the admitting nurse did not transcribe the orders correctly to the MAR on 02/26/16 related to the dates and times the antibiotic medication was to be administered, and nursing staff, should have reviewed the resident's admitting orders and not just the MAR. LPN #9 stated, medications were ordered for a reason and they were all important to the resident. Continued review of the MAR dated February 2016, and the resident's Narcotic Sign-Out Sheet, on 02/27/16, revealed the resident requested two (2) [MEDICATION NAME] every time he/she requested the [MEDICATION NAME] PRN for pain. Per the MAR, staff signed the resident received his/her [MEDICATION NAME] (2) times on 02/27/16 at 3:30 AM and 2:00 PM; however, review of the resident's Narcotic sign-out sheet revealed the resident received his/her medication five (5) times that day at 3:30 AM, 8:45 AM, 2:00 PM, 6:00 PM, and 10:00 PM indicating a discrepancy in the MAR and the Narcotic Sign Out Sheet. In addition, review of the resident's PRN Pain Management Flow Sheet revealed there was no documented evidence the resident was assessed for his/her pain level before the administration of his/her pain medication or after to determine the effectiveness of the medication on 02/27/16, other than the one time documentation on 02/27/16 at 3:30 AM. Continued review of the MAR dated February 2016, revealed on 02/28/16, the resident was given [MEDICATION NAME] three (3) times and was administered two (2) tablets at 10:00 AM, 4:00 PM, and 8:00 PM; however, the Narcotic sign-out sheet revealed the resident took his/her [MEDICATION NAME] four (4) times on 02/28/16, and was administered two (2) tablets at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM indicating a discrepancy in the MAR and the Narcotic Sign Out Sheet. In addition, there was no documented evidence the resident's pain level was assessed before his/her pain medication was given nor after the administration of the medication to determine the effectiveness of the medication on 02/28/16, per the facility's policy. Further review of Resident #10's MAR, dated February 2016, revealed the resident was given [MEDICATION NAME] 10/325 mg two (2) tablets on 02/29/16 at 4:00 AM, and there was no further documented doses per the MAR on 02/29/16. However; the Narcotic sign-out sheet revealed the resident was given [MEDICATION NAME] 10/325 two (2) tablets five (5) times on 02/29/16, at 4:00 AM, 9:30 AM, 1:00 PM, 5:00 PM, and 9:00 PM indicating a discrepancy in the MAR and the Narcotic Sign Out Sheet. In addition, review of the PRN Pain Management Flow Sheet for 02/29/16, revealed no documented evidence the resident was assessed prior to administration of his/her medication or after administration of the medication to determine if the medication was effective per the facility's policy. Interview on 03/04/16 at 3:27 PM, with LPN #1, who worked on the 100 Wing, revealed he had worked with Resident #10 once and was knowledgeable about his/her care. He stated while he did not document the resident's pain level, the resident expressed his/her pain was at a level of eight (8) out of ten (10) at the time he was assigned on 02/29/16 from 7:00 AM to 3:00 PM. He revealed he gave the resident's pain medication to him/her when he/she requested the medication. LPN #1 revealed he should have documented the resident's pain assessment prior to and after administration of medication to assess the effectiveness of the medication. LPN #1 revealed the resident was noticeably in pain, especially when he/she would walk with his/her walker and would grimace while walking. Review of the Physicians Orders dated March 2016 revealed orders for [MEDICATION NAME] 10-325 mg one (1) tablet by mouth every four (4) hours as needed for mild pain; and [MEDICATION NAME] 10-325 mg two (2) tablets by mouth every four (4) hours as needed for severe pain. Review of LPN #9's Late Entry Nurse's Notes dated 03/02/16 at 11:17 AM, revealed on 03/01/16 at 4:00 PM a call was placed to the facility's Pharmacy requesting to know where the resident's pain medication was. Further review revealed the LPN was told that the medication was on its way and left the Pharmacy at 1:30 PM. LPN #9 documented she offered the resident a Tylenol (mild [MEDICATION NAME] medication), however he/she declined. Continued interview with Resident #10 on 03/01/16 at 12:00 PM revealed he/she had to take half of his/her recommended of PRN [MEDICATION NAME] because he/she was told by staff that they ran out of his/her [MEDICATION NAME]. The resident stated he/she wondered how the facility could run out of his/her medications. Review of Resident #10's Prescriptions delivered to the facility, dated March 2016, revealed the resident's [MEDICATION NAME] ([MEDICATION NAME]) left the Pharmacy at 12:08 PM on 03/01/16. Interview with Pharmacist/General Manager 03/04/16 at 6:25 PM, revealed the [MEDICATION NAME] arrived to the facility at 4:30 PM. Review of Resident #10's Narcotic Sign-Out Sheet revealed the resident had been receiving [MEDICATION NAME] 10-325, two (2) tablets from 02/27/16 through 02/29/16 and it was noted on the Narcotic Sign Out Sheet, on 02/29/16 at 9:00 PM after administering two (2) tablets, there was only two (2) tablets left. Per the Narcotic Sign out Sheet on 03/01/16 the resident only received one (1) tablet for the next two (2) doses at 3:00 AM, and at 10:30 AM, and then the resident did not receive another dose of [MEDICATION NAME] until 03/01/16 at 6:15 PM, when the resident received (2) tablets after the medication was delivered from the pharmacy. This was a time span of almost eight (8) hours the resident went without the pain medication from 10:30 AM until 6:15 PM. Further interview with LPN #9/Unit Manager, on 03/02/16 at 10:55 PM, revealed the the resident received only one (1) [MEDICATION NAME] 10/325 mg tablet at 3:00 AM and one (1) tablet at 10:30 AM, on 03/01/16; however, the resident had a history of [REDACTED]. Further interview, revealed although the resident normally would receive the medication about every four (4) hours, the medication was unavailable and after the 03/01/16 dose at 10:30 AM of one (1) tablet, the resident did not receive another tablet until 6:15 PM when the resident received two (2) tablets, which was almost eight (8) hours later. Continued interview revealed the resident was without his/her [MEDICATION NAME] normal dose of two (2) [MEDICATION NAME] every four (4) hours for approximately fifteen (15) hours, until his/her Pain Medication arrived from Pharmacy, from 03/01/16 at 3:00 AM until 03/01/16 until 6:15 PM. Continued review of the MAR dated March 2016, revealed the resident was given [MEDICATION NAME] three (3) times on 03/01/16; one (1) tablet at 3:00 AM, one (1) tablet at 10:30 AM, and one (1) tablet at 10:00 PM; however, review of the resident's Narcotic Sign-Out Sheet revealed the resident received his/her medications four (4) times on 03/01/16; one (1) tablet at 3:00 AM, one (1) tablet at 10:30 AM, two (2) tablets at 6:15 PM, and (one) tablet at 10:00 PM, indicating a discrepancy in the MAR and the Narcotic Sign Out Sheet. Review of the MAR dated 03/02/16 revealed the resident was administered [MEDICATION NAME] one (1) time when the resident received two (2) tablets at 6:45 AM. However review of the Narcotic Sign-Out Sheet revealed the resident was provided his/her pain medication four (4) times on 03/02/16; at 6:45 AM two (2) tablets, at 12:15 PM two (2) tablets, at 5:00 PM one (1) tablet, and at 10:30 PM two (2) tablets, indicating a discrepancy in the MAR and the Narcotic Sign Out Sheet. Review of the MAR for 03/03/16, revealed [MEDICATION NAME] was not signed out for that day. However, review of the Narcotic sign-out book showed two (2) tablets were signed out at 5:00 AM on 03/02/15. (per sequential order of times and dates, should have been written as 03/03/16 on the Narcotic sign out book), indicating a discrepancy in the MAR and the Narcotic Sign Out Sheet. In addition, review of the PRN Pain Management Flow Sheet for March 2016, revealed the resident was not assessed for his/her pain level prior to the administration of his/her medication or for the effectiveness of the medication for the month of March 2016 per the facility's policy. Interview with the Director of Nursing (DON), on 03/03/16 at 3:20 PM in regards to Resident #10, revealed staff should have been more proactive in meeting the needs of the resident to ensure the resident received pain medication and antibiotics as ordered. She stated, staff should have contacted the resident's physician to determine if another pain medication or antibiotic medication could have been administered to the resident until the resident's medications were received from pharmacy because the Physician may have recommended something the facility already had in the E-Box. In addition, she stated the narcotic pain medications should be ordered in time for the pharmacy to fill them and if this did not happen, pharmacy should be notified for immediate delivery. She stated on 02/29/16, the Physician should have been notified the resident did not receive his/her pain medication. The DON revealed staff should have been documenting pain assessments in Nurse's Notes or the PRN Pain Medication Flow Sheet, prior to and after administration of pain medications to assess effectiveness of pain medications for Resident #10. Interview with the Nurse Practitioner (APRN) on 03/04/16 at 10:50 AM, revealed she would have expected the facility to have notified Resident #10's medical provider when his/her antibiotic and pain medication did not arrive at the facility on the day of admission, and also when it was noted the resident was running out of pain medication a few days after admission. Interview with the Administrator, on 03/04/16 at 11:50 PM, revealed in regards to Resident #10, staff should have notified the pharmacy when the facility did not receive the [MEDICATION NAME] and [MEDICATION NAME], and informed them the medications needed to be delivered as soon as possible. Additionally, she revealed she would have expected staff to contact the physician to see what they would have recommended because the facility could have utilized their E-Box. She further stated staff should ensure narcotic pain medication was ordered timely. 2. Review of the medical record revealed the facility admitted Resident #12 on 04/14/15, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 02/07/16, revealed the facility assessed Resident #12 to have a BIMS score of thirteen (13) which indicated the resident was cognitively intact. Continued review of the MDS revealed the resident was assessed to have frequent severe pain. Review of Resident #12's Comprehensive Care Plan, dated 01/13/16, revealed a problem of resident exhibiting or at risk for alteration in comfort related to Chronic Pain, and Arthritis, with a goal stating the resident would achieve acceptable level of pain control. The interventions revealed nurses were to evaluate pain characteristics of quality, severity, location, and precipitating/relieving factors. Further review revealed nurses were to utilize the pain scale and observe the effectiveness of the Pain Medication. Review of the Order Summary Report (physician's orders [REDACTED].#12 revealed, the resident was ordered [MEDICATION NAME] Tablet ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 MG every six (6) hours as needed for pain. Per the Report, the pain medication order was started on 05/14/15 and continued. Review of Resident #12's February 2016 Narcotic Sign Out Sheets for [MEDICATION NAME] revealed on 02/12/16 at 6:30 AM, the resident received the last dose of [MEDICATION NAME] pain medication. Continued review of the Narcotic Sign Out Sheets revealed the resident did not receive [MEDICATION NAME] from 02/12/16 at 6:30 AM until 02/15/16 at 8:40 AM, when thirty (30) [MEDICATION NAME] tablets were delivered. Interview, on 03/04/16 at 6:40 PM, with Resident #12 revealed he/she on more than one occasion has been in pain and asked for pain medication, and was told by nursing he/she did not have any pain medication and it was on order. Continued interview revealed the most recent time the resident was told he/she was out of medication, he/she would rate his/her pain eight (8) out of ten (10) with ten (10) being the most severe pain. Additionally, Resident #12 revealed he/she was not always asked what his/her pain level was before receiving pain medication from the nurses. Resident #12 stated the longest he/she had to go without pain medication when he needed it was for a weekend. Interview on 03/04/16 at 5:05 PM, with Licensed Practical Nurse (LPN) #7 revealed after reviewing the Narcotic Sign Out Sheets, Resident #12 received his/her last available dose of [MEDICATION NAME] on 02/12/16 at 6:30 AM, prior to the refill on 02/15/16. However, review of the Nurse's Notes and the PRN Pain Management Flow Sheet revealed there was no documented evidence of a pain assessment utilizing the rating scale in either the Nurse's Notes or the PRN Pain Management Flow Sheet for the dose administered on 02/12/16 at 6:30 AM. LPN #7 further stated on the morning of 02/15/16 she received shift report from the night shift nurse, and it was reported to her Resident #12 had been requesting pain medication over the weekend and he/she was out, but it would arrive that morning. Although LPN #7 administered the [MEDICATION NAME] one (1) tablet on 02/15/16 at 8:40 AM per the Narcotic Sign Out Sheet and per the MAR, there was no documented evidence of a pain assessment in either the Nurse's Notes or the PRN Pain Management Flow Sheet utilizing the rating scale for the dose administered on 02/15/16 at 8:40 AM as per policy. Further interview with LPN #7, revealed she could not remember if she asked the resident if he/she was in pain prior to administration of the medication; however, she was supposed to do a pain assessment prior to the administration of PRN pain medication and document the assessment on the PRN Pain Management Flow Sheet. Post survey phone interview on 3/14/16 at 1:30 PM, with LPN #13, confirmed she was assigned to Resident #12 on 02/12/16 on the 3:00 PM to 11:30 PM shift, and she remembered a nurse on the prior shift had called the Physician for a prescription because in this instance the resident needed a new prescription for a refill. She stated she was not sure where the ball was dropped. Continued interview revealed she didn't remember the resident asking for pain medication during that

Based on interview, record review, and review of the facility's policies, it was determined the facility failed to provide medications to meet the needs of the residents and failed to implement procedures for acquiring, receiving, dispensing, documenting and accurately administering medications for eight (8) of twenty-four (24) sampled residents (Residents #4, #6, #10, #12, #15, #16, #19, and #20). Resident #10 was admitted to the facility on [DATE] at approximately 5:00 PM after being hospitalized for [REDACTED]. Per the Hospital Discharge Summary, the resident received the last dose of Percocet pain medication at the hospital on [DATE] at 3:00 PM. Although the medication was ordered to be administered every four (4) hours as needed for pain, the resident did not receive his/her pain medication until 02/27/16 at 3:30 AM, eight and a half (8 1/2) hours after the resident requested the medication. Simultaneously, Resident #10 did not receive the antibiotic to treat Discitis/Oste[DIAGNOSES REDACTED] (a bone infection) as ordered on admission. physician's orders [REDACTED]. Per the Hospital Discharge Summary, the resident received the last dose of antibiotic on 02/26/16 at 1:34 PM at the hospital. However, the resident did not receive the antibiotic medication at the facility until 02/27/16 at 2:00 PM, which resulted in the resident missing two (2) doses of the antibiotic. Also, the facility failed to reorder Resident #10's Percocet pain medication in a timeframe which would allow the pharmacy to deliver the medication prior to the supply running out. The facility failed to notify the pharmacy of the immediate need for the medication and the resident was unable to receive his/her normal dose of two (2) Percocet every four (4) hours as needed, for over fifteen (15) hours, from 03/01/16 at 3:00 AM until the Percocet arrived from Pharmacy on 03/01/16 at 6:15 PM. Additionally, the facility failed to document the administration of narcotic pain medication on the Medication Administration Record [REDACTED]. In addition, the facility failed to ensure Resident #12's Percocet pain medication was available upon request. The resident received his/her last available dose of Percocet medication on 02/12/16 at 6:30 AM and although the resident had physician's orders [REDACTED]. Furthermore, the facility failed to ensure periodic reconciliation was performed for controlled medications to include pertinent documentation for three (3) of the three (3) nursing units. Review of the Narcotic Count documentation, on 03/03/16, revealed numerous days and shifts failed to have the required documentation verifying the narcotic drawer had been counted by two (2) licensed nurses, the count was correct or incorrect, and the date of the narcotic count as per facility protocol for the timeframe reviewed of 12/20/16 to 03/03/16. The findings include: Review of the facility's Policy, titled Providing Pharmacy Service, revised 03/01/11, revealed the pharmacy would provide pharmacy and prescription delivery services as specified by the pharmacy provider contract. The purpose of the policy was to provide a continuum of pharmaceutical services to the Center and essential medication and services for the residents and to ensure that Center staff had access to medications, emergency service for medications, and drug information on a twenty-four (24) hour basis. Continued review of the policy revealed staff should prioritize needs and place orders accordingly. When possible, staff should place new and emergency orders only. General refills received in the pharmacy during this time were held from processing, allowing for concentration on new and emergency orders only. Per Policy, pharmacy must be notified if the refill was a necessity. Review of the facility's Pharmacy Services Agreement, signed 08/05/15, revealed the pharmacy agreed to provide delivery services to the facility during the Pharmacy regular business hours and on an emergency basis. In the event the pharmacy could not furnish an ordered medication on a prompt and timely basis, the pharmacy would make arrangements with another pharmacy supplier in a community local to the facility to provide such services to the facility. 1. Review of Resident #10's clinical record revealed the facility admitted the resident on 02/26/16 with [DIAGNOSES REDACTED]. Review of Resident #10's Hospital Discharge Summary, dated 02/26/16, revealed the resident was prescribed Percocet (Oxycodone-Acetaminophen -narcotic pain medication) 10/325 milligrams (mg) one (1) to two (2) tablets by mouth every four (4) hours as needed (PRN) for pain. Per the Hospital Summary, Resident #10 received the last dose on 02/26/16 at 3:00 PM and the next dose was scheduled on 02/26/16 after 7:00 PM, if needed. Further review of the Hospital Discharge Summary revealed Resident #10 received a dose of Cefazolin (antibiotic medication) two (2) Grams (G) in dextrose 5% (five percent) intravenously on 02/26/16 at 1:34 PM and was scheduled for the next dose on 02/26/16 at 10:00 PM. Review of Resident #10's physician's orders [REDACTED]. Review of the facility's Fax Confirmation Sheet revealed orders for the Percocet and the Cefazolin were faxed to the pharmacy on 02/26/16 at 8:10 PM. Further review revealed a prescription for Oxycodone-Acetaminophen, dated 02/26/16, was faxed to the Pharmacy on 02/26/16 at 6:52 PM. Review of the Medication Administration Record [REDACTED]. In addition, review of the MAR, revealed the resident did not receive the first dose of intravenous Cefazolin antibiotic until 02/27/16 at 2:00 PM, although the antibiotic was scheduled every eight (8) hours and should have been administered on 02/26/16 at 10:00 PM, and 02/27/16 at 6:00 AM. Review of Resident #10's Pharmacy Connection, Proof of Delivery, printed on 03/02/16, revealed the resident's Oxycodone/Acetaminophen thirty (30) tablets were delivered to the facility on [DATE] at 3:31 AM. Further review of the Pharmacy Connection, Proof of Delivery, printed on 03/02/16, revealed the resident's Cefazolin Sodium-Dextrose 2 GM/100 ML was delivered to the facility on [DATE] at 1:45 PM. Review of Licensed Practical Nurse (LPN) #2's, Nurse's Notes, dated 02/26/16 at 10:35 PM, revealed Resident #10 was upset his/her medications were not at the facility and the resident had arrived at the facility around 5:00 PM. Interview with Resident #10, on 03/01/16 at 12:00 PM, revealed he/she was admitted to the facility on Friday, 02/26/16, and was informed by staff he/she was a late admission. Further interview revealed the resident suffered in pain for approximately twelve and a half (12 ½) hours after arriving at the facility. Resident #10 stated the last time he/she received pain medication from the hospital was at 3:00 PM on 02/26/16 and he/she did not receive another dose of pain medication until approximately 3:30 AM on 02/27/16, even though he/she repeatedly requested the pain medication. Continued interview with Resident #10, revealed he/she was on an antibiotic for his/her spine. The resident stated the last dose of antibiotic received at the hospital was on 02/26/16 at 2:00 PM, and he/she missed two (2) doses of antibiotics after arrival at the facility on 02/26/16 due to the pharmacy thinking he/she had an allergic reaction to the antibiotic medication. Interview with Licensed Practical Nurse (LPN) #2, 03/02/16 at 10:51 AM and 03/04/16 at 10:57 AM, who worked on the 100 wing where Resident #10 resided, revealed she admitted Resident #10 and was assigned to the resident on 02/26/16 from admission until she left work which was about 7:00 PM. Continued interview revealed the delivery and administration of medication was not a concern on her shift because to her knowledge the resident just had his/her medications administered before leaving the hospital and the medications would have been delivered after her shift. Further interview with LPN #2, revealed she received a telephone call the day the resident was admitted , on 02/26/16, from Pharmacy and they were concerned about the resident's allergy to Penicillin, wondering if the resident should have the intravenous antibiotic. LPN #2 stated she told the pharmacist it should not have been a concern since the resident came from the hospital on the antibiotic. LPN #2 stated she verified with Resident #10 that the resident was not allergic to the antibiotic around 7:00 PM when she was getting off work. Interview with LPN #4 on 03/02/16 at 7:15 PM, revealed she was assigned to the resident on 02/26/16 from 11:00 PM to 7:00 AM. She stated, during the admission process, all the residents physician's orders [REDACTED]. LPN #4 revealed Resident #10 told her, when she reported to work at 11:00 PM, he/she was in pain. LPN #4 stated Resident #10 continuously requested the pain medication and she advised the resident the medication had not arrived; however, she did not call pharmacy to inquire about the medication. Further interview with LPN #4, revealed the facility had an E-Box, but the dosage of the Percocet the resident was ordered was not on the Emergency Box List. She stated she should have contacted the Physician and pharmacy to see if anything could have been given to the resident from the E-Box. LPN #4 revealed the resident's Percocet arrived to the facility between 2:00 AM and 3:00 AM on 02/27/16 and she administered the pain medication. Continued interview with LPN #4, revealed she did not follow up on Resident #10's antibiotic because per the MAR, the resident's antibiotic was not due to start during her shift, and she didn't check the physician's orders [REDACTED]. She stated the nurse before her, LPN #2 did not transcribe the physician's orders [REDACTED]. Interview with the facility's Pharmacist/General Manager, on 03/04/16 at 6:25 PM, revealed the pharmacy received Resident #10's physician's orders [REDACTED]. He stated there was a delay in the resident's medication because the pharmacist filling the order asked the facility to clarify the resident's allergy for the antibiotic and this was not clarified until 7:10 PM on the same day. Continued interview revealed Percocet was then sent on the next run, which was at 12:00 AM. He further stated the resident's pain medication arrived to the facility at 3:31 AM; however, the resident's antibiotic was not on that run because the information about the resident's allergy was not communicated to the intravenous (IV) department. The General Manager revealed the delay occurred in his department because of miscommunication. Interview on 03/02/16 at 10:55 PM with LPN #9/Unit Manager for the 100 Unit where Resident #10 was admitted on [DATE], revealed she was responsible for ensuring the new admissions physician's orders [REDACTED]. She stated she faxed Resident #10's physician's orders [REDACTED]. LPN #9 revealed if the facility did not have the pain medication and the resident was complaining of pain, the nurse should have notified the Physician to obtain a one (1) time order for something to be given to Resident #10 from the E-Box. Further interview with LPN #9/Unit Manager, revealed she received a phone call at home the morning of 02/27/16 from LPN #10 who informed her when she signed for Resident #10's medications on 02/27/16 from pharmacy, the antibiotic was not included. LPN #9 further stated, LPN #10 should have called the pharmacy to get the medication delivered to the facility stat and the Physician should have been called to see if another antibiotic could have been given until the medication arrived. LPN #9 stated the admitting nurse did not transcribe the orders correctly to the MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. Per the MAR, staff signed the resident received his/her Percocet (2) times on 02/27/16 at 3:30 AM and 2:00 PM; however, review of the Narcotic sign-out sheet revealed the resident received his/her medication five (5) times that day at 3:30 AM, 8:45 AM, 2:00 PM, 6:00 PM, and 10:00 PM. Continued review of the MAR indicated [REDACTED]. Further review of Resident #10's MAR, dated February 2016, revealed the resident was given Percocet 10/325 mg two (2) tablets on 02/29/16 at 4:00 AM, and there was no further documented evidence Percocet was given as per the MAR indicated [REDACTED]. Review of Resident #10's Narcotic Sign-Out Sheet revealed the resident had been receiving Percocet 10-325, two (2) tablets from 02/27/16 through 02/29/16 and it was noted on the Narcotic Sign Out Sheet, on 02/29/16 at 9:00 PM after administering two (2) tablets, there was only two (2) tablets left. Review of Resident #10's Physicians Orders dated March 2016 revealed orders for Percocet 10-325 mg one (1) tablet by mouth every four (4) hours as needed for mild pain; and Percocet 10-325 mg two (2) tablets by mouth every four (4) hours as needed for severe pain. Review of the Narcotic Sign out Sheet revealed on 03/01/16 the resident only received one (1) tablet for the next two (2) doses at 3:00 AM, and at 10:30 AM, and then the resident did not receive another dose of Percocet until 03/01/16 at 6:15 PM, when the resident received (2) tablets after the medication was delivered from the pharmacy. This was a time span of almost eight (8) hours the resident went without the pain medication from 10:30 AM until 6:15 PM. Review of LPN #9's Late Entry Nurse's Notes dated 03/02/16 at 11:17 AM, revealed on 03/01/16 at 4:00 PM a call was placed to the Facility's Pharmacy requesting to know where the resident's pain medication was. Further review revealed the LPN was told that the medication was on its way and left the Pharmacy at 1:30 PM. LPN #9 documented she offered the resident a Tylenol, however he/she declined. Continued interview with Resident #10 on 03/01/16 at 12:00 PM revealed he/she had to take half of his/her recommended of PRN Percocet because he/she was told by staff that they ran out of his/her Percocet. The resident stated, he/she wondered how the facility could run out of the medications. Review of Resident #10's Prescriptions delivered to Bridge Point Center, dated March 2016, revealed the resident's Oxycodone (Percocet) left the Pharmacy at 12:08 PM on 03/01/16. Interview with Pharmacist/General Manager 03/04/16 at 6:25 PM, revealed the Oxycodone arrived to the facility at 4:30 PM. Continued interview with LPN #9/Unit Manager, on 03/02/16 at 10:55 PM revealed she was made aware Resident #10 was out of Percocet on 03/01/16. She stated, she called the pharmacy on 03/01/16 at 1:30 PM to inquire about the resident's pain medication and was told the medication was en route. Continued interview revealed Resident #10's medication arrived to the facility around 4:25 PM on 03/01/16, at which time she administered the pain medication to the resident. Further interview with LPN #9/Unit Manager, on 03/02/16 at 10:55 PM, revealed the resident received only one (1) Percocet 10/325 mg tablet at 3:00 AM and one (1) tablet at 10:30 AM, on 03/01/16, however; the resident had a history of [REDACTED]. Per interview the resident was without his/her normal dose of two (2) Percocet every four (4) hours for approximately fifteen (15) hours, from 03/01/16 at 3:00 AM until 03/01/16 until 6:15 PM. Interview with LPN #1 on 03/04/16 at 3:37 PM, revealed there was a blue skid on the narcotic medication container indicating when the medication was to be refilled, and at that point the tab should be pulled for pharmacy to refill the medication. After reviewing the Narcotic Sign-out sheet, LPN #1 revealed he should have requested a prescription from the physician to refill the resident's pain medication on 02/29/16 on the day shift. Further interview with the Pharmacist/General Manager, on 03/04/16 at 6:25 PM, revealed the resident did not receive his/her pain medication supply on 02/29/16, because the facility did not place the order for the prescription refill until 02/29/16 at 5:49 PM. He revealed since the medication was not put in for immediate delivery, the prescription was not filled until the next business day. He further stated the facility received the next delivery at 4:30 PM on 03/01/16, adding the facility would need to place an order for [REDACTED]. Continued Review of the MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. However review of the Narcotic Sign-Out Sheet revealed Resident #10 was provided his/her pain medication four (4) times on 03/02/16; at 6:45 AM two (2) tablets, at 12:15 PM two (2) tablets, at 5:00 PM one (1) tablet, and at 10:30 PM two (2) tablets. Review of the MAR indicated [REDACTED]. However, review of the Narcotic sign-out book showed two (2) tablets were signed out at 5:00 AM on 03/02/15. (per sequential order of times and dates, should have been written as 03/03/16 on the Narcotic sign out book). Interview with the Director of Nursing (DON), on 03/03/16 at 3:20 PM revealed in regards to Resident #10, staff should have been more proactive in meeting the resident's needed to ensure the resident received pain medication and antibiotics as ordered. She further stated, staff should have contacted the resident's physician to determine if another pain medication or antibiotic medication could have been administered to the resident until the resident's medications were received from pharmacy because the Physician may have recommended something the facility already had in the E-Box. Additionally, she stated the narcotic pain medications should be ordered in time for the pharmacy to fill them and if this did not happen, pharmacy should be notified for immediate delivery. She stated by 02/29/16 on the first shift, the Physician should have been notified, the resident needed a prescription for the pain medication. Interview with the Nurse Practitioner (APRN) on 03/04/16 at 10:50 AM, revealed she would have expected the facility to have notified Resident #10's medical provider when his/her antibiotic and pain medication did not arrive at the facility on 02/26/16, the day of admission, and also when it was noted the resident was running out of pain medication a few days after admission. Interview with the Administrator, on 03/04/16 at 11:50 PM, revealed in regards to Resident #10, staff should have notified the pharmacy when the facility did not receive the antibiotic and pain medication, and informed them the medications needed to be delivered as soon as possible. Additionally, she revealed staff should have contacted the physician for recommendations because the facility could have utilized their E-Box. The Administrator further stated staff should ensure narcotic pain medication was ordered timely. 2. Review of Resident #12's medical record revealed the facility admitted the resident on 04/14/15, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 02/07/16, revealed the facility assessed the resident to have frequent severe pain. Review of the Order Summary Report (physician's orders [REDACTED]. Review of Resident #12's February 2016 Narcotic Sign Out Sheets for Percocet revealed the last dose of Percocet was administered on 02/12/16 at 6:30 AM. Further review of the Narcotic Sign Out Sheets revealed the resident did not receive Percocet from 02/12/16 at 6:30 AM until 02/15/16 at 8:40 AM, when thirty (30) Percocet tablets were delivered. Interview, on 03/04/16 at 6:40 PM, with Resident #12 revealed there had been more than one (1) occasion when he/she had been in pain and asked for pain medication, and was told by nursing the resident did not have the pain medication and it was on order. Further interview revealed the most recent time the resident was told he/she was out of medication, he/she would rate his/her pain eight (8) out of ten (10) with ten (10) being the most severe pain. Resident #12 stated the longest he/she had to go without the pain medication was when he needed it was for a weekend. Interview and medical record review, on 03/04/16 at 5:05 PM, with Licensed Practical Nurse (LP) #7 revealed on 02/12/16 at 6:30 AM Resident #12 received the last dose of Percocet pain medication. LPN #7 stated on the morning of 02/15/16 she received shift report from the night shift nurse, and it was reported Resident #12 had been requesting pain medication over the weekend and he/she was out, but it would arrive that morning. Post survey phone interview on 3/14/16 at 1:30 PM, with LPN #8, revealed she was assigned to Resident #12 on 02/12/16 on the 3:00 PM to 11:30 PM shift, and she remembered a nurse prior to her shift had called the Physician for a prescription for Percocet because in this instance the resident needed a new prescription for a refill. She stated she was not sure where the ball was dropped. Further interview revealed she didn't remember the resident asking for pain medication during that shift but options for getting narcotic pain medication included: the Physician could call in a prescription to pharmacy for a three (3) day emergency supply until the Physician could come in and write a prescription; or medication could be received from the E- Box if a prescription was written for the medication which was supplied in the E- Box. Further interview with LPN #8, revealed to re-order a narcotic pain medication, the nurse was to pull the prescription sticker from the medication skid and fax the prescription sticker to pharmacy. She stated there had been times when residents did not have their narcotic pain medication and she would call and inform pharmacy and was told the medication would be delivered, only to find out after a follow up phone call to pharmacy, a prescription was needed for the refill. She further stated she got frustrated with pharmacy because even if the sticker was pulled in time for the refill to be filled before running out of medication, pharmacy would not let them know a prescription was needed until the facility followed up with them to see why the medication had not been delivered. Post survey phone interview with Registered Nurse (RN) #5, on 3/14/16 2:35 PM, revealed on 02/13/16 on the 3:00 PM to 11:00 PM shift, Resident #12 asked for a Percocet about 8:00 PM during her medication pass and when she realized there was no Percocet available, she offered Tylenol (analgesic for mild pain) which the resident refused. She stated she called pharmacy and was told a prescription was needed for the refill of Percocet. However, she stated she didn't notify the Physician of the need for the Percocet prescription. Continued interview revealed she should have called the Physician to notify him the resident was out of pain medication and a one (1) time order could have been written for a medication from the E-Box or a three (3) day supply of pain medication could haven been requested with the Physician giving a verbal prescription to pharmacy. However, she revealed the resident was not grimacing or showing signs of pain and she just notified the next shift the resident was out of pain medication. She stated every so often residents would run out of narcotic pain medication and the nurses were to check the narcotics during shift count to re-order when the supply became low. Post survey phone interview with the facility Consulting Pharmacist on 3/14/16 at 2:45 PM, revealed after reviewing the records the facility didn't call the pharmacy triage department prior to 02/15/16 at 6:11 AM to request the Percocet medication for Resident #12 and there was no record of a fax being sent for a re-order of the Percocet. She further stated there was no prescription needed for the Percocet medication that was delivered on 02/15/16. Further interview revealed she couldn't tell if the facility had called the usual pharmacy department number, asking for the refill on the medication prior to 02/15/16 because they did not keep logs of those phone calls. She revealed pharmacy delivered the medication on 02/15/16 at 8:41 AM. Post survey phone interview with the DON on 03/14/16 at 3:00 PM, revealed she had reviewed Resident #12's medical record and the resident didn't have pain medication available for three (3) days from 02/12/16 until 02/15/16. Further interview with the DON, revealed the Physician attended the morning meeting Monday through Friday and the clinical team would let him know which resident's needed refills on their narcotic pain medication and prescriptions were written as needed. She further stated on Wednesdays and Thursdays the nurses on the medication carts were to check to see which narcotics needed refilled before the weekend. The DON revealed, in order to re-order a narcotic pain medication, staff was to call pharmacy or scan the prescription sticker from the medication skid. She further stated if there was a need for a new prescription for a refill the Physician had to be notified to refill the prescription. The DON further stated, on the weekends the Physician could call pharmacy and authorize a prescription. Per interview, the Physician could have also ordered a one (1) time stat order for something which was available in the E-Box until the medication was delivered for Resident #12. She stated the Physician should have been notified of Resident #12 having no Percocet medication to administer. 3. Review of Resident #4's medical record revealed the resident was admitted by the facility on 09/25/15 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #4 as almost constantly in pain in the last five (5) days making it difficult for the resident to sleep at night and limiting his/her day-to-day activities. Further review of the MDS, revealed the resident rated his/her pain level at a ten (10), on a scale of one (1) to ten (10) with ten (10) being the worst pain. Review of Resident #4's March 2016 physician's orders [REDACTED]. Review of the MARs dated February and March 2016, revealed staff initialed the MAR indicated [REDACTED]. However, review of the Narcotic Sign-Out Sheet revealed the Percocet was signed out fifty-two (52) times between 02/02/16 and 03/02/16, a difference of thirteen (13) times in which the resident's PRN medications were not documented on the resident's MAR. 4. Review of Resident #16's medical record revealed the facility admitted the resident on 12/23/14 with [DIAGNOSES REDACTED]. Review of Resident #16's Quarterly MDS Assessment, dated 12/08/15, revealed the facility assessed the resident as having pain frequently within the last five (5) days making it hard for him/her to sleep at night and limiting his/her day-to-day activities. Further review revealed the resident was asked to rate his/her pain on a scale of zero (0) to ten (10) over the past five (5) days and the resident stated nine (9), with a score of ten (10) being the worst pain. Review of Resident #16's Physician order [REDACTED]. Review of the February and March 2016 MARs revealed staff initialed the resident was administered Norco twenty-one (21) times from 02/01/16 to 03/02/16. However, review of Resident #16's Narcotic Sign-Out Sheet revealed the Norco medication was signed out sixty-four (64) times between 02/01/16 and 03/02/16, a difference of forty-three (43) times in which the resident's PRN medications were not documented in the resident's MAR. 5. Review of Resident #19's medical record revealed the facility admitted to the resident on 10/08/14, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 02/02/16, revealed the facility assessed Resident #19 to have occasional pain with the numeric rating of a seven (7) out of ten (10), with zero (0) being no pain and ten (10) being the worst pain. The facility assessed the resident's BIMS score as a fifteen (15) out of fifteen (15) indicating no cognitive impairment. Review of the Order Summary Report (physician's orders [REDACTED].

Based on interview, record review, and review of facility policies, it was determined the facility failed to have an effective system to ensure clinical records were maintained in accordance with accepted professional standards and practices which were complete and accurately documented, for twelve (12) of twenty four (24) sampled residents (Residents #2, #4, #6, #8, #10, #13, #15, #16, #17, #19, #20 and #21). The facility failed to follow their policies related to documenting the residents' pain presence on the Medication Administration Record (MAR), and if PRN (as needed) medications were given, documenting on the PRN Pain Management Flow Sheet on the back of the MAR. In addition, the facility failed to ensure Physician's orders were accurately transcribed to the MAR. Also, the facility failed to ensure accurate documentation on the MAR related to narcotic pain medication administered as evidenced by discrepancies in the number of doses administered per the MAR and per the Narcotic Sign Out Sheet. The findings include: Review of the facility policy titled, Clinical Record: Charting and Documentation, revised 01/01/13, revealed the purpose of the policy was to provide a complete account of the patients total stay from admission through discharge, provide information about the patient that will be used in developing a care plan, and as a tool for measuring the quality of care provided to the patient. Further review, revealed staff was to chart pertinent changes in the patient's condition, reaction to treatment, medication, etc., as well as routine observations. Per Policy, be concise, accurate, complete, factual and objective. Review of the facility policy titled, Pain Management, with a revision date of 01/02/14, revealed staff would document the residents' pain presence on the Medication Administration Record (MAR). Per policy, if PRN (as needed) medications were given, staff would document on the PRN Pain Management Flow Sheet on the back of the MAR. Review of the Facility's Policy, titled, NSG305 Medication Administration: General, revision date 07/01/15, revealed staff would monitor the patient for adverse reactions and effectiveness of medication and staff would document the administration of medication on the Medication Administration Record (MAR) including the resident's response to medication, and effectiveness of as needed (PRN) medications. Review of the facility policy titled NSG 300 Controlled Drugs: Management of, revised 05/15/14, revealed a complete count of all Schedule II - IV controlled drugs was required at the change of shift per state regulation or at any time in which narcotic keys were surrendered from one (1) licensed nursing staff to another. Continued review, revealed the count would be performed by two (2) licensed nurses. 1. Review of Resident #10's medical record revealed the facility admitted the resident on 02/26/16. Review of Resident #10's Physician Order Sheet and Interim Plan of Care, dated 02/26/16, revealed orders for [MEDICATION NAME] 2 G in D5W- 1GM/50 ML (two grams in [MEDICATION NAME] 5% water one gram/ fifty milliliters) every eight (8) hours for thirty-six (36) days. Review of the MAR dated February 2016, revealed the resident did not receive the first dose of intravenous [MEDICATION NAME] antibiotic until 02/27/16 at 2:00 PM, although the antibiotic was scheduled every eight (8) hours and should have been administered on 02/26/16 at 10:00 PM, and 02/26/16 at 5:30 PM. Interview with Licensed Practical Nurse (LPN) #2, on 03/02/16 at 10:51 AM and 03/04/16 at 10:57 AM, who worked on the 100 wing where Resident #10 resided, revealed she was Resident #10's admitting nurse and was assigned to the resident on 02/26/16 from admission until she left work which was about 7:00 PM. Interview with Licensed Practical Nurse (LPN) #4 on 03/02/16 at 7:15 PM, who worked on the 100 wing, and was assigned to the resident on 02/26/16 from 11:00 PM to 7:00 AM, revealed she did not follow up on Resident #10's antibiotic because it was noted on the MAR, the resident's antibiotic was not due to start on her shift. She stated, the MAR had been transcribed incorrectly by LPN #2 and per the MAR, the medication administration times were marked out with x's for 02/26/16 and 02/27/16 at 6:00 AM, 2:00 PM, and 10:00 PM, and should have indicated the medication was to start on 02/16/16 at 10:00 PM as per orders. She stated if she had checked the orders she would have realized pharmacy needed to be notified the medication was unavailable for administration. Interview with LPN #9/Unit Manager on 03/02/16 at 10:55 PM and 03/04/16 at 9:30 AM, revealed she was the Unit manager for the unit where Resident #10 was admitted on [DATE]. Further interview with LPN #9/Unit Manager, revealed the admitting nurse did not transcribe the orders correctly to the MAR on 02/26/16 related to the antibiotic dates and times the medication was to be administered as per orders. Review of the MAR dated February 2016, and the resident's Narcotic Sign-Out Sheet, on 02/27/16, revealed staff signed the resident received [MEDICATION NAME] (2) times on 02/27/16 at 3:30 AM and 2:00 PM; however, review of the resident's Narcotic sign-out sheet revealed the resident received [MEDICATION NAME] five (5) times that day at 3:30 AM, 8:45 AM, 2:00 PM, 6:00 PM, and 10:00 PM revealing a discrepancy in the MAR and the Narcotic Sign Out Sheet. Also, review of Resident #10's PRN Pain Management Flow Sheet revealed there was no documented evidence the resident was assessed for his/her pain level before the administration of his/her pain medication or after to determine the effectiveness of the medication on 02/27/16, other than the one (1) time documentation on 02/27/16 at 3:30 AM. Further review of the MAR dated February 2016, revealed on 02/28/16, the resident was given [MEDICATION NAME] three (3) times and was administered two (2) tablets at 10:00 AM, 4:00 PM, and 8:00 PM; however, the Narcotic sign-out sheet revealed the resident took his/her [MEDICATION NAME] four (4) times on 02/28/16, and was administered two (2) tablets at 6:00 AM, 11:00 AM, 4:00 PM, and 8:00 PM revealing a discrepancy in the MAR and the Narcotic Sign Out Sheet. Also, there was no documented evidence the resident's pain level was assessed before his/her pain medication was given nor after the administration of the medication to determine the effectiveness of the medication on 02/28/16. Review of Resident #10's MAR, dated February 2016, revealed the resident was given [MEDICATION NAME] 10/325 mg two (2) tablets on 02/29/16 at 4:00 AM, and there was no further documented doses per the MAR on 02/29/16. However; the Narcotic sign-out sheet revealed the resident was given [MEDICATION NAME] 10/325 two (2) tablets five (5) times on 02/29/16, at 4:00 AM, 9:30 AM, 1:00 PM, 5:00 PM, and 9:00 PM revealing a discrepancy in the MAR and the Narcotic Sign Out Sheet. Also, review of the PRN Pain Management Flow Sheet for 02/29/16, revealed no documented evidence the resident was assessed prior to administration of his/her medication or after administration of the medication to determine if the medication was effective. Continued Review of the MAR dated March 2016, revealed Resident #10 was given [MEDICATION NAME] three (3) times on 03/01/16; one (1) tablet at 3:00 AM, one (1) tablet at 10:30 AM, and one (1) tablet at 10:00 PM; however, review of the resident's Narcotic Sign-Out Sheet revealed the resident received his/her medications four (4) times on 03/01/16; one (1) tablet at 3:00 AM, one (1) tablet at 10:30 AM, two (2) tablets at 6:15 PM, and (one) tablet at 10:00 PM, revealing a discrepancy in the MAR and the Narcotic Sign Out Sheet. Review of the MAR dated 03/02/16 revealed the resident was administered [MEDICATION NAME] one (1) time when the resident received two (2) tablets at 6:45 AM. However review of the Narcotic Sign-Out Sheet revealed the resident was provided his/her pain medication four (4) times on 03/02/16; at 6:45 AM two (2) tablets, at 12:15 PM two (2) tablets, at 5:00 PM one (1) tablet, and at 10:30 PM two (2) tablets, revealing a discrepancy in the MAR and the Narcotic Sign Out Sheet. Review of the MAR for 03/03/16, revealed [MEDICATION NAME] was not signed out for that day. However, review of the Narcotic sign-out book showed two (2) tablets were signed out at 5:00 AM on 03/02/15. (per sequential order of times and dates, should have been written as 03/03/16 on the Narcotic sign out book), revealing a discrepancy in the MAR and the Narcotic Sign Out Sheet. In addition, review of the PRN Pain Management Flow Sheet for March 2016, revealed the resident was not assessed for his/her pain level prior to the administration of his/her medication or for the effectiveness of the medication for the month of March 2016. 2. Review of Resident #4's medical record revealed orders for [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]) one (1) tablet to be given by mouth every six (6) hours PRN for moderate pain and two (2) tablets by mouth every six (6) hours PRN for Severe Pain. Review of the MARs dated February and March 2016, revealed staff initialed the MAR thirty-nine (39) times to indicate the resident was administered the pain medications from 02/02/16 to 03/02/16. However, review of the Narcotic Sign-Out Sheet revealed the medication was signed out fifty-two (52) times between 02/02/16 and 03/02/16, a discrepancy of of thirteen (13) times in which the resident's PRN medications were not documented on the resident's MAR. Further review of the resident's record revealed there was no documented evidence of the PRN Pain Evaluation Flow Sheet being completed to assess the resident's pain level prior to administering the medication nor after administration of the medication to assess the effectiveness of the medication for February and March 2016. 3. Review of Resident #16's Physician Orders for March 2016 revealed orders for [MEDICATION NAME] Tablet 10-325 MG ([MEDICATION NAME]-[MEDICATION NAME]-narcotic pain medication) one (1) tablet by mouth every four (4) hours as needed for pain. Review of the February and March 2016 MARs revealed staff initialed the resident was administered his/her pain medication twenty-one (21) times from 02/01/16 to 03/02/16. However, review of Resident #16's Narcotic Sign-Out Sheet revealed the medication was signed out sixty-four (64) times between 02/01/16 and 03/02/16. This was a discrepancy of forty-three (43) times in which the resident's PRN medications were not documented on the resident's MAR. In addition, there was no documented evidence the resident's PRN Pain Evaluation Flow Sheet was completed to assess the resident's pain level prior to administering the pain medication nor after administration of the pain medication to monitor the effectiveness of the pain medication for February and March 2016. 4. Review of Resident #19's Physician's Orders as of 03/03/16 revealed orders for [MEDICATION NAME] Tablet (An opoid combination narcotic medication to treat moderate to severe pain) 5-325 Milligrams (MG) to be administered PRN for pain. Review of the Narcotic Sign-out Sheet for Resident #19's [MEDICATION NAME] Tablet revealed six (6) doses of the [MEDICATION NAME] Tablet were signed out for Resident #19; one (1) tablet on 02/03/16 at 1:00 PM, and at 10:00 PM; one (1) tablet on 02/07/16 at 10:45 AM; one (1) tablet on 02/17/16 at 12:00 PM; one (1) tablet on 02/20/16 at 2:00 PM, and one (1) tablet on 02/26/16 at 12:00 AM. However, review of the February 2016 MAR revealed Resident #19 received a dose of the [MEDICATION NAME] medication on only three (3) occasions; twice on 02/03/16, at 12:00 PM and again at 10:00 PM, and once on 02/07/16 at 10:45 AM. Staff failed to document administration of the medication three (3) times on the MAR. Further review of the Physician's Orders as of 03/03/16 revealed orders for [MEDICATION NAME] Tablet (An opoid combination narcotic medication to relieve moderate to severe pain) 2.5-325 MG to be administered at bedtime. Review of Resident #19's MAR dated February 2016, revealed staff documented the administration of the bedtime dose of the [MEDICATION NAME] Tablet from 02/01/16 through 02/29/16 at 8:00 PM. However, the area for the pain level assessment for the bedtime dose of the scheduled [MEDICATION NAME] was blank. In addition, review of Resident #19's PRN Pain Management Flow Sheet dated February 2016, revealed no documented evidence of an assessment of the resident's pain level prior to the administration of the pain medication nor after administration to reassess for effectiveness of the pain medication. 5. Review of Resident #20's Physician's Orders dated 02/26/16 revealed orders for [MEDICATION NAME] (A narcotic-like pain reliever to treat moderate to severe pain.) 50 MG every six (6) hours as needed for pain. Review of the Narcotics Sign-out Sheet for Resident #20's [MEDICATION NAME] for February 2016, revealed the facility staff documented seven (7) occasions the medication was administered to Resident #20: two (2) doses signed out on 02/27/16 with one dose at 9:30 AM and the other at 5:30 PM; three (3) doses signed out on 02/28/16 at 5:30 AM, 3:00 PM and then again at 7:00 PM; and two (2) doses signed out on 02/29/16 at 1:30 PM and at 7:30 PM. However, review of Resident #20's MAR dated February 2016 revealed staff documented only three (3) occasions the [MEDICATION NAME] was administered: three (3) different doses on 02/28/16 at 5:30 AM, 3:00 PM and again at 7:00 PM with only one (1) dose documented on the PRN Pain Management Flow Sheet with the appropriate pain assessment which was on 02/28/16 at 5:30 AM. Review of the Narcotics Sign-out Sheet for Resident #20's [MEDICATION NAME] revealed the facility staff had documented administration of two (2) doses of [MEDICATION NAME]: one (1) on 03/01/16 at 5:00 PM and the other on 03/02/16 at 8:00 PM. However, review of Resident #20's MAR dated March 2016 revealed revealed a discrepancy, as staff documented the only administration of [MEDICATION NAME] was on 03/03/16 at 4:00 AM. 6. Review of Resident #21's Physician Orders dated March 2016, revealed the resident was ordered to receive [MEDICATION NAME]-50 Patch (a [MEDICATION NAME] formulation of [MEDICATION NAME] indicated for the management of persistent, moderate to severe chronic pain, around the clock opoid [MEDICATION NAME]) one (1) patch every seventy-two (72) hours. Review of the Controlled Drug Record (document for accounting for narcotic medications), revealed the [MEDICATION NAME]-50 was signed out for Resident #21 ten (10) times between 02/08/16 and 03/02/16. Further review revealed there was no documented evidence of a Pain Evaluation completed for the [MEDICATION NAME]-50 Patch for February 2016 or March 2016. 7. Review of Resident #8's Physicians Orders dated February 2016 and March 2016, revealed Resident #8 had orders for [MEDICATION NAME] HCI (narcotic to treat moderate to severe pain), forty (40) milligrams (mg) two (2) times per day; [MEDICATION NAME] (narcotic medication used to treat moderate to severe pain) twenty (20) MG/ML sublingual scheduled every two (2) hours for pain, [MEDICATION NAME] 10 MG/ML every two (2) hours for mild pain PRN, [MEDICATION NAME] thirty (30) MG/ML every two (2) hours for severe pain PRN; and [MEDICATION NAME] Patch (medication to treat severe pain), apply two (2) seventy- five (75) microgram (mcg)/hour patches to the skin every seventy- two (72) hours. Further review revealed staff was to check patch placement and monitor effectiveness every shift. Review of the MARs dated February 2016 and March 2016, revealed a directive to assess and document the resident's level of pain on every shift. Further review revealed there was a space to document the resident's pain level. However, review of the January and February 2016 MARs revealed a documented pain assessment only two (2) times during the two (2) month period of review. 8. Review of Resident #2's MAR, dated February 2016, revealed Resident #2 received [MEDICATION NAME]/[MEDICATION NAME] (opoid pain medication )10/325 mg every six (6) hours, as needed for pain: 02/06/16 at 8:00 AM, 2:00 PM and 8:30 PM; 02/07/16 at 4:45; 02/11/16 at 2:00 PM and 10:00 PM; 02/12/16 at 2:00 PM and 10:00 PM; 02/15/16 at 5:00 AM; 02/16/16 at 11:00 AM; 02/21/16 at 4:00 PM and 10:00 PM; 02/24/16 at 2:45 PM; 02/25/16 at 4:00 PM and 8:00 PM; 02/26/16 4:00 AM, 4:00 PM and 8:00 PM; and 02/27/16 at 10:30 PM. However, there was no documented evidence of a pain assessment completed before the medication was administered nor after the administration of the medication to evaluate the effectiveness of the medication for February 2016. 9. Review of Resident #13's Physician orders, dated 02/2016, revealed orders for [MEDICATION NAME]-[MEDICATION NAME] (narcotic pain medication) 7.5/325 mg, one (1) tablet every four (4) hours as needed (PRN) for pain. Review of Resident #13's MAR dated February 2016, revealed [MEDICATION NAME]/[MEDICATION NAME] 7.5/325 mg was administered on the following dates and times: 02/08/16 at 5:00 AM, 9:00 AM and 9:00 PM; 02/10/16 at 5:00 PM and 9:00 PM; 02/11/16 at 5:00 AM and 11:30 AM; 02/19/16 at 5:30 AM; 02/21/16 at 5:15 AM; and 02/27/16 at 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM. However, there was no documented evidence a pain assessment was performed before the medication was administered, nor after the medication administration to evaluate the effectiveness of the pain medication for February 2016. 10. Review of Resident #17's of Physician's orders dated February 2016, revealed orders for [MEDICATION NAME] (narcotic medication used to treat moderate to severe pain) ten (10) mg every four (4) hours PRN for pain. Further review of Physicians orders dated 02/26/16, revealed the PRN pain medication order had been increased to [MEDICATION NAME] fifteen (15) mg every four (4) hours for pain. Review of Resident #17's February 2016 MAR, revealed [MEDICATION NAME] ten (10) mg was documented as being administered on the following dates and times: 02/06/16 at 11:15 AM; 02/07/16 at 5:00 AM; 02/12/16 at 1:00 AM; 02/13/16 at 6:00 PM and 10:15 PM; 02/17/16 at 4:00 PM and 9:00 PM; 02/29/16 at 4:00 PM and 9:00 PM; 02/20/16 at 10:45 AM, 2:45 PM, 6:45 PM and 10:45 PM; 02/21/16 at 10:30 AM; 02/22/16 at 4:00 PM and 8:00 PM; 02/24/16 at 9:00 AM, 1:40 PM, 6:00 PM, and 10:00 PM; 02/25/16 at 4:00 PM and 9:00 PM; and 02/26/16 at 4:00 PM and 9:00 PM. Continued review revealed [MEDICATION NAME] fifteen (15) mg was documented as administered on 02/28/16 at 10:30 PM. However, there was no documented evidence a pain assessment was performed before the medication was administered, nor after the administration to evaluate the effectiveness of the pain medication for the dates and times noted. In addition, review of Resident #17's MAR dated March 2016 revealed Resident #17 received PRN pain medication of [MEDICATION NAME] fifteen (15) mg on 03/02/16 at 4:00 PM and 8:00 PM; however, there was no documented evidence a pain assessment was performed before the medication was given nor after the administration to evaluate the effectiveness of the pain medication on 03/02/16. 11. Review of Resident #6's Physician Order Sheet dated 02/25/16 revealed orders for [MEDICATION NAME]-[MEDICATION NAME] ([MEDICATION NAME]-narcotic pain medication) 10-325 MG every four (4) hours as needed for pain. Review of Resident #6's Narcotic Sign-Out Sheets for [MEDICATION NAME] for the month of February 2016 revealed there were twenty-nine (29) total doses signed out. However review of the resident's MAR dated February 2016, revealed only eight (8) total documented doses administered to the resident leaving twenty-one (21) doses which were not signed out on the MAR. Further review of the MAR revealed Resident #6's PRN Pain Management Flow Sheet, dated February 2016, was blank with no documentation which indicated the resident's pain rating had not been assessed before or after the administration of pain medication. 12. Review of Resident #15's Physician's Orders dated February 2016, revealed orders for [MEDICATION NAME] Tablet (narcotic pain medication) 5-325 MG by mouth every six (6) hours as needed for pain. Review of Resident #15's February 2016 Narcotic Sign Out Sheets for [MEDICATION NAME] Tablet 5-325 MG revealed thirty-one (31) total doses of the resident's pain medication was signed out. However, review of the residents MAR dated February 2016 revealed only three (3) total documented doses were signed out as administered to Resident #12, a discrepancy of twenty-eight (28) doses. Further review of Resident #15's MAR dated February 2016 revealed his/her PRN Pain Management Flow Sheet, revealed no documentation of what the resident's pain rating was before and after the administration of the [MEDICATION NAME]. Further review of Resident #15's MAR dated 02/01/16-02/29/16, revealed a directive for staff to monitor and record Resident #15's pain level every shift. Per the MAR the resident's pain level was documented only seven (7) dates with all seven (7) of the dates being completed on the 7:00 AM- 7:00 PM shift. These dates were 02/01/16, 02/02/16, 02/03/16, 02/11/16, 02/18/16, 02/23/16, and 02/26/16. Interview with RN #1, on 03/04/16 at 10:30 AM, revealed pain medications administered should be documented on the MAR, and the blue book (Narcotic sign-out log), and the pain assessment should be documented on the Pain Assessment Flow Sheet. However, she revealed she did not always follow this process, and had recognized documentation related to pain medications was a concern and added, it's across the whole facility. Interview with Licensed Practical Nurse (LPN) #6 on 03/04/16 at 4:55 PM, revealed she had fifty-eight (58) residents and was busy trying to take care of them and would forget to complete the needed documentation. Interview with Licensed Practical Nurse (LPN) #5 on 03/04/16 at 5:00 PM, revealed while she knew documenting pain assessments was important, she felt like the residents' care was more important and finding the time for documentation wasn't always possible. Interview with Unit Manager (UM) #3 on 03/04/16 at 5:10 PM, revealed staff was to document pain and severity on the PRN Pain Flowsheet in the MAR and document effectiveness of pain medication on the Pain Flowsheet. UM #3 revealed medication should be signed out on the narcotic book and signed out on the MAR as well by staff for administration of narcotic pain medication. She stated, there was no formal method in place to ensure accurate documentation of the PRN medications. Interview with UM #2, of Hall 200 on 03/04/16 at 6:00 PM, revealed if she noticed a blank space in the MAR, she notified the responsible nurse to obtain the reason the documentation was missing. Upon further interview, it was revealed the nurses would inform her, I forgot. Per interview, her expectation was for the nurses to fill out the MAR as they were taught to do with a pre-pain assessment and post-pain assessment. Interview with the Director of Nursing (DON), on 03/03/16 at 3:20 PM revealed it was her expectation that the PRN narcotic medications would be documented on the Pain Flow Sheet, MAR, and Narcotic Sign Out Sheet. After reviewing the documentation, the DON stated staff should have been documenting in Nurse's Notes or the PRN Pain Medication Flow Sheet, the pain assessment prior to the administration of medications and the effectiveness of pain medications through a pain assessment. Interview with the Nurse Practitioner (APRN), on 03/04/16 at 10:50 AM, revealed she reviewed the MARs to determine how much pain medication the residents were receiving. The APRN stated the administered doses of PRN pain medications needed to be accurately documented on the MARs, in order for her to be able to tell which residents were receiving PRN pain medications and how often the residents were receiving the PRN pain medications. Interview with the Administrator on 03/04/16 at 11:50 PM, revealed staff should follow policies related to documentation of narcotic pain medication.

Based on interview, record review, and review of the facility's Policies and Guidelines, it was determined the facility failed to immediately notify the Physician when medications were unavailable to administer as ordered for two (2) of twenty-four (24) sampled residents (Resident #10 and #12). Resident #10 was admitted to the facility on [DATE] at approximately 5:00 PM after being hospitalized for [REDACTED]. The Hospital Discharge Summary revealed the resident received the last dose of [MEDICATION NAME] (narcotic pain medication used to treat moderate to moderately severe pain) at the hospital on [DATE] at 3:00 PM. The facility Physician's orders on admission revealed [MEDICATION NAME] was ordered to be administered every four (4) hours as needed (PRN) for pain. However, although the resident requested the [MEDICATION NAME] on 02/26/16, the medication was not delivered from pharmacy until 02/27/16 at 3:31 AM, eight and a half (8 1/2) hours after the resident could have received PRN medication as per MD orders. There was no documented evidence the facility notified the Physician the medication was unavailable in order to obtain orders necessary to ensure the resident's pain was addressed. Also, Resident #10 did not receive the antibiotic to treat Discitis/Oste[DIAGNOSES REDACTED] (a bone infection) as ordered after admission to the facility. The Hospital Discharge Summary revealed the resident received the last dose of antibiotic on 02/26/16 at 1:34 PM and next dose would be due at 10:00 PM. Although facility Physician's Orders were received on 02/26/16 for [MEDICATION NAME] (antibiotic medication) intravenously every eight (8) hours for thirty-six (36) days, the resident did not receive the antibiotic medication until 02/27/16 at 2:00 PM, which resulted in the resident missing two (2) doses of antibiotic. There was no documented evidence the Physician was notified of the antibiotic being unavailable for administration. Additionally, the resident was unable to receive the normal dose of two (2) [MEDICATION NAME] every four (4) hours as needed, for over fifteen (15) hours, from 03/01/16 at 3:00 AM until the [MEDICATION NAME] arrived from Pharmacy on 03/01/16 at 6:15 PM due to the facility failing to ensure the medication was received from pharmacy. During this timeframe there was no documented evidence the Physician was notified of the medication being unavailable for administration. Furthermore, Resident #12 had Physician's Orders for [MEDICATION NAME] (narcotic pain medication) every six (6) hours as needed for pain and the resident's supply of medication ran out after the resident received the last dose on 02/12/16 at 6:30 AM. The facility allowed the resident to suffer from pain for three (3) days without the pain medication and there was no documented evidence the Physician was notified of the immediate need for the medication. Resident #12 did not receive the next dose of [MEDICATION NAME] until 02/15/16 at 8:40 AM, even though the resident requested the [MEDICATION NAME]. The findings include: Review of the facility policy titled, Physician/Mid-level Provider Notification, revised 03/01/16, revealed upon identification of a patient who had a change in condition, a licensed nurse would perform appropriate clinical observations and data collection and report to physician/mid-level provider. Further review revealed the purpose of the Policy, was to communicate a change in patient's condition to physician/mid-level provider and initiate interventions as needed/ordered. Review of the facility Guidelines for Physician/Mid-level Provider Notification, revised 01/02/14, revealed the urgency grid was to be used for general reference only and clinical judgement and patient baseline should always be the primary determinate of the timing of physician/mid-level provider notification. Review of the grid, revealed if the condition or problem was general pain, the physician or mid-level provider should be notified urgently if the pain was new and severe, and not responsive to prescribed medications. Further review revealed the physician or mid-level provider should be notified routinely if the resident had new mild or moderate pain. Review of the facility policy titled Pain Management, with a revision date of 01/02/14, revealed the purpose of the facility's policy was to maintain the highest possible level of comfort for the residents by providing a system to identify, assess, treat, and evaluate pain. Per Policy, the nurse would notify the physician/mid-level provider as appropriate and obtain treatment orders as indicated. 1. Review of Resident #10's clinical record revealed the facility admitted the resident on 02/26/16 with [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) List provided by the facility revealed the facility assessed the resident as having a BIMs score of fifteen (15) out of fifteen (15) indicating no cognitive impairment, date unknown of the BIMS assessment. Review of Resident #10's Hospital Discharge Summary, dated 02/26/16, revealed the resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]-[MEDICATION NAME] 10/325 milligrams (mg) one (1) to two (2) tablets by mouth every four (4) hours as needed for pain. Per the Summary, Resident #10 received the last dose of [MEDICATION NAME] on 02/26/16 at 3:00 PM and the next dose could be administered on 02/26/16 after 7:00 PM PRN. Continued review of the Hospital Discharge Summary revealed Resident #10 received the last dose of [MEDICATION NAME] (antibiotic medication) two (2) Grams (G) in [MEDICATION NAME] 5% (five percent) intravenously on 02/26/16 at 1:34 PM and was scheduled for the next dose to be received on 02/26/16 at 10:00 PM. Review of the Physician's Order Sheet, dated 02/26/16, revealed Resident #10 was ordered [MEDICATION NAME] ([MEDICATION NAME]/[MEDICATION NAME])10/325 mg one (1) or two (2) every four (4) hours PRN for pain and [MEDICATION NAME] 2 G in D5W- 1GM/50 ML (two grams in [MEDICATION NAME] 5% water one gram/ fifty milliliters) every eight (8) hours for thirty-six (36) days. Review of the facility's Fax Confirmation Sheet revealed orders for the [MEDICATION NAME] and the [MEDICATION NAME] was faxed to the pharmacy on 02/26/16 at 8:10 PM and a prescription for [MEDICATION NAME]-[MEDICATION NAME], dated 02/26/16, was faxed to the Pharmacy on 02/26/16 at 6:52 PM. Review of the Medication Administration Record [REDACTED]. Also, review of the MAR, revealed the resident did not receive the first dose of intravenous [MEDICATION NAME] antibiotic until 02/27/16 at 2:00 PM, although the antibiotic was scheduled every eight (8) hours and was due to be administered on 02/26/16 at 10:00 PM, and 02/27/16 at 6:00 AM. Review of Resident #10's Pharmacy Connection, Proof of Delivery, printed on 03/02/16, revealed the resident's [MEDICATION NAME]/[MEDICATION NAME] thirty (30) tablets was not delivered to the facility until 3:31 AM on 02/27/16. Further review of the Pharmacy Connection, Proof of Delivery, printed on 03/02/16, revealed the resident's [MEDICATION NAME] Sodium-[MEDICATION NAME] 2 GM/100 ML was not delivered and received by the facility until 02/27/16 at 1:45 PM. Review of Licensed Practical Nurse (LPN) #2's, Nurse's Notes, dated 02/26/16 at 10:35 PM, revealed Resident #10 was upset his/her medications were not at the facility and the resident had arrived at the facility around 5:00 PM. Interview on 03/01/16 at 12:00 PM with Resident #10, revealed he/she was admitted to the facility on [DATE], and suffered in pain for approximately twelve and a half (12 ½) hours before receiving prescribed pain medication. Resident #10 revealed the last time he/she received pain medication from the hospital was at 3:00 PM on 02/26/16, and he/she did not receive another dose of pain medication until approximately 3:30 AM on 02/27/16, even though he/she repeatedly asked for the pain medication. Further interview with Resident #10, revealed he/she received the last dose of antibiotic to treat infection in his/her spine at the hospital on [DATE] at 2:00 PM, and he/she missed two (2) doses of antibiotics after arrival at the facility on 02/26/16, due to the pharmacy thinking he/she had an allergic reaction to the medication. Interview on 03/02/16 at 10:51 AM, and 03/04/16 at 10:57 AM, with Licensed Practical Nurse (LPN) #2 who worked on the 100 wing where Resident #10 resided, revealed if Resident #10's pain medications were not delivered timely, LPN #4 should have notified the Physician for a verbal order for the [MEDICATION NAME] dosage in the Emergency (E-Box), and the resident could have been given the [MEDICATION NAME] in the E-Box from the 200 Wing until the resident's pain medication was delivered. Interview with LPN #4 on 03/02/16 at 7:15 PM, who worked on the 100 wing, and was assigned to the resident on 02/26/16 from 11:00 PM to 7:00 AM, revealed Resident #10 told her, when she reported to work at 11:00 PM, he/she was in pain. LPN #4 stated the resident would continuously ask when his/her medication would be there and she informed the resident his/her medication had not arrived and she would administer the medication as soon as it arrived. Further interview with LPN #4 revealed Resident #10's [MEDICATION NAME] arrived from pharmacy between 2:00 AM and 3:00 AM on 02/27/16, and she immediately administered Resident #10's pain medication when it arrived, stating it was very important the resident received his/her pain medication because the resident was in pain. LPN #4, revealed she was aware the facility had an E-Box, but the dosage of [MEDICATION NAME] the resident was ordered was not on the Emergency Box List; therefore, the facility did not have the medication to provide for the resident. LPN #4 further revealed she should have addressed the resident's pain by contacting the resident's Physician and calling pharmacy to see if anything could have been given to the resident from the E-Box. Further interview with LPN #4, revealed she did not follow up on Resident #10's antibiotic because it was noted on the MAR, the resident's antibiotic was not due to start on her shift, adding per the MAR indicated [REDACTED]. She stated the nurse before her, LPN #2 should have ensured the MAR indicated [REDACTED] Interview with LPN #9/Unit Manager on 03/02/16 at 10:55 PM and 03/04/16 at 9:30 AM, revealed she was the Unit manager for the unit where Resident #10 was admitted on [DATE] and was responsible for ensuring new admissions Physician's Orders were sent to pharmacy. She stated she faxed Resident #10's Physician's Orders to pharmacy stat after the resident was admitted on [DATE]. LPN #9 revealed if the facility had not yet received pain medication and the resident was complaining of pain, the nurse should have notified the Physician to obtain a one (1) time order for something to be given to Resident #10 from the E-Box. Further interview with LPN #9/Unit Manager, revealed she received a phone call at home the morning of 02/27/16 from LPN #10 who informed her when she signed for the residents medications on 02/27/16 from pharmacy, the antibiotic was not included. LPN #9 further stated, LPN #10 should have called the pharmacy to get the antibiotic medication delivered to the facility stat and the physician should have been notified to see if another antibiotic could have been given until the medication arrived. Review of Resident #10's Physicians Orders dated March 2016 revealed orders for [MEDICATION NAME] 10/325 mg one (1) tablet by mouth every four (4) hours as needed for mild pain; and [MEDICATION NAME] 10/325 mg two (2) tablets by mouth every four (4) hours PRN for severe pain. Review of LPN #9's Late Entry Nurse's Notes, dated 03/02/16 at 11:17 AM, revealed on 03/01/16 at 4:00 PM a call was placed to the facility's pharmacy requesting asking where the resident's pain medication was. Further review revealed LPN #9 was told the medication was on its way and left the pharmacy at 1:30 PM. LPN #9 documented she offered the resident a Tylenol ([MEDICATION NAME] for mild pain), however he/she declined. Continued interview with Resident #10, on 03/01/16 at 12:00 PM, revealed he/she had to take half of his/her recommended of PRN [MEDICATION NAME] because he/she was informed by staff they ran out of his/her [MEDICATION NAME]. The resident stated, he/she wondered how the facility could run out of the medications. Review of Resident #10's Narcotic Sign-Out Sheet revealed Resident #10 had been receiving [MEDICATION NAME] 10/325, two (2) tablets with each PRN administration from 02/27/16 through 02/29/16 and it was noted on the Narcotic Sign Out Sheet, on 02/29/16 at 9:00 PM after administering two (2) tablets, there was only two (2) tablets left. Per the Narcotic Sign out Sheet on 03/01/16 the resident only received one (1) tablet for the next two (2) doses at 3:00 AM, and at 10:30 AM, and then the resident did not receive another dose of [MEDICATION NAME] until 03/01/16 at 6:15 PM, when the resident received (2) tablets after the medication was delivered from the pharmacy. This was a period of almost eight (8) hours the resident went without the pain medication from 10:30 AM until 6:15 PM. Review of Resident #10's Prescriptions delivered to Bridge Point Center, dated March 2016, revealed the resident's [MEDICATION NAME] ([MEDICATION NAME]) left the Pharmacy at 12:08 PM on 03/01/16. Interview with Pharmacist/General Manager on 03/04/16 at 6:25 PM, revealed the [MEDICATION NAME] arrived to the facility at 4:30 PM on 03/01/16. Continued interview with LPN #9/Unit Manager on 03/02/16 at 10:55 PM, revealed she became aware Resident #10's had run out of [MEDICATION NAME] on 03/01/16 and called the pharmacy on 03/01/16 at 1:30 PM to find out where the resident's pain medication was and was told the medication was en route. Continued interview revealed Resident #10's medication arrived to the facility around 4:25 PM on 03/01/16, at which time she administered the pain medication to the resident. Further interview with LPN #9/Unit Manager, revealed the resident received only one (1) [MEDICATION NAME] 10/325 mg tablet at 3:00 AM and one (1) tablet at 10:30 AM, on 03/01/16; however, the resident had a history of [REDACTED]. Further interview, revealed although Resident #10 would normally receive the medication about every four (4) hours, the medication was unavailable to administer and after the 03/01/16 dose at 10:30 AM of one (1) tablet, the resident did not receive another tablet until 6:15 PM when the resident received two (2) tablets, which was almost eight (8) hours later. Continued interview revealed the resident did not receive the normal dose of two (2) [MEDICATION NAME] every four (4) hours for approximately fifteen (15) hours, until the pain medication arrived from pharmacy, from 03/01/16 at 3:00 AM until 03/01/16 until 6:15 PM. However, there was no documented evidence the Physician was notified the resident had no [MEDICATION NAME] available for administration during this time frame. Interview with the Director of Nursing (DON), on 03/03/16 at 3:20 PM in regards to Resident #10, staff should have been more proactive in meeting the needs of the resident to ensure he/she received pain medication and antibiotics as ordered. She stated, staff should have contacted the resident's physician to determine if another pain medication or antibiotic medication could have been administered to the resident until the resident's medications were received from pharmacy because the Physician may have recommended something the facility already had in the E-Box. Also, she stated the narcotic pain medications should be ordered in time for the pharmacy to fill them and if this did not happen, pharmacy should be notified for immediate delivery. She further stated on 02/29/16, the Physician should have been notified the resident did not receive his/her pain medication. Interview with the Nurse Practitioner (APRN) on 03/04/16 at 10:50 AM, revealed staff should have notified Resident #10's medical provider when his/her antibiotic and pain medication did not arrive at the facility on the day of admission, and also when it was noted the resident was running out of pain medication a few days after admission. 2. Review of the clinical record revealed the facility admitted Resident #12 on 04/14/15, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 02/07/16, revealed the facility assessed the resident to have a BIMS score of thirteen (13) indicating the resident was cognitively intact, and to have frequent severe pain. Review of the Order Summary Report (Physician's Orders), dated 03/02/16 for Resident #12, revealed orders for [MEDICATION NAME] Tablet ([MEDICATION NAME]-[MEDICATION NAME]) 10-325 MG every six (6) hours as needed for pain. Per the Report, the pain medication order was started on 05/14/15 and continued. Review of Resident #12's February 2016 Narcotic Sign Out Sheets revealed on 02/12/16 at 6:30 AM, the resident received the last available dose of [MEDICATION NAME] pain medication. Continued review of the Narcotic Sign Out Sheets revealed the resident did not receive another dose of [MEDICATION NAME] from 02/12/16 at 6:30 AM until 02/15/16 at 8:40 AM, three (3) days later. Interview, on 03/04/16 at 6:40 PM, with Resident #12 revealed on more than one occasion the resident had been in pain and requested [MEDICATION NAME], only to be told the medication was unavailable and was on order. Resident #12 revealed the most recent time the medication was unavailable, he/she would rate his/her pain eight (8) out of ten (10) with ten (10) being the most severe. Also, Resident #12 revealed the longest he/she had to go without pain medication when he needed it was for a weekend. Interview and medical record review, on 03/04/16 at 5:05 PM, with Licensed Practical Nurse (LPN) #7, confirmed on 02/12/16 at 6:30 AM Resident #12 received his/her last dose of [MEDICATION NAME] pain medication until 02/15/16. LPN #7 revealed the morning of 02/15/16 the night nurse reported to her, Resident #12 had been requesting pain medication over the weekend and was out, but it would arrive that morning. Post survey phone interview on 3/14/16 at 1:30 PM, with LPN #13, confirmed she was assigned to Resident #12 on 02/12/16 on the 3:00 PM to 11:30 PM shift, and remembered one of the nurses prior to her shift had called and notified the Physician of the need for a prescription because in this instance a new prescription was needed for a refill. LPN #13 didn't remember the resident asking for pain medication during that shift. Post survey phone interview on 3/14/16 2:35 PM with Registered Nurse (RN) #5, revealed on 02/13/16 on the 3:00 PM to 11:00 PM shift, Resident #12 asked for a [MEDICATION NAME] about 8:00 PM during her medication pass and when she checked there was no [MEDICATION NAME] available. She stated she offered Tylenol and the resident refused. She further stated she called pharmacy and was told a prescription was needed for the refill of [MEDICATION NAME]. RN #5 stated she didn't notify the Physician of the need for the [MEDICATION NAME] prescription. Further interview revealed she should have notified the Physician of the resident having no [MEDICATION NAME] available, and the Physician could have given a one (1) time verbal order for a medication from the E-Box or a three (3) day supply of pain medication could haven been requested with the Physician giving a verbal prescription to pharmacy. Further interview revealed since the resident was not grimacing or showing signs of pain, she passed the information on in report related to not having the narcotic medication for Resident #12 versus calling the physician. Post survey phone interview with the DON on 03/14/16 at 3:00 PM, confirmed after reviewing Resident #12's record, the resident was without [MEDICATION NAME] pain medication for three (3) days from 02/12/16 until 02/15/16. Further interview with the DON, revealed if there was a need for a new prescription for a refill the Physician was to be notified to refill the prescription. The DON stated on the weekends the Physician could call pharmacy and authorize a prescription. Further interview revealed the Physician could have also ordered a one (1) time stat order for a pain medication which was available in the E- Box until the medication was delivered. She stated the Physician should have been notified of Resident #12's need for the medication. Interview with the Administrator, on 03/04/16 at 11:50 PM, revealed she would have expected staff to contact the physician if medications were unavailable for administration.

Based on observation, record review, interview and review of the facility's policy, it was determined the facility failed to have an effective system to ensure services were provided in accordance with each resident's written Comprehensive Care Plan for two (2) of seventeen (17) sampled residents (Residents #11 and #16) and one (1) of eight (8) unsampled residents (Unsampled Resident G) as evidenced by failure to implement the care plan interventions to keep the residents safe. Observation on 05/07/14 at 9:15 AM, revealed forty-five (45) blister pack medication cards with a count of one thousand and eighty-three (1083) tablets and liquid respiratory inhalation medications to be lying on top of the nurse's station counter and accessible to residents, unauthorized staff and visitors. Continued observation revealed no facility nursing staff at the nurse's station or in the surrounding area until six (6) minutes later, at 9:21 AM. Further observation revealed Unsampled Resident G who was wearing a Wander Guard bracelet (special bracelet which alarms in resident wanders near exits), Resident #11 and Resident #16 in the area of the Unit 300 hall nurse's station where the unsecured medications were located. (Refer to F-323) The facility's failure to ensure an effective system was in place to ensure residents' care plans were implemented in regards to a safe and secure environment was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 05/07/14, and determined to exit on 05/06/14. The facility was notified of the Immediate Jeopardy on 05/08/14. The facility provided an acceptable credible Allegation of Compliance (AOC) was on 05/14/14 with the facility alleging removal of the Immediate Jeopardy on 05/10/14. The Immediate Jeopardy was verified to be removed on 05/10/14 as alleged with remaining non-compliance at a Scope and Severity of a "D", while the facility develops and implements the Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure residents' Comprehensive Care Plans are implemented. The findings include: Review of the facility's policy titled, "Care Plans", with a revision date of 01/02/14, revealed a comprehensive, individualized care plan was to be developed by the interdisciplinary team for each resident. Continued review revealed the purpose of the care plan was to provide the necessary care and services to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing. 1. Review of Unsampled Resident G's medical record revealed the facility admitted Unsampled Resident G on 06/05/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed Unsampled Resident G to be severely cognitively impaired and to be at risk for wandering behaviors. Review of Unsampled Resident G's Comprehensive Care Plan, dated 03/12/14, revealed the facility care planned Unsampled Resident G's risk for wandering behaviors, such as, wandering into other resident rooms and sleeping in other's bed at times. Continued review of the risk for wandering behavior care plan revealed the facility's goal for Unsampled Resident G was for the resident not to wander from a secured location unattended and to be easily redirected to a safe area as needed. Further review of this care plan revealed the interventions to be implemented by staff included allowing Unsampled Resident G to wander freely in a secured environment. 2. Review of Resident #11's medical record revealed the facility admitted Resident #11 on 10/09/10, with [DIAGNOSES REDACTED]. Review of the Annual MDS Assessment, dated 03/09/14, revealed the facility assessed Resident #11 to have a Brief Interview for Mental Status (BIMS) score of four (4) out of fifteen (15), indicating severe cognitive impairment. Further review of the MDS Assessment revealed the facility assessed Resident #11 to be at risk for wandering. Review of Resident #11's Comprehensive Care Plan, revealed a care plan dated 04/28/14, related to the resident's risk for wandering. Continued review of this care plan revealed Resident #11 wandered in and out of other residents' rooms related to his/her confusion secondary to the [DIAGNOSES REDACTED].#11 to "remain safe". 3. Review of Resident #16's medical record revealed the facility admitted Resident #16 on 09/04/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the facility assessed Resident #16 to also have [DIAGNOSES REDACTED]. Review of Resident #16's Comprehensive Care Plan, dated 10/21/13, revealed the facility had care planned Resident #16 to be at risk for wandering from secure locations related to confusion and might follow others out of the building. Continued review of the at risk for wandering care plan revealed the goal stated Resident #16 would not wander from secure locations unattended "until further review". Observation at 9:15 AM on 05/07/14, revealed Unsampled Resident G, Resident #11 and Resident #16 in the vicinity of the Unit 300 hall nurse's station. Observation revealed Unsampled Resident G was mobile without staff assistance. Continued observation revealed forty-five (45) blister pack medication cards containing a total of one thousand and eighty-three (1083) tablets and liquid inhalation medications to be located on top of the nurse's station counter which were unattended by nursing staff and accessible to Unsampled Resident G, Resident #11 and Resident #16. Further observation revealed no nursing staff present at the nurse's station or in the surrounding area until 9:21 AM, six (6) minutes later. Interview with Licensed Practical Nurse (LPN) #6 on 05/8/14 at 8:40 AM, revealed she had signed for the medications when they were delivered on 05/06/14 around 6:00 PM. She stated the medications were unsafe when they were not stored properly in the medication room or the resident's medication drawer. Interview with Licensed Practical Nurse (LPN) #7 on 5/15/14 at 11:30 AM, revealed she had worked the night of 05/06/14, from 11:00 PM until approximately 7:30 AM the morning of 05/07/14. She stated a tote with medications was delivered on the previous shift which were stored under the counter at the nurse's station. LPN #7 stated she removed the medications packs from the tote on 05/07/14 at approximately 6:30 AM, and placed them on the nurse's station counter. Continued interview revealed the medications when stored under the counter and then stored on the counter created an unsafe environment for residents as they could have been accessed by residents. Interview with LPN #1 on 05/08/14 at 10:26 AM, revealed she worked the night of 05/06/14, and had seen a tote stored under the counter at the nurse's station when she received report at 11:00 PM. She stated on 05/07/14 at "around" 6:30 AM, LPN #7 took medications out of the tote and placed them on the counter of the nurse's station. LPN #1 stated the medications should not have been left unattended by nursing staff and accessible to residents. Continued interview revealed unsecured medications were a hazard to residents if they accessed the medications. Interview with the Director of Nursing (DON) on 05/07/14 at 9:32 AM, revealed the medications should not have been left unattended by the nursing staff as this was a safety issue and could be hazardous for the residents. Continued interview revealed the resident television (TV) area, adjacent to the nurse's station, was designated as a safe area for residents and the medications left unsecured did not ensure a safe area for residents. She indicated she expected staff to follow residents' care plans and they should not have left the medications unsecured as this created an unsafe environment. Interview with the Administrator on 05/07/14 at 6:14 PM, revealed the medications when left on the nurse's station counter unattended by nursing staff and accessible to residents were not secured. The facility provided an acceptable credible Allegation of Compliance (AOC) on 05/14/14 that alleged removal of the Immediate Jeopardy (IJ) effective 05/10/14. Review of the AOC revealed the facility implemented the following: 1. The three (3) involved nurses on the Unit 300 hall were provided education by the DON and Administrator on 05/07/14 regarding the drug storage policy and procedure with a post-test following the education and verbalization of understanding. 2. The medications were removed on 05/07/14 upon discovery from Unit 300 hall nurse's station and stored in the locked medication room or medication cart. 3. On 05/07/14, medications delivered to Unit 300 hall were verified by validating the delivery slip and identifying the medications to determine that all medications were accounted for. All medications represented on the pharmacy delivery slip dated 05/06/14 to Units 100, 200 and 300 halls were located with no doses missing which were unaccounted for during medication pass. 4. Licensed nursing staff completed an assessment of all nurse's stations and areas accessible to residents in the facility to determine no drugs or biologicals were left unsecured on 05/07/14. Any items identified were secured upon discovery. 5. On 05/07/14 licensed nursing staff completed an assessment of all residents on Unit 300 hall to determine any potential change in condition from base line. No concerns were identified. 6. On 05/08/14 licensed nursing staff completed assessments of residents on Unit 100 and 200 halls who were cognitively impaired and able to ambulate, self-propel in a wheelchair, wander, or are an elopement risk to determine any possible change in condition from base line. No concerns were identified. 7. On 05/09/14 a review of current residents' care plans and observation of the resident was completed by the licensed nursing staff to determine the care and services provided were as indicated on the plan of care. Any concerns identified were addressed upon discovery. 8. All licensed nursing staff was re-educated to the facility's "Drug Storage" policy and completed a post-test to validate understanding and comprehension of the policy by the Administrator and/or Nurse Management or Nurse Educator by 05/09/14. No nurses were to work without having this education. The facility did not employ agency staff at the time the AOC was developed. 9. All licensed nurses and nursing staff were re-educated to the Accident/Incident Policy including securement of medications and the Care Plan policy and procedure by nursing management or the Administrator by 05/09/14. A post-test was completed to validate understanding and comprehension of the policies. The facility did not employ agency staff at the time the AOC was developed. 10. Newly hired licensed nurses or Medications Technicians (Med Techs) will be educated to the Accident/Incident Policy including "securement" of medications, the Care Plan policy and the "Drug Storage" Policy in orientation. 11. Newly hired nursing assistants will be educated to the Accident/Incident Policy and the Care Plan Policy in orientation. 12. The DON, Nurse Management or Administrator will perform Drug Storage and Environment Safety Audits to Prevent Accident/Incidents will be conducted through observation across all shifts daily for fourteen (14) days, then three (3) times a week for two (2) weeks then monthly for two (2) months; then as determined by monthly Performance Improvement (PI) Committee. Monitoring will include observations of each nurse's station and areas accessible to residents to determine that no drug or biologicals were left unsecured and the environment remained free of hazards. Any concerns identified were to be addressed upon discovery. 13. The DON or Nurse Management will perform an audit completed through observation of ten (10) residents and of the resident care plan to determine interventions across all shifts are followed weekly for eight (8) weeks then monthly for one month. Any concerns identified would be addressed upon discovery. 14. The Administrator, DON and Medical Director reviewed the concerns regarding drug storage, accident/incidents related to a safe environment and following the plan of care, and developed and implemented this plan of action in a PI Committee meeting held on 05/0814. 15. The findings of the audits will be submitted by the Administrator or DON to the PI Committee monthly for three (3) months for review and further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of education material and post-test given to the three (3) nursing staff involved revealed all were re-educated of the facility's policy and procedures related to safe medication storage. Interview with LPN #1 on 05/08/14 at 9:14 AM; LPN #6 on 05/08/14 at 8:40 AM and LPN #7 on 05/15/14 at 11:30 AM, revealed each had received re-education on safe medication storage and taken the post-test. 2. Observation on 05/07/14 at 10:00 AM revealed the DON removed the medications from Unit 300 hall nursing station and secured those medications in the medication room. 3. Observation on 05/07/14 at 9:32 AM revealed the DON verified and accounted for medications by validating medications on hand with delivery document. 4. Review of the drug storage areas checklist which was performed by staff, dated 05/07/14 revealed no medications were found unsecured. Observations on 05/07/14, 05/08/14, 05/13/14, 05/14/14 and 05/15/14 of the nurse's stations and medication carts revealed the carts were locked with no drugs observed to be unsecured. Interview on 05/07/14 with LPN #2 at 10:59 AM and LPN #3 at 4:38 PM, validated they had completed the drug storage area checklist. 5. Review of the facility's assessments of all residents who resided on the Unit 300 hall revealed all the residents were assessed by facility staff with progress notes written in the residents' medical record. Interview with the Unit 300 hall Manager on 05/08/14 at 11:29 AM, verified the assessments were completed. 6. Review of the facility's assessments of residents residing on the Unit 100 and 200 halls with cognitive impairment and who were able to ambulate, self-propel in a wheelchair, wander, or were an elopement risk revealed progress notes for these residents validating the assessments were performed. Interview with LPN #9 on 05/08/14 at 2:12 PM validated the assessments of the residents were completed as per the AOC. 7. Review of the facility's audit of resident medical records and care plans revealed observations to ensure the plan of care was being followed were completed. Interview with LPN #3 and LPN #10, on 05/14/14 at 2:30 PM, validated the completion of the audits. 8. Review of the facility's in-service material revealed post-test and sign in sheets related to safe drug and biological storage were completed. Staff interviews on 05/07/14 with LPN #3 at 4:38 PM, LPN #4 at 6:11 PM and LPN #5 at 6:45 PM; on 05/08/14 with LPN #6 at 8:40 AM, LPN #1 at 10:26 AM, Registered Nurse (RN) #3 at 11:29 AM and LPN #9 at 2:12 PM; and on 05/14/14 with RN #1 at 10:50 AM, LPN #12 at 10:55 AM, LPN #7 at 11:30 AM, LPN #13 at 3:50 PM, LPN #8 at 3:55 PM, Minimum Data Set (MDS) Nurse at 5:10 PM and RN #2 at 5:15 PM validated the education and post-test was provided as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the facility started utilizing agency staff on an as needed basis on 05/14/14. The Administrator stated the agency staff were provided new employee orientation prior to their first shift which included the facility's policy and procedure regarding safe drug and biological storage and resident care plans. Further interview revealed no agency licensed nursing staff utilized as of that date. 9. Review of the facility's in-service materials revealed education and post-test were provided to all licensed nurses and nursing assistants related to the Accident/Incident policy, Care Plan policy and procedures. Staff interviews on 05/07/14 with LPN #3 at 4:38 PM, LPN #4 at 6:11 PM and LPN #5 at 6:45 PM; on 05/08/14 with LPN #6 at 8:40 AM, CNA #4 at 9:00 AM, LPN #1 at 10:26 AM, RN #3 at 11:29 AM and LPN #9 at 2:12 PM; and, on 05/14/14 with CNA #5 at 10:30 AM, RN #1 at 10:50 AM, LPN #12 at 10:55 AM, LPN #7 at 11:30 AM, LPN #13 at 3:50 PM, LPN #8 at 3:55 PM, MDS at 5:10 PM and RN #2 at 5:15 PM validated the education and post-test was performed as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the facility initiated the use of agency staff on an as needed basis on 05/14/14. The Administrator stated with new employee orientation was provided prior to the agency staff's first shift which included the facility's policy and procedure regarding safe drug and biological storage, Accident/Incidents and care plans. Further interview revealed no agency nurse had been utilized as of that date; however, one (1) CNA was utilized on 05/14/14. Review of the new employee orientation training of the agency CNA revealed education was provided as per the AOC. Observations on 05/08/14 and 05/09/14 revealed nursing management staff talking one on one with resident care staff regarding policy and procedures. 10. Review of the new employee orientation packet for licensed nurses or Med Techs revealed it included safe medication storage and Accident/Incident reporting, as well as, physician's orders [REDACTED]. 11. Review of the new employee orientation education for CNAs revealed it included policies on Accident/Incident and care plans with a post-test to verify understanding. Review of the agency CNA education revealed it included education regarding the policies on Accident/Incident and care plans with a post-test to verify understanding. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed no new CNA staff had been hired within previous two (2) week time frame; however, one (1) agency CNA was utilized. 12. Review of the drug storage and environmental safety audits revealed the audits were performed daily on every shift starting on 05/07/14. Interview with the Administrator on 05/15/14 at 11:20 AM, regarding the facility's implemented process, revealed the audits were being performed as per the AOC. Staff interviews on 05/14/14 with LPN #11 at 5:10 PM and LPN #3 at 5:20 PM; and on 05/15/14 with LPN #7 at 11:30 AM revealed the audits were being completed as per the AOC. 13. Review of the audits of resident observation and residents care plans started on 05/07/14 revealed at least ten (10) reviews and observations had been completed by the DON or Nursing Management staff as per the AOC. Review revealed the audits were completed across all shifts and all units/halls within the facility as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed an additional management staff had been added to the schedule each day for each shift to observe, audit and be a resource. The Administrator stated the management staff were directed to immediately contact her for any and all issues identified. 14. Review of the minutes of the PI Committee meeting held 05/08/14 regarding the Immediate Jeopardy findings in regards to drug storage, Accident/Incidents related to a safe environment and following the plan of care revealed the action plan (AOC) had been developed by the Administrator, DON and Medical Director. Interview with the DON on 05/08/14 at 3:30 PM, revealed the facility immediately initiated an investigation into the incident which occurred on 05/07/14. She stated the facility had identified this to be an educational failure and immediately initiated re-education for staff on 05/07/14 as per the AOC. Interview with the RCO Manager on 05/08/14 at 5:25 PM, revealed the facility had responded immediately to correct the identified issue to comply with the facility's policy regarding safe medication storage. 15. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the PI Committee would meet monthly for at least three (3) months for review of the collected data. She stated the first monthly meeting was not due; however, the data collected was being reviewed daily. The Administrator revealed the next PI Committee meeting was scheduled the first week of June 2014. Interview with the Medical Director on 05/15/14 at 2:06 PM, revealed he had been made aware of the unsecured medications. He stated this was an unsafe practice. Continued interview revealed he was actively involved in the PI Committee and had discussed the plan of action (AOC) with the facility "almost daily".

Based on observation, interview and review of the facility's policy, it was determined the facility failed to have an effective system in place to ensure the resident environment remained as free from accident hazards as was possible which affected one (1) of three (3) units in the facility, and two (2) of seventeen (17) sampled residents (Residents #11 and #16) and one (1) of eight (8) unsampled residents (Unsampled Resident G) as evidenced by medications not stored securely. Observation on 05/07/14 at 9:15 AM, revealed forty-five (45) blister pack medication cards with a total count of one thousand and eighty-three (1083) tablets and liquid respiratory inhalation medications were on the counter of the nurse's station, accessible to residents, unauthorized staff and visitors. Continued observation revealed the medications remained unsecured with no facility nursing staff present in the nurse's station or surrounding area until six (6) minutes later at 9:21 AM. Interviews determined the medications had been delivered by the Pharmacy and had been accessible to residents, unauthorized staff and visitors since 6:07 PM on 05/06/14. The facility reported twenty-nine (29) residents assessed with [REDACTED]. Observation on 05/07/14 at 9:15 AM revealed three (3) mobile residents were in the area surrounding the nurse's station (Resident #11, Resident #16 and Unsampled Resident G). The facility's failure to have an effective system was in place to ensure the residents' environment remained as free of accident hazards as possible by ensuring the safe storage of medications was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy (IJ) was identified on 05/07/14, and determined to exit on 05/06/14. The facility was notified of the Immediate Jeopardy on 05/08/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 05/14/14 with the facility alleging removal of the Immediate Jeopardy on 05/10/14. The Immediate Jeopardy was verified to be removed on 05/10/14 as alleged with remaining non-compliance at a Scope and Severity of a "D", while the facility develops and implements the Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure medications are store securely to maintain an environment as free of accident hazards as possible. The findings include: Review of the facility's policy titled, "Storage and Expiration of Medications, Biologicals, Syringes and Needles" with a revision date of 01/01/13, revealed the facility was to ensure all medications and biologicals, including treatment items, were securely stored in a locked cabinet or cart or locked medication room which was not accessible to residents and visitors. Observation on 05/07/14 at 9:15 AM, of the 300 hall nurse's station revealed medications lying on the top of the nurse's station counter unsecured which were accessible residents, visitors and unauthorized staff. Observation revealed there were forty-five (45) blister pack medication cards which contained a total of one thousand and eighty-three (1083) tablets and liquid inhalation medications. Continued observation revealed no nursing staff present at the nurse's station or the surrounding area until 9:21 AM, six (6) minutes later. Further observation of the general area surrounding the nurse's station, revealed three (3) mobile residents (Residents #11, #16 and Unsampled Resident G) who had varying degrees of cognitive impairment, and Unsampled Resident G was observed to be wearing a Wander Guard bracelet. Review of Unsampled Resident G's medical record revealed [DIAGNOSES REDACTED]. Record review revealed the facility assessed Unsampled Resident G to be severely cognitively impaired. Review of Unsampled Resident G's Comprehensive Care Plan revealed the facility had care planned Unsampled Resident G for risk for wandering behaviors with a goal for the resident not to wander from a secured location unattended and to be easily redirected to a safe area as needed. Continued review revealed the care plan interventions included allowing Unsampled Resident G to wander freely in a secured environment, for staff to observe the resident for safe balance and provide a safe environment. Review of Resident #11's medical record revealed [DIAGNOSES REDACTED]. Record review review revealed the facility assessed Resident #11 on 03/09/14, to be severely cognitively impaired. Review of Resident #11's Comprehensive Care Plan revealed the facility care planned Resident #11 to be at risk for wandering behaviors with a goal for the resident to remain safe. Review of Resident #16's medical record revealed [DIAGNOSES REDACTED]. Review of Resident #16's Comprehensive Care Plan revealed the facility care planned Resident #16 to be at risk for wandering from secure locations with a goal for the resident not to wander from secured locations unattended. Additionally, review of the facility's, "Assessment Scoring Report" dated 05/07/14, revealed a total of twenty-nine (29) residents with cognitive impairment who were mobile within the facility and had the potential to access the unsecured medications on that date. Interview with Pharmacy Technician (Tech) #1 on 05/07/14 at 5:00 PM, revealed the medications were delivered to the facility on [DATE] at 6:07 PM by Pharmacy Delivery Personnel #1. Interview with Pharmacy Delivery Personnel #1 on 05/07/14 at 5:50 PM, revealed he had delivered the medication tote with the blister packs of medications and liquid inhalation medication to the facility on [DATE], and placed the medication tote with the medications under the counter at the nurse's station. Interview with Licensed Practical Nurse (LPN) #6 on 05/08/14 at 8:40 AM, revealed she had signed for the medications in the medication tote on 05/06/14 around 6:00 PM. She stated she had received narcotics, which were handed to her by the delivery person; however, stated she was not aware she had signed for the tote of medications as well and was not sure what happened to the medication tote. LPN #6 revealed the medications were unsafe for residents when they were not stored properly in the medication room or the residents' medication drawers. Interview with LPN #7 on 5/15/14 at 11:30 AM, revealed she had worked the night of 05/06/14, from 11:00 PM until approximately 7:30 AM. She stated the medications tote was delivered on the previous shift and was stored under the counter at the nurse's station. LPN #7 revealed she removed the medications from the tote and placed them on the counter at approximately 6:30 AM on 05/07/14. According to LPN #7, she secured her residents' medications in each of the residents' medication drawers and notified LPN #1 of the need for her to do the same with the remaining medications in the tote. LPN #7 stated the medications were still on the counter at the nurse's station, during report, around 7:00 AM on 05/07/14. LPN #7 reported the medications should have been secured in the medication room upon delivery on 05/06/14. She stated the medications were unsecured in the tote under the nurse's station counter. Further interview revealed not only the medications on the counter of the nurse's station but also any medications stored in the tote under the counter of the nurse's station created an unsafe environment for residents. LPN #7 stated she should have ensured the medications she removed from the tote were secured and not left unattended by nursing staff and accessible to residents, visitors and unauthorized staff. Interview with LPN #1 on 05/08/14 at 10:26 AM, revealed she worked the night of 05/06/14. She stated she saw a tote under the counter at the nurse's station when she got report at 11:00 PM on 05/06/14. LPN #1 revealed during morning medication pass on 05/07/14 "around" 6:30 AM, LPN #7 took the medications out of the tote and placed them on the counter of the nurse's station. Continued interview revealed during report at shift change around 7:00 AM, the medications were still on the counter; however, the nursing staff was at the nurse's station for report. She stated she informed the oncoming shift she had not had time to put the medications "up". She stated the medications should not be left unattended by nursing staff and accessible to residents, visitors and unauthorized staff. Further interview revealed unsecured medications were a hazard to residents. Interview with LPN #10, on 05/08/14 at 10:59 AM, revealed she was one (1) of the nurses that came in on the day shift of 05/07/14. She stated the medications from the previous day had not be "put up" when she came in the morning of 05/07/14 at 7:00 AM. LPN #10 revealed she did not take the medications out of the tote and did not know who did. According to LPN #10, during her morning medication pass on 05/07/14, she saw the medications "all over the desk". Further interview revealed it was not safe to leave medications unsecured. Interview with Certified Nursing Assistant (CNA) #6/Certified Medication Aide (CMA) on 05/07/14 at 11:09 AM, revealed she passed medications at times. She stated she recalled seeing the medications lying on the counter at the nurse's station at approximately 6:45 AM that morning and the medications were not stored in the medication tote. She indicated the medication tote should have been stored in the medication room until staff was ready to put them away. Interview with the Regional Clinical Operations (RCO) Manager on 05/08/14 at 5:25 PM, revealed she saw the medications on the nurse's station counter on 05/07/14 at 9:21 AM and notified the Director of Nursing (DON). The RCO Manager stated the DON came to the nurse's station while making her rounds, prior to being paged for the identified situation. Interview with the DON on 05/07/14 at 9:32 AM and 9:42 AM, and on 05/08/14 at 3:30 PM, revealed the medications should not be left unattended by the nursing staff; this was a safety issue and could be hazardous for the facility's residents. According to the DON, she was not aware the medication tote was being placed under the counter at the nurse's station until the nurses completed their medication pass. She indicated the nursing staff needed education because they left the medications unsecured which was against the policy. The DON stated the unsecured medications were a safety issue as they could be "hazardous" for residents. Interview with the Administrator on 05/07/14 at 6:14 PM, revealed the medications should not have been left on the nurse's station counter unattended by nursing staff and accessible to residents, visitors and unauthorized staff. She indicated the unsecured medications had been a potentially harmful situation if residents had accessed the medications. The facility provided an acceptable credible Allegation of Compliance (AOC) on 05/14/14 that alleged removal of the Immediate Jeopardy (IJ) effective 05/10/14. Review of the AOC revealed the facility implemented the following: 1. The three (3) involved nurses on the Unit 300 hall were provided education by the DON and Administrator on 05/07/14 regarding the drug storage policy and procedure with a post-test following the education and verbalization of understanding. 2. The medications were removed on 05/07/14 upon discovery from Unit 300 hall nurse's station and stored in the locked medication room or medication cart. 3. On 05/07/14, medications delivered to Unit 300 hall were verified by validating the delivery slip and identifying the medications to determine that all medications were accounted for. All medications represented on the pharmacy delivery slip dated 05/06/14 to Units 100, 200 and 300 halls were located with no doses missing which were unaccounted for during medication pass. 4. Licensed nursing staff completed an assessment of all nurse's stations and areas accessible to residents in the facility to determine no drugs or biologicals were left unsecured on 05/07/14. Any items identified were secured upon discovery. 5. On 05/07/14 licensed nursing staff completed an assessment of all residents on Unit 300 hall to determine any potential change in condition from base line. No concerns were identified. 6. On 05/08/14 licensed nursing staff completed assessments of residents on Unit 100 and 200 halls who were cognitively impaired and able to ambulate, self-propel in a wheelchair, wander, or are an elopement risk to determine any possible change in condition from base line. No concerns were identified. 7. On 05/09/14 a review of current residents' care plans and observation of the resident was completed by the licensed nursing staff to determine the care and services provided were as indicated on the plan of care. Any concerns identified were addressed upon discovery. 8. All licensed nursing staff was re-educated to the facility's "Drug Storage" policy and completed a post-test to validate understanding and comprehension of the policy by the Administrator and/or Nurse Management or Nurse Educator by 05/09/14. No nurses were to work without having this education. The facility did not employ agency staff at the time the AOC was developed. 9. All licensed nurses and nursing staff were re-educated to the Accident/Incident Policy including securement of medications and the Care Plan policy and procedure by nursing management or the Administrator by 05/09/14. A post-test was completed to validate understanding and comprehension of the policies. The facility did not employ agency staff at the time the AOC was developed. 10. Newly hired licensed nurses or Medications Technicians (Med Techs) will be educated to the Accident/Incident Policy including "securement" of medications, the Care Plan policy and the "Drug Storage" Policy in orientation. 11. Newly hired nursing assistants will be educated to the Accident/Incident Policy and the Care Plan Policy in orientation. 12. The DON, Nurse Management or Administrator will perform Drug Storage and Environment Safety Audits to Prevent Accident/Incidents will be conducted through observation across all shifts daily for fourteen (14) days, then three (3) times a week for two (2) weeks then monthly for two (2) months; then as determined by monthly Performance Improvement (PI) Committee. Monitoring will include observations of each nurse's station and areas accessible to residents to determine that no drug or biologicals were left unsecured and the environment remained free of hazards. Any concerns identified were to be addressed upon discovery. 13. The DON or Nurse Management will perform an audit completed through observation of ten (10) residents and of the resident care plan to determine interventions across all shifts are followed weekly for eight (8) weeks then monthly for one month. Any concerns identified would be addressed upon discovery. 14. The Administrator, DON and Medical Director reviewed the concerns regarding drug storage, accident/incidents related to a safe environment and following the plan of care, and developed and implemented this plan of action in a PI Committee meeting held on 05/0814. 15. The findings of the audits will be submitted by the Administrator or DON to the PI Committee monthly for three (3) months for review and further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of education material and post-test given to the three (3) nursing staff involved revealed all were re-educated of the facility's policy and procedures related to safe medication storage. Interview with LPN #1 on 05/08/14 at 9:14 AM; LPN #6 on 05/08/14 at 8:40 AM and LPN #7 on 05/15/14 at 11:30 AM, revealed each had received re-education on safe medication storage and taken the post-test. 2. Observation on 05/07/14 at 10:00 AM revealed the DON removed the medications from Unit 300 hall nursing station and secured those medications in the medication room. 3. Observation on 05/07/14 at 9:32 AM revealed the DON verified and accounted for medications by validating medications on hand with delivery document. 4. Review of the drug storage areas checklist which was performed by staff, dated 05/07/14 revealed no medications were found unsecured. Observations on 05/07/14, 05/08/14, 05/13/14, 05/14/14 and 05/15/14 of the nurse's stations and medication carts revealed the carts were locked with no drugs observed to be unsecured. Interview on 05/07/14 with LPN #2 at 10:59 AM and LPN #3 at 4:38 PM, validated they had completed the drug storage area checklist. 5. Review of the facility's assessments of all residents who resided on the Unit 300 hall revealed all the residents were assessed by facility staff with progress notes written in the residents' medical record. Interview with the Unit 300 hall Manager on 05/08/14 at 11:29 AM, verified the assessments were completed. 6. Review of the facility's assessments of residents residing on the Unit 100 and 200 halls with cognitive impairment and who were able to ambulate, self-propel in a wheelchair, wander, or were an elopement risk revealed progress notes for these residents validating the assessments were performed. Interview with LPN #9 on 05/08/14 at 2:12 PM validated the assessments of the residents were completed as per the AOC. 7. Review of the facility's audit of resident medical records and care plans revealed observations to ensure the plan of care was being followed were completed. Interview with LPN #3 and LPN #10, on 05/14/14 at 2:30 PM, validated the completion of the audits. 8. Review of the facility's in-service material revealed post-test and sign in sheets related to safe drug and biological storage were completed. Staff interviews on 05/07/14 with LPN #3 at 4:38 PM, LPN #4 at 6:11 PM and LPN #5 at 6:45 PM; on 05/08/14 with LPN #6 at 8:40 AM, LPN #1 at 10:26 AM, Registered Nurse (RN) #3 at 11:29 AM and LPN #9 at 2:12 PM; and on 05/14/14 with RN #1 at 10:50 AM, LPN #12 at 10:55 AM, LPN #7 at 11:30 AM, LPN #13 at 3:50 PM, LPN #8 at 3:55 PM, Minimum Data Set (MDS) Nurse at 5:10 PM and RN #2 at 5:15 PM validated the education and post-test was provided as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the facility started utilizing agency staff on an as needed basis on 05/14/14. The Administrator stated the agency staff were provided new employee orientation prior to their first shift which included the facility's policy and procedure regarding safe drug and biological storage and resident care plans. Further interview revealed no agency licensed nursing staff utilized as of that date. 9. Review of the facility's in-service materials revealed education and post-test were provided to all licensed nurses and nursing assistants related to the Accident/Incident policy, Care Plan policy and procedures. Staff interviews on 05/07/14 with LPN #3 at 4:38 PM, LPN #4 at 6:11 PM and LPN #5 at 6:45 PM; on 05/08/14 with LPN #6 at 8:40 AM, CNA #4 at 9:00 AM, LPN #1 at 10:26 AM, RN #3 at 11:29 AM and LPN #9 at 2:12 PM; and, on 05/14/14 with CNA #5 at 10:30 AM, RN #1 at 10:50 AM, LPN #12 at 10:55 AM, LPN #7 at 11:30 AM, LPN #13 at 3:50 PM, LPN #8 at 3:55 PM, MDS at 5:10 PM and RN #2 at 5:15 PM validated the education and post-test was performed as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the facility initiated the use of agency staff on an as needed basis on 05/14/14. The Administrator stated with new employee orientation was provided prior to the agency staff's first shift which included the facility's policy and procedure regarding safe drug and biological storage, Accident/Incidents and care plans. Further interview revealed no agency nurse had been utilized as of that date; however, one (1) CNA was utilized on 05/14/14. Review of the new employee orientation training of the agency CNA revealed education was provided as per the AOC. Observations on 05/08/14 and 05/09/14 revealed nursing management staff talking one on one with resident care staff regarding policy and procedures. 10. Review of the new employee orientation packet for licensed nurses or Med Techs revealed it included safe medication storage and Accident/Incident reporting, as well as, physician's orders [REDACTED]. 11. Review of the new employee orientation education for CNAs revealed it included policies on Accident/Incident and care plans with a post-test to verify understanding. Review of the agency CNA education revealed it included education regarding the policies on Accident/Incident and care plans with a post-test to verify understanding. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed no new CNA staff had been hired within previous two (2) week time frame; however, one (1) agency CNA was utilized. 12. Review of the drug storage and environmental safety audits revealed the audits were performed daily on every shift starting on 05/07/14. Interview with the Administrator on 05/15/14 at 11:20 AM, regarding the facility's implemented process, revealed the audits were being performed as per the AOC. Staff interviews on 05/14/14 with LPN #11 at 5:10 PM and LPN #3 at 5:20 PM; and on 05/15/14 with LPN #7 at 11:30 AM revealed the audits were being completed as per the AOC. 13. Review of the audits of resident observation and residents care plans started on 05/07/14 revealed at least ten (10) reviews and observations had been completed by the DON or Nursing Management staff as per the AOC. Review revealed the audits were completed across all shifts and all units/halls within the facility as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed an additional management staff had been added to the schedule each day for each shift to observe, audit and be a resource. The Administrator stated the management staff were directed to immediately contact her for any and all issues identified. 14. Review of the minutes of the PI Committee meeting held 05/08/14 regarding the Immediate Jeopardy findings in regards to drug storage, Accident/Incidents related to a safe environment and following the plan of care revealed the action plan (AOC) had been developed by the Administrator, DON and Medical Director. Interview with the DON on 05/08/14 at 3:30 PM, revealed the facility immediately initiated an investigation into the incident which occurred on 05/07/14. She stated the facility had identified this to be an educational failure and immediately initiated re-education for staff on 05/07/14 as per the AOC. Interview with the RCO Manager on 05/08/14 at 5:25 PM, revealed the facility had responded immediately to correct the identified issue to comply with the facility's policy regarding safe medication storage. 15. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the PI Committee would meet monthly for at least three (3) months for review of the collected data. She stated the first monthly meeting was not due; however, the data collected was being reviewed daily. The Administrator revealed the next PI Committee meeting was scheduled the first week of June 2014. Interview with the Medical Director on 05/15/14 at 2:06 PM, revealed he had been made aware of the unsecured medications. He stated this was an unsafe practice. Continued interview revealed he was actively involved in the PI Committee and had discussed the plan of action (AOC) with the facility "almost daily".

Based on observation, interview and review of the facility's policy, it was determined the facility failed to have an affective system to ensure drugs and biologicals were stored safe and securely in locked compartments as evidenced by observation on 05/07/14 at 9:15 AM, of forty-five (45) blister pack medication cards lying on the top of the counter at the nurse's station, accessible to residents, unauthorized staff or visitors. Observation revealed there were a total of one thousand and eighty-three (1083) tablets and liquid respiratory inhalation medications on the counter with no facility nursing staff present at the nurse's station or in the surrounding area to secure the medications until 9:21 AM, six (6) minutes after the initial observation. Interview revealed Pharmacy delivered the medication to the nurse's station in a tote on 05/06/14 at 6:07 PM. The facility's failure to have an effective system to ensure drugs and biologicals were stored safely and securely in locked compartments was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy was identified on 05/07/14, and determined to exit on 05/06/14. The facility was notified of the Immediate Jeopardy on 05/08/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 05/14/14, with the facility alleging removal of the Immediate Jeopardy on 05/10/14. The Immediate Jeopardy was verified to be removed on 05/10/14 as alleged with remaining non-compliance at a Scope and Severity of a "D", while the facility develops and implements the Plan of Correction (POC), and the facility's Quality Assurance monitors the effectiveness of the systemic changes to ensure medications are stored safely and securely in locked compartments. The findings include: Review of the facility's policy titled, "Storage and Expiration of Medications, Biologicals, Syringes and Needles" revised on 01/01/13, revealed the facility was to ensure all medications and biologicals, including treatment items, were securely stored in a locked cabinet or cart or locked medication room which was not accessible to residents and visitors. Review of the facility's policy titled, "Delivery and Receipt of Routine Deliveries" revised on 01/01/13, revealed upon delivery by Pharmacy the facility nurse or other authorized designee on behalf of the facility was to take responsibility for the receipt, proper storage and distribution of the delivered medications. Observation of the Unit 300 hall nurse's station, on 05/07/14 at 9:15 AM, revealed medications lying on top of the counter unsupervised by nursing staff which were accessible to residents, unauthorized staff and visitors. Continued observation revealed there were forty-five (45) blister pack medication cards with a total of one thousand and eighty-three (1083) tablets and liquid inhalation medications on the counter. Further observation revealed no nursing staff present at the Unit 300 hall nurse's station or in the surrounding area to secure the medications until 9:21 AM, six (6) minutes after the first observation. In addition, observation of the general area of the Unit 300 hall nurse's station, revealed three (3) residents who were mobile, and one (1) of those residents, Unsampled Resident G, was wearing a Wander Guard bracelet (specialized alarming bracelet for residents at risk for wandering). Interview, on 05/07/14 at 5:00 PM, with Pharmacy Technician (Tech) #1 revealed the medications were delivered to the facility on [DATE] at 6:07 PM. Pharmacy Tech #1 reported Licensed Practical Nurse (LPN) #6 signed for receipt of the medications on that date. Interview, on 05/07/14 at 5:50 PM, with Pharmacy Delivery Personnel #1 revealed on the evening of 05/06/14 he had delivered the medications in a tote to the facility. According to Pharmacy Delivery Personnel #1 he had placed the tote with the medications under the counter at the Unit 300 hall nurse's station. Interview, on 05/8/14 at 8:40 AM, with Licensed Practical Nurse (LPN) #6 revealed she had signed for medications delivered by the Pharmacy on 05/06/14 around 6:00 PM. She stated when she signed she had received narcotics, which were handed to her, and she was not aware she had signed for the entire medication tote. According to LPN #6, she was not sure what happened to the medication tote because she did not see the tote and was not aware of it being delivered. However, she stated in the past if the tote was delivered when nurses were passing medications to residents, it was common practice for the tote to be stored under the counter of the nurse's station, until the nurses were finished with their medication pass. Continued interview revealed storing the tote under the counter at the nurse's station was not the facility's policy. LPN #6 indicated she was responsible for all the medications she had signed for and should have ensured they were all securely stored in the medication room. Interview, on 5/15/14 at 11:30 AM, with LPN #7 revealed she had worked night shift on 05/06/14, beginning her shift at 11:00 PM. She stated on arrival to work she saw the medication tote with the medications, which were delivered on the previous shift, under the nurse's station counter. According to LPN #7, she removed the medications from the tote and placed them on top of the nurse's station counter at approximately 6:30 AM on 05/07/14. She stated she then secured her residents' medications in each of the resident's medication drawers and told LPN #1 she needed to do the same thing. LPN #7 revealed the medications were lying on the nurse's station counter during shift report, around 7:00 AM. Continued interview revealed after report was given to the oncoming shift, she overheard LPN #10 tell LPN #1 to put the medications back into the tote and "she would get them later". LPN #7 stated the medications were not securely stored when left in the tote under the counter at the nurse's station. LPN #7 said it was common practice to leave the medications at the nurse's station until staff had time to put them up and the medications should have been secured in the medication room when delivered on 05/06/14, until placed in the residents' locked medication drawers. Further interview revealed she should have ensured the medications she removed from the tote were securely stored, and not left unattended by nursing staff accessible to residents, visitors and unauthorized staff. Interview, on 05/08/14 at 10:26 AM, with LPN #1 revealed she worked the night of 05/06/14, and had seen the medication tote stored under the counter at the nurse's station when she received report at 11:00 PM. According to LPN #1, during the morning medication pass on 05/07/14 around 6:30 AM, LPN #7 took the medications out of the tote and placed them on top of the nurse's station counter. Continued interview revealed during report at shift change around 7:00 AM, the medications were still lying on top of the counter. She stated the medications should have been stored in the medication room behind a locked door as per the facility's policy and procedure. Interview, on 05/07/14 at 10:59 AM, with LPN #10 revealed she was one (1) of the nurses who worked on day shift on 05/07/14. She stated the medications delivered the previous day had not been "put up" when she arrived to work at approximately 6:30 AM. LPN #10 stated she had not taken the medications out of the tote and did not know who had, but it was common practice for the medications to remain in the tote until the nurse had a chance to put them in the residents' medication drawers. Continued interview revealed during her morning medication pass, she went to the nurse's station and she saw the medications "all over the desk". Interview, on 05/08/14 at 5:25 PM, with the Regional Clinical Operations (RCO) Manager revealed she observed the medications lying on top of the nurse's station counter on 05/07/14. She stated she had identified this to be against the facility's policy, and initiated steps to respond to the situation. The RCO Manager stated the Director of Nursing (DON) was notified of the unsecured medications lying on top of the counter at the nurse's station. Further interview revealed the facility's practice with storing medications should be in compliance with the facility's policy. Interview, on 05/07/14 at 9:32 AM, with the DON revealed it was the nurses' responsibility to sign for medications and secure them upon delivery. She stated she was not aware the medication tote was placed under the counter at the nurse's station when delivered, until nurses completed their medication pass. The DON indicated the facility's policy was for the nurse to sign for the delivery of the medications, take responsibility of the medications and ensure the medications were stored in the appropriate resident's locked medication drawer. Interview, on 05/07/14 at 6:14 PM, with the Administrator revealed the medications were not secure when left on top of the nurse's station counter or when stored in a tote under the nurse's station counter. The Administrator stated the medications should have been secured as per the facility's policy. The facility provided an acceptable credible Allegation of Compliance (AOC) on 05/14/14 that alleged removal of the Immediate Jeopardy (IJ) effective 05/10/14. Review of the AOC revealed the facility implemented the following: 1. The three (3) involved nurses on the Unit 300 hall were provided education by the DON and Administrator on 05/07/14 regarding the drug storage policy and procedure with a post-test following the education and verbalization of understanding. 2. The medications were removed on 05/07/14 upon discovery from Unit 300 hall nurse's station and stored in the locked medication room or medication cart. 3. On 05/07/14, medications delivered to Unit 300 hall were verified by validating the delivery slip and identifying the medications to determine that all medications were accounted for. All medications represented on the pharmacy delivery slip dated 05/06/14 to Units 100, 200 and 300 halls were located with no doses missing which were unaccounted for during medication pass. 4. Licensed nursing staff completed an assessment of all nurse's stations and areas accessible to residents in the facility to determine no drugs or biologicals were left unsecured on 05/07/14. Any items identified were secured upon discovery. 5. On 05/07/14 licensed nursing staff completed an assessment of all residents on Unit 300 hall to determine any potential change in condition from base line. No concerns were identified. 6. On 05/08/14 licensed nursing staff completed assessments of residents on Unit 100 and 200 halls who were cognitively impaired and able to ambulate, self-propel in a wheelchair, wander, or are an elopement risk to determine any possible change in condition from base line. No concerns were identified. 7. On 05/09/14 a review of current residents' care plans and observation of the resident was completed by the licensed nursing staff to determine the care and services provided were as indicated on the plan of care. Any concerns identified were addressed upon discovery. 8. All licensed nursing staff was re-educated to the facility's "Drug Storage" policy and completed a post-test to validate understanding and comprehension of the policy by the Administrator and/or Nurse Management or Nurse Educator by 05/09/14. No nurses were to work without having this education. The facility did not employ agency staff at the time the AOC was developed. 9. All licensed nurses and nursing staff were re-educated to the Accident/Incident Policy including securement of medications and the Care Plan policy and procedure by nursing management or the Administrator by 05/09/14. A post-test was completed to validate understanding and comprehension of the policies. The facility did not employ agency staff at the time the AOC was developed. 10. Newly hired licensed nurses or Medications Technicians (Med Techs) will be educated to the Accident/Incident Policy including "securement" of medications, the Care Plan policy and the "Drug Storage" Policy in orientation. 11. Newly hired nursing assistants will be educated to the Accident/Incident Policy and the Care Plan Policy in orientation. 12. The DON, Nurse Management or Administrator will perform Drug Storage and Environment Safety Audits to Prevent Accident/Incidents will be conducted through observation across all shifts daily for fourteen (14) days, then three (3) times a week for two (2) weeks then monthly for two (2) months; then as determined by monthly Performance Improvement (PI) Committee. Monitoring will include observations of each nurse's station and areas accessible to residents to determine that no drug or biologicals were left unsecured and the environment remained free of hazards. Any concerns identified were to be addressed upon discovery. 13. The DON or Nurse Management will perform an audit completed through observation of ten (10) residents and of the resident care plan to determine interventions across all shifts are followed weekly for eight (8) weeks then monthly for one month. Any concerns identified would be addressed upon discovery. 14. The Administrator, DON and Medical Director reviewed the concerns regarding drug storage, accident/incidents related to a safe environment and following the plan of care, and developed and implemented this plan of action in a PI Committee meeting held on 05/0814. 15. The findings of the audits will be submitted by the Administrator or DON to the PI Committee monthly for three (3) months for review and further recommendations. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of education material and post-test given to the three (3) nursing staff involved revealed all were re-educated of the facility's policy and procedures related to safe medication storage. Interview with LPN #1 on 05/08/14 at 9:14 AM; LPN #6 on 05/08/14 at 8:40 AM and LPN #7 on 05/15/14 at 11:30 AM, revealed each had received re-education on safe medication storage and taken the post-test. 2. Observation on 05/07/14 at 10:00 AM revealed the DON removed the medications from Unit 300 hall nursing station and secured those medications in the medication room. 3. Observation on 05/07/14 at 9:32 AM revealed the DON verified and accounted for medications by validating medications on hand with delivery document. 4. Review of the drug storage areas checklist which was performed by staff, dated 05/07/14 revealed no medications were found unsecured. Observations on 05/07/14, 05/08/14, 05/13/14, 05/14/14 and 05/15/14 of the nurse's stations and medication carts revealed the carts were locked with no drugs observed to be unsecured. Interview on 05/07/14 with LPN #2 at 10:59 AM and LPN #3 at 4:38 PM, validated they had completed the drug storage area checklist. 5. Review of the facility's assessments of all residents who resided on the Unit 300 hall revealed all the residents were assessed by facility staff with progress notes written in the residents' medical record. Interview with the Unit 300 hall Manager on 05/08/14 at 11:29 AM, verified the assessments were completed. 6. Review of the facility's assessments of residents residing on the Unit 100 and 200 halls with cognitive impairment and who were able to ambulate, self-propel in a wheelchair, wander, or were an elopement risk revealed progress notes for these residents validating the assessments were performed. Interview with LPN #9 on 05/08/14 at 2:12 PM validated the assessments of the residents were completed as per the AOC. 7. Review of the facility's audit of resident medical records and care plans revealed observations to ensure the plan of care was being followed were completed. Interview with LPN #3 and LPN #10, on 05/14/14 at 2:30 PM, validated the completion of the audits. 8. Review of the facility's in-service material revealed post-test and sign in sheets related to safe drug and biological storage were completed. Staff interviews on 05/07/14 with LPN #3 at 4:38 PM, LPN #4 at 6:11 PM and LPN #5 at 6:45 PM; on 05/08/14 with LPN #6 at 8:40 AM, LPN #1 at 10:26 AM, Registered Nurse (RN) #3 at 11:29 AM and LPN #9 at 2:12 PM; and on 05/14/14 with RN #1 at 10:50 AM, LPN #12 at 10:55 AM, LPN #7 at 11:30 AM, LPN #13 at 3:50 PM, LPN #8 at 3:55 PM, Minimum Data Set (MDS) Nurse at 5:10 PM and RN #2 at 5:15 PM validated the education and post-test was provided as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the facility started utilizing agency staff on an as needed basis on 05/14/14. The Administrator stated the agency staff were provided new employee orientation prior to their first shift which included the facility's policy and procedure regarding safe drug and biological storage and resident care plans. Further interview revealed no agency licensed nursing staff utilized as of that date. 9. Review of the facility's in-service materials revealed education and post-test were provided to all licensed nurses and nursing assistants related to the Accident/Incident policy, Care Plan policy and procedures. Staff interviews on 05/07/14 with LPN #3 at 4:38 PM, LPN #4 at 6:11 PM and LPN #5 at 6:45 PM; on 05/08/14 with LPN #6 at 8:40 AM, CNA #4 at 9:00 AM, LPN #1 at 10:26 AM, RN #3 at 11:29 AM and LPN #9 at 2:12 PM; and, on 05/14/14 with CNA #5 at 10:30 AM, RN #1 at 10:50 AM, LPN #12 at 10:55 AM, LPN #7 at 11:30 AM, LPN #13 at 3:50 PM, LPN #8 at 3:55 PM, MDS at 5:10 PM and RN #2 at 5:15 PM validated the education and post-test was performed as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the facility initiated the use of agency staff on an as needed basis on 05/14/14. The Administrator stated with new employee orientation was provided prior to the agency staff's first shift which included the facility's policy and procedure regarding safe drug and biological storage, Accident/Incidents and care plans. Further interview revealed no agency nurse had been utilized as of that date; however, one (1) CNA was utilized on 05/14/14. Review of the new employee orientation training of the agency CNA revealed education was provided as per the AOC. Observations on 05/08/14 and 05/09/14 revealed nursing management staff talking one on one with resident care staff regarding policy and procedures. 10. Review of the new employee orientation packet for licensed nurses or Med Techs revealed it included safe medication storage and Accident/Incident reporting, as well as, physician's orders [REDACTED]. 11. Review of the new employee orientation education for CNAs revealed it included policies on Accident/Incident and care plans with a post-test to verify understanding. Review of the agency CNA education revealed it included education regarding the policies on Accident/Incident and care plans with a post-test to verify understanding. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed no new CNA staff had been hired within previous two (2) week time frame; however, one (1) agency CNA was utilized. 12. Review of the drug storage and environmental safety audits revealed the audits were performed daily on every shift starting on 05/07/14. Interview with the Administrator on 05/15/14 at 11:20 AM, regarding the facility's implemented process, revealed the audits were being performed as per the AOC. Staff interviews on 05/14/14 with LPN #11 at 5:10 PM and LPN #3 at 5:20 PM; and on 05/15/14 with LPN #7 at 11:30 AM revealed the audits were being completed as per the AOC. 13. Review of the audits of resident observation and residents care plans started on 05/07/14 revealed at least ten (10) reviews and observations had been completed by the DON or Nursing Management staff as per the AOC. Review revealed the audits were completed across all shifts and all units/halls within the facility as per the AOC. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed an additional management staff had been added to the schedule each day for each shift to observe, audit and be a resource. The Administrator stated the management staff were directed to immediately contact her for any and all issues identified. 14. Review of the minutes of the PI Committee meeting held 05/08/14 regarding the Immediate Jeopardy findings in regards to drug storage, Accident/Incidents related to a safe environment and following the plan of care revealed the action plan (AOC) had been developed by the Administrator, DON and Medical Director. Interview with the DON on 05/08/14 at 3:30 PM, revealed the facility immediately initiated an investigation into the incident which occurred on 05/07/14. She stated the facility had identified this to be an educational failure and immediately initiated re-education for staff on 05/07/14 as per the AOC. Interview with the RCO Manager on 05/08/14 at 5:25 PM, revealed the facility had responded immediately to correct the identified issue to comply with the facility's policy regarding safe medication storage. 15. Interview with the Administrator on 05/15/14 at 11:20 AM, revealed the PI Committee would meet monthly for at least three (3) months for review of the collected data. She stated the first monthly meeting was not due; however, the data collected was being reviewed daily. The Administrator revealed the next PI Committee meeting was scheduled the first week of June 2014. Interview with the Medical Director on 05/15/14 at 2:06 PM, revealed he had been made aware of the unsecured medications. He stated this was an unsafe practice. Continued interview revealed he was actively involved in the PI Committee and had discussed the plan of action (AOC) with the facility "almost daily".

Based on interview, record review and review of the facility's policy and grievance forms, it was determined the facility failed to have an effective system to ensure each resident remained free from abuse for two (2) of seven (7) sampled residents (Residents #1 and #2). On 03/02/14, a Grievance/Concern Report was completed by Licensed Practical Nurse (LPN) #4, which revealed Resident #2 had stated he/she tried to use the phone and LPN #1 "snatched" the phone away, hung it up, and told the resident he/she was not allowed to use it. Continued review of the Grievance/Concern Report revealed Resident #2 reported to LPN #4, he/she had been told by LPN #1 if he/she continued to curse at her the LPN would not give Resident #2 his/her pain medication. Interview and record review revealed the facility failed to investigate the incident as abuse, therefore failed to follow the abuse policy procedures to interview other residents about abuse and/or staff who had potentially witnessed the verbal abuse and, failed to report the abuse to State Agencies. As a result of the facility's failure to investigate the incident as abuse, LPN #1 was only suspended one (1) day, 03/03/14, and allowed to continue working caring for residents placing the residents at risk for potential further abuse by LPN #1. On 03/07/14 early in the morning, staff witnessed LPN #6 being verbally abusive to Resident #1 room and yelled at the resident due to his/her multiple use of the call light to request pain medication. LPN #6 was overheard telling the resident he/she would not get his/her pain medication any quicker by banging the call light, and also told Resident #1 he/she was acting like a child. Interview with Certified Nursing Assistant (CNA) #3 and CNA #7 revealed they thought what they had witnessed LPN #6 do was abuse but failed to report the abuse incident immediately, as per the facility's abuse policy. The incident was not reported to the facility until evening shift on 03/09/14, and LPN #6 had worked an entire shift on 03/08/14 prior to being suspended by the facility. The facility indicated LPN #6 would be terminated from employment at the facility after the initiation of the Abbreviated Survey. The facility's failure to have an effective system was in place to ensure each resident remained free from abuse, was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/03/14 and was determined to exist on 03/02/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/08/14 with the facility alleging removal of the Immediate Jeopardy on 04/07/14. The Immediate Jeopardy was verified to be removed on 04/07/14 as alleged with remaining non-compliance at a Scope and Severity of "D", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "OPS310 KY Abuse Prohibition", dated 07/01/13, revealed verbal abuse was any use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents and mental abuse which included threats of punishment or deprivation. The policy revealed staff who witnessed an incident of suspected abuse was to tell the abuser to stop immediately and report the incident to his/her supervisor immediately who was to report the suspected abuse to the Administrator/designee immediately. Continued review of the policy revealed the employee alleged to have committed the abuse was to be "immediately removed from duty". Further policy review revealed a written report was to be provided "immediately" to the State Agency, not to exceed twenty-four (24) hours. In addition, the policy stated the facility protected residents from further harm during an investigation. 1. Review of the facility's grievance form titled, "Grievance/Concern Report", undated, revealed on 03/02/14 Resident #2 reported to LPN #4 he/she tried to use the phone and LPN #1 "snatched" away the phone, hung it up, and told Resident #2 he/she was not allowed to use it. Review revealed LPN #1 told Resident #2 she would not give him/her pain medication if he/she continued to curse at the LPN. Continued review revealed no documented evidence the facility investigated the incident as potential abuse to include interviewing other residents and staff who had witnessed the incident. Further review revealed no documented evidence the facility reported the incident to State Agencies as per facility policy. LPN #1 was only suspended for one (1) day, 03/03/14, by the Director of Nursing Services (DNS) who documented the grievance as resolved on 03/04/14 and allowed LPN #1 to continue working with residents. Review of LPN #1's "Timecard" punches revealed she worked the dayshift, 7:00 AM to 3:00 PM on: 03/04/14 through 03/06/14; 03/10/14 through 03/13/14; 03/15/14 through 03/17/14; 03/24/14 through 03/27/14; 03/29/14 through 03/31/14; and on 04/02/14, a total of eighteen (18) days, before being suspended on 04/03/14. Review of Resident #2's medical record revealed the facility admitted the resident on 06/21/13, with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/05/14, revealed the facility assessed Resident #2 to have a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated the resident was moderately cognitively impaired. Continued review of the medical chart revealed the March 2014 monthly Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the staffing schedule revealed LPN #1 worked the 7:00 AM to 3:00 PM shift on 03/02/14. Interview, on 04/03/14 at 2:30 PM, with Resident #2 revealed LPN #1 grabbed the phone from his/her ear and "slammed" it down on the receiver and told the resident he/she had already made two (2) calls. Resident #2 stated he/she had not made two (2) calls and needed to call his/her nephew. According to Resident #2, LPN #1 then said "wait until you want another pain pill". Resident #2 stated he had a lot of pain problems and got pain medication about every four (4) hours. Resident #2 revealed it hurt his/her feelings "real bad" when LPN #1 had done that and after the incident the nurse never talked to him/her again. The resident stated he/she went and told LPN #4 what had happened and LPN #4 said it was a grievance. Interview, on 04/02/14 at 2:39 PM, with Certified Nursing Assistant (CNA) #10 revealed she worked on 03/02/14, and heard Resident #2 being loud. CNA #10 stated she heard LPN #1 tell Resident #2 he/she would not get his/her medicine on time because the resident was not doing what he/she was supposed to do. The CNA stated LPN #1 sounded "aggravated" and "short" when she talked to the resident. CNA #10 stated she had talked to LPN #4 about the incident and the nurse was going to call the DNS. Interview, on 04/09/14 at 3:05 PM, with CNA #11 revealed she worked dayshift on 03/02/14, and thought around 12:00 PM, she witnessed Resident #2 trying to use the phone at the Unit 200 nurse's station. She stated Resident #2 had the phone up by his/her ear and LPN #1, who was at the desk, told Resident #2 he/she was not allowed to use the phone. CNA #11 stated the nurse "grabbed" the phone out of the resident's hand and "slammed" it down on the receiver which startled the CNA. The CNA stated LPN #1 told Resident #2 if he/she tried to use the phone again she was not going to give his/her pain medication. CNA #11 revealed she considered the incident verbal or mental abuse and possibly physical abuse because the nurse "jerked" the phone out of the resident's hand. She stated LPN #4 was also at the nurse's station ,and indicated she was going to take care of the incident. Interview, on 04/01/14 at 3:52 PM, with LPN #1 revealed at one point in time Resident #2 was limited to two (2) phone calls a day by his/her sister, who was Guardian at the time, because he/she would call her too much. The LPN stated one (1) time she asked him/her to use the phone later because he/she had been on the phone "a lot". LPN #1 stated Resident #2 got upset and said some curse words then walked away. The LPN further stated "there was nothing said about pain medication". LPN #1 indicated she was not aware of any allegation related to pain medication. Interview, on 04/02/14 at 11:36 AM, with LPN #4 revealed on 03/02/14, around shift change, Resident #2 came down to the 100 Unit nurse's station to use the phone. She stated Resident #2 also reported LPN #1 "snatched" the phone out of his/her hand and told the resident he/she could not use it anymore. LPN #4 stated Resident #2 reported he/she was upset about phone incident and "cussed" at the nurse, who then told the resident she would not give him/her his/her pain medication if he/she kept talking to her like that. LPN #4 revealed she then went and spoke to LPN #1 about what Resident #2 reported and told LPN #1 services could not be withheld because of the way a resident spoke to them. She stated LPN #1 then got upset and went out to the nurse's station and said out loud, no one was going to talk to her like that and if they (residents) did she was not going to give them their pain medication. Continued interview with LPN #4 revealed she had called the DNS about the incident and was told the DNS would take care of it. Interview with Social Worker (SW) #1 on 04/03/14 at 1:57 PM and 2:53 PM, revealed the Ombudsman had reported to her there had been a phone issue concerning Resident #2 and said something about pain medication. She stated around 03/03/014 or 03/04/14 after the Ombudsman's report, she talked to the resident about phone usage and the DNS talked to him/her about pain medication. The SW stated on 04/03/14 she again interviewed Resident #2, about the incident on 03/02/14. The SW stated Resident #2 informed her the nurse told him/her she was not going to give his/her pain medication if he/she used the phone again. She stated based on her interview with Resident #2 on 04/03/14, it sounded like it was an abuse allegation. In an additional interview with SW #1 on 04/08/14 at 6:02 PM, she stated she had first read the grievance sometime between the week of 03/03/14 through 03/08/14, and was concerned because the content stated the nurse had "snatched" the phone away from Resident #2 and, the nurse told the resident if he/she continued to curse at her she would not give his/her pain medication. The SW revealed she talked to the Administrator and the DNS, who are in charge of abuse investigations, about the grievance, her concern and what to do next. She stated she could not remember what all was discussed or if she identified the grievance as an allegation of abuse or only a concern. Interview, on 04/02/14 at 12:30 PM and on 04/03/14 at 5:34 PM, with the DNS revealed the Grievance/Concern Report form was in her mailbox on 03/03/14, and she as indicated by LPN #4 was not called by phone. The DNS stated she thought it was an abuse incident when she read the statement. However, on 03/03/14 she talked to Resident #2, who was alert and oriented, about the incident and the resident denied the nurse had threatened not to give him/her the pain medication. The DNS stated she went by what the resident said, and did not think it was abuse after all. She called LPN #1 and told her she had to take courses on customer service, resident rights, and the facility's abuse policy before returning to work. Interview, on 04/02/14 at 1:53 PM and on 04/08/14 at 6:46 PM, with the Administrator revealed she had not seen the grievance until "about" 03/06/14 when she got it out of her mailbox, but should have been made aware immediately. The Administrator stated she had previously discussed the incident with the DNS and talked about a nurse and Resident #2's phone usage; however, she did not believe they talked about the medication allegation. The Administrator stated once she saw the Grievance/Concern Report form content she should have recognized the threat to withhold pain medication as mental abuse or even neglect, removed the alleged perpetrator from resident care and conducted a thorough investigation of the allegation. The Administrator indicated there was a concern for potential further abuse of residents when an employee who allegedly committed abuse was allowed to continue working. She stated as the Administrator she was ultimately responsible for the protection of the residents. Interview, on 04/09/14 at 4:13 PM, with the Medical Director revealed the facility reported the incident involving Resident #2 to him; however, did not indicate when he was notified. He stated it was wrong for the nurse to threaten not to give the pain medication to Resident #2. The Medical Director further stated there was no excuse for the nurse to have done that. He indicated the facility should have investigated the allegation. 2. Review of the facility's final report to the State Agency dated 03/14/14, revealed it noted a grievance form was turned into the facility by Resident #1's family member on 03/09/14, stating a nurse (LPN #6) had spoken to the resident unprofessionally. Review of the final report revealed Resident #1 reported on night shift during the early morning hours of 03/07/14, the resident had used her call light multiple times and banged it on the table to get staff's attention for his/her medication and was told the nurse was on break. The final report indicated Resident #1 was interviewed and told staff she had began requesting the medication at 2:45 AM, and received it at approximately 4:00 AM. The final report noted when the nurse entered the resident's room she told the resident he/she was going to listen to what she said and proceeded to tell the resident he/she was bothering other residents by making so much noise. Review of the final report revealed in interview Resident #1 stated the nurse told him/her this behavior would not help the resident get pain medication any quicker. Additionally, the report noted interviews with staff revealed the nurse was "yelling" at Resident #1 and, could be heard at the nurse's station saying to the resident that hitting the bedside table would not get his/her assistance any faster. Further review of the final report revealed another employee stated LPN #6 came back from the resident's room and told other employees she had instructed the resident to stop ringing his/her call light every few minutes and then proceeded to call the resident a "child" to the employees present. In addition, review of the final report revealed the facility substantiated abuse on the part of LPN #6 and she was to be terminated from employment at the facility. Review of LPN #6's "Timecard" punches revealed she worked on 03/07/14 until 7:34 AM and also worked on 03/08/14 from 11:00 PM until 8:18 AM on 03/09/14. Review of Resident #1's medical record revealed the facility admitted the resident on 01/24/14, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident to be cognitively intact. Continued review of the MDS revealed the resident was assessed by the facility to have almost constant pain which effected the resident's sleep. Continued review of the medical record revealed the March 2014 monthly Physician Orders, included [MEDICATION NAME] 5-325 MG PRN 1-2 tablets every six (6) hours for pain which started on 02/04/14. Review of Resident #1's March 2014 MAR indicated [REDACTED]. Interview, on 04/01/14 at 2:16 PM and on 04/02/14 at 4:15 PM and 5:14 PM, with Resident #1 revealed the resident did not speak, but mouthed words or shook his/her head, as he/she had a [MEDICAL CONDITION] (trach). Resident #1 stated staff was all nice but one (1) nurse and reported a nurse on night shift had yelled at him/her and it took three (3) hours to get pain medication after she requested the medication. Resident #1 indicated the nurse was upset with her/him banging the call light and the nurse said he/she was acting like a kid. The resident mouthed it felt like she was a child when the nurse yelled and was scared. Interview, on 04/02/14 at 8:55 AM, with CNA #7 revealed she cared for Resident #1 and reported on night shift of 03/06/14 the resident wanted pain medication and rang his/her call light multiple times, thinks about ten (10) times). CNA #7 stated Resident #1 banged the light on the table, and described the resident as appearing aggravated while the nurse was out on lunch break for over an hour. The CNA stated she was at the nurse's station, multiple rooms away from Resident #1's room, when the nurse came back answered the call light and was very loud. CNA #7 reported she heard the nurse "banging on the table" and informing the resident he/she would not get the medication any quicker by banging on the table. According to CNA #7, she went into Resident #1's room after the nurse had left and apologized to the resident for the way the nurse had acted and she stated the resident was upset. The CNA revealed she should have reported the incident immediately, but did not because she was scared if it got back to the nurse. Interview, on 04/02/14 at 8:55 AM and 04/09/14 at 6:58 PM, with CNA #3, who worked night shift on 03/06/14, revealed Resident #1 had used the call light approximately six (6) times while the nurse was on lunch break for about an hour and when the nurse returned she told her the resident needed pain medication. The CNA stated when she came back from break she heard LPN #6 at the nurse's station stating she had told Resident #1 he/she acted like a child by banging the call light. CNA #3 stated she estimated the incident occurred around 4:00 AM and the resident seemed upset when the CNA went into the room after the incident. The CNA revealed the nurse should not have called the resident a child and thought it was mental/verbal abuse, indicating she would be upset if someone said that to her mother. Interview, on 04/10/14 at 3:54 PM, with RN #4/Weekend Supervisor revealed on second shift on 03/09/14 at about 8:00 PM, one (1) of the nurses talked to her about the incident involving Resident #1 and she went and talked to the resident. RN #4/Weekend Supervisor stated Resident #1 had [MEDICAL CONDITION] using the call light and banging the call light was his/her voice. She stated Resident #1 reported he/she was banging the call light on the table to get attention because he/she wanted a pain pill and LPN #6 screamed at him/her and told the resident he/she annoyed other residents by making the noise. She stated she also talked to CNA #7 who reported LPN #6 had yelled so loud she could hear the nurse at the nurse's station. RN #4/Weekend Supervisor stated CNA #7 told her she was afraid the nurse would be mad at her if she reported the incident. Interview, on 04/01/14 at 5:54 PM, with SW #1 revealed when she initially followed up with Resident #1 on 03/13/14, regarding the grievance the resident reported a nurse had raised her voice, was "curt" and "being nasty" to him/her. The SW stated the resident started crying and she was unable to understand Resident #1. She stated on 03/17/14, she spoke to Resident #1 again regarding the grievance and the way the resident described the incident she would consider it abuse. Interview with the DNS on 04/02/14 at 12:30 PM and on 04/04/14 at 5:00 PM, revealed the incident occurred on nightshift of 03/06/14 to the morning of 03/07/14. The DNS stated she was not made aware of the incident until 03/09/14, when Resident #1 and his/her family had spoken to evening shift staff about it and they called her. She stated LPN #6 was suspended and did not work the night of 03/09/14, but had worked nightshift on 03/08/14, from 11:00 PM to 7:00 AM on 03/09/14. The DNS stated from the facility's investigation they had determined staff were aware on 03/07/14, but did not report the abuse. She indicated if she had known about the incident when it occurred the nurse would have been suspended immediately. However, she stated the nurse had worked on 03/08/14, and there was an opportunity for more abuse to that resident and other residents. Interview, on 04/08/14 at 6:46 PM, with the Administrator revealed the employee alleged to have committed the abuse, towards Resident #1, worked another shift before Administration became aware of the allegation. She stated, however some staff had been aware of the incident when it happened and should have reported the allegation immediately. She indicated the nurse worked another shift and there was potential for another abuse incident before the nurse was suspended. The Administrator stated if she had been made aware of the incident she would have come in immediately, started the investigation, and suspended the nurse immediately. On 04/02/14 at 10:39 AM an attempt was made to contact LPN #6 by phone; however, the attempt was unsuccessful and there was no way to leave a message. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 04/08/14 which alleged removal of the Immediate Jeopardy (IJ) effective 04/07/14. Review of the AOC revealed the facility had implemented the following: 1. The facility's DNS, Administrator and Nurse Supervisors interviewed all interviewable residents to determine if they had experienced or witnessed any abuse in the facility or any issues with receiving PRN medications timely or threatening to have their medication withheld. The facility completed the interviews 03/14/14 and on 04/04/14. 2. The facility's DNS and Nurse Supervisors completed assessments of all non-interviewable residents to determine any injury associated with possible abuse. The facility completed the assessments on 03/14/14 and on 04/04/14. 3. The DNS and Administrator were re-educated to the Abuse Policy, the timely reporting requirements and completion of a thorough investigation by the MCO on 03/12/14 and on 04/03/14. 4. The facility's DNS, Administrator and Nurse Supervisors educated administrative, therapy, dietary, housekeeping, laundry, and maintenance staff on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution. Staff was also inserviced on stress management. Employees completed the Abuse Prevention post-test. The facility completed the inservices on 03/14/14 and again on 04/04/14. 5. The facility's DNS and Nurse Supervisors educated licensed nurses to count off controlled medications and relinquish med cart keys with another nurse if leaving the facility for lunch breaks or other periods of time to ensure medications were accessible to administer to residents as needed. The facility completed the inservices on 03/14/14. 6. The facility's DNS and Administrator were responsible for terminating the nurse involved in the allegation of abuse for Resident #1 and reporting the nurse to the Kentucky Board of Nursing. The facility completed the action on 03/14/14. 7. The two (2) staff members who heard the incident involving Resident #1, but did not report the allegation received disciplinary action by the DNS and Administrator. The facility completed the action on 03/14/14. 8. A Performance Improvement (PI) Meeting, to include the Administrator, DNS and Medical Director was held to discuss the late reporting of the allegation of abuse related to Resident #1 and the plan to correct this. The facility completed this action on 03/14/14. Additionally, a Performance Improvement Meeting, to include the Administrator, DNS and Medical Director, was held to discuss the late reporting of the allegation of abuse related to Resident #2, the Immediate Jeopardy citations, root cause and plan of correction. The facility completed this on 04/04/14. 9. The nurse identified in the allegation of abuse for Resident #2 was suspended on 04/03/14. The facility identified the DNS and Administrator as being responsible for the action. The facility completed the action on 04/03/14. 10. The initial report of the allegation involving Resident #2 was submitted to the State Agencies on 04/03/14, the persons assigned responsibility were the DNS and Administrator. The facility completed the action on 04/03/14. 11. The facility's DNS and Administrator was responsible for interviewing Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 12. The facility's DNS, Administrator and Nursing Supervisors were responsible for interviewing the sister of Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 13. The facility's DNS, Administrator and Nurse Supervisors were responsible for interviewing employees who worked 7:00 AM to 3:00 PM on 03/02/14 regarding the allegation of abuse related to Resident #2. The facility completed the interviews on 04/05/14. 14. The facility's DNS and Nurse Supervisors were responsible to enter the allegation of abuse for Resident #2 into the Risk Management System (RMS). The facility completed the action on 04/04/14. 15. The facility's DNS, Nurse Supervisors and Administrator were responsible to provide education to new hires on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution during orientation. This was an ongoing action. The facility did not use agency staff. 16. The facility was to assign supervisors on each shift to monitor staff and resident interactions and to determine any allegations of abuse were reported immediately to the Administrator. The facility's Administrator and DNS were responsible to implement the action and the facility completed on 04/04/14. 17. The facility was to implement monitoring actions to include interview of five (5) employees weekly for four (4) weeks and then monthly for three (3) months to determine: staff understood the facility's abuse policy; understood reporting allegations to the Administrator immediately; and understood allegations or statements were kept confidential and there was no fear of retribution for reporting. Any concerns were to be addressed at the time of interview. The facility identified the DNS, Nurse Supervisors and Administrator as being responsible for the audits which were ongoing. 18. The facility was to implement monitoring actions to include interview of five (5) residents weekly for four (4) weeks and then monthly for three (3) months to determine any issues with staff treatment or abuse and any issues with withholding of medication. Any concerns identified were to be addressed at that time. The facility identified the Administrator as being responsible for he audits and they were ongoing. 19. The facility was to implement monitoring actions to include an audit of all abuse investigations to determine that abuse allegations were reported timely as per the abuse policy and the investigations were thoroughly completed. Any concerns identified during the audit were to be addressed at that time. The facility identified the Administrator as being responsible for the audits and they were to be ongoing. 20. The findings of the monitoring identified above were to be reported to the Performance Improvement Committee monthly for four (4) months for further review and recommendation. The Administrator and DNS were responsible and this was to be ongoing. 21. The facility was to perform an audit on abuse allegations identified for the prior thirty (30) days, 03/06/14 through 04/06/14, to assure a thorough investigation was completed and any abuse was reported timely as per the facility policy. The person responsible was the MCO and the facility was to complete this on 04/07/14. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all interviewable residents. The resident interviews were performed by the DNS and Nursing Supervisors which included Unit Managers. Reviewed the documented resident interviews all completed by 03/14/14 and 04/04/14. Interview with the Assistant Director of Nursing (ADON) on 04/10/14 at 4:27 PM, and RN #5/100 Unit Manager on 04/10/14 at 4:48 PM revealed resident interviews were performed as per the AOC. Interview on 04/10/14, with Resident #1 at 12:58 PM; Resident #2 at 10:19 AM; Unsampled Resident A at 5:05 PM; Unsampled Resident B at 4:49 PM; and Unsampled Resident C at 5:10 PM revealed they were all interviewed by facility staff two (2) different times recently about abuse and medications. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she was in charge of the AOC plan to make sure everything was completed as indicated and verified all the resident interviews were completed by the 03/14/14 and 04/04/14 as noted on the AOC. 2. Interview and review of the facility's AOC implementation documentation with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all non-interviewable residents. The DNS stated they had two (2) staff present for skin assessments and no problems were identified indicating abuse, such as, bruises, scratches, any type of redness or any signs they were not getting care. Review and interview with the DNS revealed the skin assessments were performed by the DNS and Nursing Supervisors on 03/13/14, 03/14/14 and again on 04/04/14 with no issues identified. Interview with the ADON on 04/10/14 at 4:27 PM and RN #5/100 Unit Manager at 4:48 PM, revealed skin assessments were performed on non-interviewable residents. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she had verified all skin assessments of non-interviewable residents were completed by 03/14/14 and 04/05/14 as noted on the AOC with no issues identified. 3. Review of a documented inservice on 03/12/14 and 04/03/14 revealed the DNS and Administrator were re-educated on the facility's abuse policy and reporting requirements by the MCO. Interview with the DNS on 04/10/14 at 12:13 PM, and the Administrator on 04/10/14 at 5:29 PM, revealed both had received an inservice on the abuse policy and reporting requirements on 03/12/14 and 04/03/14 by the MCO. 4. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, at 12:13 PM and at 1:16 PM, revealed the facility used a master list of employees to inservice all staff on 03/10/14 thru 03/14/14 and on 04/03/14 thru 04/04/14. The DNS stated staff inservices included review of the abuse policy which included examples of abuse and reporting, investigations and reporting were confidential, stress management, and abuse post-test. She further stated inservices were performed by the Administrative team which included herself, the Administrator and Nursing Supervisors. The DNS stated staff who were not present were contacted by phone and given the inservice on the abuse policy and stress management. She indicated staff who the facility was unable to contact by phone were sent the inservice education by certified mail. The list of staff who were sent the inservice education by certified mail and the certified mail receipts were reviewed. Interview with the DNS revealed when the staff who were not present at the inservice came in to work they went over the post test and signed inservice sheets prior to beginning work. She stated the inservices

Based on interview, record review and review of the facility's policy and grievance forms, it was determined the facility failed to have an effective system to ensure alleged incidents were immediately reported to Administration, thoroughly investigated and reported to State Agencies, and failed to protect residents from further potential abuse for two (2) of seven (7) sampled residents (Residents #1 and #2). (Refer to F-223) Licensed Practical Nurse (LPN) #4 completed a Grievance/Concern Report on 03/02/14, after Resident #2 reported to her LPN #1 had "snatched" the phone away from him/her, hung it up, and informed the resident he/she was not permitted to use it. Resident #2 indicated to LPN #4, LPN #1 had threatened not to give his/her pain medication if he/she continued to curse at her. The facility considered this incident a grievance, and therefore it was not thoroughly investigated to include interviews with other residents or staff and was not reported immediately to the Administrator and State Agencies. The the grievance investigation conducted on 03/03/14 by the Director of Nursing Services (DNS) only included interviews with Resident #2 and LPN #1, who was suspended 03/03/14. The DNS resolved the grievance on 03/04/14 and allowed LPN #1 to return to work. Therefore, the facility failed to protect residents from further potential abuse by LPN #1. Additionally, staff witnessed an incident of verbal abuse by LPN #6 who yelled at Resident #1 in the early morning of 03/07/14, due to his/her using the call light multiple times to request pain medication. Staff heard LPN # 6 tell Resident #1 he/she was acting like a child and would not get his/her pain medication any quicker by banging the call light. Certified Nursing Assistant (CNA) #3 and CNA #7 were witnesses to the incident; however, failed to immediately report the incident. The facility's Administration was not notified until the evening shift on 03/09/14, therefore an investigation was not conducted immediately after the incident, residents were not protected from further potential abuse, and the incident was not reported to State Agencies until 03/10/14. Based on the above findings, it was determined the facility's failure to thoroughly investigate alleged incidents of abuse to prevent further potential abuse, and failure to ensure alleged incidents of abuse were immediately reported to the Administrator and appropriate State Agencies was likely to cause serious injury, harm, impairment or death to a resident. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/03/14 and was determined to exist on 03/02/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/08/14 with the facility alleging removal of the Immediate Jeopardy on 04/07/14. The Immediate Jeopardy was verified to be removed on 04/07/14 as alleged with remaining non-compliance at a Scope and Severity of "D", while the facility develops and implements the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. The findings include: Review of the facility's policy: "OPS310 KY Abuse Prohibition", effective date 07/01/13, revealed anyone who witnessed an incident of abuse was to tell the abuser to stop immediately and report the abuse to the supervisor immediately. Policy review revealed the supervisor would then immediately report the alleged abuse to the Administrator and a written report was to be sent to the State Agency immediately, not to exceed twenty-four (24) hours. Further review of the policy revealed an investigation was to be initiated within twenty-four (24) hours of an allegation of abuse. Additionally, the policy revealed the facility was to protect residents from further "harm" during an investigation. 1. Review of the "Grievance/Concern Report" form revealed LPN #4 had completed it on 03/02/14. Review of the form revealed Resident #2 had reported to LPN #4 he/she tried to use the phone and LPN #1 "snatched" the phone away, hung it up, and told the resident he/she was not allowed to use it. Continued review of the form revealed Resident #2 also reported to LPN #4, LPN #1 told the resident if he/she continued to curse at her she would not give his/her pain medication. Further review revealed no documented evidence the incident was investigated as abuse or reported to State Agencies within twenty-four (24) hours after the alleged abuse. Review of LPN #1's personnel file revealed the employee was initially hired 12/11/12 and signed and dated she had received training on the facility's abuse policy on 12/11/12. Interview, on 04/03/14 at 2:30 PM, with Resident #2 revealed LPN #1 grabbed the phone from his/her ear, "slammed" it down on the receiver and said he/she had already made two (2) calls. Resident #2 revealed the LPN then said "wait until you want another pain pill" and indicated he/she had a lot of pain problems. Resident #2 reported going to LPN #4 and telling her what LPN #1 had done. The resident stated LPN #4 told him/her this was a grievance. According to Resident #2, the Director of Nursing Services (DNS) had talked to him/her the next day about the pain medication incident. Interview, on 04/02/14 at 2:39 PM, with Certified Nursing Assistant (CNA) #10 revealed when she worked on 03/02/14, she overheard LPN #1 tell Resident #2 he/she wouldn't get his/her medicine on time because the resident wasn't doing what he/she was supposed to do. The CNA indicated she told LPN #4 about what she had heard LPN #1 tell Resident #2 and LPN #4 said she would call the DNS. The CNA revealed she thought the incident was abuse; however, no one interviewed her about the incident. She indicated she felt the incident was not properly investigated. Interview, on 04/09/14 at 3:05 PM, with CNA #11 revealed she worked on 03/02/14 and witnessed Resident #2 trying to use the phone at the Unit 200 nurse's station and LPN #1 "grabbed" the phone from the resident's hand and "slammed" it down on the receiver. She stated LPN #1 told the resident he/she was not allowed to use the phone. According to CNA #11, LPN #1 told Resident #2 if he/she attempted to use the phone again she would not given the resident pain medication. She stated she considered LPN #1's actions as verbal or mental abuse and possible physical abuse because the nurse had "jerked" the phone from the resident's hand. CNA #11 indicated LPN #4, who was there, was going to take care of reporting the incident. Continued interview with the CNA revealed the facility did not contact her about the incident until last Friday, 04/04/14, and this was not the normal process when an allegation of abuse occurred. She indicated the facility's process was if an employee was involved they were suspended and the facility did an investigation at the time. Interview with LPN #4 on 04/02/14 at 11:36 AM, revealed sometime around shift change on 03/02/14, Resident #2 reported to her LPN #1 had "snatched" the phone from him/her and told the resident he/she could not use it anymore. According to LPN #4, Resident #2 told her he/she was upset when LPN #1 did that and he/she had cursed the nurse. LPN #1 then informed the resident if he/she kept talking to her like that she would not give his/her pain medication. LPN #4 stated she felt Resident #2's report of how LPN #1 had treated him/her was an allegation of abuse and called the DNS who told her she would take care of it and did not tell her to send LPN #1 home. LPN #4 indicated she also documented the incident on a grievance form, attached a statement and gave one (1) to the Administrator, DNS and Social Services (SS). Interview, on 04/01/14 at 3:52 PM, with LPN #1 revealed she asked Resident #2 once to use the phone at a later time because he/she had been on the phone "a lot" and the resident got upset, cursed, and walked away. LPN #1 stated there had been nothing said about pain medication and she unaware of any allegations related to pain medication. Interview with Social Worker (SW) #1 on 04/03/14 at 1:57 PM and 2:53 PM and on 04/08/14 at 6:02 PM, revealed she had read the grievance form around the first week of March and was concerned because the content indicated the nurse had snatched the phone from Resident #2. SW #1 stated the grievance form had also stated the nurse had told Resident #2 if he/she kept cursing at her she would not give his/her pain medication. According to SW #1 she had discussed the grievance with the Administrator and DNS and what should be done next. However, she stated she could not recall what all was discussed or whether she had regarded the incident as abuse or only as a concern. SW #1 stated she interviewed Resident #2 on 04/03/14 regarding the alleged incident on 03/02/14 and after her interview with Resident #2, the incident sounded like abuse and the facility should have performed a more thorough investigation when the incident first occurred as per the abuse policy. SW #1 stated the nurse was allowed to continue working after the incident and this was a concern regarding resident safety. She indicated the facility should have made sure residents were protected. Interview with the DNS on 04/02/14 at 12:30 PM and on 04/03/14 at 5:34 PM, revealed she had not been contacted by phone regarding the incident, but had the grievance form in her mailbox on 03/03/14. According to the DNS, initially she thought the incident was abuse and suspended the nurse after reading the statement. However, after interviewing Resident #2 twice, who denied the nurse had aggressively removed the phone from his/her hand and denied the nurse threatened him/her with not giving his/her pain medication, she did not think it was abuse after all. She revealed from the first day there was a breakdown in the facility's process, as other staff got the grievance and no one followed up to see if it was investigated. The DNS indicated she and the Administrator were responsible for taking the lead in investigations and she had suspended the nurse on 03/03/14 until she figured it out. She indicated she did not talk to the person who turned in the grievance form. She stated there had been a breakdown in her process for notifying the Administrator of the grievance. The DNS stated the facility did not follow the abuse investigation process and interview staff or residents. According to the DNS, if the facility did not fully investigate an allegation of abuse and the alleged perpetrator continued to work there was the potential for other abuse to have occurred. She further revealed it was important to ensure residents were safe and protected against abuse. Interview with the Administrator on 04/03/14 at 6:23 PM and on 04/08/14 at 6:46 PM, revealed she should have been notified of the incident immediately. She stated she had not seen the grievance form until "around" 03/06/14 and after reading it she should have recognized the threat to withhold pain medication as an allegation of abuse. According to the Administrator, she should have removed the alleged perpetrator from resident care, reported to the State Agencies and done a thorough investigation of the allegation. The Administrator stated there was a breakdown in the recognition of the abuse allegation by the facility which led to the lack of an investigation and the failure to report. 2. Review of the facility's, "Self-Reported Incident Form", dated 03/14/14 revealed Resident #1's family had filed a grievance on 03/09/14, stating a nurse had spoken to the resident "unprofessionally". The Form stated Resident #1 requested his/her medication on night shift on the morning of 03/07/14 by using the call light multiple times and banging the call light on the table. LPN #6 went into the resident's room and told Resident #1 he/she was going to listen to what LPN #6 said and also told the resident he/she was bothering other residents by making so much noise. The nurse informed Resident #1 his/her behavior would not help get his/her pain medication any quicker. According to the Form, interviews with staff revealed they had overheard the nurse yelling at the resident and telling him/her that hitting the bedside table would not get assistance any faster. LPN #6 also called the resident a "child" to the staff. Review of LPN #6's personnel file revealed the employee was initially hired 04/20/10 and had signed and dated she had received training on the facility's abuse policy on 12/11/12. Interview, on 04/01/14 at 2:16 PM and on 04/02/14 at 4:15 PM and 5:14 PM with Resident #1, revealed a nurse on night shift had yelled at him/her and it took three (3) hours to get pain medication. Resident #1 indicated the nurse was upset because the resident was banging the call light and the nurse said he/she was acting like a kid. The resident further revealed when the nurse yelled it made him/her feel like a child and scared. Interview, on 04/02/14 at 8:55 AM, with CNA #7 revealed on the night of 03/06/14, Resident #1 requested pain medication, rang his/her call light multiple times, and banged the call light on the bedside table while the nurse was gone on break for over an hour. CNA #7 stated the nurse answered the resident's call light, was very loud and she could hear banging on the table and the nurse told Resident #1 he/she would not get the medication any quicker by banging on the table. According to CNA #7, she should have reported the incident immediately, but did not because she was scared it would get back to the nurse she had reported it. CNA #7 further revealed when she came back on Sunday, 03/09/14, two (2) days after the incident occurred, she talked to a nurse and weekend supervisor about the incident. Interview with CNA #3 on 04/02/14 at 8:55 AM and 04/09/14 at 6:58 PM, who also worked nightshift on 03/06/14 with CNA #7, revealed Resident #1 had used the call light approximately six (6) times for approximately an hour while the nurse was on lunch break. CNA #3 stated when the nurse, LPN #6 returned she told her Resident #1 needed pain medication. She stated she later overheard LPN #6 at the nurse's station say she had told Resident #1 he/she acted like a child by banging the call light. CNA #3 stated the nurse should not have called the resident a child. She stated she thought the incident was mental or verbal abuse; however, had not reported the incident. The CNA indicated she probably should have reported it because if abuse was suspected it was supposed to be reported immediately. Interview, on 04/03/14 at 12:38 PM, with Registered Nurse (RN) #3/ Unit 300 Manager, where Resident #1 resided, revealed she worked dayshift on 03/07/14, 7:00 AM to 3:00 PM. RN #3/Unit 300 Manager stated she was not aware of the incident until 03/10/14. She stated the staff who were aware of the incident should have reported the allegation of abuse immediately. Interview, on 04/10/14 at 3:54 PM, with RN #4/Weekend Supervisor revealed about 8:00 PM on 03/09/14, one (1) of the nurses reported the incident involving Resident #1 and she went and spoke to the resident about it. She stated Resident #1 reported he/she wanted a pain pill, was banging the call light on the table to get attention and LPN #6 screamed at him/her. RN#4/Weekend Supervisor revealed she talked to CNA #7, who was working at the time of the incident, and the CNA stated the nurse had yelled so loudly she heard her at the nurse's station. According to RN #4/Weekend Supervisor, she questioned CNA #7 why she had not reported the incident when it occurred, the CNA told her she was afraid the nurse would be mad at her. RN #4/Weekend Supervisor revealed the incident should have been reported immediately by the CNA and anyone else aware of the incident. Interview, on 04/01/14 at 5:54 PM with SW #1 revealed on 03/17/14, when she spoke to Resident #1 about the incident, the conversation was about the nurse and from the way the resident described the incident she would consider it abuse. SW #1 indicated if staff were aware of the incident it should have been reported immediately to the supervisor. Interview with the DNS on 04/02/14 at 12:30 PM and on 04/04/14 at 5:00 PM, revealed the facility expectation was if staff were aware an abuse event might have occurred they were supposed to report it immediately to their supervisor. The DNS revealed the abuse allegation involving LPN #6 and Resident #1 occurred sometime on nightshift on 03/06/14, to the early morning of 03/07/14, but she was not made aware of the incident until evening shift on 03/09/14 and started the investigation then. She stated the facility's investigation revealed staff did not follow the facility's policy on reporting abuse immediately after witnessing the incident. She stated the staff who were aware did not report the abuse because they were concerned about reporting the nurse involved. The DNS indicated if staff had reported the alleged abuse at the time it occurred the investigation could have been started at that time and the nurse suspended pending the results of the investigation. Interview with the Administrator on 04/02/14 at 1:53 PM, revealed her expectation was any suspected abuse needed to be reported immediately to the supervisor and the supervisor was to call her or her designee. The Administrator indicated when abuse was reported they were to report to the State Agency, do an investigation and report the findings to the State Agency. The Administrator stated investigating alleged abuse was important to make sure if an employee was involved they were taken out of the equation. She stated the facility's investigation process was to ask the person who reported the alleged abuse and the resident involved what occurred. She stated the process also included collecting witness statements from other staff and sometimes other residents depending on the allegation. Additional interview, on 04/08/14 at 6:46 PM, with the Administrator revealed staff had been aware of the event when it happened and should have reported the alleged abuse immediately. She indicated as a result of staff not reporting the incident immediately, the nurse involved was able to work on night shift on 03/08/14 before Administration was made aware. Interview, on 04/10/14 at 1:40 PM, with the Manager of Clinical Operations (MCO) revealed the abuse allegations involving Resident #1 and Resident #2 were not reported timely as per facility policy. The MCO indicated she felt the breakdown was due to staff not understanding the abuse policy, on what situations constituted abuse and reporting. In addition, she stated for Resident #2 the breakdown was also at the Administrative level as the facility had interpreted it as a grievance and not as abuse. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 04/08/14 which alleged removal of the Immediate Jeopardy (IJ) effective 04/07/14. Review of the AOC revealed the facility had implemented the following: 1. The facility's DNS, Administrator and Nurse Supervisors interviewed all interviewable residents to determine if they had experienced or witnessed any abuse in the facility or any issues with receiving PRN medications timely or threatening to have their medication withheld. The facility completed the interviews 03/14/14 and on 04/04/14. 2. The facility's DNS and Nurse Supervisors completed assessments of all non-interviewable residents to determine any injury associated with possible abuse. The facility completed the assessments on 03/14/14 and on 04/04/14. 3. The DNS and Administrator were re-educated to the Abuse Policy, the timely reporting requirements and completion of a thorough investigation by the MCO on 03/12/14 and on 04/03/14. 4. The facility's DNS, Administrator and Nurse Supervisors educated administrative, therapy, dietary, housekeeping, laundry, and maintenance staff on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution. Staff was also inserviced on stress management. Employees completed the Abuse Prevention post-test. The facility completed the inservices on 03/14/14 and again on 04/04/14. 5. The facility's DNS and Nurse Supervisors educated licensed nurses to count off controlled medications and relinquish med cart keys with another nurse if leaving the facility for lunch breaks or other periods of time to ensure medications were accessible to administer to residents as needed. The facility completed the inservices on 03/14/14. 6. The facility's DNS and Administrator were responsible for terminating the nurse involved in the allegation of abuse for Resident #1 and reporting the nurse to the Kentucky Board of Nursing. The facility completed the action on 03/14/14. 7. The two (2) staff members who heard the incident involving Resident #1, but did not report the allegation received disciplinary action by the DNS and Administrator. The facility completed the action on 03/14/14. 8. A Performance Improvement (PI) Meeting, to include the Administrator, DNS and Medical Director was held to discuss the late reporting of the allegation of abuse related to Resident #1 and the plan to correct this. The facility completed this action on 03/14/14. Additionally, a Performance Improvement Meeting, to include the Administrator, DNS and Medical Director, was held to discuss the late reporting of the allegation of abuse related to Resident #2, the Immediate Jeopardy citations, root cause and plan of correction. The facility completed this on 04/04/14. 9. The nurse identified in the allegation of abuse for Resident #2 was suspended on 04/03/14. The facility identified the DNS and Administrator as being responsible for the action. The facility completed the action on 04/03/14. 10. The initial report of the allegation involving Resident #2 was submitted to the State Agencies on 04/03/14, the persons assigned responsibility were the DNS and Administrator. The facility completed the action on 04/03/14. 11. The facility's DNS and Administrator was responsible for interviewing Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 12. The facility's DNS, Administrator and Nursing Supervisors were responsible for interviewing the sister of Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 13. The facility's DNS, Administrator and Nurse Supervisors were responsible for interviewing employees who worked 7:00 AM to 3:00 PM on 03/02/14 regarding the allegation of abuse related to Resident #2. The facility completed the interviews on 04/05/14. 14. The facility's DNS and Nurse Supervisors were responsible to enter the allegation of abuse for Resident #2 into the Risk Management System (RMS). The facility completed the action on 04/04/14. 15. The facility's DNS, Nurse Supervisors and Administrator were responsible to provide education to new hires on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution during orientation. This was an ongoing action. The facility did not use agency staff. 16. The facility was to assign supervisors on each shift to monitor staff and resident interactions and to determine any allegations of abuse were reported immediately to the Administrator. The facility's Administrator and DNS were responsible to implement the action and the facility completed on 04/04/14. 17. The facility was to implement monitoring actions to include interview of five (5) employees weekly for four (4) weeks and then monthly for three (3) months to determine: staff understood the facility's abuse policy; understood reporting allegations to the Administrator immediately; and understood allegations or statements were kept confidential and there was no fear of retribution for reporting. Any concerns were to be addressed at the time of interview. The facility identified the DNS, Nurse Supervisors and Administrator as being responsible for the audits which were ongoing. 18. The facility was to implement monitoring actions to include interview of five (5) residents weekly for four (4) weeks and then monthly for three (3) months to determine any issues with staff treatment or abuse and any issues with withholding of medication. Any concerns identified were to be addressed at that time. The facility identified the Administrator as being responsible for he audits and they were ongoing. 19. The facility was to implement monitoring actions to include an audit of all abuse investigations to determine that abuse allegations were reported timely as per the abuse policy and the investigations were thoroughly completed. Any concerns identified during the audit were to be addressed at that time. The facility identified the Administrator as being responsible for the audits and they were to be ongoing. 20. The findings of the monitoring identified above were to be reported to the Performance Improvement Committee monthly for four (4) months for further review and recommendation. The Administrator and DNS were responsible and this was to be ongoing. 21. The facility was to perform an audit on abuse allegations identified for the prior thirty (30) days, 03/06/14 through 04/06/14, to assure a thorough investigation was completed and any abuse was reported timely as per the facility policy. The person responsible was the MCO and the facility was to complete this on 04/07/14. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all interviewable residents. The resident interviews were performed by the DNS and Nursing Supervisors which included Unit Managers. Reviewed the documented resident interviews all completed by 03/14/14 and 04/04/14. Interview with the Assistant Director of Nursing (ADON) on 04/10/14 at 4:27 PM, and RN #5/100 Unit Manager on 04/10/14 at 4:48 PM revealed resident interviews were performed as per the AOC. Interview on 04/10/14, with Resident #1 at 12:58 PM; Resident #2 at 10:19 AM; Unsampled Resident A at 5:05 PM; Unsampled Resident B at 4:49 PM; and Unsampled Resident C at 5:10 PM revealed they were all interviewed by facility staff two (2) different times recently about abuse and medications. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she was in charge of the AOC plan to make sure everything was completed as indicated and verified all the resident interviews were completed by the 03/14/14 and 04/04/14 as noted on the AOC. 2. Interview and review of the facility's AOC implementation documentation with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all non-interviewable residents. The DNS stated they had two (2) staff present for skin assessments and no problems were identified indicating abuse, such as, bruises, scratches, any type of redness or any signs they were not getting care. Review and interview with the DNS revealed the skin assessments were performed by the DNS and Nursing Supervisors on 03/13/14, 03/14/14 and again on 04/04/14 with no issues identified. Interview with the ADON on 04/10/14 at 4:27 PM and RN #5/100 Unit Manager at 4:48 PM, revealed skin assessments were performed on non-interviewable residents. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she had verified all skin assessments of non-interviewable residents were completed by 03/14/14 and 04/05/14 as noted on the AOC with no issues identified. 3. Review of a documented inservice on 03/12/14 and 04/03/14 revealed the DNS and Administrator were re-educated on the facility's abuse policy and reporting requirements by the MCO. Interview with the DNS on 04/10/14 at 12:13 PM, and the Administrator on 04/10/14 at 5:29 PM, revealed both had received an inservice on the abuse policy and reporting requirements on 03/12/14 and 04/03/14 by the MCO. 4. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, at 12:13 PM and at 1:16 PM, revealed the facility used a master list of employees to inservice all staff on 03/10/14 thru 03/14/14 and on 04/03/14 thru 04/04/14. The DNS stated staff inservices included review of the abuse policy which included examples of abuse and reporting, investigations and reporting were confidential, stress management, and abuse post-test. She further stated inservices were performed by the Administrative team which included herself, the Administrator and Nursing Supervisors. The DNS stated staff who were not present were contacted by phone and given the inservice on the abuse policy and stress management. She indicated staff who the facility was unable to contact by phone were sent the inservice education by certified mail. The list of staff who were sent the inservice education by certified mail and the certified mail receipts were reviewed. Interview with the DNS revealed when the staff who were not present at the inservice came in to work they went over the post test and signed inservice sheets prior to beginning work. She stated the inservices were performed by the Administrative team which included herself, the Administrator and Nursing Supervisors. Review of the AOC implementation documentation revealed a master list of employees which showed staff were inserviced from 03/10/14 through 03/14/14 and on 04/03/14 and 04/04/14, on the abuse policy, reporting requirements, promise of confidentiality, no fear of retribution and stress management. The inservice material and post-tests completed by employees after the inservicing were reviewed. Interview on 04/10/14 with the ADON at 4:27 PM; RN #4/Weekend Supervisor at 4:08 PM; Activities Director at 2:44 PM; the Employee Benefits and Payroll Coordinator at 3:13 PM; the Maintenance Director at 3:39 PM; and RN #5/100 Unit Manager at 4:48 PM revealed they had inserviced staff on the facility's abuse policy and stress management in March and April. Staff interviews on 04/09/14 with LPN #10 at 5:22 PM; CNA #18 at 5:30 PM; LPN #11 at 5:41 PM; CNA #14 at 5:51 PM; CNA #3 at 6:55 PM; and, on 04/10/14 with LPN #12 at 7:30 AM; LPN # 13 at 7:50 AM; LPN # 14 at 7:55 AM; Dietary Aide #1 at 2:05 PM; Housekeeping #1 at 2:18 PM; Dietary Aide #2 at 2:27 PM; Housekeeping #2 at 2:32 PM; Activities Director at 2:44 PM; Maintenance #1 at 2:55 PM; Laundry #1 at 3:04 PM; Employee Payroll and Benefits Coordinator at 3:13 PM; Occupation Therapist (OT) #1 at 3:21 PM; Physical Therapy Assistant (PTA) #1 at 3:26 PM; CNA #16 at 3:33 PM; Maintenance #2 at 3:39 PM; CNA #17 at 3:47 PM; RN #4/Weekend Supervisor at 4:08 PM; and LPN #15 at 4:17 PM revealed all indicated they had received inservices on abuse in March and April which included the types of abuse, how and when to report abuse, confidentiality/retribution, and stress management. 5. Interview and review of the facility's AOC implementation documentation for Resident #1, with the DNS on 04/10/14 at 12:13 PM and at 1:16 PM, revealed the facility used a master list of nurses identified as receiving inservice education on 03/13/14 and 03/14/14 on counting controlled medications in the medication carts and giving the medication cart keys to another nurse before leaving the facility for lunch breaks. She stated the inservices were performed by herself and the Nursing Supervisors. Interview on 04/10/14 with DNS and ADON at 4:27 PM, RN #4/Weekend Supervisor at 4:08 PM, Activities Director at 2:44 PM, and RN #5/Unit Manager 100 at 4:48 PM revealed they inserviced staff on abuse in March and when applicable nursing staff on med cart. Staff interviews on 04/09/14 with LPN #10 at 5:22 PM; LPN #11 at 5:41 PM; and on 04/10/14 with LPN #12 at 7:30 AM; LPN #13 at 7:50 AM; LPN #14 at 7:55 AM; RN #4/Weekend Supervisor at 4:08 PM; and LPN #15 at 4:17 PM revealed all indicated they had received inservices on counting controlled medications in the medication carts and on giving the medication cart keys to another nurse prior to leaving the facility for lunch breaks in March. Interview with the Administrator, on 04/10/14 at 5:29 PM, revealed nurses were inserviced staff as indica

Based on interview, record review and review of the facility's policy and grievance forms, it was determined the facility failed to have an effective system in place to ensure policies and procedures were implemented related to abuse for two (2) of seven sampled residents (Resident #2 and Resident #1). The facility failed to ensure staff reported allegations of abuse, failed to identify allegations of abuse, failed to investigate allegations of abuse, failed to prevent the potential for further abuse, and failed to report the allegation to appropriate State Agencies per the facility's policy and procedures. (Refer to F-223 and F-225) Resident #2 informed Licensed Practical Nurse (LPN) #4 on 03/02/14, another nurse, LPN #1 had "snatched" the phone from him/her and told the resident he/she allowed to use the phone. Resident #2 reported to LPN #4 that LPN #1 told him/her if he/she continued to curse she would not give the resident his/her pain medication. LPN #4 completed a Grievance/Concern Report, called the Director of Nursing Services (DNS) and gave copies of the grievance form to the Administrator, DNS and Social Services (SS). However, the facility considered the incident a grievance, not potential abuse and failed to thoroughly investigate the incident to include interviews with other residents and staff. Therefore, LPN #1 was suspended for only one (1) day and then allowed to continue providing care for residents which could have resulted in the potential for further abuse. The facility also failed to report the incident to the appropriate State Agencies. Additionally, in the early morning hours of 03/07/14, two (2) Certified Nursing Assistants (CNAs), who had been trained on the facility's abuse policy, witnessed verbal abuse of Resident #1 by LPN #6. The CNAs heard LPN #6 yell at Resident #1 due to him/her using the call light multiple times to ask for pain medication. The CNAs also heard LPN #6 inform Resident #1 he/she was acting like a child and banging the call light would not get the pain medication administered any faster. After witnessing the verbal abuse the CNAs failed to immediately report it as per facility policy. Therefore, LPN #6 was allowed to work an entire night shift on 03/08/14, caring for residents which put them at risk for further potential abuse by the LPN. Administration was not notified until the evening shift of 03/09/14, after the resident's family filed a grievance. Because the CNAs did not immediately report the alleged abuse, an abuse investigation was not conducted within twenty-four (24) hours and the incident was not reported to State Agencies until 03/10/14. The facility's failure to have an effective system in place to ensure policies and procedures were implemented related to abuse was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/03/14 and was determined to exist on 03/02/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/08/14 with the facility alleging removal of the Immediate Jeopardy on 04/07/14. The Immediate Jeopardy was verified to be removed on 04/07/14 as alleged, prior to exit from the facility on 04/10/14, with remaining non-compliance at a Scope and Severity of "D", while the facility develops and implements the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "OPS310 KY Abuse Prohibition", effective 07/01/13, revealed the facility prohibited abuse for all residents through: identification of possible incidents or allegations which required investigation; investigation of incidents and allegations; protection of residents during investigations; and reporting of incidents and investigation results. The policy revealed staff who witnessed an incident of suspected abuse were to report the incident immediately to his/her supervisor and the supervisor was to report the suspected abuse immediately to the Administrator or designee. The policy noted upon receiving information concerning a report of suspected or alleged abuse the Administrator or designee would fax a report to the appropriate State Agencies. Review of the policy revealed any employee alleged to have committed an act of abuse was to be immediately removed from duty pending investigation. In addition, policy review revealed the facility was to initiate an investigation within twenty-four (24) hours of an allegation of abuse that focused on whether the abuse occurred and to what extent. 1. Review of the facility's "Grievance/Concern Report", completed on 03/02/14, by LPN #4 revealed Resident #2 told her when trying to use the phone LPN #1 "snatched" the phone, hung it up and told the resident he/she was not allowed to use the phone. Continued review of the "Grievance/Concern Report" revealed Resident #2 had also reported LPN #1 told the resident if he/she continued to curse at the LPN she would not give the resident his/her pain medication. Review revealed LPN #1 was suspended on 03/03/14 and then allowed to return to work after education on "Customer Service" and re-education on resident rights and the facility's abuse policy. Review of the "Grievance/Concern Report" revealed the grievance was noted as resolved on 03/04/14 by the DNS as Resident #2 and LPN #1 denied "pain meds would be withheld". Further review revealed no documented evidence the facility completed an abuse investigation as per facility policy or evidence the alleged abuse was reported to the State Agencies within twenty-four (24) hours as per the policy. Additionally, there was no documented evidence other residents or staff were interviewed. Interview with Resident #2 on 04/03/14 at 2:30 PM, revealed LPN #1 grabbed the phone from his/her ear, slammed it down on the receiver, and said "wait until you want another pain pill". Resident #2 reported he/she told LPN #4 what LPN #1 had done and LPN #4 had indicated to the resident it was a grievance. Interview, on 04/02/14 at 2:39 PM, with CNA #10 revealed she had overheard LPN #1 telling Resident #2, on 03/02/14, that he/she would not get his/her medicine on time because the resident was not doing what he/she was supposed to do. CNA #10 indicated she talked to LPN #4 about what she had overheard and LPN #4 told her she was going to call the DNS. CNA #10 stated she felt the facility had not properly investigated the incident as she was never interviewed about it. However, the facility's policy and procedures stated the facility would investigate incidents and allegations. Interview, on 04/09/14 at 3:05 PM, with CNA #11 revealed the facility's policy was when there was an allegation of abuse which involved an employee, the employee was suspended and the facility did an investigation at the time. CNA #11 stated she witnessed Resident #2 trying to use the phone at the nurse's station and LPN #1 told the resident he/she was not allowed to use the phone. She stated she observed LPN #1 grab the phone from Resident #2's hand and slam it down on the receiver which startled the CNA. CNA #11 revealed the nurse also told Resident #2 if he/she tried to use the phone again she was not going to give his/her pain medication. She stated she felt this was verbal/mental abuse and maybe physical abuse as the LPN had jerked the phone from Resident #2's hand. CNA #11 stated she did not report the incident because LPN #4, who was aware of the incident, was going to take care of it. She stated the facility's normal process was to suspend an employee involved in an allegation of abuse and investigate it at that time. CNA #11 reported the facility had not contacted her regarding the incident at the time. Interview, on 04/02/14 at 11:36 AM, with LPN #4 revealed on 03/02/14, Resident #2 reported LPN #1 had "snatched" the phone from him/her and told the resident he/she couldn't use the phone anymore. LPN #4 stated Resident #2 reported being upset when this happened and had cursed the nurse. LPN #4 reported Resident #2 told her LPN #1 stated if the resident kept talking to her like that she would not give him/her pain medication. LPN #4 reported she felt LPN #1's actions were abuse and so she called the DNS to inform her. LPN #4 stated the DNS told her she would take care of the incident. LPN #4 indicated the facility's policy was to investigate allegations of abuse which included interviewing residents and staff. However, she stated the facility did not interview her about the incident. In addition to calling the DNS, the LPN stated she completed a grievance form, attached a statement and gave one (1) to the Administrator, the DNS and SS. Interview with Social Worker (SW) #1 on 04/03/14 at 1:57 PM and 2:53 PM, and on 04/08/14 at 6:02 PM, revealed she did receive a copy of the grievance and read it somewhere between the week of 03/03/14 and 03/08/14. She stated she was concerned after reading it because the content stated the nurse "snatched" the phone from Resident #2, and told the resident if he/she continued to curse she would not give his/her pain medication. SW #1 stated she had discussed the grievance, her concern and what to do next with the Administrator and DNS around that time. SW #1 stated she could not remember what all was discussed or if she identified the grievance as an abuse allegation or only a concern. Per interview SW #1, revealed on 04/03/14 she interviewed Resident #2 who told her a nurse had informed him/her she was not going to give his/her pain medication if he/she tried to use the phone again. The Social Worker stated, based on Resident #2's interview, it sounded like abuse and the facility should have followed the abuse policy and did a more thorough investigation when the incident first occurred on 03/02/14. SW #1 stated resident safety was a concern because the LPN involved continued to work. Interview, on 04/02/14 at 12:30 PM and on 04/03/14 at 5:34 PM, with the DNS revealed she did not receive a phone call regarding the incident. However, LPN #4 had stated she called the DNS. The DNS stated a copy of the grievance form was in her mailbox on 03/03/14. She stated initially she had thought it was abuse and suspended LPN #1. The DNS stated she interviewed Resident #2 two (2) times and he/she denied the nurse aggressively removing the phone from his/her hand and threatening his/her pain medication. She stated she also got a written statement from LPN #1 who denied the incident. The DNS stated based on the interviews with Resident #2 and LPN #1, she did not think it was abuse after all. However, in looking back at the incident she felt it was an allegation of abuse and should have been investigated as per the policy. The DNS indicated there had been a breakdown in the process from the first day of the incident and the facility's abuse investigation process was not followed and the Administrator was not notified immediately. According to the DNS, if a full investigation of an abuse allegation was not completed and the alleged perpetrator was allowed to continue working there was a potential for additional abuse by the employee. The DNS reported the facility had re-opened an investigation into the alleged abuse and LPN #1 had been suspended. Review of LPN #1's "Timecard" punched revealed the nurse did not work on 03/03/14. Further review revealed she worked 03/04/14 through 03/06/14; 03/15/14 through 03/17/14; 03/24/14 through 03/27/14; 03/29/14 through 03/31/14; and 04/02/14. 2. Review of the facility's, "Self-Reported Incident Form 5 Day Follow up/Final Report", dated 03/14/14, revealed on 03/09/14, Resident #1's family had turned in a grievance form which indicated a nurse had talked "unprofessionally" to the resident. Review of the Incident Form revealed the resident had a tracheotomy (trach) and to make his/her needs known mouthed words. Review of the Incident Form revealed Resident #1, on the morning of 03/07/14, had used his/her call light multiple times and banged the call light on a table to request medication. Continued review of the Incident Form revealed the nurse was on break and when she returned she went to Resident #1's room and told the resident he/she was going to listen to her and told the resident he/she was bothering other residents by making so much noise. Review of the Incident Form revealed the nurse told the resident this behavior would not get his/her pain medication any quicker. Further review of the Incident Form revealed staff interviews indicated they heard the nurse yelling at the resident and telling him/her that hitting the bedside table would not get assistance any faster. In addition, review of the Incident Form revealed a staff person reported LPN #6 came back from Resident #1's room stating she had told the resident to quit ringing the call light every few minutes and the called Resident #1 a child. Interview with Resident #1 on 04/01/14 at 2:16 PM and on 04/02/14 at 4:15 PM and 5:14 PM, revealed on night shift one (1) night a nurse had yelled at Resident #1. Resident #1 indicated it had taken three (3) hours to get his/her pain medication. Resident #1 revealed because he/she was banging the call light this nurse got upset and told the resident he/she was acting like a kid. Further interview revealed Resident #1 was scared when the nurse yelled at him/her and it made him/her feel like a child. Interview, on 04/02/14 at 8:55 AM, with CNA #7 revealed she indicated she had been trained on the facility's abuse policy in orientation when she was hired. CNA #7 stated when she worked the nightshift on 03/06/14, Resident #1 had rang the call light numerous times and banged the call light on the bedside table to request pain medication. CNA #7 reported she was at the nurse's station, multiple rooms away from Resident #1's room, and hear the nurse being very loud and she stated she could hear banging on the table. The CNA stated she heard the nurse tell Resident #1 he/she would not get his/her medication any quicker by banging on the table. CNA #7 indicated she should have reported what had happened immediately per the facility's policy; however, she was scared the nurse would find out she had reported it. CNA #7 did not report the incident until 03/09/14, three (3) days later. Interview with CNA #3 on 04/02/14 at 8:55 AM and 04/09/14 at 6:58 PM, revealed she indicated she had been trained on the facility's abuse policy on hire. CNA #3 stated she worked nightshift on 03/06/14, and Resident #1 had used his/her call light frequently to request pain medication. She stated the nurse had been on break and when the nurse returned she told her Resident #1 needed pain medication. CNA #3 reported she later overheard LPN #6 at the nurse's station telling other staff she had informed Resident #1 by banging the call light he/she was acting like a child. CNA #3 stated the nurse should not have called Resident #1 a child and thought the incident was mental or verbal abuse. However, she had not reported the incident as per the facility's policy, but probably should have. CNA #3 indicated if abuse was suspected it was supposed to be reported immediately as per the policy. Interview, on 04/10/14 at 3:54 PM, with RN #4/Weekend Supervisor revealed on 03/09/14 at approximately 8:00 PM, a nurse told her about an incident involving Resident #1 and she had gone and talked to the resident. RN #4/Weekend Supervisor reported Resident #1 told her he/she had banged the call light on the table to get attention as he/she wanted a pain pill as he/she was in pain. The RN stated Resident #1 told her LPN #6 had screamed at him/her and told him/her by making that noise he/she was annoying other residents. She stated she also talked to CNA #7, who had worked at the time of the incident, and CNA #7 told her the nurse had yelled so loudly at Resident #1 she could be heard at the nurse's station. RN #4/Weekend Supervisor stated she asked CNA #7 why she had not reported the incident when it occurred and the CNA indicated she was afraid the nurse would be mad at her. The RN indicated CNA #7 should have reported the alleged abuse immediately and so should any other staff who had knowledge of the incident as that was the facility's policy. RN#4/Weekend Supervisor stated she called the DNS who told her LPN #6 could not work and the LPN did not work. She indicated the DNS came in and took Resident #1's written statement. Interview, on 04/03/14 at 12:38 PM, with Registered Nurse (RN) #3/300 Unit Manager, where Resident #1 resided, revealed she found about the incident on 03/10/14. She indicated staff should have reported the incident immediately as this was the facility's policy. Interview with Social Worker (SW) #1 on 04/01/14 at 5:54 PM, revealed she had discussed the incident with Resident #1 on 03/17/14, and from what the resident described had happened she would consider the nurse's actions as abuse. SW #1 indicated if staff was aware of the incident it should have been reported immediately to the supervisor as per the facility policy. Interview with the DNS on 04/02/14 at 12:30 PM and on 04/04/14 at 5:00 PM, revealed she was not aware of the incident until evening shift on 03/09/14, and she started an investigation at that time. The DNS stated the facility's investigation had determined staff who had witnessed the incident had not followed the facility policy and reported the alleged abuse immediately. She reported staff who had knowledge of the incident did not report it because of concern over reporting the nurse involved. The DNS indicated if the alleged abuse had been reported immediately an investigation could have been initiated at that time and the nurse suspended. She stated the facility's expectation was for staff to report immediately to their supervisor if they became aware of an abuse allegation. Interview, on 04/02/14 at 1:53 PM and on 04/08/14 at 6:46 PM, with the Administrator revealed she indicated her expectation was for any suspected abuse staff should report it immediately to their supervisor and the supervisor was to call her or her designee as per the policy. She stated it was important allegations were investigated to ensure if it involved a staff person, the person was taken out of the equation. She stated the investigation process included asking the person who reported it what happened, talking to the resident involved and collecting witness statements from other residents and staff, depending on what the allegation concerned to ensure resident safety. The Administrator indicated when abuse was reported the facility was to report it to the State Agencies, do the investigation and report the results to the State Survey Agency as per the policy. However, the facility failed to follow the policies and procedures to investigate and protect residents related to the incident involving Resident #1 and Resident #2. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 04/08/14 which alleged removal of the Immediate Jeopardy (IJ) effective 04/07/14. Review of the AOC revealed the facility had implemented the following: 1. The facility's DNS, Administrator and Nurse Supervisors interviewed all interviewable residents to determine if they had experienced or witnessed any abuse in the facility or any issues with receiving PRN medications timely or threatening to have their medication withheld. The facility completed the interviews 03/14/14 and on 04/04/14. 2. The facility's DNS and Nurse Supervisors completed assessments of all non-interviewable residents to determine any injury associated with possible abuse. The facility completed the assessments on 03/14/14 and on 04/04/14. 3. The DNS and Administrator were re-educated to the Abuse Policy, the timely reporting requirements and completion of a thorough investigation by the MCO on 03/12/14 and on 04/03/14. 4. The facility's DNS, Administrator and Nurse Supervisors educated administrative, therapy, dietary, housekeeping, laundry, and maintenance staff on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution. Staff was also inserviced on stress management. Employees completed the Abuse Prevention post-test. The facility completed the inservices on 03/14/14 and again on 04/04/14. 5. The facility's DNS and Nurse Supervisors educated licensed nurses to count off controlled medications and relinquish med cart keys with another nurse if leaving the facility for lunch breaks or other periods of time to ensure medications were accessible to administer to residents as needed. The facility completed the inservices on 03/14/14. 6. The facility's DNS and Administrator were responsible for terminating the nurse involved in the allegation of abuse for Resident #1 and reporting the nurse to the Kentucky Board of Nursing. The facility completed the action on 03/14/14. 7. The two (2) staff members who heard the incident involving Resident #1, but did not report the allegation received disciplinary action by the DNS and Administrator. The facility completed the action on 03/14/14. 8. A Performance Improvement (PI) Meeting, to include the Administrator, DNS and Medical Director was held to discuss the late reporting of the allegation of abuse related to Resident #1 and the plan to correct this. The facility completed this action on 03/14/14. Additionally, a Performance Improvement Meeting, to include the Administrator, DNS and Medical Director, was held to discuss the late reporting of the allegation of abuse related to Resident #2, the Immediate Jeopardy citations, root cause and plan of correction. The facility completed this on 04/04/14. 9. The nurse identified in the allegation of abuse for Resident #2 was suspended on 04/03/14. The facility identified the DNS and Administrator as being responsible for the action. The facility completed the action on 04/03/14. 10. The initial report of the allegation involving Resident #2 was submitted to the State Agencies on 04/03/14, the persons assigned responsibility were the DNS and Administrator. The facility completed the action on 04/03/14. 11. The facility's DNS and Administrator was responsible for interviewing Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 12. The facility's DNS, Administrator and Nursing Supervisors were responsible for interviewing the sister of Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 13. The facility's DNS, Administrator and Nurse Supervisors were responsible for interviewing employees who worked 7:00 AM to 3:00 PM on 03/02/14 regarding the allegation of abuse related to Resident #2. The facility completed the interviews on 04/05/14. 14. The facility's DNS and Nurse Supervisors were responsible to enter the allegation of abuse for Resident #2 into the Risk Management System (RMS). The facility completed the action on 04/04/14. 15. The facility's DNS, Nurse Supervisors and Administrator were responsible to provide education to new hires on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution during orientation. This was an ongoing action. The facility did not use agency staff. 16. The facility was to assign supervisors on each shift to monitor staff and resident interactions and to determine any allegations of abuse were reported immediately to the Administrator. The facility's Administrator and DNS were responsible to implement the action and the facility completed on 04/04/14. 17. The facility was to implement monitoring actions to include interview of five (5) employees weekly for four (4) weeks and then monthly for three (3) months to determine: staff understood the facility's abuse policy; understood reporting allegations to the Administrator immediately; and understood allegations or statements were kept confidential and there was no fear of retribution for reporting. Any concerns were to be addressed at the time of interview. The facility identified the DNS, Nurse Supervisors and Administrator as being responsible for the audits which were ongoing. 18. The facility was to implement monitoring actions to include interview of five (5) residents weekly for four (4) weeks and then monthly for three (3) months to determine any issues with staff treatment or abuse and any issues with withholding of medication. Any concerns identified were to be addressed at that time. The facility identified the Administrator as being responsible for he audits and they were ongoing. 19. The facility was to implement monitoring actions to include an audit of all abuse investigations to determine that abuse allegations were reported timely as per the abuse policy and the investigations were thoroughly completed. Any concerns identified during the audit were to be addressed at that time. The facility identified the Administrator as being responsible for the audits and they were to be ongoing. 20. The findings of the monitoring identified above were to be reported to the Performance Improvement Committee monthly for four (4) months for further review and recommendation. The Administrator and DNS were responsible and this was to be ongoing. 21. The facility was to perform an audit on abuse allegations identified for the prior thirty (30) days, 03/06/14 through 04/06/14, to assure a thorough investigation was completed and any abuse was reported timely as per the facility policy. The person responsible was the MCO and the facility was to complete this on 04/07/14. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all interviewable residents. The resident interviews were performed by the DNS and Nursing Supervisors which included Unit Managers. Reviewed the documented resident interviews all completed by 03/14/14 and 04/04/14. Interview with the Assistant Director of Nursing (ADON) on 04/10/14 at 4:27 PM, and RN #5/100 Unit Manager on 04/10/14 at 4:48 PM revealed resident interviews were performed as per the AOC. Interview on 04/10/14, with Resident #1 at 12:58 PM; Resident #2 at 10:19 AM; Unsampled Resident A at 5:05 PM; Unsampled Resident B at 4:49 PM; and Unsampled Resident C at 5:10 PM revealed they were all interviewed by facility staff two (2) different times recently about abuse and medications. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she was in charge of the AOC plan to make sure everything was completed as indicated and verified all the resident interviews were completed by the 03/14/14 and 04/04/14 as noted on the AOC. 2. Interview and review of the facility's AOC implementation documentation with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all non-interviewable residents. The DNS stated they had two (2) staff present for skin assessments and no problems were identified indicating abuse, such as, bruises, scratches, any type of redness or any signs they were not getting care. Review and interview with the DNS revealed the skin assessments were performed by the DNS and Nursing Supervisors on 03/13/14, 03/14/14 and again on 04/04/14 with no issues identified. Interview with the ADON on 04/10/14 at 4:27 PM and RN #5/100 Unit Manager at 4:48 PM, revealed skin assessments were performed on non-interviewable residents. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she had verified all skin assessments of non-interviewable residents were completed by 03/14/14 and 04/05/14 as noted on the AOC with no issues identified. 3. Review of a documented inservice on 03/12/14 and 04/03/14 revealed the DNS and Administrator were re-educated on the facility's abuse policy and reporting requirements by the MCO. Interview with the DNS on 04/10/14 at 12:13 PM, and the Administrator on 04/10/14 at 5:29 PM, revealed both had received an inservice on the abuse policy and reporting requirements on 03/12/14 and 04/03/14 by the MCO. 4. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, at 12:13 PM and at 1:16 PM, revealed the facility used a master list of employees to inservice all staff on 03/10/14 thru 03/14/14 and on 04/03/14 thru 04/04/14. The DNS stated staff inservices included review of the abuse policy which included examples of abuse and reporting, investigations and reporting were confidential, stress management, and abuse post-test. She further stated inservices were performed by the Administrative team which included herself, the Administrator and Nursing Supervisors. The DNS stated staff who were not present were contacted by phone and given the inservice on the abuse policy and stress management. She indicated staff who the facility was unable to contact by phone were sent the inservice education by certified mail. The list of staff who were sent the inservice education by certified mail and the certified mail receipts were reviewed. Interview with the DNS revealed when the staff who were not present at the inservice came in to work they went over the post test and signed inservice sheets prior to beginning work. She stated the inservices were performed by the Administrative team which included herself, the Administrator and Nursing Supervisors. Review of the AOC implementation documentation revealed a master list of employees which showed staff were inserviced from 03/10/14 through 03/14/14 and on 04/03/14 and 04/04/14, on the abuse policy, reporting requirements, promise of confidentiality, no fear of retribution and stress management. The inservice material and post-tests completed by employees after the inservicing were reviewed. Interview on 04/10/14 with the ADON at 4:27 PM; RN #4/Weekend Supervisor at 4:08 PM; Activities Director at 2:44 PM; the Employee Benefits and Payroll Coordinator at 3:13 PM; the Maintenance Director at 3:39 PM; and RN #5/100 Unit Manager at 4:48 PM revealed they had inserviced staff on the facility's abuse policy and stress management in March and April. Staff interviews on 04/09/14 with LPN #10 at 5:22 PM; CNA #18 at 5:30 PM; LPN #11 at 5:41 PM; CNA #14 at 5:51 PM; CNA #3 at 6:55 PM; and, on 04/10/14 with LPN #12 at 7:30 AM; LPN # 13 at 7:50 AM; LPN # 14 at 7:55 AM; Dietary Aide #1 at 2:05 PM; Housekeeping #1 at 2:18 PM; Dietary Aide #2 at 2:27 PM; Housekeeping #2 at 2:32 PM; Activities Director at 2:44 PM; Maintenance #1 at 2:55 PM; Laundry #1 at 3:04 PM; Employee Payroll and Benefits Coordinator at 3:13 PM; Occupation Therapist (OT) #1 at 3:21 PM; Physical Therapy Assistant (PTA) #1 at 3:26 PM; CNA #16 at 3:33 PM; Maintenance #2 at 3:39 PM; CNA #17 at 3:47 PM; RN #4/Weekend Supervisor at 4:08 PM; and LPN #15 at 4:17 PM revealed all indicated they had received inservices on abuse in March and April which included the types of abuse, how and when to report abuse, confidentiality/retribution, and stress management. 5. Interview and review of the facility's AOC implementation documentation for Resident #1, with the DNS on 04/10/14 at 12:13 PM and at 1:16 PM, revealed the facility used a master list of nurses identified as receiving inservice education on 03/13/14 and 03/14/14 on counting controlled medications in the medication carts and giving the medication cart keys to another nurse before leaving the facility for lunch breaks. She stated the inservices were performed by herself and the Nursing Supervisors. Interview on 04/10/14 with DNS and ADON at 4:27 PM, RN #4/Weekend Supervisor at 4:08 PM, Activities Director at 2:44 PM, and RN #5/Unit Manager 100 at 4:48 PM revealed they inserviced staff on abuse in March and when applicable nursing staff on med cart. Staff interviews on 04/09/14 with LPN #10 at 5:22 PM; LPN #11 at 5:41 PM; and on 04/10/14 with LPN #12 at 7:30 AM; LPN #13 at 7:50 AM; LPN #14 at 7:55 AM; RN #4/Weekend Supervisor at 4:08 PM; and LPN #15 at 4:17 PM revealed all indicated they had received inservices on counting controlled medications in the medication carts and on

Based on interview, record review, and review of the facility's policy, grievances forms, and final investigative reports it was determined the facility's Administration failed to have an effective system to ensure policy and procedures were implemented related to abuse. The facility failed to immediately report an allegation of abuse; investigate allegations of abuse; prevent the potential for further abuse; and report allegations to appropriate State Agencies as per the facility's policy and procedures. This failure affected two (2) of seven (7) sampled residents (Residents #1 and #2). Licensed Practical Nurse (LPN) #4 completed a Grievance/Concern Report on 03/02/14, after being informed by Resident #2 that LPN #1 had "snatched" the phone from him/her and told the resident he/she was not allowed to use the phone. Resident #2 also reported LPN #1 told him/her if he/she continued to curse at her, the LPN would not give the resident his/her pain medication. LPN #4 gave copies of the Grievance/Concern Report to the Administrator, Director of Nursing Services (DNS) and Social Services (SS). Although the facility's Administration was aware of the grievance they failed to view the incident as potential abuse. Therefore, the facility's Administration failed to perform a thorough investigation to include staff and other resident interviews, failed to suspend the alleged perpetrator which could have resulted in potential further abuse and failed to report the alleged abuse to the State Agencies. Additionally, staff witnessed an incident of verbal abuse by Licensed Practical Nurse (LPN) #6 on 03/07/14 early in the morning. Staff heard LPN #6 yelling at Resident #1 for using the call light multiple times to request pain medication. Staff heard LPN #6 inform Resident #1 he/she would not get pain medication any quicker by banging his/her call light. LPN #6 was heard telling Resident #1 he/she was acting like a child. Interviews with Certified Nursing Assistants (CNA) #3 and CNA #7 revealed they were aware of the incident; however, had not reported it immediately as per the abuse policy. As a result of the staff not reporting the alleged abuse immediately, LPN #6 worked another entire shift the night of 03/08/14. The facility's Administration only became aware of the incident after Resident #1's family filed a grievance. (Refer to F-223, F-225 and F-226) The facility's Administration's failure to have an effective system in place to ensure the facility's policies were implemented was likely to cause serious injury, harm, impairment or death. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 04/03/14 and was determined to exist on 03/02/14. The facility provided an acceptable credible Allegation of Compliance (AOC) on 04/08/14 with the facility alleging removal of the Immediate Jeopardy on 04/07/14. The Immediate Jeopardy was verified to be removed on 04/07/14 as alleged, prior to exit from the facility on 04/10/14, with remaining non-compliance at a Scope and Severity of "D", while the facility develops and implements the Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure residents are free from abuse. The findings include: Review of the facility's policy titled, "OPS310 KY Abuse Prohibition", effective 07/01/13, revealed the facility prohibited abuse through: identifying and investigating possible incidents or allegations; protecting residents during investigations; and reporting the incidents/allegations and results of the investigations to State Agencies. Review revealed staff witnessing suspected abuse were to report the incident immediately to the supervisor, who would report the allegations immediately to the Administrator or designee. Policy review revealed the Administrator was to fax a report to the State Agencies of the alleged abuse. Review of the policy revealed employees alleged to have committed abuse would be immediately removed from duty pending investigation. Further policy review revealed an investigation was to be initiated within twenty-four (24) hours of allegations of abuse to determine if the abuse occurred and to what extent. 1. Review of the facility's grievance form completed by LPN #4 on 03/02/14 revealed Resident #2 told her LPN #1 had "snatched" the phone from him/her and told the resident he/she was not allowed to use it anymore. Continued review of the form revealed Resident #2 also told LPN #4 that LPN #1 told him/her if he/she continued to curse her she would not give his/her pain medication. Further review revealed no documented evidence the facility's Administration had performed an abuse investigation or reported the incident within twenty-four (24) hours to State Agencies as per the policy. Interview, on 04/02/14 at 11:36 AM, with LPN #4 revealed on 03/02/14 Resident #2 reported LPN #1 had "snatched" the phone from him/her and told the resident he/she could not use the phone anymore. LPN #4 indicated Resident #2 told her he/she was upset when LPN #1 did that and had cursed her. LPN #4 stated she felt this was abuse and called the DNS who told her she would take care of it. However, LPN #4 filed the incident as a grievance and gave copies of the grievance form to the Administrator, the DNS and SS. Interview, on 04/02/14 at 12:30 PM and on 04/03/14 at 5:34 PM, with the DNS revealed the facility's abuse investigation process had not been followed and the Administrator had not been notified immediately. The DNS reported if the facility did not fully investigate abuse allegations and the alleged perpetrator remained working there was the potential for additional abuse to occur. The DNS stated the facility had re-opened the incident, an investigation was being performed and the nurse had been suspended. Interview, on 04/02/14 at 1:53 PM with the Administrator revealed she had seen the grievance form regarding the incident involving Resident #2 sometime around 03/06/14. According to the Administrator, she had heard about the incident prior to reading the grievance, but thought it had been minimized when told to her. She stated after she read the grievance she should have recognize it as an allegation of abuse or even neglect because there was a threat to withhold pain medication. The Administrator stated she should have had the alleged perpetrator removed from resident care, reported the incident to the State Agencies and performed a thorough investigation of the alleged abuse. She indicated a breakdown had occurred because of the lack of recognition of abuse which lead to the absence of investigation and failure to report the alleged abuse. She stated she had not followed the abuse policy. 2. Review of the facility's final report sent to the State Agency, dated 03/14/14 revealed Resident #1's family completed a grievance related to LPN #6 talking to the resident "unprofessionally" the early morning of 03/07/14. Further review revealed an investigation was initiated. Interview with Resident #1 on 04/01/14 at 2:16 PM and on 04/02/14 at 4:15 PM and 5:14 PM revealed a night shift nurse had yelled at him/her and became upset with the resident because he/she had been banging the call light. Resident #2 indicated the nurse had told him/her he/she was acting like a kid. Resident #2 revealed when the nurse yelled it had scared him/her and had made him/her feel like a child. Interview with CNA #7 on 04/02/14 at 8:55 AM and CNA #3 on 04/02/14 at 8:55 AM and 04/09/14 at 6:58 PM revealed both heard the nurse yelling at Resident #1. However, neither CNA reported the incident immediately per the facility's policy. CNA #7 reported the incident to the nurse and weekend supervisor on 03/09/14, two (2) days after she had witnessed the incident. Interview with the DNS on 04/02/14 at 12:30 PM and on 04/04/14 at 5:00 PM, revealed the facility's expectation was for staff to report any abuse allegation immediately to their supervisor. She stated when she became aware of the incident on the evening of 03/09/14 she had initiated an investigation. She indicated the investigation had revealed staff was aware of the incident; however, had not reported it immediately as per the policy. The DNS indicated as a result of the staff's failure to report LPN #6 worked the next night after the incident. She stated the investigation revealed staff had not followed the facility's abuse policy as they were aware of the alleged abuse and did not report it immediately. Interview, on 04/03/14 at 6:23 PM, with the Administrator revealed staff was aware of the incident involving Resident #1 and should have reported it immediately. She stated staff had failed to report it immediately, allowed the nurse involved to work another shift before being suspended, which could have led to the potential for additional abuse of residents. The Administrator reported if staff had reported the incident immediately and she had been notified she would have immediately suspended the nurse and started the investigation. Further interview with the Administrator, on 04/08/14 at 6:46 PM, revealed she expected her staff to report any suspected abuse immediately to their supervisor and the supervisor to call Administration. She stated the process was then to report the alleged abuse to the State Agencies, perform an investigation, and report the results of the investigation to the State Survey Agency. According to the Administrator, the investigation process included interviewing the person reporting the abuse and the residents involved, and collecting witness statements from staff and other residents. She stated the investigation was important for ensuring allegations regarding staff took the person out of the equation. Further interview revealed as the Administrator she was ultimately responsible for the protection of residents. Interview, on 04/10/14 at 1:40 PM, with the Manager of Clinical Operations (MCO) revealed she felt there was a breakdown at the Administrative level for the incident involving Resident #2. She stated she felt the breakdown was due to staff not understanding the abuse policy, in regards to what constituted abuse and the process for reporting alleged abuse. She stated she also thought there was a breakdown at the Administrative level because they had not interpreted the incident as abuse, but as a grievance. The MCO indicated the allegations involving Resident #2 and Resident #1 had not been reported as they should have been per the policy. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 04/08/14 which alleged removal of the Immediate Jeopardy (IJ) effective 04/07/14. Review of the AOC revealed the facility had implemented the following: 1. The facility's DNS, Administrator and Nurse Supervisors interviewed all interviewable residents to determine if they had experienced or witnessed any abuse in the facility or any issues with receiving PRN medications timely or threatening to have their medication withheld. The facility completed the interviews 03/14/14 and on 04/04/14. 2. The facility's DNS and Nurse Supervisors completed assessments of all non-interviewable residents to determine any injury associated with possible abuse. The facility completed the assessments on 03/14/14 and on 04/04/14. 3. The DNS and Administrator were re-educated to the Abuse Policy, the timely reporting requirements and completion of a thorough investigation by the MCO on 03/12/14 and on 04/03/14. 4. The facility's DNS, Administrator and Nurse Supervisors educated administrative, therapy, dietary, housekeeping, laundry, and maintenance staff on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution. Staff was also inserviced on stress management. Employees completed the Abuse Prevention post-test. The facility completed the inservices on 03/14/14 and again on 04/04/14. 5. The facility's DNS and Nurse Supervisors educated licensed nurses to count off controlled medications and relinquish med cart keys with another nurse if leaving the facility for lunch breaks or other periods of time to ensure medications were accessible to administer to residents as needed. The facility completed the inservices on 03/14/14. 6. The facility's DNS and Administrator were responsible for terminating the nurse involved in the allegation of abuse for Resident #1 and reporting the nurse to the Kentucky Board of Nursing. The facility completed the action on 03/14/14. 7. The two (2) staff members who heard the incident involving Resident #1, but did not report the allegation received disciplinary action by the DNS and Administrator. The facility completed the action on 03/14/14. 8. A Performance Improvement (PI) Meeting, to include the Administrator, DNS and Medical Director was held to discuss the late reporting of the allegation of abuse related to Resident #1 and the plan to correct this. The facility completed this action on 03/14/14. Additionally, a Performance Improvement Meeting, to include the Administrator, DNS and Medical Director, was held to discuss the late reporting of the allegation of abuse related to Resident #2, the Immediate Jeopardy citations, root cause and plan of correction. The facility completed this on 04/04/14. 9. The nurse identified in the allegation of abuse for Resident #2 was suspended on 04/03/14. The facility identified the DNS and Administrator as being responsible for the action. The facility completed the action on 04/03/14. 10. The initial report of the allegation involving Resident #2 was submitted to the State Agencies on 04/03/14, the persons assigned responsibility were the DNS and Administrator. The facility completed the action on 04/03/14. 11. The facility's DNS and Administrator was responsible for interviewing Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 12. The facility's DNS, Administrator and Nursing Supervisors were responsible for interviewing the sister of Resident #2 regarding the allegation of abuse reported on 03/02/14. The facility completed the action on 04/04/14. 13. The facility's DNS, Administrator and Nurse Supervisors were responsible for interviewing employees who worked 7:00 AM to 3:00 PM on 03/02/14 regarding the allegation of abuse related to Resident #2. The facility completed the interviews on 04/05/14. 14. The facility's DNS and Nurse Supervisors were responsible to enter the allegation of abuse for Resident #2 into the Risk Management System (RMS). The facility completed the action on 04/04/14. 15. The facility's DNS, Nurse Supervisors and Administrator were responsible to provide education to new hires on the facility's abuse policy, reporting requirements, promise of confidentiality, and no fear of retribution during orientation. This was an ongoing action. The facility did not use agency staff. 16. The facility was to assign supervisors on each shift to monitor staff and resident interactions and to determine any allegations of abuse were reported immediately to the Administrator. The facility's Administrator and DNS were responsible to implement the action and the facility completed on 04/04/14. 17. The facility was to implement monitoring actions to include interview of five (5) employees weekly for four (4) weeks and then monthly for three (3) months to determine: staff understood the facility's abuse policy; understood reporting allegations to the Administrator immediately; and understood allegations or statements were kept confidential and there was no fear of retribution for reporting. Any concerns were to be addressed at the time of interview. The facility identified the DNS, Nurse Supervisors and Administrator as being responsible for the audits which were ongoing. 18. The facility was to implement monitoring actions to include interview of five (5) residents weekly for four (4) weeks and then monthly for three (3) months to determine any issues with staff treatment or abuse and any issues with withholding of medication. Any concerns identified were to be addressed at that time. The facility identified the Administrator as being responsible for he audits and they were ongoing. 19. The facility was to implement monitoring actions to include an audit of all abuse investigations to determine that abuse allegations were reported timely as per the abuse policy and the investigations were thoroughly completed. Any concerns identified during the audit were to be addressed at that time. The facility identified the Administrator as being responsible for the audits and they were to be ongoing. 20. The findings of the monitoring identified above were to be reported to the Performance Improvement Committee monthly for four (4) months for further review and recommendation. The Administrator and DNS were responsible and this was to be ongoing. 21. The facility was to perform an audit on abuse allegations identified for the prior thirty (30) days, 03/06/14 through 04/06/14, to assure a thorough investigation was completed and any abuse was reported timely as per the facility policy. The person responsible was the MCO and the facility was to complete this on 04/07/14. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all interviewable residents. The resident interviews were performed by the DNS and Nursing Supervisors which included Unit Managers. Reviewed the documented resident interviews all completed by 03/14/14 and 04/04/14. Interview with the Assistant Director of Nursing (ADON) on 04/10/14 at 4:27 PM, and RN #5/100 Unit Manager on 04/10/14 at 4:48 PM revealed resident interviews were performed as per the AOC. Interview on 04/10/14, with Resident #1 at 12:58 PM; Resident #2 at 10:19 AM; Unsampled Resident A at 5:05 PM; Unsampled Resident B at 4:49 PM; and Unsampled Resident C at 5:10 PM revealed they were all interviewed by facility staff two (2) different times recently about abuse and medications. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she was in charge of the AOC plan to make sure everything was completed as indicated and verified all the resident interviews were completed by the 03/14/14 and 04/04/14 as noted on the AOC. 2. Interview and review of the facility's AOC implementation documentation with the DNS on 04/10/14 at 10:37 AM, 12:13 PM and at 1:16 PM, revealed the facility used a Resident Census Report to identify all non-interviewable residents. The DNS stated they had two (2) staff present for skin assessments and no problems were identified indicating abuse, such as, bruises, scratches, any type of redness or any signs they were not getting care. Review and interview with the DNS revealed the skin assessments were performed by the DNS and Nursing Supervisors on 03/13/14, 03/14/14 and again on 04/04/14 with no issues identified. Interview with the ADON on 04/10/14 at 4:27 PM and RN #5/100 Unit Manager at 4:48 PM, revealed skin assessments were performed on non-interviewable residents. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she had verified all skin assessments of non-interviewable residents were completed by 03/14/14 and 04/05/14 as noted on the AOC with no issues identified. 3. Review of a documented inservice on 03/12/14 and 04/03/14 revealed the DNS and Administrator were re-educated on the facility's abuse policy and reporting requirements by the MCO. Interview with the DNS on 04/10/14 at 12:13 PM, and the Administrator on 04/10/14 at 5:29 PM, revealed both had received an inservice on the abuse policy and reporting requirements on 03/12/14 and 04/03/14 by the MCO. 4. Interview and review of the facility's AOC implementation documentation for Resident #1 and Resident #2, with the DNS on 04/10/14 at 10:37 AM, at 12:13 PM and at 1:16 PM, revealed the facility used a master list of employees to inservice all staff on 03/10/14 thru 03/14/14 and on 04/03/14 thru 04/04/14. The DNS stated staff inservices included review of the abuse policy which included examples of abuse and reporting, investigations and reporting were confidential, stress management, and abuse post-test. She further stated inservices were performed by the Administrative team which included herself, the Administrator and Nursing Supervisors. The DNS stated staff who were not present were contacted by phone and given the inservice on the abuse policy and stress management. She indicated staff who the facility was unable to contact by phone were sent the inservice education by certified mail. The list of staff who were sent the inservice education by certified mail and the certified mail receipts were reviewed. Interview with the DNS revealed when the staff who were not present at the inservice came in to work they went over the post test and signed inservice sheets prior to beginning work. She stated the inservices were performed by the Administrative team which included herself, the Administrator and Nursing Supervisors. Review of the AOC implementation documentation revealed a master list of employees which showed staff were inserviced from 03/10/14 through 03/14/14 and on 04/03/14 and 04/04/14, on the abuse policy, reporting requirements, promise of confidentiality, no fear of retribution and stress management. The inservice material and post-tests completed by employees after the inservicing were reviewed. Interview on 04/10/14 with the ADON at 4:27 PM; RN #4/Weekend Supervisor at 4:08 PM; Activities Director at 2:44 PM; the Employee Benefits and Payroll Coordinator at 3:13 PM; the Maintenance Director at 3:39 PM; and RN #5/100 Unit Manager at 4:48 PM revealed they had inserviced staff on the facility's abuse policy and stress management in March and April. Staff interviews on 04/09/14 with LPN #10 at 5:22 PM; CNA #18 at 5:30 PM; LPN #11 at 5:41 PM; CNA #14 at 5:51 PM; CNA #3 at 6:55 PM; and, on 04/10/14 with LPN #12 at 7:30 AM; LPN # 13 at 7:50 AM; LPN # 14 at 7:55 AM; Dietary Aide #1 at 2:05 PM; Housekeeping #1 at 2:18 PM; Dietary Aide #2 at 2:27 PM; Housekeeping #2 at 2:32 PM; Activities Director at 2:44 PM; Maintenance #1 at 2:55 PM; Laundry #1 at 3:04 PM; Employee Payroll and Benefits Coordinator at 3:13 PM; Occupation Therapist (OT) #1 at 3:21 PM; Physical Therapy Assistant (PTA) #1 at 3:26 PM; CNA #16 at 3:33 PM; Maintenance #2 at 3:39 PM; CNA #17 at 3:47 PM; RN #4/Weekend Supervisor at 4:08 PM; and LPN #15 at 4:17 PM revealed all indicated they had received inservices on abuse in March and April which included the types of abuse, how and when to report abuse, confidentiality/retribution, and stress management. 5. Interview and review of the facility's AOC implementation documentation for Resident #1, with the DNS on 04/10/14 at 12:13 PM and at 1:16 PM, revealed the facility used a master list of nurses identified as receiving inservice education on 03/13/14 and 03/14/14 on counting controlled medications in the medication carts and giving the medication cart keys to another nurse before leaving the facility for lunch breaks. She stated the inservices were performed by herself and the Nursing Supervisors. Interview on 04/10/14 with DNS and ADON at 4:27 PM, RN #4/Weekend Supervisor at 4:08 PM, Activities Director at 2:44 PM, and RN #5/Unit Manager 100 at 4:48 PM revealed they inserviced staff on abuse in March and when applicable nursing staff on med cart. Staff interviews on 04/09/14 with LPN #10 at 5:22 PM; LPN #11 at 5:41 PM; and on 04/10/14 with LPN #12 at 7:30 AM; LPN #13 at 7:50 AM; LPN #14 at 7:55 AM; RN #4/Weekend Supervisor at 4:08 PM; and LPN #15 at 4:17 PM revealed all indicated they had received inservices on counting controlled medications in the medication carts and on giving the medication cart keys to another nurse prior to leaving the facility for lunch breaks in March. Interview with the Administrator, on 04/10/14 at 5:29 PM, revealed nurses were inserviced staff as indicated on the AOC in March. 6. Review of the facility's report of LPN #6 to KBN revealed the nurse was reported on 03/21/14. Personnel record review revealed LPN #6 was terminated from employment. Interview with the DNS on 04/10/14 at 1:16 PM and the Administrator at 5:29 PM, revealed LPN #6 was terminated on 03/17/14 per the AOC and reported to KBN by the DNS. 7. Interview with the DNS on 04/10/14 at 1:16 PM and the Administrator at 5:29 PM, revealed the two (2) staff who did not report the abuse of Resident #1 received final written warnings by the DNS for not reporting timely. The final written warnings for CNA #3 and CNA #7 were reviewed. Interview with CNA #7 on 04/02/14 at 8:55 AM and CNA #3 on 04/09/14 at 6:58 PM, revealed they were counseled by the facility about reporting abuse sooner. 8. Review of the PI meeting sign in sheets dated 03/14/14 and 04/04/14, revealed it was signed by Administrator, DNS and Medical Director. Interview with the Medical Director on 04/09/14 at 4:13 PM, revealed he attended the PI meeting in March about the allegation of abuse involving Resident #1 and a nurse. He stated they discussed what happened and an action plan on how to prevent it from happening again. Additionally, the Medical Director stated he attended the PI meeting in April regarding the allegation of abuse involving Resident #2 and in the meeting they had discussed the Immediate Jeopardy related to the abuse incident and the action plan to prevent reoccurrence. Interview with the DNS on 04/10/14 at 12:13 PM and the Administrator at 5:29 PM, revealed they attended the March and April PI meeting with the Medical Director and discussed the allegation of abuse and action plan related to Resident #1 and Resident #2 and also discussed the Immediate Jeopardy and action plan in April. 9. Review of LPN #1's "Timecard" punches revealed the nurse clocked out on 04/03/14 at 2:04 PM. Interview with the DNS on 04/10/14 at 10:37 AM and Administrator at 5:29 PM revealed LPN #1 was suspended on 04/03/14. 10. Review of the initial faxed report sent to the State Survey Agency regarding the 03/02/14 abuse allegation involving Resident #2 and LPN #1 was sent on 04/03/14 by the Administrator. Interview with the Administrator on 04/10/14 at 5:29 PM confirmed she sent the faxed report on 04/03/14. 11. Review of an interview with Resident #2 was completed on 04/04/14 as indicated on the AOC plan. Interview with the DNS on 04/10/14 at 10:37 AM and the Administrator at 5:29 PM revealed they interviewed Resident #2 on 04/04/14, and he/she confirmed the nurse threatened not to give the resident pain medication. Interview with Resident #2 on 04/10/14 at 10:19 AM, revealed the DNS and Administrator talked to him/her about the phone incident and pain medication. 12. Review of the facility's documented interview with Resident #2's sister revealed it was performed on 04/04/14 as indicated on the AOC. Interview with the Administrator on 04/10/14 at 5:29 PM, revealed she interviewed Resident #2's sister on 04/04/14, and she asked about the incident. The Administrator stated the sister already knew about the allegation, but thought the nurse was trying to limit the resident's phone calls to her as requested. Interview with DNS on 04/10/14 at 12:13 PM revealed the Administrator interviewed the resident's sister. 13. Review of witness statements of employees who worked from 7:00 AM to 3:00 PM on 03/02/14 were reviewed by comparison with the 03/02/14 dayshift schedule. Interview with the DNS on 04/10/14 at 10:37 AM and 12:13 PM and the Administrator at 5:29 PM, revealed all staff who worked dayshift on 03/02/14 were interviewed mostly by the DNS and were asked did you hear a nurse yell or scream at a resident and did you hear a nurse threaten to withhold medication. Interview with the ADON on 04/10/14 at 4:27 PM, revealed she interviewed some of the staff who worked on 03/02/14 about the allegation. Interview with CNA #11 on 04/09/14 at 3:05 PM and with LPN #4 at 3:15 PM, revealed they had worked on 03/02/14 and were interviewed by the facility about the event on 04/04/14. 14. Interview with the DNS on 04/10/14 at 10:37 AM and review of the facility's AOC implemented for Resident #2 revealed the facility entered the allegation of abuse for Resident #2 into the Risk Management System on 04/04/14. 15. Review of the AOC documentation revealed the facility had new employees who were inserviced on 04/07/14 on the abuse policy, reporting requirements, promise of confidentiality and no fear of retribution. Interview with the DNS on 04/10/14 at 10:37 AM, revealed the facility had several newly hired staff who were interviewed on 04/07/14 regarding their inservice. Interview with the Administrator 04/09/14 at 1:28 PM, revealed the facility does not use agency staff. 16. Review of the facility's work schedule 04/04/14 through 04/06/14 revealed the facility had supervisors on each shift. Interview with the DNS on 04/10/14 at 10:37 AM and the Administrator at 5:29 PM, revealed supervisors were assigned to each shift to monitor for abuse and were supposed to monitor interactions between residents and employees to ensure they were appropriate. They indicated if there was an allegation reported to the supervisor it was to be reported immediately to the Administrator. Interviews on 04/10/14 with the Maintenance Director at 3:39 PM; the ADON at 4:27 PM; RN #4/100 Unit Manager at 4:48 PM; Employee Benefits and Payroll Coordinator at 3:13 PM; and Activities Director at 2:44 PM revealed they all had a list of shifts and they picked up different shifts to observe and supervise interactions of employees and residents and if a suspected allegation of abuse was identified they were to call the DNS and Administrator immediately. The staff indicated no abuse allegations had been identified. 17. Reviewed the audit tool which was to be utilized for employee abuse interviews. Interview with the DNS on 04/10/14 at 10:37 AM and the Administrator at 5:29 PM, revealed the facility had implemented audits to interview five (5) employees weekly for four (4) weeks and then monthly for three (3) months to determine if staff understood the abuse policy and reporting of all allegations of abuse. Continued interview revealed audits had been initiated and would be done by Administrator, DNS or Nursing Supervisors Monday through Friday, and staff would be re-educated if concerns were identified. Interview, on 04/10/14 at 4:27 PM, with the ADON revealed she had interviewed some employees for the abuse audits and they were supposed to do five (5) employees each week. The ADON indicated if she identified a problem during the audit she was to address it at that time; however had not identified a problem in her abuse audits. 18. Reviewed the audit tool which was to be utilized for resident interviews. Interview with the DNS on 04/10/14 at 10:37 AM and the Administrator at 5:29 PM, revealed the facility had implemented the audits to interview five (5) residents weekly for four (4) weeks and then monthly for three (3) months to determine any issues with staff treatment and any withholding of medication. Continued interview with the DNS and Administrator revealed audits had been initiated and residents were to be interviewed by the Administrator, DNS and Nursing Supervisors Monday through Friday. Interview on 04/101/4 at 4:27 PM, with the ADON revealed she had performed resident interviews for the audits and they were supposed to do five (5) per week. She indicated if a concern was identified it was to be addressed at the time of interview; however, had not identified any concerns in her resident interview audits. 19. Interview with the DNS on 04/10/14 at 10:37 AM and the Administrator at 5:29 PM, revealed the facility did not have a specific form for auditing the abuse investigation but the Administrator would be performing audits on all abuse investigations to determine if the allegations were reported timely, investigations were thoroughly completed and the initial report was sent to the State Survey Agency in twenty-four (24) hours and the five (5) day follow up was sent in timely. Continued interview with the DNS and Administrator revealed any concerns would b

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to have an effective system to ensure the comprehensive plan of care was reviewed and revised to address the risk factors of elopement, and implement interventions to provide adequate supervision to prevent elopement for one (1) of seven (7) sampled residents (Resident #1). Resident #1 was assessed and identified at risk for wandering/elopement per the resident care plan on 05/20/12 with interventions to keep the resident safe which included a wander guard. On 07/26/13, the resident's Physician noted in a Progress Note the resident's wander guard could be removed due to the resident not exhibiting exit seeking behavior. On 07/29/13, the resident's wander guard was removed and the resident's elopement care plan was discontinued. On 07/30/13, at approximately 3:00 PM, Resident #1 left the facility premises without staff knowledge, and was found at approximately 3:10 PM, approximately 0.2 miles from the facility on a busy two (2) lane highway. The resident was returned to the facility by the Administrator. However, the facility failed to consider this an elopement; therefore, no assessment or care plan revision was completed. On 08/17/13, Resident #1 left the premises after 4:30 PM, without staff knowledge and was found by the local Police Department on Interstate 75 (an 8 lane interstate) at 5:09 PM. The resident was given a ride by the Police to the resident's mother's old address approximately 24.4 miles from the facility. The Police notified the resident's daughter when the people living at the address did not know the resident. The facility was not aware the resident had left the premises until approximately 5:30 PM, when the resident's daughter called the facility. The resident's daughter picked the resident up and returned the resident to the facility at approximately 6:30 PM. (Refer to F323) Based on the above findings the facility's failure to revise the Comprehensive Care Plan to include supervision and monitoring for residents with a history and/or at risk for elopement/wandering behaviors was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 08/23/13, and was determined to exist on 07/30/13. An acceptable Allegation of Compliance (AOC) was received on 08/28/13, and alleged removal of the Immediate Jeopardy on 08/24/13. The state survey agency determined the Immediate Jeopardy was removed on 08/24/13, prior to exit, which lowered the scope/severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled "Care Plan: Patient", revised 05/01/11, revealed the purpose was to provide necessary care and services to attain or maintain the patient's highest practicable, physical, mental and psychosocial well being. Further review revealed that per the policy (section 2.2) care plans were developed based on Nursing Assessments, subsequent assessments and other observations. Continued review of the policy (section 2.4) revealed care plans were reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. Record review revealed the facility admitted Resident #1 on 05/07/12, with [DIAGNOSES REDACTED]. Review of Resident #1 Annual Minimum Data Set (MDS) Assessment, dated 05/15/13, revealed the facility assessed the resident as being severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15) and independent with activities of daily living (ADL's). Review of Resident #1's Comprehensive Care Plan, dated 05/20/13, revealed the facility assessed and identified Resident #1 at risk for wandering/elopement. Interventions were put in place to keep the resident safe which included a wander guard. Record review revealed on 07/26/13, Resident #1's Physician wrote a Progress Note stating "OK to remove wander guard since resident is coherent and does not display exit seeking behaviors". On 07/29/13, the wander guard was removed from the resident, and review of the Comprehensive Care Plan revealed the elopement care plan was discontinued on 07/29/13, with no interventions to monitor Resident #1 without the wander guard. On 07/30/13, Resident #1 was sitting unsupervised on the front porch of the facility. Resident #1 exited the facility premises without staff knowledge, walked down the facility driveway to a busy, two (2) lane highway, crossed the highway and was walking on the side walk approximately 0.2 miles from the facility when staff located the resident. Further record review revealed no Elopement Risk Assessment was completed on 07/30/13, when the resident was returned to the facility. Record review revealed no documentation of an Interdisciplinary Team (IDT) Assessment of Resident #1 and no documented care plan to monitor Resident #1 after the resident left the facility grounds on 07/30/13. Interview with the Administrator on 08/22/13 at 4:10 PM, revealed the facility administration and/or interdisciplinary team (IDT) never considered elopement when Resident #1 left the faciity on [DATE], as the resident had a motive for leaving and knew the date. He further stated "We let our residents go and come as they please", therefore there was no reason to revise the care plan. Interview with the Assistant Director of Nursing (ADON) and Administrator on 08/29/13 at 1:00 PM, revealed that when the resident went for his/her "walk" it was never considered an elopement by anyone at the facility. There was no change so there was no need to complete an assessment or complete a care plan. Interview with the Director of Nursing (DON), on 08/22/13 at 3:35 PM, revealed that she was on vacation on 07/30/13, and had not been told about any elopement. Further interview revealed that she felt that she would have considered the resident's exit without staff knowledge an elopement and would have reassessed the resident and updated the care plan. Review of the quarterly MDS Assessment, dated 08/15/13, revealed a BIMS score of three (3) out of fifteen (15) for cognition, indicating Resident #1 was severely impaired in cognition and independent with ADL's. Review of the care plan revealed there was no update/revision of the care plan to include the resident's exit from the facility on 07/30/13, when the resident had left the facility without staff knowledge. In addition, there was no documentation was found in the record that the resident had left the facility property on 07/30/13, without staff knowledge. Record review of "Change of Condition Documentation" revealed that on 08/17/13, Resident #1 was last seen at about 4:30 PM sitting on the facility's front porch; left the facility property without staff knowledge; was found by Police at 5:09 PM; and, was returned to the facility by the resident's daughter at approximately 6:30 PM. Interview with ADON, on 08/22/13 at 2:00 PM, revealed Resident #1 returned to the facility on [DATE], at approximately 6:30 PM, upon return the resident was reassessed for elopement, and interventions for elopement risk was initiated including 1:1 supervision, and placement of a wander guard. The resident's care plan was reviewed and revised on 08/17/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/28/13, that alleged removal of the IJ effective 08/24/13. Review of the AOC revealed the facility implemented the following: 1) On 08/17/13, Resident #1 was placed on 1:1 supervision, a head to toe assessment was completed by licensed nurse, no injuries were identified, wander guard was tested for functionality and then placed on the resident. 2) A head count of residents residing in the facility was completed on 08/17/13, by the licensed nurse to validate all residents were accounted for. 3) The Administrator and ADON validated that all doors and alarms were working properly on 08/17/13. 4) Residents residing in the facility were reviewed by licensed nurses to determine that residents with elopement potential had appropriate assessments, devices as necessary, care plans to address risk of elopement on 08/17/13. 5) One hundred percent (100%) of residents in the facility were assessed by the licensed nurse using the "Resident Elopement Risk Screen and Assessment Tool" to further identify residents at risk for elopement on 08/23/13. Using this assessment tool the licensed nurse updated the resident care plan, care card and also identified each resident to either require or not require supervision for outdoor activities. 6) Administrator, DON, and ADON initiated re-education to all staff on 08/17/13, and completed on 08/21/13. The topics reviewed were Elopement Management Program to include procedure for missing resident, response to door alarm, that facility door codes were changed, new facility policy to not give door codes to any resident or visitor. 7) The Maintenance Director changed all door codes on 08/19/13. 8) The Administrator, DON, and ADON, was re-educated on 08/23/13 by the Manager of Clinical Operations to the facility's Elopement Policy and Procedures. 9) The Administrator, DON, ADON, and/or Maintenance Director will conduct missing resident/elopement drills three (3) times weekly on varied shifts, and report results to QA Committee monthly for further review and recommendations. 10) The Administrator and/or Maintenance will conduct observations of facility exit doors five (5) times weekly, at varied times, to validate that residents nor visitors are aware of the door codes, and will report findings to the QA Committee monthly for further review and recommendations. 11) The DON/ADON will audit elopement assessments on admission, readmission, annual, quarterly and significant change assessments, to ensure care plans, care cards and elopement assessments are complete. The State Agency validated the implementation of the facility's AOC as follows: 1) Review of the resident record revealed that 08/17/13, Resident #1 was placed on 1:1 supervision, a head to toe assessment was completed by licensed nurse, no injuries were identified, wander guard was tested for functionality and then placed on the resident. 2) Review of the facility investigation binder revealed a head count was conducted on all residents residing in the facility on 08/17/13, by the licensed nurse to validate all residents were accounted for. 3) Review of the facility's investigation binder revealed the Administrator and ADON validated that all doors and alarms were working properly on 08/17/13. 4) Review of Residents elopement assessments revealed that all residents residing in the facility were reviewed by licensed nurses to determine that residents with elopement potential had appropriate assessments, devices as necessary, care plans to address risk of elopement on 08/17/13. 5) Review of random residents records revealed all residents in the facility were assessed by the licensed nurse using the "Resident Elopement Risk Screen and Assessment Tool" to further identify residents at risk for elopement on 08/23/13. Using this assessment tool the licensed nurse updated the resident care plan, care card and also identified each resident to either require or not require supervision for outdoor activities 6) Review of the facility's investigation binder revealed that the Administrator, DON, and ADON initiated re-education to all staff on 08/17/13, and completed on 08/21/13. The topics reviewed were Elopement Management Program to include procedure for missing resident, response to door alarm, that facility door codes were changed, new facility policy to not give door codes to any resident or visitor. Interviews on 08/30/13 at 9:32 AM, with Licensed Practical Nurse (LPN) #1, at 9:32 AM with LPN #2, at 10:10 AM with LPN #3 at 9:40 AM with Registered Nurse (RN) #1, at 8:20 AM with RN #2, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors and when to complete elopement assessments. Interviews on 08/30/13 at 9:25 AM with SRNA #1, at 9:10 AM with SRNA #2, at 10:40 AM with SRNA #3, at 10:30 AM with SRNA #5, at 10:50 with SRNA #4, and at 8:30 AM with SRNA #6, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors. Interviews with other facility staff on 08/30/13, at 9:35 AM with Occupational Therapist, at 9:00 AM with House Keeping (HK) #1, at 10:45 AM with HK #2, at 8:15 AM with HK #3, at 9:05 AM with Activities/SRNA, at 9:20 AM with Cook #1, at 9;25 am with Cook #2, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors. 7) Review of the facility's investigation binder revealed that the Maintenance Director changed all door codes on 08/19/13, and will change the codes anytime it is determined that a resident or visitor knows the code. 8) Review of the facility's investigation binder revealed that the Administrator, DON, and ADON, was re-educated by the Manager of Clinical Operations to the facility's Elopement Policy and Procedures on 08/23/13. 9) Review of the facility's investigation binder revealed that the Administrator, DON, ADON, and/or Maintenance Director conducted missing resident/elopement drills on 08/18/13, 08/19/13, and 08/20/13 on all three shifts. 10) Review of the facility's investigation binder revealed that the Administrator and/or Maintenance conducted observations of facility exit on 08/18/13, 08/19/13, 08/20/13, and 08/21/13, at varied times, and the door codes have been changed due to a visitor was aware of the door codes. The findings will be reported to the QA Committee monthly for further review and recommendations. 11) Interview with the DON, on 08/30/2013 at 11:10 AM, revealed that the DON/ADON will audit all elopement assessments on admission, readmission, annual, quarterly and significant change assessments during the daily Clinical Meeting, to ensure care plans, care cards and elopement assessments are complete.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to have an effective system to ensure resident safety through monitoring and supervision for one (1) of seven (7) sampled residents (Resident #1). The facility failed to ensure adequate interventions were in place to prevent resident elopement. The facility assessed and identified Resident #1 as at risk for wandering/elopement per the resident care plan on 05/20/12. Interventions were put into place to keep the resident safe which included a wander guard. On 07/26/13, the resident's Physician noted in a Progress Note the resident's wander guard could be removed due to the resident not exhibiting exit seeking behavior. On 07/29/13, the resident's wander guard was removed and the resident's elopement care plan was discontinued. On 07/30/13 at approximately 3:00 PM, Resident #1 left the facility premises without staff knowledge, and was found at approximately 3:10 PM, approximately 0.2 miles from the facility on a busy two (2) lane highway. The resident was returned to the facility by the Administrator. However, the facility failed to consider this an elopement; therefore, no assessment or care plan revision was completed. (Refer to F-280) On 08/17/13, Resident #1 left the premises after 4:30 PM, without staff knowledge and was found by the local Police Department on Interstate 75 (an 8 lane Interstate) at 5:09 PM. The resident was given a ride by the Police to the resident's mother's old address approximately 24.4 miles from the facility. The police notified the resident's daughter when the people living at the address did not know the resident. The facility was not aware the resident had left the premises until approximately 5:30 PM, when the resident's daughter called the facility. The resident's daughter picked the resident up and returned the resident to the facility at approximately 6:30 PM. The facility's failure to have an effective system in place to ensure adequate supervision and monitoring for residents with a history and/or at risk for elopement/wandering behaviors was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy (IJ) was identified on 08/23/13, and was determined to exist on 07/30/13. Substandard Quality of Care (SQC) was identified at 42 CRF 483.25, Quality of Care F-323. An acceptable Allegation of Compliance (AOC) was received on 08/28/13, and alleged removal of the Immediate Jeopardy on 08/24/13. The state survey agency determined the Immediate Jeopardy was removed on 08/24/13, prior to exit, which lowered the scope/severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility "Elopement" Policy, dated 01/2008, revealed the intent of the facility was to provide a safe environment and that residents who were at risk for elopement were identified. The policy further noted "upon return of resident to the facility, an Elopement Risk Evaluation would be completed and/or updated and the resident care plan would be reviewed and updated as necessary". Record review revealed the facility admitted Resident #1 on 05/07/12, with [DIAGNOSES REDACTED]. Further review revealed on admission the resident was assessed as an elopement/wander risk. The care plan dated 05/20/12, revealed interventions were put in place to keep the resident safe, which included a wander guard. Review of Resident #1 Annual Minimum Data Set (MDS) Assessment, dated 05/15/13, revealed the facility assessed the resident as being severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of three (3) out of fifteen (15), indicating severe cognitive impairment and the resident was assessed as independent with activities of daily living (ADL's). Review of the elopement risk assessment for the assessment period of 05/15/13, revealed the resident was at risk for elopement. Review of the care plan dated 05/30/13, revealed the resident was at risk for elopement and interventions were put in place to keep the resident safe which included a wander guard. Record review revealed on 07/26/13, the resident's Physician saw Resident #1 and wrote a Progress Note stating "OK to remove wander guard since resident is coherent and does not display exit seeking behaviors". However, record review revealed no documentation of an Interdisciplinary Team (IDT) Assessment of Resident #1 for removal of the wander guard. The wander guard was removed and the resident's elopement care plan was discontinued on 07/29/13. Furthermore, there was no documented plan to monitor Resident #1 after the removal of the wander guard on 07/29/13. Interview with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), on 08/22/13 at 12:00 PM, revealed that the clinical team had made the decision to remove the wander guard, after the resident's Physician had assessed the resident and said it was okay to remove the wander guard. They further stated they just never thought about monitoring the resident for elopement when the wander guard was removed. Interview with House Keeper #1, on 08/22/13, at 3:05 PM, revealed Resident #1 had exited the facility without staff knowledge near the end of July. Interview with the House Keeping Assistant Supervisor, on 08/22/13 at 3:25 PM, revealed Resident #1 did leave the facility at the end of July. He further stated staff was down stairs when a code was called and they all started looking for the resident. He stated Resident #1 was up the street by the two matching buildings almost to the home improvement store. The Administrator brought the resident back to the facility. He further stated the resident was always saying he/she wanted to go home. Interview with Resident #1's daughter, Power of Attorney (POA), on 08/22/13 at 2:20 PM, revealed on 07/30/13, the resident had left the facility without staff knowledge. Resident #1's daughter further stated that when the Administrator called her on 07/30/13 about the incident, he told her the resident was allowed to go for walks. Interview with the Administrator, on 08/22/13 at 4:10 PM, revealed Resident #1 was sitting on the front porch on 07/30/13, at about 2:30 PM to 3:00 PM. He said he took a phone call that lasted about two (2) minutes and when he looked out the window the resident wasn't on the porch. He checked to see if the resident had come back into the facility and then started looking for the resident. He stated Resident #1 was across the street on the sidewalk, walking towards a grocery store. The Administrator drove the resident back to the facility. He further stated he did not consider the resident's exit an elopement as the resident had a motive to go to grocery store to buy a soda, and could also tell him the date. Furthermore, the Administrator stated "we let the residents go and come as they please, based on the resident's response I didn't feel it was an elopement". Even though Resident #1 was assessed by the facility on 05/15/13, with severe cognitive impairment. Further record review revealed no Elopement Risk Assessment was completed on 07/30/13, when the resident was returned to the facility. This failure prevented the facility from establishing effective interventions to prevent future elopement recurrence for this resident. Further record review revealed the resident's Comprehensive Plan of Care was not revised related to the incident on 07/30/13. Review of the resident's quarterly MDS Assessment, dated 08/15/13, revealed the facility assessed no change in the resident's cognition with a BIMS score of three (3) for cognition and the resident remained independent with ADL's. Record review of "Change of Condition Documentation" revealed that on 08/17/13 Resident #1 left the facility premises without staff knowledge. Staff reported that Resident #1 was last seen by nursing staff at about 4:30 PM, sitting on the facility's front porch. Review of the Police run sheet on 08/17/13, revealed the local Police received a call from a motorist at 4:55 PM, that an older person was sitting Indian style on the side of Interstate 75 (a high traffic, 8 lane Interstate) before the exit. The Police Officer arrived at 5:09 PM, at which time Resident #1 told him that his/her car was broken down and that he/she was trying to get home. The resident gave the Police his/her mother's old address, as his/her address. The Police Officer took the resident to the address which was approximately 24.4 miles from the facility. When they arrived at the address, the person living at the address did not know the resident; however, the people across the street from the address did know the resident and told the police officer the resident's daughter's name and phone number. The Police Officer contacted the daughter who was also the resident's Power of Attorney (POA). The daughter went and picked Resident #1 up and returned him/her to the facility at approximately 6:30 PM. Interview with Licensed Practical Nurse (LPN) #1, on 08/22/13 at 2:30 PM, revealed she had received a phone call on 08/17/2013, sometime after 5:00 PM, from Resident #1 daughter. The daughter ask where the resident was and she replied in his/her room or on smoke break and stated she would check and placed the phone on hold. She stated she was unable to locate the resident so she called a code yellow and returned to the phone to tell the resident's daughter. Resident #1's daughter told her the resident was with the police in Verona and she was going to get him/her and bring him/her back to the facility. LPN #1 further stated she did not know how long it would have been before the staff would have known the resident was not in the facility. She further stated she did notify the DON and Administrator. She stated Resident #1's daughter returned the resident to the facility at approximately 6:30 PM. Interview with State Registered Nursing Assistant SRNA #4, on 08/22/13 at 3:17 PM, revealed she was assigned to care for Resident #1 on 08/17/13, 3-11 shift. She stated that she had done her rounds when she arrived for work at approximately 3:06 PM. Resident #1 was not in his/her room so she asked her co-workers if they had seen Resident #1 and a nurse told her he/she was on the front porch at 3:40 PM, so she completed her work. She further stated she didn't know that Resident #1 was not at the facility until they got the call from his/her daughter sometime after 5:00 PM. Interview with ADON, on 08/22/13 at 2:00 PM, revealed Resident #1 returned to the facility on [DATE], at approximately 6:30 PM, upon return the resident was reassessed for elopement, a head to toe assessment completed for injuries, interventions for elopement risk were initiated including 1:1 supervision, and placement of a wander guard. She stated the resident's care plan was reviewed and revised on 08/17/13. Interview with the Administrator, on 08/22/13 at 1:30 PM, revealed Resident #1 knew the code on the door. He stated a lot of the residents knew the code because the one's that were safe to be outside unsupervised could come and go as they pleased. Interview revealed Resident #1 could come and go as he/she pleased. Even though the facility had assessed the resident with severe cognitive impairment. He further stated visitors knew the code as well. Interview with Unit Manager #1, on 08/23/13 at 11:00 AM, revealed she was unaware of any system in place to identify the residents that were safe to sit outside unsupervised. She stated as a nurse if she felt a resident was not safe to be outside unsupervised she would apply a wander guard. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/28/13, that alleged removal of the IJ effective 08/24/13. Review of the AOC revealed the facility implemented the following: 1) On 08/17/13, Resident #1 was placed on 1:1 supervision, a head to toe assessment was completed by licensed nurse, no injuries were identified, wander guard was tested for functionality and then placed on the resident. 2) A head count of residents residing in the facility was completed on 08/17/13, by the licensed nurse to validate all residents were accounted for. 3) The Administrator and ADON validated that all doors and alarms were working properly on 08/17/13. 4) Residents residing in the facility were reviewed by licensed nurses to determine that residents with elopement potential had appropriate assessments, devices as necessary, care plans to address risk of elopement on 08/17/13. 5) One hundred percent (100%) of residents in the facility were assessed by the licensed nurse using the "Resident Elopement Risk Screen and Assessment Tool" to further identify residents at risk for elopement on 08/23/13. Using this assessment tool the licensed nurse updated the resident care plan, care card and also identified each resident to either require or not require supervision for outdoor activities. 6) Administrator, DON, and ADON initiated re-education to all staff on 08/17/13, and completed on 08/21/13. The topics reviewed were Elopement Management Program to include procedure for missing resident, response to door alarm, that facility door codes were changed, new facility policy to not give door codes to any resident or visitor. 7) The Maintenance Director changed all door codes on 08/19/13. 8) The Administrator, DON, and ADON, was re-educated on 08/23/13 by the Manager of Clinical Operations to the facility's Elopement Policy and Procedures. 9) The Administrator, DON, ADON, and/or Maintenance Director will conduct missing resident/elopement drills three (3) times weekly on varied shifts, and report results to QA Committee monthly for further review and recommendations. 10) The Administrator and/or Maintenance will conduct observations of facility exit doors five (5) times weekly, at varied times, to validate that residents nor visitors are aware of the door codes, and will report findings to the QA Committee monthly for further review and recommendations. 11) The DON/ADON will audit elopement assessments on admission, readmission, annual, quarterly and significant change assessments, to ensure care plans, care cards and elopement assessments are complete. The State Agency validated the implementation of the facility's AOC as follows: 1) Review of the resident record revealed that 08/17/13, Resident #1 was placed on 1:1 supervision, a head to toe assessment was completed by licensed nurse, no injuries were identified, wander guard was tested for functionality and then placed on the resident. 2) Review of the facility investigation binder revealed a head count was conducted on all residents residing in the facility on 08/17/13, by the licensed nurse to validate all residents were accounted for. 3) Review of the facility's investigation binder revealed the Administrator and ADON validated that all doors and alarms were working properly on 08/17/13. 4) Review of Residents elopement assessments revealed that all residents residing in the facility were reviewed by licensed nurses to determine that residents with elopement potential had appropriate assessments, devices as necessary, care plans to address risk of elopement on 08/17/13. 5) Review of random residents records revealed all residents in the facility were assessed by the licensed nurse using the "Resident Elopement Risk Screen and Assessment Tool" to further identify residents at risk for elopement on 08/23/13. Using this assessment tool the licensed nurse updated the resident care plan, care card and also identified each resident to either require or not require supervision for outdoor activities 6) Review of the facility's investigation binder revealed that the Administrator, DON, and ADON initiated re-education to all staff on 08/17/13, and completed on 08/21/13. The topics reviewed were Elopement Management Program to include procedure for missing resident, response to door alarm, that facility door codes were changed, new facility policy to not give door codes to any resident or visitor. Interviews on 08/30/13 at 9:32 AM, with Licensed Practical Nurse (LPN) #1, at 9:32 AM with LPN #2, at 10:10 AM with LPN #3 at 9:40 AM with Registered Nurse (RN) #1, at 8:20 AM with RN #2, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors and when to complete elopement assessments. Interviews on 08/30/13 at 9:25 AM with SRNA #1, at 9:10 AM with SRNA #2, at 10:40 AM with SRNA #3, at 10:30 AM with SRNA #5, at 10:50 with SRNA #4, and at 8:30 AM with SRNA #6, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors. Interviews with other facility staff on 08/30/13, at 9:35 AM with Occupational Therapist, at 9:00 AM with House Keeping (HK) #1, at 10:45 AM with HK #2, at 8:15 AM with HK #3, at 9:05 AM with Activities/SRNA, at 9:20 AM with Cook #1, at 9;25 am with Cook #2, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors. 7) Review of the facility's investigation binder revealed that the Maintenance Director changed all door codes on 08/19/13, and will change the codes anytime it is determined that a resident or visitor knows the code. 8) Review of the facility's investigation binder revealed that the Administrator, DON, and ADON, was re-educated by the Manager of Clinical Operations to the facility's Elopement Policy and Procedures on 08/23/13. 9) Review of the facility's investigation binder revealed that the Administrator, DON, ADON, and/or Maintenance Director conducted missing resident/elopement drills on 08/18/13, 08/19/13, and 08/20/13 on all three shifts. 10) Review of the facility's investigation binder revealed that the Administrator and/or Maintenance conducted observations of facility exit on 08/18/13, 08/19/13, 08/20/13, and 08/21/13, at varied times, and the door codes have been changed due to a visitor was aware of the door codes. The findings will be reported to the QA Committee monthly for further review and recommendations. 11) Interview with the DON, on 08/30/2013 at 11:10 AM, revealed that the DON/ADON will audit all elopement assessments on admission, readmission, annual, quarterly and significant change assessments during the daily Clinical Meeting, to ensure care plans, care cards and elopement assessments are complete.

Based on interview, record review and review of the facility's policies, it was determined facility Administration failed to have an effective system to ensure its resources, including policies related to resident assessment and care plan, were used effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being for one (1) of seven (7) sampled residents (Resident #1). The Administrator failed to ensure assessment and care plan policies and procedures were implemented by failing to assess and evaluate Resident #1 for elopement/wandering. On 07/30/13, at approximately 3:00 PM, Resident #1 left the facility premises without staff knowledge, and was found at approximately 3:10 PM, approximately 0.2 miles from the facility on a busy two (2) lane highway. The resident was returned to the facility by the Administrator. However, the facility failed to consider this an elopement; therefore, no assessment or care plan revision was completed. On 08/17/13, Resident #1 left the premises after 4:30 PM, without staff knowledge and was found by the local Police Department on Interstate 75 (an 8 lane interstate) at 5:09 PM. The resident was given a ride by the Police to the resident's mothers old address approximately 24.4 miles from the facility. The Police notified the resident's daughter when the people living at the address did not know the resident. The facility was not aware the resident had left the premises until approximately 5:30 PM, when the resident's daughter called the facility. The resident's daughter picked the resident up and returned the resident to the facility at approximately 6:30 PM. (Refer to F-280 and F-323) The Administration's failure to ensure facility policies/procedures related to resident assessment and care plan were implemented caused, or was likely to cause, serious injury, harm, impairment, or death to residents at the facility. Immediate Jeopardy and Substandard Quality of Care were determined to exist on 07/30/13. The facility was notified of the Immediate Jeopardy on 08/23/2013. An acceptable Allegation of Compliance was received on 08/28/13, and alleged removal of the Immediate Jeopardy on 08/24/13. The state survey agency determined the Immediate Jeopardy was removed on 08/24/13, which lowered the scope/severity to "D" while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy and procedure related to "Elopement", dated 01/2008, revealed the intent of the facility was to provide a safe environment and that residents who were at risk for elopement were identified. The policy further noted "upon return of resident to the facility, an Elopement Risk Evaluation would be completed and/or updated and the resident care plan would be reviewed and updated as necessary". Review of the facility's policy titled "Care Plan: Patient", revised 05/01/11, revealed the purpose was to provide necessary care and services to attain or maintain the patient's highest practicable physical, mental and psychosocial well being. Further review revealed that per policy (section 2.2) care plans were developed based on Nursing Assessments, subsequent assessments and other observations. Continued review of the policy (section 2.4) revealed care plans were reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. Interview and record review revealed the facility admitted Resident #1 on 05/07/12, with [DIAGNOSES REDACTED]. The care plan dated 05/20/12, revealed interventions were put in place to keep the resident safe, which included a wander guard; however, this care plan was discontinued on 07/29/13, when the wander guard was discontinued. The resident was assessed to be severely cognitive impaired by the facility. Record review revealed on 07/30/13, Resident #1 left the facility premises without staff knowledge; however, upon return to the facility, the facility failed to assess the resident for elopement risk and failed to implement interventions to keep Resident #1 safe. On 08/17/13, Resident #1 left the facility premises again without staff knowledge and was located by local Police on a busy eight (8) lane Interstate. Interview with the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), on 08/22/13 at 12:00 PM, revealed that the clinical team had made the decision to remove the wander guard on 07/29/13 and never thought about monitoring the resident for elopement when the wander guard was removed. Interview with the Administrator, on 08/22/13 at 4:10 PM, revealed that he did not consider the resident's exit on 07/30/13, an elopement as the resident had a motive to go to the grocery store to buy a soda, and the resident could also tell him the date. Furthermore, the Administrator stated "we let the residents go and come as they please", based on the resident's response, "I don't feel it was an elopement". Interview also revealed Resident #1 and other residents knew the code on the door and were safe to be outside unsupervised and could come and go as they pleased. Even though the facility had assessed Resident #1 with severe cognitive impairment and the resident was not his own responsible party. In addition, the facility's policy and procedure "Elopement", dated 01/2008, revealed "upon return of resident to the facility, an Elopement Risk Evaluation would be completed and /or updated and the resident care plan would be reviewed and updated as necessary". However, record review revealed no Elopement Risk Assessment was completed on 07/30/13, when the resident was returned to the facility. This failure prevented the facility from revising the resident's care plan to establish effective interventions to prevent future elopement recurrence for this resident and the resident left the facility premises again on 08/17/13. The facility provided an acceptable credible Allegation of Compliance (AOC) on 08/28/13, that alleged removal of the IJ effective 08/24/13. Review of the AOC revealed the facility implemented the following: 1) On 08/17/13, Resident #1 was placed on 1:1 supervision, a head to toe assessment was completed by licensed nurse, no injuries were identified, wander guard was tested for functionality and then placed on the resident. 2) A head count of residents residing in the facility was completed on 08/17/13, by the licensed nurse to validate all residents were accounted for. 3) The Administrator and ADON validated that all doors and alarms were working properly on 08/17/13. 4) Residents residing in the facility were reviewed by licensed nurses to determine that residents with elopement potential had appropriate assessments, devices as necessary, care plans to address risk of elopement on 08/17/13. 5) One hundred percent (100%) of residents in the facility were assessed by the licensed nurse using the "Resident Elopement Risk Screen and Assessment Tool" to further identify residents at risk for elopement on 08/23/13. Using this assessment tool the licensed nurse updated the resident care plan, care card and also identified each resident to either require or not require supervision for outdoor activities. 6) Administrator, DON, and ADON initiated re-education to all staff on 08/17/13, and completed on 08/21/13. The topics reviewed were Elopement Management Program to include procedure for missing resident, response to door alarm, that facility door codes were changed, new facility policy to not give door codes to any resident or visitor. 7) The Maintenance Director changed all door codes on 08/19/13. 8) The Administrator, DON, and ADON, was re-educated on 08/23/13 by the Manager of Clinical Operations to the facility's Elopement Policy and Procedures. 9) The Administrator, DON, ADON, and/or Maintenance Director will conduct missing resident/elopement drills three (3) times weekly on varied shifts, and report results to QA Committee monthly for further review and recommendations. 10) The Administrator and/or Maintenance will conduct observations of facility exit doors five (5) times weekly, at varied times, to validate that residents nor visitors are aware of the door codes, and will report findings to the QA Committee monthly for further review and recommendations. 11) The DON/ADON will audit elopement assessments on admission, readmission, annual, quarterly and significant change assessments, to ensure care plans, care cards and elopement assessments are complete. The State Agency validated the implementation of the facility's AOC as follows: 1) Review of the resident record revealed that 08/17/13, Resident #1 was placed on 1:1 supervision, a head to toe assessment was completed by licensed nurse, no injuries were identified, wander guard was tested for functionality and then placed on the resident. 2) Review of the facility investigation binder revealed a head count was conducted on all residents residing in the facility on 08/17/13, by the licensed nurse to validate all residents were accounted for. 3) Review of the facility's investigation binder revealed the Administrator and ADON validated that all doors and alarms were working properly on 08/17/13. 4) Review of Residents elopement assessments revealed that all residents residing in the facility were reviewed by licensed nurses to determine that residents with elopement potential had appropriate assessments, devices as necessary, care plans to address risk of elopement on 08/17/13. 5) Review of random residents records revealed all residents in the facility were assessed by the licensed nurse using the "Resident Elopement Risk Screen and Assessment Tool" to further identify residents at risk for elopement on 08/23/13. Using this assessment tool the licensed nurse updated the resident care plan, care card and also identified each resident to either require or not require supervision for outdoor activities 6) Review of the facility's investigation binder revealed that the Administrator, DON, and ADON initiated re-education to all staff on 08/17/13, and completed on 08/21/13. The topics reviewed were Elopement Management Program to include procedure for missing resident, response to door alarm, that facility door codes were changed, new facility policy to not give door codes to any resident or visitor. Interviews on 08/30/13 at 9:32 AM, with Licensed Practical Nurse (LPN) #1, at 9:32 AM with LPN #2, at 10:10 AM with LPN #3 at 9:40 AM with Registered Nurse (RN) #1, at 8:20 AM with RN #2, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors and when to complete elopement assessments. Interviews on 08/30/13 at 9:25 AM with SRNA #1, at 9:10 AM with SRNA #2, at 10:40 AM with SRNA #3, at 10:30 AM with SRNA #5, at 10:50 with SRNA #4, and at 8:30 AM with SRNA #6, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors. Interviews with other facility staff on 08/30/13, at 9:35 AM with Occupational Therapist, at 9:00 AM with House Keeping (HK) #1, at 10:45 AM with HK #2, at 8:15 AM with HK #3, at 9:05 AM with Activities/SRNA, at 9:20 AM with Cook #1, at 9;25 am with Cook #2, revealed they were all aware of the Elopement Management Program, procedure for missing resident, facility door codes changed and not to give codes to residents or visitors. 7) Review of the facility's investigation binder revealed that the Maintenance Director changed all door codes on 08/19/13, and will change the codes anytime it is determined that a resident or visitor knows the code. 8) Review of the facility's investigation binder revealed that the Administrator, DON, and ADON, was re-educated by the Manager of Clinical Operations to the facility's Elopement Policy and Procedures on 08/23/13. 9) Review of the facility's investigation binder revealed that the Administrator, DON, ADON, and/or Maintenance Director conducted missing resident/elopement drills on 08/18/13, 08/19/13, and 08/20/13 on all three shifts. 10) Review of the facility's investigation binder revealed that the Administrator and/or Maintenance conducted observations of facility exit on 08/18/13, 08/19/13, 08/20/13, and 08/21/13, at varied times, and the door codes have been changed due to a visitor was aware of the door codes. The findings will be reported to the QA Committee monthly for further review and recommendations. 11) Interview with the DON, on 08/30/2013 at 11:10 AM, revealed that the DON/ADON will audit all elopement assessments on admission, readmission, annual, quarterly and significant change assessments during the daily Clinical Meeting, to ensure care plans, care cards and elopement assessments are complete.

Based on interview, record review and review of the facility's policies, it was determined the facility failed to ensure the Physician was notified when there was a change in a resident's physical health and a need to alter treatment for one (1) of twenty-seven (27) sampled residents, (Resident #1). On 11/11/11 the facility's Dietitian identified Resident #1 experienced a significant weight loss of 5.5% in seven (7) days. Although the Dietitian made dietary recommendations on 11/11/11, there was no documented evidence the Physician was notified of the recommendations. In addition, although the resident exhibited poor food and fluid intake from admission on 11/04/11, there was no documented evidence the Physician was notified of the significant weight loss or the decrease in food/fluid consumption. On 11/15/11 the facility transferred the resident to the hospital related to critical laboratory values and was diagnosed with [REDACTED]. The findings include: Review of the "Hydration Policy", dated 01/08, revealed the nurse was to notify the Physician upon identification of resident hydration concerns and document this notification in the Interdisciplinary Progress Notes. Review of Resident #1's medical record revealed [DIAGNOSES REDACTED]. Review of the admission physician's orders [REDACTED]. Review of Resident #1's Functional Performance Record Meal Intake, revealed the following: On 11/05/11, the resident refused all meals and drank 240 milliliters (ml's) of fluid. On 11/06/11, the resident refused breakfast and lunch and consumed 25% of supper and drank 360 ml's. On 11/07/11, the resident consumed 75% for breakfast, 50% for lunch and 50% for supper, and drank 720 ml's. On 11/08/11, had no documentation for breakfast or lunch, and the resident refused supper and drank 120 ml's. On 11/09/11, the resident consumed 25% for breakfast, 25% for lunch and 25% for supper and drank 840 ml's. On 11/10/11, the resident refused breakfast, refused lunch and consumed 25% for supper and drank 1560 ml's. On 11/11/11, there was no documentation for breakfast and lunch and the resident refused supper and drank 720 ml's. The resident's weekly weight on 11/11/11 revealed a weight of 113.6 pounds which was a significant weight loss of 5.5% in seven (7) days. (Refer to F-325) Review of the "Nutrition Therapy Assessment", dated 11/11/11, revealed the Dietitian's dietary recommendations included House Shakes twice a day and increased fluids provided by dietary. Further review revealed the supplements would provide an extra 480 ml's of fluids per day. The Assessment stated the resident's estimated fluid requirement was 1500 ml's to 1650 ml's per day. Interview with the Dietitian, on 12/20/11 at 3:00 PM, revealed she had five (5) to seven (7) days to see new admissions and she had completed the Nutritional Assessment on 11/11/11. She stated, in reviewing Resident #1's meal intakes she noted the resident was eating so little, she went straight to supplements and also recommended an increase in fluids on the meal trays. Continued interview revealed she placed her dietary recommendations in the Unit Managers mail box on 11/11/11. However, review of the physician's orders [REDACTED]. Interview, on 12/20/11 at 2:30 PM, with the Unit Manager/Licensed Practical Nurse (LPN) #13, revealed the dietary recommendations were to be placed in her mail box by the Dietitian and she was responsible for notifying the Physician of the recommendations. Further interview revealed the 11/11/11 recommendations were made on a Friday and she probably would not have checked her mailbox for the recommendations until Monday, 11/14/11. She indicated a two (2) to three (3) day turn around for notification to the Physician of dietary recommendations was a long time and she did not remember ever receiving the 11/11/11 recommendations in her mailbox. Interview, on 12/22/11 at 10:00 AM, with the Director of Nursing (DON) revealed the Dietitian should have communicated the dietary recommendations verbally to nursing on 11/11/11 and the Physician should have been notified of the recommendations the same day. Further review of the Resident Functional Performance Record Meal Intake revealed on 11/12/11, the resident consumed 25% for breakfast and refused lunch and supper. On 11/13/11, the resident refused breakfast, refused lunch and consumed 25% for supper. On 11/14/11, the resident refused breakfast, refused lunch. Continued review of the physician's orders [REDACTED]. Review of the laboratory values on 11/08/11 revealed abnormal values for Blood Urea Nitrogen (BUN) 82-Critical (normal range 7-29). New orders were obtained 11/08/11 to repeat the CMP on 11/09/11. Review of the CMP drawn 11/09/11 revealed abnormal values for BUN-84 Critical (normal range 7-29), and Creatinine 1.4 High (normal range 0.7-1.3). Further orders were obtained on 11/10/11 for a Basic Metabolic Panel (BMP) on 11/15/11. Review of the BMP on 11/15/11 revealed abnormal laboratory values for BUN-145 Critical (normal range of 7-29), and Creatinine-2.5 High (normal range of 0.7-1.3). Review of physician's orders [REDACTED]. Review of the hospital record revealed the resident was admitted to the hospital with [REDACTED]. Review of the Hospital Discharge Summary, dated 12/01/11, revealed the resident was dehydrated on admission and was hypotensive (low blood pressure). The resident received intravenous fluids and was transferred to the Intensive Care Unit where he/she received [MEDICAL TREATMENT]. Per the Summary the resident was also treated for a Urinary Tract Infection. The discharge [DIAGNOSES REDACTED]. Interview, on 12/20/11 at 2:30 PM and 12/22/11 at 10:00 AM, with Unit Manager/Licensed Practical Nurse (LPN) #13, revealed she only reviewed the meal consumption if she was notified that a resident was not eating or drinking well. Continued interview revealed she had not notified the Physician related to the resident's decreased food and fluid intake until 11/15/11 prior to the resident going to the hospital. There was no documented evidence in the record that she or any nurse had notified the Physician of the low intake prior to 11/15/11. Interview, on 12/20/11 at 3:30 PM, with LPN #14 revealed she had been assigned to Resident #1 a few times after admission and she had encouraged staff to feed him/her due to weakness. However, she stated she was not informed Resident #1 was eating/drinking poorly and had not notified the Physician. Interview with Certified Nursing Assistant (CNA) #10, on 12/21/11 at 9:30 PM, revealed Resident #1 did not eat well and had to be fed. She stated he/she ate about 25% for meals and refused snacks; however, would sometimes ask for milk between meals. Further interview revealed she notified the nurses of the poor intake and documented the meal intakes on the record each day. Interview, on 12/22/11 at 9:15 AM, with RN #4, who was assigned to Resident #1 several times from admission until hospitalization on [DATE], revealed she was aware the resident was not eating and drinking and had notified the Nurse Practitioner on 11/08/11; however, had not documented this in the medical record. Interview, on 12/21/11 at 3:15 PM, with the Nurse Practitioner revealed she did not remember being notified of Resident #1's decreased food and fluid intake and if she had been notified she would have documented this in her notes. Interview, on 12/20/11 at 5:10 PM and on 12/22/11 at 10:00 AM, with the Director of Nursing (DON) revealed Resident #1 should have been identified to be a nutritional/hydration risk from the meal intakes and observations of the resident during meals. She further stated the Physician should have been made aware of this resident's decreased food and fluid intakes and weight loss. Interview, on 12/21/11 at 12:45 PM, with Resident #1's Physician revealed he did not remember being informed of the resident's decreased food and fluid intake and if he was informed he would have documented this in the medical record. Further interview revealed he would have written physician's orders [REDACTED]. He stated he had drawn labs for a baseline on 11/07/11 and the lab results on 11/08/11 for the increased BUN could indicate dehydration. Further interview revealed he did not remember being notified of dietary recommendations or of the resident's weight loss prior to the resident being hosptalized on [DATE]. He further stated for some reason this resident's nutrition and hydration status was not addressed with him or the Nurse Practitioner per record review until 11/15/11 when the resident was transferred to the hospital.

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure that a resident maintains acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible for one (1) of twenty-seven (27) sampled residents, (Resident #1). Resident #1 had a significant weight loss of 5.5% from 11/04/11 until 11/11/11. Although the Dietitian was aware of the weight loss and made dietary recommendations on 11/11/11, there was no documented evidence the facility acted on the dietary recommendations in an attempt to prevent further weight loss. In addition, there was no documented evidence the facility followed their Nutrition Policy and Clinical at Risk Team Meeting Policy. Although Resident #1 refused most meals from admission on 11/04/11 through 11/15/11, there was no documented evidence staff identified this resident's risk for decline in nutritional status, developed a Plan of Care to promote food and fluid intake, documented the resident's poor food and fluid on the Twenty-four (24) Hour Report, discussed the resident's poor food and fluid intake in the Clinical at Risk Meetings, provided ongoing monitoring of the resident's food consumption, or notified the Physician of the resident's poor food intake and weight loss as per facility policy. The findings include: Review of the facility's policy titled, "Nutrition Management Program" dated 01/08, revealed the interdisciplinary (IDT) team was to identify persons at risk for dehydration and or decline in nutrition status, develop individualized care plans to promote food and fluid intake and weight stabilization, identify new instances of unplanned weight loss, document the change in condition, and evaluate the effectiveness of the interventions. Further review revealed any changes in the clinical condition of a resident was to be recorded on the Twenty-four (24) Hour Report to be distributed to the Dietitian to screen for changes in condition which may affect nutrition or hydration. The Physician and family were to be notified as applicable. Continued review revealed there was to be a weekly Clinical at Risk Evaluation Process (CARE) and the nurse was to conduct ongoing monitoring to validate that resident food consumption was documented accurately. Review of the "Clinical At Risk Team Meeting Policy", dated 01/08, revealed prior to the meetings, residents were to be identified if at risk related to unplanned weight loss and new admissions were to be taken to the meeting weekly for four weeks. Further review revealed the residents' charts, and care plans were to be discussed and a summary of the discussion with interventions was to be documented in the IDT Notes. The licensed nurse was to communicate the findings to the staff. Review of Resident #1's medical record revealed the facility admitted the resident on 11/04/11 with [DIAGNOSES REDACTED]. Review of the Interim Plan of Care, dated 11/04/11, revealed there was no Plan of Care related to nutrition. Record review revealed Resident #1's admission weight on 11/04/11 was 120.2 pounds. Review of the Resident Functional Performance Record Meal Intake, revealed the following: On 11/05/11, the resident refused all meals. On 11/06/11, the resident refused breakfast and lunch and consumed 25% of supper. On 11/07/11, the resident consumed 50% for breakfast and 50% for supper. On 11/08/11, the resident had no documentation for breakfast or lunch, and the resident refused supper. On 11/09/11, the resident consumed 25% for breakfast, 25% for lunch and 25% for supper. On 11/10/11, the resident refused breakfast, refused lunch and consumed 25% for supper. On 11/11/11, there was no documentation for breakfast and lunch and the resident refused supper. Review of the weekly weight on 11/11/11 revealed a weight of 113.6 pounds, a weight loss of 6.6 pounds in seven (7) days, which was a significant weight loss of 5.5%. Review of the Nutrition Therapy Assessment, dated 11/11/11, revealed the dietary recommendations included House Shakes twice a day and increased fluids provided by dietary. Review of the physician's orders [REDACTED]. Record review revealed no documented evidence of the development of a care plan to address the significant weight loss and no evidence the facility notified the Physician. On 11/12/11, the resident consumed 25% for breakfast and refused lunch and supper. On 11/13/11, the resident refused breakfast, refused lunch and consumed 25% for supper. On 11/14/11, the resident refused breakfast, refused lunch, and consumed 100% for supper. On 11/15/11 the resident was transferred to the hospital with [DIAGNOSES REDACTED]. Interview with Certified Nursing Assistant (CNA) #10, on 12/21/11 at 9:30 PM, revealed the resident did not eat well and had to be fed. She stated Resident #1 ate about 25% and refused snacks a lot but would sometimes ask for milk between meals. She further stated she would notify the nurses of the poor intake and document the meal intakes on the Meal Intake Form. Interview with the Dietitian, on 12/20/11 at 3:00 PM, revealed the aides recorded the meal intakes and she reviewed them when it was time for an initial, quarterly, significant change or yearly MDS Assessment. She stated if there was decreased intake the nurses were to notify her verbally or send a Communication Form which she had not received for this resident. She further stated she had five (5) to seven (7) days to see new admissions and she had completed her Nutritional Assessment on 11/11/11. She stated, when she reviewed the resident's meal intakes, she noted the resident was eating so little she went straight to supplements and recommended an increase in fluids on the trays. She further stated she placed the dietary recommendations in the Unit Manager's mailbox. Interview, on 12/20/11 at 2:30 PM, with the Unit Manager/Licensed Practical Nurse (LPN) #13, revealed there was a two (2) to three (3) day turn around on dietary recommendations. She stated the dietary recommendations were to be placed in her mail box by the Dietitian and she was responsible for calling the Physician with the recommendation. Continued interview revealed the 11/11/11 recommendations for Resident #1 were made on a Friday and she probably would not have checked her mailbox for the recommendations until 11/14/11. Continued interview revealed a two (2) to three (3) day turnaround for notification to the Physician of dietary recommendations was a long time and she did not remember ever receiving the 11/11/11 recommendations in her mailbox. Interview, on 12/22/10 at 10:00 AM, with the Director of Nursing (DON) revealed the Dietitian should have communicated the dietary recommendations verbally to nursing the day they were written and the Physician should have been notified of the recommendations also on 11/11/11. Further review revealed there was no documented evidence the facility had taken action on the Dietitian's recommendation on 11/11/11 when she identified the resident's significant weight loss. Additionally, there was no evidence of the development of a care plan related to weight loss. Interview, on 12/20/11 at 2:30 PM and 12/22/11 at 10:00 AM, with Unit Manager/LPN #13, revealed it would have been the staff nurses' responsibility to initiate the nutrition care plan during an acute situation such as this when the resident was not eating well. She stated she was unaware of the Hydration/Nutrition Policy and only reviewed the meal consumption if a Certified Nursing Assistant (CNA) notified her a resident was not eating or drinking well. She further stated as far as she knew, it was the Dietitian's responsibility to review the meal intakes. Continued interview revealed she had notified the Physician related to the residents decreased food and fluid intake on 11/15/11, prior to the resident going to the hospital; however, could find no documentation in the record where she or any nurse had notified the Physician of the low intake prior to 11/15/11. Interview, on 12/20/11 at 3:30 PM, with LPN #14 revealed she had been assigned to the resident a few times after admission and she had encouraged staff to feed him/her due to weakness. She stated she was unaware the resident was eating/drinking poorly prior to hospitalization on [DATE]. Interview, on 12/21/11 at 8:50 PM, with Registered Nurse (RN) #6 revealed she had taken care of Resident #1 a few times on the night shift from 7:00 PM until 7:00 AM on 11/04/11 through 11/15/11; however, she was never notified of the resident losing weight and did not receive information in report related to the resident not eating and drinking. She stated the evening/night shift nurses did not review meal consumption for the residents and did not review fluid intake unless they were on strict Intake and Output. Interview, on 12/22/11 at 9:15 AM, with RN #4 who worked the day shift, revealed the nurses were to chart on the residents every shift for seventy-two (72) hours for new admissions. She stated she was assigned to Resident #1 several times from admission until hospitalization on [DATE]. She further stated she was aware the resident was not eating and drinking and notified the Nurse Practitioner on 11/08/11; however, did not document this in the medical record. Interview, on 12/21/11 at 3:15 PM, with the Nurse Practitioner revealed she did not remember being notified of the resident's decreased intake and stated if she had been notified she would have documented this in her notes. Continued interview revealed she did not think she was aware of the resident's poor food/fluid intake prior to that date, even though she was assessing and documenting on the resident in the medical record during the initial seventy-two (72) hour period. She stated she should have inquired about the resident's meal consumption while doing the required seventy-two (72) hour charting after admission. Continued interview revealed the nurses did not review the meal consumption's for the residents routinely. However, she stated she did document the resident's low intake on the 24 Hour Report. Interview, on 12/20/11 at 5:10 PM and on 12/22/11 at 10:00 AM, with the Director of Nursing (DON), revealed Resident #1 should have been identified at nutritional risk from the meal intakes and observation of the resident at meal times. She further stated a Plan of Care should have been implemented to address this resident's nutritional status and the Physician should have been made aware of this resident's decreased intakes and weight loss. Continued interview revealed the nurses were to chart on residents every shift for seventy-two hours (72) after admission and should be talking to the CNA's for information related to the residents' nutritional status while doing the assessment and documentation. Continued interview revealed the nurses were to document in the Nurses Notes and on the 24 Hour Report if a resident was not eating and drinking well. Review of the 24 Hour Report revealed the resident was on the report when a new physician's orders [REDACTED]. Further interview revealed new admission charts and care plans were to be brought to the morning meeting every day for 72 hours and the Nurses Notes were reviewed as well as the Resident Functional Performance Record which included the meal intake sheets. She stated this resident's decreased intake may not have been discussed because there was no documentation in the Nurses Notes to alert the IDT of the decreased food and fluid intake. Continued interview, revealed any resident with weight loss was to be discussed in the weekly CARE Meeting and interventions were to be initiated and implemented to assist in preventing weight loss. Review of the CARE Meeting minutes from 11/10/11 revealed the resident's labs and physician's orders [REDACTED]. She stated, she was unaware until this survey that there was nobody responsible for routine monitoring of the residents' meal consumption records and there was no effective system in place to ensure staff was following the Nutrition Policy. Interview, on 12/21/11 at 12:45 PM, with Resident #1's Physician revealed he did not recall being informed of the resident's decreased food intake and if he had been notified he would have documented this in his Physician's Progress Notes. Further interview revealed he did not remember being notified of dietary recommendations or of the resident's weight loss prior to the resident being hosptalized on [DATE]. He stated, for some reason this resident's nutrition status was not addressed with him or the Nurse Practitioner per record review.

Based on interview and record review it was determined the facility failed to ensure each resident was provided with sufficient fluid intake to maintain proper hydration and health for one (1) of twenty-seven (27) sampled residents (Resident #1). Resident #1 had poor fluid intake from admission on 11/04/11; however, there was no documented evidence the facility implemented their "Hydration Policy" or "Clinical at Risk Team Meeting Policy". Although the resident had risk factors for dehydration including abnormal labs, weight loss, poor fluid intake, and the use of diuretics, there was no documented evidence this resident was identified at risk for dehydration and no documented evidence a Plan of Care was initiated to promote fluid intake. In addition, there was no documented evidence staff provided ongoing monitoring of the resident's fluid intake or notified the Physician of the resident's poor fluid intake. On 11/15/11 the facility transferred Resident #1 to the hospital where he/she was admitted to the hospital with [REDACTED]. The findings include: Review of the facility "Hydration Policy" dated 01/08, revealed the Dietician was to determine the residents daily fluid needs and was to document this on the medical Nutrition Therapy Assessment. The interdisciplinary team (IDT) would review residents who had the following conditions as defined as risk factors for dehydration; weight loss, abnormal lab values, dependence on staff for the provision of fluids, limited fluid intake, use of diuretics, and residents who did not meet their estimated fluid need for three consecutive days and were evidencing fluid depletion. Further review revealed the Registered Nurse (RN) was to assess the need for Intake and Output (I & O) monitoring. If the resident was identified for monitoring of I & O, the nurse ensured that intake and output of fluids were documented on the Total I & O Record. The 11-7 nurse was to tally the twenty-four (24) hour intake of fluids on the I & O Record and evaluate variances. The Policy stated, the nurse was to notify the Physician upon identification of resident hydration concerns, document this notification in the Interdisciplinary Progress Notes and initiate an appropriate care plan. Review of the "Clinical At Risk Team Meeting Policy", dated 01/08, revealed newly admitted residents were discussed and reviewed for identified risks and potential risks weekly for four weeks. Further review revealed the residents charts, and care plans were to be reviewed and a summary of the discussion with interventions was to be documented in the IDT Notes. Also, the licensed nurse was to communicate the findings to the staff. Review of Resident #1's medical record revealed the facility admitted the resident on 11/04/11 with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Interim Plan of Care, dated 11/04/11, revealed there was no Plan of Care related to the risk of dehydration, and there was no documented evidence of a Plan of Care related to hydration prior to the residents hospitalization [DATE]. Review of the Resident Functional Performance Record Meal Intake, revealed the following: On 11/05/11, the resident consumed 240 milliliter's (ml's) of fluids. On 11/06/11, the resident consumed 720 ml's of fluids. On 11/07/11, the resident consumed 720 ml's of fluids. Review of the physician's orders [REDACTED]. Review of the laboratory values on 11/08/11 revealed abnormal values for Chloride -97 Low-(normal range 98-108), Blood Urea Nitrogen (BUN) 82-Critical (normal range 7-29). New orders were received 11/08/11 to repeat the CMP on 11/09/11. On 11/08/11, the resident consumed 120 ml's of fluids. On 11/09/11, the resident consumed 840 ml's of fluids. Review of the CMP drawn 11/09/11 revealed abnormal values for BUN-84 Critical (normal range 7-29), and Creatinine 1.4 High (normal range 0.7-1.3). On 11/10/11, the resident consumed 1560 ml's of fluids. Orders were obtained on 11/10/11 for a Basic Metabolic Panel (BMP) on 11/15/11. On 11/11/11 the resident consumed 720 ml's of fluids. Review of the Nutritional Therapy Assessment, dated 11/11/11, completed by the Dietician, revealed the residents estimated fluid requirement was 1500 ml's to 1650 ml's per day. Further review of the meal consumption record revealed the resident did not meet the estimated fluid requirement for five (5) consecutive days from 11/5/11 through 11/09/11. Further review revealed the dietary recommendations included House Shakes twice a day and increased fluids provided by dietary. Further review revealed the supplements would provide an extra 480 ml's of fluids per day. However, review of the physician's orders [REDACTED]. Review of the BMP on 11/15/11 revealed abnormal laboratory values for BUN-145 Critical (normal range of 7-29), and Creatinine-2.5 High (normal range of 0.7-1.3). Review of physician's orders [REDACTED]. Review of the Hospital Discharge Summary, dated 12/13/11, revealed the resident was dehydrated on admission and was hypotensive (low blood pressure). The resident received intravenous fluids and was transferred to the Intensive Care Unit where he/she received [MEDICAL TREATMENT]. Per the Summary the resident was also treated for [REDACTED]. Interview with CNA #10, on 12/21/11 at 9:30 PM, revealed Resident #1 did not eat well and had to be fed. She stated Resident #1 ate about 25% and refused snacks frequently. She indicated she would notify the nurses of the poor food and fluid intake. Review of the medical record revealed there was no documented evidence the facility had identified this resident's risk for dehydration and implemented a Plan of Care in an attempt to promote fluid intake even though the resident did not meet his/her fluid requirement from 11/05/11 through 11/09/11, had abnormal labs, had weight loss, and was receiving a diuretic. Interview, on 12/20/11 at 2:30 PM and on 12/22/11 at 10:00 AM, with Unit Manager/Licensed Practical Nurse (LPN) #13, revealed it would have been the staff nurses' responsibility to initiate the nutrition/hydration care plan during an acute situation such as this when the resident was having poor fluid intake. She further stated the admitting nurse should look at risk factors for the resident and Resident #1 was at risk for dehydration related to his/her [DIAGNOSES REDACTED]. She further stated, she had notified the Physician related to the residents decreased food and fluid intake; however, could find no documentation in the chart where she or any nurse had notified the physician of the poor fluid intake prior to 11/15/11. Continued interview revealed the resident should have been placed on Intake and Output monitoring to ensure the total fluid intake was monitored daily by the night shift nurses. Interview with LPN #14, on 12/20/11 at 3:30 PM, revealed she had been assigned to the resident a few times after admission and she had encouraged staff to feed him/her due to weakness. She further stated she was unaware the resident was eating/drinking poorly prior to hospitalization on [DATE]. Interview with Registered Nurse (RN) #6, on 12/21/11 at 8:50 PM, revealed she was assigned to the resident a few times on the night shift from 7:00 PM until 7:00 AM on 11/04/11 through 11/15/11; however, she did not receive information in report related to the resident not eating and drinking. She further stated the evening/night shift nurses did not review meal and fluid consumption for the residents and did not review fluid intake unless they were on strict Intake and Output. Interview with RN #4, on 12/22/11 at 9:15 AM, revealed she worked the day shift and was assigned to the resident several times from admission until hospitalization [DATE]. She stated the nurses were to chart on the residents every shift for seventy-two (72) hours for new admissions. Continued interview revealed she was aware the resident was not eating and drinking and notified the Nurse Practitioner on 11/08/11, however, had failed to document this in the medical record. Interview, on 12/21/11 at 3:15 PM, with the Nurse Practitioner revealed she did not remember being notified of the resident's decreased food and fluid intake and stated if she had been notified she would have documented this in her notes. Further interview revealed she did not think she was aware of the resident's poor food/fluid intake prior to 11/08/11, even though she was assessing and documenting on the resident in the medical record. RN #4 stated, she should have inquired about the resident's meal consumption while doing the required seventy-two (72) hour charting on admission. Further interview revealed the nurses did not review the meal and fluid consumption routinely. Interview, on 12/20/11 at 5:10 PM and on 12/22/11 at 10:00 AM, with the Director of Nursing (DON), revealed Resident #1 should have been identified to be at risk for dehydration from the meal intakes and observation of the resident during meals and a Plan of Care should have been implemented to address the resident's risk for dehydration. She further stated if a resident did not meet their estimated fluid requirement, a clinical reason should be identified and the resident should have been placed on Intake and Output to ensure the fluid intake was monitored. Continued interview revealed the Physician should have been notified of Resident #1's decreased intakes. She stated, the nurses were to chart on residents every shift for seventy-two hours (72) after admission in the Nurses Notes and should include information related to the resident's fluid consumption if the resident was drinking poorly. She further stated, if a resident was not drinking well, this should be documented on the Twenty-four (24) Hour Report which was taken to the morning meetings. Review of the 24 Hour Report revealed no documentation related to the resident's poor fluid intake. Continued interview revealed new admissions charts and care plans were to be brought to the morning meeting every day for 72 hours and the Nursing Notes were reviewed, as well as the Resident Functional Performance Record, which included the food and fluid consumption by the interdisciplinary team (IDT). She indicated this resident's decreased intake may not have been discussed because there was no documentation in the Nurses Notes to alert the IDT of the decreased food and fluid intake. Further interview revealed residents with poor fluid intake were to be discussed in the weekly CARE Meeting and interventions were to be initiated and implemented to assist in preventing dehydration. Review of the CARE Meeting minutes for 11/10/11 revealed the resident's labs and physician's orders [REDACTED]. Continued interview revealed she was unaware until this survey that there was nobody responsible for routine monitoring of the residents' meal consumption records for fluid intake and there was no effective system in place to ensure staff were following the Hydration Policy. Interview, on 12/20/11 at 3:00 PM, with the Dietitian revealed she reviewed meal intakes for fluid consumption for an initial, quarterly, significant change or yearly MDS Assessment. She stated if there was poor food or fluid intake the nurses were to notify her verbally or send a Communication Form; however, she had not received communication from nursing related to this residents poor intake prior to her Nutritional Assessment which she completed on 11/11/11. She stated, when she reviewed the resident's meal intakes prior to the assessment, she recommended an increase in fluids on the trays. She stated she left the recommendation in the mailbox for the Unit Manager. Interview, on 12/20/11 at 2:30 PM, with the Unit Manager/Licensed Practical Nurse (LPN) #13, revealed she did not remember ever receiving the 11/11/11 recommendations in her mailbox. Interview, on 12/22/10 at 10:00 AM, with the Director of Nursing (DON), revealed the Dietitian should have communicated the dietary recommendations verbally to nursing the day they were written and the Physician should have been notified of the recommendations on 11/11/11. (Refer to F-157). Interview, on 12/21/11 at 12:45 PM, with Resident #1's Physician revealed he did not remember being informed of the resident's decreased fluid intake and if he had been notified he would have documented this in the medical record. Continued interview revealed he would have written physician's orders [REDACTED]. He further stated he had drawn labs for a baseline on 11/07/11 and the lab results on 11/08/11 for the increased BUN could indicate dehydration. Further interview revealed he did not remember being notified of dietary recommendations prior to the resident being hosptalized on [DATE]. He stated for some reason this resident's hydration status was not addressed with him or the Nurse Practitioner per record review until 11/15/11 when the resident was transferred to the hospital.