Every finding on record at Berea Health and Rehabilitation

Based on observation, interview, record review, and review of facility policy, 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, which had the potential to affect 30 of 30 sampled residents, and other facility residents.The findings include: Review of the facility policy titled, Infection Prevention and Control Program, revised 08/20/2025, revealed the facility infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Continued review revealed, Facility infection control policies and practices apply equally to all personnel, consultants, contractors, residents .regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payer source. Further review revealed the facility infection control policy, provides guidelines for the safe cleaning and reprocessing of reusable resident care equipment. Observation on 04/07/2026 at 9:30 AM, revealed oxygen tubing in room [ROOM NUMBER]B lying on the floor beside the wheelchair, unbagged. Observation on 04/07/2026 at 10:37 AM, revealed Housekeeping Aide 16 entering and exiting an enhanced barrier precaution (EBP) resident's room and donning personal protective equipment (PPE). Per observation, Housekeeping Aide 16 was observed wearing the PPE out of the EBP room and into the hallway, touching her cart, and the cart touching her scrubs. Further observation revealed Housekeeping Aide 16 continued to enter and exit other resident rooms. Observation on 04/07/2026 at 10:31 AM, revealed the Social Services Director (SSD) entering and exiting room [ROOM NUMBER] without using proper hand hygiene. Observation on 04/07/2026 at 12:43 PM, in the first-floor shower room revealed a shower chair with visible blood and hair. Observation on 04/07/2026 at 2:50 PM, revealed Housekeeping Aide 16 exiting room [ROOM NUMBER] wearing PPE into the hallway, discarding it and putting it in the garbage on her cleaning cart. Housekeeping Aide 16 was then observed to push the discarded PPE down into the garbage bag; coming in full contact with her arm and hand. In interview on 04/07/2026 at 10:22 AM, LPN 1 stated oxygen tubing being in contact with the floor was, an infection control concern for resident safety. The LPN further stated the oxygen tubing touching the floor was an infection control concern because we don't know what types of germs the tubing is coming in contact with on the floor. In interview on 04/07/2026 at 10:27 AM, Housekeeping Aide 16 stated, I guess they shouldn't touch. It is hard to take PPE on and off when I come in and out and go back in it would be a waste of materials. It would be a concern for me to wear contaminated clothes into other residents' rooms; I could spread germs from one resident to another and not know it. Housekeeping Aide 16 further stated, I do not know why I am wearing PPE. I was told to wear it if I saw a sign but I do not understand why or what [EBP] precautions mean. In interview on 04/07/2026 at 12:35 PM, when the State Survey Agency (SSA) Surveyor asked the Director of Nursing (DON) why there was visible blood and hair on a shower chair, the DON stated, I whisked the shower aide away to the dining room and she probably didn't have time to clean the shower room. The DON further stated the blood and hair on the shower chair was an infection control issue. In interview on 04/09/2026 at 2:25 PM, the Infection Preventionist (IP) stated their expectations for staff was for them to abide by the facility's infection control policy at all times and if they did not know or were unsure, then they should ask a nurse or the IP for clarification. The IP reported staff wearing PPE were expected to take off the PPE at the door, throw it away immediately in the provided garbage bag in the room and that it was not appropriate for PPE to be worn outside of the room. The IP stated shower room equipment was expected and supposed to be cleaned before and after each use. The IP further stated the (SSA Surveyor's) observations were a major infection control issue. In interview on 04/09/2026 at 3:00 PM, the Administrator stated their expectation for staff regarding infection control was for staff to follow proper protocol and abide by the facility's infection control policy as they were taught upon hire and in serviced on monthly.

Based on interview, and review of facility documents and policy, the facility failed to establish a system to ensure thorough accounting of the disposition of all controlled drugs to enable accurate reconciliation of those drugs, which had the potential to affect residents on narcotic medications out of the 30 sampled residents. The findings include: Review of the facility policy titled, Controlled Medication, dated 08/13/2024, revealed controlled drugs were to be counted at each shift by two staff members who were licensed nurses, medication technicians, or appropriate staff per state regulations. Continued review revealed the controlled drug counts were to be documented on the controlled medications accountability record. Further review revealed the Controlled Substance Drug Record was to be signed by the nurse leaving and the nurse coming on duty to signify the count had been done and was correct. Review of the facility's, Controlled Substance Drug Record for April 2026, for the 200 Hall Medication Cart 3 revealed six out of 14 staff signatures not documented for the April 2026 narcotic counts. During interview on 04/07/2026 at 12:03 PM, Licensed Practical Nurse (LPN) 5 stated, at the start and end of shift the medication cart log should be signed (by the oncoming and offgoing nurses). LPN 5 further stated it was important to make sure that the count is correct. During interview on 04/09/2026 at 9:18 AM, Unit Manager 1, stated the logs should be, signed by the oncoming and offgoing nurses when leaving to make sure the counts were correct. During interview on 04/09/2026 at 10:31AM, the Director of Nursing (DON) stated the Drug Record log should have a sign in and sign out every day (by the nurses). He further stated if not, he expected to be contacted and if he was not available staff should follow the chain of command. During interview on 04/09/2026 at 3:18 PM, the Administrator and Administrator In Training stated their expectation was for the Drug Record log to be signed by each nurse at each shift. They further stated if not the log (not signed as required) should go to the DON to follow-up on.

Based on observation, interview, and review of facility policy and the U.S. Public Health Service Food Code, the facility failed to serve food in accordance with professional standards for food service safety by not ensuring staff followed proper hand sanitation (i.e. not wearing gloves and wearing nail polish), which had the potential to affect all residents consuming food from the facility's kitchen. The findings include: Review of the facility policy titled, Infection Control, last reviewed 08/20/2025, revealed the policies and practices of the facility were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. Review of the, U.S. Public Health Service Food Code, dated 2013, revealed unless wearing intact gloves, which were in good repair, a food employee may not wear fingernail polish or artificial fingernails when working with exposed food. (Exposed food refers to raw, cooked, or processed food that was not covered or protected) Observation, on 04/07/2026 at 12:29 PM, revealed the Dietary Manager assumed duties on the meal tray line. Further observation revealed the Dietary Manager plated resident meals without donning gloves and was wearing pink nail polish. Interview, on 04/07/2026 at 3:09 PM, the Health Environmentalist II, for the local health department, stated gloves should be worn when working with exposed food, such as on a tray line, when staff have painted nails or artificial nails. She reported painted nails, could harbor bacteria and microorganisms beneath and around the nail surface, increasing the risk of food contamination. The Health Environmentalist II explained without glove use, there was an increased likelihood of cross contamination, as food employees might unknowingly transfer bacteria from their hands or nails to resident food items. She said chipped, or worn nail polish could create additional areas where bacteria might accumulate and the polish might also flake into food during meal preparation. Additionally, she stated staff might not recognize when contamination had occurred, particularly when handling multiple food items on a tray line. She further stated the local health department provided educational materials to facilities emphasizing the importance of proper hand hygiene and glove use when staff had painted or artificial nails, due to the increased risk for cross contamination associated with those. In interview, on 04/08/2026 at 10:21 AM, the Dietary Manager stated she should not have painted nails while working on the tray line as it exposed residents to the spread of germs or paint potentially chipping and entering the food. The Dietary Manager reported she should have worn gloves to provide an additional level of protection while her nails were painted. She further stated however, due to the meal service being delayed, she took over the tray line to assist and had not applied gloves, acknowledging that had been an oversight and not in accordance with proper infection control practices. In interview, on 04/09/2026 at 10:30 AM, the Regional Food Service and Nutritional Manager stated it was her expectation for her staff to operate a clean kitchen and follow proper hand hygiene. She said the facility followed all local, state, and federal guidelines. The Regional Food Service and Nutritional Manager reported knowing the Food and Drug Administration's (FDA's) stance on glove use was for staff to wear gloves if they had false or painted nails, they would ensure that occurred, to reduce the possibility of cross-contamination and for the safety of residents. Interview, on 04/09/2026 at 3:18 PM, the Administrator On Record stated staff were trained to follow all local, state, and federal guidelines. He further stated it was his expectation for all that guidance was followed. Interview, on 04/09/2026 at 3:18 PM, the Administrator In Training stated she was in agreeance with the Administrator On Record, in that staff were trained on all local, state, and federal guidelines. She further stated staff should follow what they had been trained on.

Based on observation, interview, and review of the facility's policy, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, which had the potential to affect 30 of 30 sampled residents.The findings include: Review of the facility's, Housekeeping Services policy, undated, revealed routine cleaning of resident care areas was to be done daily. Continued review revealed routine cleaning of resident care areas was to occur more frequently if spillage or visible soiling occurred. Review of the facility's, Resident's Rights policy, undated, revealed the resident had a right to a safe, clean, comfortable, and homelike environment. Observation on 04/07/2026 at 10:00 AM revealed Resident (R)71's bathroom was missing toilet bowl caps/covers. R71 stated, I would fix it if I was at home. Observation on 04/07/2026 at 12:43 PM, in the first-floor shower room, revealed unpainted plaster observed surrounding the hand sanitizer dispenser. Per observation, a wooden door had scratches extending across the surface, and the door frame was rusted. Continued observation revealed a black, mold-like substance was in the crevices of the shower tiles, and chipped walls and floor tiles were present throughout the area. Observation revealed a shower chair with visible blood and hair on it. Further observation revealed the exit door had scratches along the bottom, and the floor tiles at the entry to the shower area were discolored. Additional observation revealed blue paint smudged on the white ceiling, and the peach paint beneath the sink was chipped. Observation on 04/07/2026 at 12:58 PM, in the second-floor shower room, revealed the shower wall tiles had approximately eight holes, and a mold-like substance observed in the tile crevices. Per observation, the drywall had holes and scratches in a corner area beside the restroom door, and the door had scratches extending across its surface. Continued observation revealed the ventilation unit in the restroom was discolored with visible dust accumulated on it. Further observation revealed a black, mold-like substance observed on the wall, with underlying paint visible where the top layer had chipped off above the handrails. Observation on 04/07/2026 at 3:36 PM, revealed R25's bathroom was missing the toilet bowl caps/covers, and the resident stated, I would fix those. During interview on 04/07/2026 at 12:35 PM, the Director of Nursing (DON) stated, I the shower aide away to the dining room and she probably didn't have time to clean it. During interview on 04/09/2026 at 8:47 AM, the Maintenance Director stated the facility used the TELS system (A software building management program that assists with maintenance). He said, sometimes if there is a quick fix we tell the staff to put it into TELS. The Maintenance Director further stated, we are caught up on anything outstanding. During an Interview on 04/09/2026 at 9:00 AM, SRNA 5, stated that she is responsible for cleaning the shower room on the first floor between every resident and does a deep clean on it once a week. She went on to state that it is important to ensure the shower room stays clean and well organized for the safety or residents, to prevent the spread of germs. During interview on 04/09/2026 at 9:35 AM, the Corporate Director of Plant Operations stated the facility did not have a preventative maintenance policy. He said the facility used the TELS system to input work orders (for maintenance). The Corporate Director of Plant Operations further stated there were two outstanding work orders this morning but they had been completed leaving no other outstanding orders for the facility. During interview on 04/09/2026 at 3:18 PM, the Administrator stated maintenance issues should be reported to maintenance for it be addressed.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan to provide effective and person-centered care of residents and meet professional standards of care for 1 of 5 sampled residents (Resident (R))1. The facility admitted R1 on [DATE] at 11:30 AM, with a diagnosis of lumbar vertebra fracture. R1's Physician's Orders included supplemental oxygen (O2) at five liters per minute (5 LPM) per nasal cannula (nc) continuously. However, the facility failed to develop and implement a baseline care plan with detailed interventions related to R1's Physician's Order for supplemental O2 per nc at 5 LPM. The facility found R1 unresponsive on [DATE], with an oxygen saturation (O2 sat) level of 41% on supplemental O2 at 2 LPM per nc (and not the ordered 5 LPM). The facility transferred R1 to the emergency room (ER) where he was admitted with a diagnosis of acute respiratory failure with hypercapnia (too much carbon dioxide in the blood). The hospital placed R1 on a Bi-level Positive Airway Pressure (Bi-pap) machine (machine to help a person breathe when not able to rid carbon dioxide in the blood). On [DATE] at 5:30 PM, R1 returned to the facility with Physician's Orders that included a Bi-pap (machine) and oxygen use. However, the facility failed to ensure the Bi-pap machine and the oxygen were care planned. The facility found R1 unresponsive on [DATE] at 4:45 AM. Emergency Medical Services pronounced R1 deceased at 5:13 AM. The facility's failure to have an effective system to develop and implement baseline care plan(s) that included instructions needed to provide effective and person-centered care and met professional standards of quality care has caused or is likely to cause serious injury, impairment, or death. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE], at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Baseline Care Plan, F655. The facility was notified of the IJ on [DATE]. An acceptable IJ Removal Plan was received on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency (SSA) validated the Immediate Jeopardy was past, following the facility's implementation of the plan for removal of the immediate jeopardy; therefore, this was determined to be past immediate jeopardy. 1. Resident 1 had been readmitted to the facility on [DATE] and expired from the facility on [DATE]. 2. On [DATE] unit coordinators reviewed all residents with c-pap/bi-pap orders to ensure orders had been transcribed correctly. Three residents were noted to have c-pap or bi-pap orders and the orders were transcribed correctly. On [DATE], unit coordinators and assistant director of nursing initiated assessments on all residents with current c-pap/bi-pap/oxygen orders to identify any acute distress. Assessments were completed on [DATE]. All residents with an order for c-pap, bi-pap or oxygen orders were monitored every shift to ensure c-pap, bi-pap, or oxygen was utilized per doctors orders. Eleven residents were noted to have c-pap. bi-pap or oxygen orders. Ten residents were assessed with no acute distress. One resident was out to the hospital and unable to be assessed. 3. On [DATE], the administrator had been educated by the [NAME] President of Operations on the expectation that all admits/re-admits to the facility who require c-pap/bi-pap respiratory services including c-pap/bi-pap were available upon the resident's arrival and if not available upon arrival the physician will be notified for further instruction. On [DATE], the administrator educated the assistant director of nursing on the expectation that all admits/re-admits to the facility that require c-pap/bi-pap were available upon arrival and if not available the physician would be notified. On [DATE], the assistant director of nursing educated all licensed nursing staff regarding new admit/re-admits to the facility who require c-pap/bi/pap have equipment available upon residents arrival to the facility and if not available the physician would be notified. Licensed nurses who were on leave were educated prior to next scheduled shift. The education had been placed in the new hire orientation packet. On [DATE] the assistant director of nursing educated all licensed nurses on the policies of admission to the facility and implementing the baseline care plan with a post test given requiring a 100% pass rate. Licensed nurses who were on leave were educated prior to the next scheduled shift and education had been placed in the new hire orientation packet. 4. An adhoc quality assurance program improvement (QAPI) meeting was held on [DATE] to review new/re-admit process, root cause of delay in delivery of c-pap/bi-pap equipment and process to ensure ongoing compliance. The adhoc QAPI committee members include: the Medical Director, Director of Nursing (DON), Unit Coordinators, and Administrator. The Medical Director had no other recommendations. Starting on [DATE] QAPI would be held weekly consisting at minimum of the DON, Administrator, unit coordinator, and Medical Director. QAPI meetings were held to discuss all audits which included baseline care planning, c-pap/bi-pap/oxygen orders, and new admission communication forms. On [DATE] QAPI audits were completed to monitor compliance of c-pap/bi-pap for admission and respiratory services were at facility prior to the resident's admission. 42 audits had been completed and audits are ongoing. Starting on [DATE] the unit coordinators and assistant director of nursing reviewed 100% of new admissions to ensure baseline care planning tool was completed, baseline care plan was initiated and reflected the resident's needs, and physician orders were reviewed to validate accuracy including oxygen. This process remains ongoing. On [DATE], the administrator initiated a New Admission Communication form to be completed by the admission coordinator to provide to the unit coordinators to notify them when an admission would require bi-pap/c-pap or oxygen. On [DATE], the Center Administrator, Center Director of Nursing, and the Assistant Director of Nursing contacted the Medical Director to discuss the survey findings and the Immediate Jeopardy. The QAPI meeting was conducted at this time with the Administrator, DON, ADON, and the Medical Director. The facility continues with weekly review with ongoing QAPI and any concerns would be addressed immediately. There were no recommendations made by the Medical Director. A Partial Extended Survey was initiated on [DATE], and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on [DATE]. Based on the findings of this survey, it was determined the immediate jeopardy was past. The findings include: In interview on ,d+[DATE] at 12:54 PM, the Administrator stated the facility did not have a separate baseline care plan policy. The Administrator stated the admitting nurse was responsible for initiating a baseline care plan, and the comprehensive care plan was developed from it. Review of R1's Hospital Discharge Summary, dated [DATE], revealed the resident had been hospitalized with a fracture to his back and was to be admitted to the facility for short-term inpatient rehabilitation (rehab). Review of R1's closed medical record revealed the facility admitted the resident on [DATE] with diagnoses that included pleural effusion (buildup of too much fluid between the layers of pleura around the lungs), diabetes, and a wedge compression fracture of the first lumbar vertebra. Continued review revealed no Minimum Data Set (MDS) Assessment was completed for R1 as the resident was newly admitted to the facility. Review of R1's Nurse Admission Note, dated [DATE] at 3:08 PM, revealed the facility admitted the resident on that date at 11:30 AM, and assessed him as alert and oriented to person and place. Further review revealed the facility also assessed R1 to exhibit shortness of breath with exertion and when lying flat. Review of R1's Physician's Orders, dated [DATE], revealed an order for O2 continuously at 5 LPM per nc. Review of R1's Activities of Daily Living (ADL) Functional/Rehab Potential Care Plan, initiated [DATE], revealed no documented evidence the facility initiated a goal or interventions for the supplemental O2 use. Review of R1's Acute Change in Condition Note, dated [DATE] at 12:25 AM, revealed the resident's O2 sat was 41% on O2 at 2 LPM per nc, and the resident was unresponsive to noxious (painful) stimuli with fixed pupils and non-reactive to light. Continued review revealed R1 had shortness of breath with rapid, shallow breathing and use of accessory muscles. Further record review revealed the facility also assessed R1 to have an O2 sat of 41% on room air (in later nursing documentation) with O2 applied at 5 LPM per a non-repeater mask. Additional review revealed the facility notified 911 and R1 was transferred to the ER via emergency medical services (EMS). Review of R1's History and Physical (H&P) documentation, dated [DATE], revealed the resident was admitted to the hospital with a diagnosis of acute on chronic respiratory failure with hypercapnia. Per review, R1 was placed on a Bi-pap (machine) and admitted to allow the facility time to make arrangements for a Bi-pap machine, which could not be arranged over the weekend. Further review revealed the plan was to discharge R1 on Monday. Review of R1's Hospital Discharge Summary, dated [DATE], revealed the discharge diagnoses included acute on chronic respiratory failure with hypercapnia and acute respiratory failure with hypoxia (low level of oxygen). Continued review revealed R1 was approved to return to rehab with orders for a Bi-pap machine, with use of a full face mask and setting of ,d+[DATE] with inline O2 at 3 LPM, which the resident needed from 1:00 PM to 4:00 PM and from 10:00 PM to 6:00 AM daily. Further review revealed R1 would require O2 per nc when not wearing the Bi-pap. Review of R1's ADL Functional/Rehab Potential Care Plan, initiated [DATE], revealed the facility had care planned the resident for impaired physical functioning with a goal to achieve/maintain maximum functional mobility. Continued review revealed an intervention initiated on [DATE], for oxygen at 5 LPM via nc when Bi-pap was not in use. Further review revealed another intervention initiated on [DATE], for Bi-pap with See MAR Review of the MAR revealed an order for R1 to have a CPAP machine, not the Bi-pap that was ordered. Further review revealed no documented evidence the facility care planned the mask required; the settings for the Bi-pap machine; nor the times the resident was to wear the Bi-pap daily. Review of R1's Nursing Admission Note, dated [DATE] at 9:55 PM and signed by Licensed Practical Nurse (LPN) 1, revealed the facility readmitted the resident at 5:30 PM. The facility assessed R1 as alert and oriented to person and place. Further review revealed the facility also assessed R1 to be short of breath with exertion and when lying flat. R1's O2 sat was 95% on room air. Review of R1's Nurse's Progress Note, dated [DATE] at 5:17 AM, signed by LPN 1, revealed the resident had a verbal response at 2:30 AM/2:45 AM with the Certified Nursing Assistant (CNA). Continued review of the Note revealed R1 was without respirations or pulse at 4:45 AM, and was cool to the touch. Further review revealed CPR (cardiopulmonary resuscitation) started at 4:47 AM and Emergency Medical Services (EMS) notified. EMS (personnel) notified the Physician who gave orders to stop the CPR at 5:13 AM. R1's was pronounced deceased . Per review of R1's progress notes and Physician's orders, LPN 1 and the current DON completed the resident's admission process. In interview on [DATE] at 10:28 AM, the previous Director of Nursing (DON) stated her expectation was for staff to follow the facility's policies and procedures and residents' orders and care plans. She stated the (baseline) care plan should be initiated by the admission nurse. The previous DON stated the facility should have care planned R1 for supplemental oxygen on [DATE] and the Bi-pap settings on [DATE]. She stated the Interdisciplinary Team (IDT) members were to discuss residents' care plans during the next IDT meeting (typically Monday to Friday mornings) and update the care plan as needed. However, she stated R1 was admitted on [DATE] (a Friday) and discharged back to the hospital on [DATE] prior to the IDT meeting. In interview on [DATE] at 11:15 AM, the current DON stated she had been the Unit Coordinator (UC) in [DATE], and looked over Physician orders to ensure the orders were correct. She stated a new resident's care plan was initiated by the admitting nurse and updated by the IDT during the next day's meeting. The DON stated the facility should have care planned R1's need for supplemental oxygen on [DATE] and the Bi-pap settings on [DATE]. In interview on [DATE] at 5:03 PM, Physician 1 stated he saw the resident while he was hospitalized from [DATE] to [DATE]. Physician 1 stated he discharged R1 from the hospital with O2 and Bi-pap orders. He further stated he expected the facility to follow Physician's orders and the resident's care plan. In interview on [DATE] at 12:54 PM, the Administrator stated the Comprehensive Care Plan Policy given to the State Survey Agency (SSA) was the one used by the facility. She stated comprehensive care plans were developed from the baseline care plan. The Administrator further stated it was a team effort to complete the care plan, with the admitting nurse starting the care plan process. Additionally, she stated the admitting nurse should have placed R1's oxygen on the baseline care plan on [DATE] and the Bi-pap settings on it on [DATE]. The Administrator stated it was the job of the IDT to review the care plan, but R1 was not in the building when the IDT met the following day on either occasion.

Based on interview, record review, and review of the facility's policy, the facility failed to ensure a resident who needed respiratory care was provided consistent with professional standards of practice for one (1) of five (5) sampled residents (Resident (R) 1). The facility admitted R1 on [DATE], for rehabilitation after sustaining a spinal fracture. R1 was noted to have a Physician's Order dated [DATE], for oxygen at five liters per minute (5 LPM) continuously. However, R1 was sent back to the hospital on [DATE] at 12:25 AM, due to low oxygen saturation (O2 sat) level of 41% while on 2 LPM oxygen (not the ordered 5 LPM) per a nasal cannula (nc). R1 was unresponsive to stimuli (painful stimulus used to assess for brain function) with pupils fixed and non-reactive to light or accommodation. R1 was admitted to Hospital #1 on [DATE], due to being hypercapnic (too much carbon dioxide in the blood) respiratory failure, and was placed on a Bi-level Positive Airway Pressure (Bi-pap) machine (a noninvasive ventilator). Arrangements were to be made for a Bi-pap machine for use upon discharge. The facility readmitted R1 on [DATE] at 5:30 PM. However, there was no documentation noting the facility obtained the necessary Bi-pap machine; that the facility provided oxygen at 5 LPM per the Physician's Order, nor that the facility notified the Physician of the unavailability of a Bi-pap machine upon the resident's readmission. On [DATE] at 5:17 AM, Licensed Practical Nurse (LPN) 1 documented a Nurse's Progress Note that R1 had found without respirations or a pulse on [DATE] at 4:45 AM and was cool to the touch. with Cardiopulmonary Resuscitation (CPR) started at 4:47 AM. Emergency Medical Services (EMS) was notified. R1 was pronounced deceased on [DATE] at 5:13 AM. The facility's failure to ensure residents received respiratory care per professional standards of care has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy (IJ) was identified on [DATE], and was determined to exist on [DATE], at 42 CFR 483.21 Comprehensive Resident Centered Care Plan, Baseline Care Plan, F655; and 42 CFR 483.25 Quality of Care, Respiratory/Tracheostomy Care and Suctioning, F695. Substandard Quality of Care was identified at 42 CFR 483.25 Quality of Care, F695. The facility was notified of the IJ on [DATE]. An acceptable IJ Removal Plan was received on [DATE], which alleged removal of the IJ on [DATE]. The State Survey Agency (SSA) validated the Immediate Jeopardy was past, following the facility's implementation of the plan for removal of the immediate jeopardy; therefore, this was determined to be past immediate jeopardy. 1. R1 had been readmitted to the facility on [DATE] and expired from the facility on [DATE]. 2. On [DATE] unit coordinators reviewed all residents with c-pap/bi-pap orders to ensure orders had been transcribed correctly. Three residents were noted to have c-pap or bi-pap orders and the orders were transcribed correctly. On [DATE], unit coordinators and assistant director of nursing initiated assessments on all residents with current c-pap/bi-pap/oxygen orders to identify any acute distress. Assessments were completed on [DATE]. All residents with an order for c-pap, bi-pap or oxygen orders were monitored every shift to ensure c-pap, bi-pap, or oxygen was utilized per doctors orders. Eleven residents were noted to have c-pap. bi-pap or oxygen orders. Ten residents were assessed with no acute distress. One resident was out to the hospital and unable to be assessed. 3. On [DATE], the administrator had been educated by the [NAME] President of Operations on the expectation that all admits/re-admits to the facility who require c-pap/bi-pap respiratory services including c-pap/bi-pap were available upon the resident's arrival and if not available upon arrival the physician will be notified for further instruction. On [DATE], the administrator educated the assistant director of nursing on the expectation that all admits/re-admits to the facility that require c-pap/bi-pap were available upon arrival and if not available the physician would be notified. On [DATE], the assistant director of nursing educated all licensed nursing staff regarding new admit/re-admits to the facility who require c-pap/bi/pap have equipment available upon residents arrival to the facility and if not available the physician would be notified. Licensed nurses who were on leave were educated prior to next scheduled shift. The education had been placed in the new hire orientation packet. On [DATE] the assistant director of nursing educated all licensed nurses on the policies of admission to the facility and implementing the baseline care plan with a post test given requiring a 100% pass rate. Licensed nurses who were on leave were educated prior to the next scheduled shift and education had been placed in the new hire orientation packet. 4. An adhoc quality assurance program improvement (QAPI) meeting was held on [DATE] to review new/re-admit process, root cause of delay in delivery of c-pap/bi-pap equipment and process to ensure ongoing compliance. The adhoc QAPI committee members include: the Medical Director, Director of Nursing (DON), Unit Coordinators, and Administrator. The Medical Director had no other recommendations. Starting on [DATE] QAPI would be held weekly consisting at minimum of the DON, Administrator, unit coordinator, and Medical Director. QAPI meetings were held to discuss all audits which included baseline care planning, c-pap/bi-pap/oxygen orders, and new admission communication forms. On [DATE] QAPI audits were completed to monitor compliance of c-pap/bi-pap for admission and respiratory services were at facility prior to the resident's admission. 42 audits had been completed and audits are ongoing. Starting on [DATE] the unit coordinators and assistant director of nursing reviewed 100% of new admissions to ensure baseline care planning tool was completed, baseline care plan was initiated and reflected the resident's needs, and physician orders were reviewed to validate accuracy including oxygen. This process remains ongoing. On [DATE], the administrator initiated a New Admission Communication form to be completed by the admission coordinator to provide to the unit coordinators to notify them when an admission would require bi-pap/c-pap or oxygen. On [DATE], the Center Administrator, Center Director of Nursing, and the Assistant Director of Nursing contacted the Medical Director to discuss the survey findings and the Immediate Jeopardy. The QAPI meeting was conducted at this time with the Administrator, DON, ADON, and the Medical Director. The facility continues with weekly review with ongoing QAPI and any concerns would be addressed immediately. There were no recommendations made by the Medical Director. A Partial Extended Survey was initiated on [DATE], and the State Survey Agency (SSA) validated the facility's IJ Removal Plan on [DATE]. Based on the findings of this survey, it was determined the immediate jeopardy was past. The findings include: Review of the facility's policy, Bi-level Positive Airway Pressure (Bi-pap)/Continuous Positive Airway Pressure (CPAP) including Trilogy, undated, revealed a licensed nurse or Respiratory Therapist (RT) was to set up and monitor a Bi-pap or CPAP with a physician's/advanced practice provider's order. Further review revealed residents requiring non-invasive therapy via Bi-pap/CPAP were to be placed on an appropriate device provided by the respiratory equipment supplier. Review of the facility's policy, Change in a Resident's Condition, dated [DATE], revealed the facility was to promptly notify . the Attending Physician, and (resident's) representative of changes in the resident's medical/mental condition and/or status (such as changes in level of care or resident rights). Additional review revealed the Nurse Supervisor or Charge Nurse would notify the resident's Attending Physician or On-Call Physician when there had been a need to significantly alter a resident's medical treatment. Review of R1's hospital Discharge Summary dated [DATE], revealed the resident had been hospitalized with a fracture to his back. R1 was admitted to the skilled nursing facility for short-term inpatient rehabilitation. Review of R1's closed medical record revealed the facility admitted the resident on [DATE], with diagnoses which included a pleural effusion (buildup of too much fluid between the layers of the pleura around the lungs), diabetes, and a wedge compression fracture of the first lumbar vertebra. Continued review revealed the facility had not completed a Minimum Data Set (MDS) Assessment due to the resident being a newly admitted resident. Review of the [DATE] Nurse Admission Note revealed the facility admitted R1 on [DATE] at 11:30 AM. The facility assessed the resident as alert and oriented to person and place. Continued review of the Note revealed the facility assessed R1 to have shortness of breath with exertion when lying flat. Review of R1's [DATE] Physician's Orders revealed an order for oxygen at five liters per minute (5 LPM) continuously per a nasal cannula (nc). Review of the [DATE] Acute Change in Condition Note, timed at 12:25 AM, revealed R1's O2 sat was 41% on 2 LPM per nc. R1 was unresponsive to stimuli with his pupils fixed and non-reactive to light or accommodation. Further review of the Note, revealed R1 also had shortness of breath with rapid, shallow breathing and was using accessory muscles. Continued review revealed the facility assessed R1 to have an O2 sat of 41% on room air. Oxygen was then applied at five liters (5 L) per non-rebreather. The facility notified 911. The facility transferred R1 to the hospital emergency room (ER) by EMS. Review of the EMS Run Sheet for R1, dated [DATE], revealed EMS personnel assessed R1 as unresponsive to deep painful stimuli. R1 was transferred to the ER at 1:15 AM. Review of R1's hospital History and Physical (H&P), dated [DATE], revealed the hospital admitted the resident with an admission diagnosis of acute on chronic respiratory failure with hypercapnia. Review of the H&P revealed R1 was placed on a Bi-pap machine and admitted to the hospital to allow time for the facility to make arrangements for a Bi-pap machine upon R1's discharge from the hospital. Continued review revealed over a few hours after being placed on the Bi-pap, R1 was awake and oriented to self. Further review revealed R1 would likely need a Bi-pap which could not be arranged over the weekend and the hospital would plan to discharge (R1) on Monday. Review of an email by the Assistant Director of Nursing (ADON) to the facility's respiratory supply company, dated [DATE] at 2:20 PM, revealed a request for a CPAP machine for R1, who would be returning to the facility on Monday ([DATE]). Continued review revealed the respiratory supply company replied to the email on [DATE] at 8:14 AM, requesting a copy of the order with settings. Further review revealed the ADON replied on [DATE] at 10:53 AM, asking if the order could be emailed as the facility's fax machine was down. Review of R1's hospital Discharge Summary, dated [DATE], revealed R1's discharge diagnoses included acute on chronic respiratory failure with hypercapnia and acute respiratory failure with hypoxia (low level of oxygen). Continued review revealed R1 was noted as approved to return to rehab (rehabilitation) with use of a Bi-pap with a full face mask with a setting of ,d+[DATE] with inline oxygen of three (3) liters, which would be in use from 1:00 PM to 4:00 PM, and at night from 10:00 PM to 6:00 AM daily. Review further revealed R1 would require oxygen per nasal cannula when not wearing the Bi-pap mask. Review of R1's hospital Case Management Discharge Note dated [DATE] at 4:34 PM, revealed the hospital discharged R1. R1 returned to the facility for short-term rehab. Further review revealed the Bi-pap was to be set up per the facility's Admissions Coordinator. Review of the EMS Run Sheet, dated [DATE], revealed R1 returned to the care of the facility at 5:00 PM, with oxygen at 2 LPM per nasal cannula. Review of R1's Physician's Orders, dated [DATE], revealed an order for a CPAP (Continuous Positive Airway Pressure) with full face mask, with settings of Inhale/Exhale (I/E) of ,d+[DATE] with inline oxygen of three (3) liters on from 1:00 PM to 4:00 PM and from 10:00 PM to 6:00 AM daily. Further review revealed an order dated [DATE], for oxygen at 5 LPM per nc when Bi-pap was not in use every shift for respiratory distress. Review of R1's Nursing Admission Note dated [DATE] at 9:55 PM, signed by LPN 1, revealed the facility admitted the resident at 5:30 PM, and assessed the resident as alert and oriented to person and place. Continued review revealed the facility assessed R1 as short of breath with exertion and when lying flat. R1's oxygen sat rate was 95% on room air. Review of the Nurse's Progress Note, dated [DATE] at 5:17 AM, noted by LPN 1, revealed R1 had been verbally responsive at 2:30 AM to 2:45 AM with the Certified Nurse Assistant (CNA). However, continued review revealed at 4:45 AM, the facility assessed R1 to be without respirations or pulse and as cool to the touch. Cardiopulmonary Resuscitation (CPR) was started at 4:47 AM and EMS was notified. Review further revealed EMS personnel notified a Physician who gave orders to stop the CPR at 5:13 AM. R1 was pronounced deceased at that time. Review of R1's Medication Administration Note dated [DATE] at 5:41 AM, documented by LPN 1, revealed the resident did not have a CPAP with full face mask with inline oxygen of 3 LPM (as ordered). However, further review revealed no documentation that the facility had notified the Physician that a Bi-pap or CPAP machine had not been obtained. Review of the facility's investigation revealed a statement by the Assistant Director of Nursing (ADON), dated [DATE], noting the respiratory supply company failed to deliver the Bi-pap (machine) to the facility. Per review of the investigation documentation, a verbal statement from LPN 1 to the current DON, dated [DATE] at 10:00 PM, which noted when the Bi-pap was due (to be placed on R1) at 10:00 PM it was not in the facility, and she (LPN 1) made a progress note regarding the Bi-pap not being available. Continued review of LPN 1's verbal statement documentation, revealed R1 had no change in his baseline which warranted a call to the Physician, Administrator or DON regarding the Bi-pap not being available. Further review of LPN 1's verbal statement revealed she had not reviewed the written report sheet or utilized the acute change log that provided information regarding the resident's instructions for the Bi-pap (machine). Additional review of the facility's investigation revealed an Employee Disciplinary Report dated [DATE], signed by the current DON, for LPN 1's failure to follow the Physician's Order which resulted in delay of care for R1. During an interview with R1's family member on [DATE] at 5:00 PM, the family member stated he/she was unable to answer any questions regarding the care R1 (received at the facility) at that time. During an interview with the previous DON on [DATE] at 10:28 AM, she stated the facility had ordered R1's Bi-pap equipment prior to his return from the hospital on [DATE]. She stated it was her understanding the equipment should arrive before the resident. However, she stated the (Bi-pap) equipment did not arrive until after the resident expired on [DATE]. She further stated she did not remember if the Physician was notified that the Bi-pap was not available, but he should have been notified. During an interview with the Admissions Coordinator on [DATE] at 10:55 AM, he stated once he received a referral, he sent it to the clinical team including the Administrator, DON, and ADON for review to see if the facility could meet the clinical needs of the resident. Per the Admissions Coordinator, once the clinical team approved the referral, he notified the referring facility they (the facility) could accept the resident. He further stated he was unaware of when residents needed specialized equipment, such as a Bi-pap, and relied on the clinical team to approve or let him know if a resident's needs could not be met so he could refuse the admission. During an interview with the current DON on [DATE] at 11:15 AM, she stated she had been the Unit Coordinator (UC) in [DATE]. She stated once an admission was approved by the DON and Admissions Coordinator, the team was notified, and the UC took over the admission process. She further stated she looked over the Physician's Orders and made sure they were correct. She stated she did have off site access to verify orders once a resident was admitted . The DON stated LPN 1 was written up but not suspended and was still employed by the facility. During an interview with LPN 1, on [DATE] at 8:53 AM, she stated the facility admitted R1 prior to her arrival to work on [DATE], and that night had been the first time she had cared for the resident. She stated she was made aware it had always been the facility's policy to have the respiratory equipment needed, including Bi-paps, in the facility prior to a resident being admitted or to send the resident back to the hospital until the equipment arrived. LPN 1 stated she was not told in report about R1's need for a Bi-pap (machine) and had not realized he needed the Bi-pap until after the resident expired and his family asked if he had been wearing his Bi-pap. During an interview with the ADON on [DATE] at 4:30 PM, she stated she placed an order for a CPAP machine for R1 on [DATE] via email to the Respiratory Supply Company, but it (the Bi-pap machine) was delivered to the wrong facility and had not arrived prior to R1 expiring. She stated she knew a CPAP and Bi-pap were not interchangeable. She stated Bi-pap machines had two (2) numbers in the settings and CPAP machines had (1) number in the setting so the respiratory company would have realized she meant a Bi-pap. However, she stated she had not clarified the order with the respiratory company. She further stated it was the facility's policy to notify the Physician and the DON if the Bi-pap was unavailable, and the resident should have been sent back to the hospital until the Bi-pap was available. During an interview with Physician 1 on [DATE] at 5:03 PM, he stated he had been R1's doctor for many years and saw him while he was hospitalized from [DATE] to [DATE], then discharged him from the hospital with orders for oxygen and the Bi-pap machine. He stated he expected the facility to follow the orders or notify him or another Physician if the orders could not be carried out, including if the required respiratory equipment was unavailable. Physician 1 stated it was not within a nurse's scope of practice to determine if additional orders were needed if the current orders were unable to be carried out or if the necessary equipment was not available. He stated it was important that nursing staff documented the correct amount of oxygen the resident was on because the Physician used that information to increase or decrease the amount of oxygen the resident needed. Additionally, he stated he kept R1 in the hospital until Monday, [DATE], because he spoke with facility staff (he was unsure with whom he spoke) and was told the facility was unable to obtain the equipment over the weekend. The Physician stated he had not received a call from the facility on [DATE] or [DATE] regarding R1, and later he found out R1 had been admitted to the facility as a patient of the Medical Director. He further stated he was shocked and upset no one called me, they didn't assign him to me. The Physician stated not having the Bi-pap could have contributed to R1's expiration, as the need for the Bi-pap was the reason the resident had been kept in the hospital over the weekend. During an interview with the Medical Director, on [DATE] at 12:32 PM, he stated he had been the facility's Medical Director for many years and did have input into the facility's policies and procedures. He stated he expected all staff to follow the policies and procedures and to notify the Physician of any issues timely. The Medical Director stated he should have been notified when R1's Bi-pap equipment was not available when it was ordered on [DATE] at 10:00 PM, because as the treating Physician, I need to know. Additionally, he stated the nurse was not capable of making the decision whether R1 needed the Bi-pap or not and when she had been unable to carry out the Physician's Order for the Bi-pap, she should have notified him. During an interview with the Administrator on [DATE] at 12:54 PM, she stated R1 should not have been admitted back to the facility without the Bi-pap being in house. The Administrator stated the facility had since made sure a policy was in place to prevent residents from returning to the facility without the needed equipment. She stated R1's Bi-pap equipment had not arrived at the facility prior to his death.

Based on observation, interview and record review it was determined the facility failed to ensure the resident's environment remained as free from accident hazards as is possible related to the use of air mattresses for three (3) of three (3) sampled residents who utilized air mattresses, (Resident #2, Resident #6 and Resident #7), out of a total of eight (8) sampled residents. Interviews and record review revealed staff placed an air mattress on Resident #2's bed on 12/23/2020, to facilitate wound healing. The resident's record revealed he/she had a fall from the bed on 12/28/2020, and review of the facility fall investigation indicated staff determined the resident's air mattress, with no bolsters, was the causative factor of the resident's fall. However, there was no evidence the facility had systems in place to ensure air mattress settings were monitored, to ensure they were on the appropriate settings according to the resident's weight, in attempts to prevent accidents in the facility. In addition, observations of Resident #6's and Resident #7's air mattress settings on 01/07/2021, revealed the settings were not set for the resident's current weight. The findings include: Interview with the Director of Nursing (DON), on 01/07/2021 at 2:10 PM, revealed the facility had no policy related to the use of air mattresses in the facility. However, the DON stated air mattress settings were determined by the resident's weight, in attempts to ensure the mattresses were safely utilized by residents in the facility. She also stated staff should monitor the air mattress settings every shift, to ensure they were on the right setting, according to the resident's weight, and she thought this monitoring was occurring in the facility. Per the DON, she was unaware that air mattress settings weren't being monitored in the facility, until the surveyor inquired about the facility process. Review of the manufactures guidelines for the air mattresses utilized in the facility last revised on 03/15/2016, revealed the pressure of the mattress should be adjusted by choosing the patient's corresponding weight setting. The guidelines provided no direction in ongoing monitoring of air mattress settings utilized in the facility. Interview with the Maintenance Director, on 01/07/2021 at 12:30 PM, revealed he set up air mattresses in the facility, after obtaining the resident's current weight from nursing staff in the facility. However, he stated he never reevaluated the air mattresses, once the resident was placed on the air mattress, to ensure the appropriate settings were maintained for facility residents. Review of Resident #2's medical record revealed the resident was admitted on [DATE] with current diagnoses, which included Contracture of muscle to the right and left lower legs, right and left ankles, and bilateral feet. Resident #2's [DIAGNOSES REDACTED]. Review of Resident #2's most recent quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed he/she was interviewable with a brief interview for mental status score (BIMS) of eleven (11). The MDS also indicated the resident had functional limitations to both lower extremities, and was always incontinent of bowel and bladder. Further review of the MDS revealed the resident had no history of falls, and he/she required extensive assistance of two (2) staff members for bed mobility and was totally dependent on two (2) staff members for toileting needs. Review of Resident #2's physician orders [REDACTED]. Review of the resident's Treatment Administration Record (TAR) dated December, 2020 indicated staff implemented an air mattress to the residents bed on 12/23/2020; however, no weight settings were indicated on the resident TAR. The TAR did include a nurse's signature daily on the nite shift. Review of Resident #2's Fall Investigation Scene Report dated 12/28/2020 (no time indicated) revealed an air mattress was in use at the time of the fall and the resident was observed in supine position with upper half of body under the bed with legs sticking out. The report also stated staff determined that resident with air mattress no bolsters caused resident to fall out of bed. The report also indicated staff implemented an air mattress with bolsters, to prevent further falls for the resident. Review of Resident #2's progress notes indicated on 12/28/2020 staff went to administer an as needed pain medication to the resident at 12:55 AM and the resident was noted to be in supine position with upper half of his/her body under the bed, and the residents' legs were sticking out from under the bed. Resident informed staff I was going to potty. The medical record also indicated Resident #2 had experienced a change in condition and was transferred and later admitted to the hospital on [DATE]. Resident #2 had not returned to the facility during the investigation; therefore, no observations or interview were completed. Interview with Licensed Practical Nurse (LPN) #6, on 01/12/2021 at 11:50 AM, revealed she was assigned to care for Resident #2 when the resident had a fall from the bed on 12/28/2020. She stated an air mattress was in use to Resident #2's bed when he/she was observed in the floor. The LPN stated she didn't look at the resident's air mattress settings to ensure the settings were appropriate for the resident, when the fall occurred, because she had never been trained to monitor the settings. Interview with Registered Nurse (RN) #1, on 01/05/2021 at 3:20 PM, revealed she cared for Resident #2, as well as other residents in the facility, and had never been trained to monitor to ensure the mattresses were set appropriately according to the resident's weight. She stated there was a place on the resident's treatment administration record (TAR) which indicated the residents utilized an air mattress, which required a nurse's signature; however, the RN stated the signature only indicated the mattress was in use, not what the settings were on for the residents. Interview with LPN #3, also the Unit Manager (UM), on 01/12/2021 at 12:30 PM, revealed LPN #3 was the Unit Manager on the unit where Resident #2 resided when the fall occurred on 12/28/2020, and also where Resident #6 and #7 resided. The LPN stated the facility had no monitoring process in place to ensure air mattresses were on the appropriate setting, according to the resident's weight, to assist in ensuring resident's safety in the facility. The UM stated she knew air mattresses could be a safety hazard because they could pop a resident out of the bed, if not utilized appropriately; however, the LPN stated she not been trained to monitor mattress settings, or to ensure staff were monitoring air mattress settings for residents in the facility. 2. Review of Resident #6's medical record revealed the facility initially admitted the resident on 06/09/2015 with [DIAGNOSES REDACTED]. Further review of the resident's record revealed he/she was readmitted to the facility, after an acute hospital stay on 12/24/2020. Review of the hospital record indicated the residents discharge [DIAGNOSES REDACTED]. Review of Resident #6's five (5) day scheduled Minimum Data Set (MDS) assessment dated [DATE] revealed he/she was totally dependent on two (2) staff members for bed mobility and toileting, and staff determined Resident #6 was interviewable, with a brief interview for mental status (BIMS) score of twelve (12). The assessment also indicated Resident #6 had one (1) Unstageable pressure sore, which was present on reentry to the facility. The assessment indicated the resident had not experienced any falls. Review of Resident #6's most current weight revealed he/she weighed 175 pounds on 01/07/2021. Review of Resident #6's physician orders [REDACTED]. Review of Resident #6's TAR indicated a nurse's signature was observed on the day and night shift (twice daily) that an air mattress was utilized to the resident's bed. However, there was no evidence of what the appropriate setting for his/her air mattress had been determined to be, or that staff had been monitoring the residents air mattress to ensure it was on the appropriate setting. Observations of Resident #6 on 01/07/2021 at 12:50 PM revealed an air mattress was on his/her bed and was in use. Continued observations revealed his/her air mattress settings, was set for the weight of two-hundred (200) pounds, which was 25 pounds more than the resident weighed on 01/07/2020 (the same date as the observation). An interview with Resident #6 on 01/07/2021 at 12:50 revealed he/she had no care concerns or any complaints related to the use of an air mattress in the facility. Interview with Licensed Practical Nurse (LPN) #6, on 01/12/2021 at 11:50 AM, revealed she had cared for Resident #6 when an air mattress was utilized for the resident. However, she was not trained to ensure air mattress settings were on the appropriate settings, in efforts to ensure residents safety related to the use of air mattresses in the facility. Interview with Registered Nurse (RN) #1 on 01/05/2021 at 3:20 PM revealed she cared Resident #6, which utilized air mattresses, and had never been trained to monitor to ensure the mattresses were set appropriately according to the resident's weight. She stated there was a place on the resident's treatment administration record (TAR) which indicated the residents utilized an air mattress, which required a nurse's signature; however, the RN stated the signature only indicated the mattress was in use, not what the settings were on for the residents. 3. Review of Resident #7's medical record revealed the facility admitted the resident on 03/30/2020 with diagnoses, which included Muscle Weakness and Anxiety Disorder. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed he/she required extensive assistance of two (2) staff members, with bed mobility and toileting. Resident #7 was assessed to be interviewable with a BIMS score of eleven (11). The MDS indicated he/she had not experienced any falls. Review of Resident #7's physician orders [REDACTED]. Review of the resident's TAR dated December, 2020 and January, 2021, revealed an air mattress was in use to the resident's bed; however, no weight settings were indicated on the TAR. Review of Resident #7's recent weights revealed on 01/07/2021, the resident weighed 181 pounds. Observations of Resident #7 on 01/07/2021 at 12:55 PM revealed an air mattress was in use on the resident's bed. Continued observations revealed the resident's air mattress settings were set for the weight of 200 pounds, which was 19 pounds more than the resident weighed on 01/07/2020 (the same day as the observation). An interview with Resident #7 on 01/07/2021 at 12:55 PM revealed he/she had no care concerns or any complaints related to the use of an air mattress in the facility. Interview with Licensed Practical Nurse (LPN) #6, on 01/12/2021 at 11:50 AM, revealed she had cared for Resident #7 when an air mattress was utilized for the resident. However, she had never been trained to ensure air mattress settings were on the appropriate settings, in efforts to ensure residents safety related to the use of air mattresses in the facility. Interview with Registered Nurse (RN) #1 on 01/05/2021 at 3:20 PM revealed she cared Resident #7, which utilized air mattresses, and had never been trained to monitor to ensure the mattresses were set appropriately according to the resident's weight. She stated there was a place on the resident's treatment administration record (TAR) which indicated the residents utilized an air mattress, which required a nurse's signature; however, the RN stated the signature only indicated the mattress was in use, not what the settings were on for the residents. Interview with LPN #3, 01/12/2021 at 12:30 PM, also the Unit Manager (UM) revealed the facility had no monitoring process in place to ensure air mattresses were on the appropriate setting, according to the resident's weight, to assist in ensuring resident's safety in the facility. The UM stated she knew air mattresses could be a safety hazard because they could pop a resident out of the bed, if not utilized appropriately; however, the LPN stated she not been trained to monitor mattress settings, or to ensure staff were monitoring air mattress settings for residents in the facility. Interview with the DON, on 01/07/2021 at 2:10 PM, revealed Resident #2's fall that occurred on 12/28/2020 was discussed on 12/29/2020 and staff determined the causative factor was the air mattress not having bolsters. However, she stated during the investigation staff failed to identify that the resident's air mattress settings were not being monitored at the time the resident's fall. The DON stated she thought air mattress settings were being monitored every shift by nursing staff to ensure they were on the appropriate setting. She stated she wasn't aware and had not identified that air mattress settings weren't being monitored in the facility, until the surveyor inquired about the facility process. Interview with the Administrator, on 01/12/2021 at 4:50 PM, revealed she was unaware that air mattress settings weren't being monitored to ensure they were on the appropriate setting. However, the Administrator stated staff should have been monitoring the air mattresses in the facility to ensure they were on the appropriate settings, according to the resident's weight.

Based on interview, record review, and review of the facility policy, it was determined the facility failed to review and revise a resident's comprehensive person-centered care plan with interventions to monitor and/or treat newly identified pressure ulcers for one (1) of eight (8) sampled residents (Resident #6). Interviews and record review revealed on 12/24/2020, Resident #6 was readmitted to the facility with an unstageable (ulcer covered with slough or eschar) pressure sore on his/her coccyx. However, there was no evidence the facility reviewed/revised the residents care plan related to his/her newly identified pressure ulcer until 12/29/2020 (five (5) days after readmission). The findings include: Review of the facility policy titled Care Plans-Comprehensive, dated 08/01/2013, revealed an individualized comprehensive care plan that included measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs should be developed for each resident. The policy also stated resident assessments were ongoing and care plans would be revised as information about the resident and the resident's changing condition were identified. According to the policy, the care planning/interdisciplinary team was responsible to ensure care plans were reviewed and updated when there was a significant change in the resident's condition and when a resident was readmitted to the facility after a hospital stay. Review of Resident #6's medical record revealed the facility initially admitted the resident on 06/09/2015 with diagnoses, which included Muscle Weakness and [MEDICAL CONDITION]. Continued review of Resident #6's record revealed he/she was readmitted to the facility on [DATE], after an acute hospital stay. Review of Resident #6's hospital record revealed the resident's discharge [DIAGNOSES REDACTED]. Review of Resident #6's five (5) day scheduled Minimum Data Set (MDS) assessment dated [DATE] revealed he/she was always incontinent of bowel and bladder, and he/she was totally dependent on two (2) staff members for bed mobility and toileting. The assessment also indicated Resident #6 was interviewable, with a brief interview for mental status (BIMS) score of twelve (12). The MDS also revealed Resident #6 was at risk for developing pressure sores and the MDS indicated he/she had one (1) unstageable pressure sore that was present on reentry to the facility. Review of Resident #6's medical record revealed the resident was readmitted to the facility on [DATE] at 3:06 PM and a Nursing Admission Assessment was completed by facility staff. The assessment indicated Resident #6 had pressure to his/her coccyx however, there was no measurements or assessment information recorded on the readmission assessment related to the residents wound. Continued review of the residents record revealed a skin and wound evaluation note dated 12/25/2020 at 12:02 AM (approximately 9 hours after readmission) indicated Resident #6's wound measurements were as follows: 27.4 centimeters (cm) in length and 8.5 cm in width. The wound evaluation also indicated 70% of Resident #6's wound was covered with eschar (dead tissue). According to the wound evaluation, Resident #6's wound was assessed to be unstageable. Review of Resident #6's most recent wound evaluation revealed on 01/05/2021 the facility wound nurse assessed his/her wound to be a stage four (4) and the measurements of his/her wound were as follows: 13.1 cm in length, 4.5 cm by 3.9 in width and 4.2 cm in depth. Observations of Resident #6's pressure sore was attempted on 01/11/2021 at 4:00 PM; however, the resident refused. An interview related to care and treatment of [REDACTED]. Review of Resident #6's comprehensive care plan revealed staff identified the resident had actual skin integrity impairment and a stage four (4) pressure area to his/her coccyx. However, the care plan provided no evidence of when the resident's care plan was reviewed/revised related to his/her newly identified pressure ulcer. Interview with Minimum Data Set (MDS) nurse #1, on 01/12/2021 at 2:05 PM, revealed she reviewed/revised Resident #6's care plan to include his/her newly developed pressure sore on 12/29/2020 (five (5) days after readmission). The MDS nurse was unable to recall how she became aware of the residents wound which triggered the review/revision of his/her care plan on 12/29/2020. She stated staff were required to do a paper care plan when residents were readmitted to the facility to identify any changes in the resident's condition. She also stated a paper care plan should have been completed when Resident #6 returned to the facility with a newly identified pressure sore on 12/24/2020. The MDS nurse also stated she reviewed staff nurses paper care plans after residents were readmitted , as well as physician orders daily Monday-Friday as a tool to ensure the residents comprehensive care plans were reviewed and revised when changes in their condition was identified. The MDS nurse stated she didn't recall reviewing a paper care plan for Resident #6 after he/she was readmitted to the facility on [DATE]. Interview on 01/12/2021 at 12:30 PM, with Licensed Practical Nurse (LPN) #3, also the Unit Manager (UM) where Resident #6 resided, revealed she doesn't really look at the residents care plans. However, she stated changes in resident's conditions should be care planned when they are identified but the UM wasn't sure if staff nurses should have reviewed/revised Resident #6's care plan related to his/her pressure sore when the resident was readmitted on [DATE]. Interview with Licensed Practical Nurse (LPN) #6, on 01/12/2021 at 11:50 AM, revealed she readmitted Resident #6 back to the facility, and identified that the resident had a pressure sore to his/her coccyx on 12/24/2020. The LPN stated this was the first admission/readmission she had completed at the facility and also stated she had not been trained to review/revise care plans when changes in a residents' condition was identified. Interview with RN #3, on 01/11/2021 at 9:55 PM, revealed she worked the 6:30 PM-7:00 AM shift on 12/24/2020 when Resident #6 was readmitted to the facility. The RN stated she assisted in completing the residents readmission paperwork; however, stated she didn't recall reviewing/revising the residents care plan related to his/her newly identified pressure sore, but stated she should have. Interview with the DON, on 01/12/2021 at 4:30 PM, revealed she had been the DON for approximately one (1) month and thought staff had been trained to complete care plan review/revisions when changes in resident condition was identified on readmission into the facility. She also stated Resident #6's care plan should have been reviewed/revised to address his/her pressure ulcer when the resident was readmitted to the facility on [DATE]. Interview with the Administrator, on 01/12/2021 at 4:50 PM, revealed she would have expected staff to review/revise Resident #6's care plan when he/she was readmitted to the facility with a newly developed pressure ulcer on 12/24/2020.

Based on record review, interview and facility policy review, it was determined that the facility failed to ensure the resident's status was accurately assessed on the Minimum Data Set (MDS) for one (1) of eight (8) sampled residents (Resident #8). The facility failed to accurately assess Resident #8's falls on the Quarterly MDS completed on 12/09/2020. The findings include: Review of the facility policy titled, Attestation to Accuracy of the Resident Assessment, dated 08/01/2013, revealed all personnel who complete any portion of the MDS assessment, tracking form, or correction request form must sign a hard copy of each assessment certifying the accuracy of that portion of the assessment. Review of Resident #8's clinical record revealed the facility admitted the resident on 02/01/2018 with [DIAGNOSES REDACTED]. Review of Resident #8's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was interviewable with a Brief Interview of Mental Status Score (BIMS) of 15. Review of incident reports/investigations revealed Resident #8 fell on [DATE] at 11:05 AM while attempting to reach the television remote that had fallen onto the floor. Resident #8 was found sitting on the floor in front of the recliner and was assessed to have no injuries. Resident #8 also had an unwitnessed fall on 12/02/2020 at 3:56 PM while getting up from his/her recliner and was found sitting in the floor in front of the recliner and assessed to have no injuries. Review of Resident #8 Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed an inaccurate representation of the resident's status related to falls. No falls were captured on Resident #8's quarterly MDS assessment. According to the MDS, the resident had no falls since the prior annual assessment completed on 11/18/2020. However, as noted above Resident #8 experienced falls on 12/01/2020 and 12/02/2020. Interview with MDS Coordinator #2, on 01/11/2021 at 11:15 AM, revealed that the Quarterly MDS assessment for Resident #8 was inaccurate. MDS Coordinator #2 stated that Resident #8's falls (12/01/2020 and 12/02/2020) should have been captured during the observation period and that the inaccuracy must have been an oversight. She further stated that MDS Coordinator #1 signs off on all final MDS assessments to ensure they are accurate. Interview with MDS Coordinator #1 on 01/12/2021 at 2:00 PM revealed that the quarterly MDS assessment for Resident #8 was inaccurate. MDS Coordinator #1 stated that she signed off on all quarterly resident MDS assessments. MDS Coordinator #1 further stated that the failure to capture Resident #8's falls on 12/01/20 and 12/02/20 on his/her quarterly MDS assessment was an oversight. Interview with the Director of Nursing (DON), on 01/12/2021 at 4:30 PM, revealed morning meetings were held daily and new orders and/or incident reports for residents were discussed. The DON also stated that the MDS Coordinator #1 attended the morning meetings, in order, to get updated resident information. The DON stated the MDS nurse verified the accuracy when she signed off each MDS. Per the DON, the morning meeting discussions and MDS sign offs were the only process in place to ensure MDS accuracy. Interview with the Administrator, on 01/12/2021 at 4:55 PM, revealed the facility conducted daily morning meetings and during these meetings new resident orders, incident reports and/or changes in resident condition were discussed. Per the Administrator, the morning team meetings are in place within the facility to ensure accuracy of the MDS.

Based on interview, medical record review and review of the facility policy, it was determined the facility failed to notify the resident representative of a change in condition in one (1) of eight (8) sampled residents (Resident #4). Resident #4 experienced a change in condition that resulted in a change in the resident's diet to puree with nectar thick liquids; however, there was no evidence the facility notified the resident's representative of the change in condition or change in diet. The findings include: Review of the facility policy titled, Change in a Resident's Condition, revealed the facility would promptly notify the resident, his/her attending physician, and representative of changes in the resident's medical/mental conditions and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Further review of the policy revealed a significant change of condition was a decline or improvement in the resident's status, and unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse would notify the family or the resident's representative when there was a significant change in the resident's physical, mental or psychosocial status. Review of the medical record revealed the facility admitted Resident #4 on 09/26/2018 with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was not interviewable with a Brief Interview of Mental Status (BIMS) score of five (5). Review of Resident #4's physician orders revealed an order to change the resident's diet to nectar thick liquid and a puree diet on 07/20/2020. Further review of progress notes revealed on 07/20/2020, LPN #4 expressed therapy concerns (the concerns were not specific) to the Advanced Practice Registered Nurse (APRN) and requested Resident #4 be downgraded to a puree diet with nectar thick liquids. The APRN gave a verbal order for the diet change. Further review of the record revealed no further documentation of the change in condition that led to the diet change. A therapy screening was requested that noted the change in Resident #4's condition or the concern, which lead to the diet change recommendation; however, no screening note was provided. Review of Resident #4's progress notes dated 07/20/2020, revealed the resident was placed on a nectar thickened liquid and puree diet. Further review of the resident's medical record revealed [REDACTED]. Interview with LPN #4, on 01/11/2021 at 2:25 PM, revealed that when a change in resident condition occurred, it was documented in the resident's progress notes and the representative was notified. The LPN stated she was working and caring for Resident #4 when the order was received on 07/20/2020 to change the resident's diet to puree with nectar thick liquids. The LPN stated it was her responsibility to notify the resident representative on 07/20/2020. Per the LPN, she could not remember if she notified Resident #4's representative of the decline and change in diet. LPN #4 stated if she had notified the resident representative, she would have documented the notification in the resident's progress notes. However, as noted above, review of the progress notes revealed no evidence the resident representative was notified of the change in condition or diet. Interview with Resident #4's Representative, on 01/10/2021 at 2:30 PM, revealed she was unaware of Resident #4's diet change on 07/20/2020 or of any change in the resident's condition. The Representative stated the only notifications she received from the facility were phone calls related to changes in skin care treatments. Resident #4's representative also stated that it was not until November 2020 that she discovered that Resident #4's diet had changed to a puree diet with nectar thickened liquids. Interview with the Director of Nursing (DON), on 01/11/2021 at 4:30 PM, revealed that facility nursing staff were responsible for notifying family and/or resident representatives of changes in condition. The DON stated nursing staff were also responsible for documenting the resident change in condition in the medical record. The DON stated that any significant change or new order should be verified in the morning meeting and nurses are expected to document changes as well as physician and resident representative notification. Interview with the Administrator, on 01/12/2021 at 4:55 PM, revealed the facility nursing staff is expected to notify the family or representative of changes in a resident's condition. The Administrator also stated nursing staff are expected to document representative notification in the resident's medical record.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (1) of eight (8) sampled residents (Resident #6). Interviews and record reviews revealed Resident #6 was readmitted to the facility on [DATE] with an unstageable (ulcers covered with slough or eschar) pressure sore on his/her coccyx. However, there was no evidence the facility obtained orders to provide treatment to the resident's pressure sore, until 12/28/2020 (four (4) days after readmission). The findings include: Review of the facility policy titled Wound Protocol, dated 01/01/2016, revealed a wound care summary would be initiated for any resident who has been assessed to have a wound, and weekly updates would be completed until the residents wound has healed. The policy did not direct staff to inform the resident's physician or to obtain treatment orders of an identified pressure sore for residents in the facility. However, an interview with the Administrator on 01/12/2021 at 4:50 PM revealed when staff identified pressure sores in the facility, they were expected to contact the physician and obtain orders to treat the pressure sore at that time. Review of Resident #6's medical record revealed the facility initially admitted the Resident #6 on 06/09/2015 with [DIAGNOSES REDACTED]. Further review of the resident's record revealed he/she was readmitted to the facility, after an acute hospital stay on 12/24/2020. Review of Resident #6's hospital record revealed the resident's discharge [DIAGNOSES REDACTED]. Further review of Resident #6's hospital record revealed no evidence the hospital had measured Resident #6's unstageable pressure sore to his/her coccyx. Review of Resident #6's five (5) day scheduled Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was always incontinent of bowel and bladder, and was totally dependent on two (2) staff members for bed mobility and toileting. The MDS indicated Resident #6 was interviewable, with a brief interview for mental status (BIMS) score of twelve (12). The assessment also revealed the resident was at risk for developing pressure sores and the assessment indicated he/she had one (1) Unstageable pressure sore, which was present on reentry to the facility. Further review of Resident #6's record revealed staff readmitted him/her, and completed a Nursing Admission Assessment on 12/24/2020 at 3:06 PM; even though, the assessment indicated Resident #6 had pressure to his/her coccyx, there was no measurements or assessment information recorded on the readmission assessment related to his/her wound. However, review of a skin and wound evaluation note revealed on 12/25/2020 at 12:02 AM (approximately 9 hours after readmission) staff documented Resident #6's wound measurements as follows: 27.4 centimeters (cm) in length and 8.5 cm in width. The wound evaluation also indicated 70% of Resident #6's wound was covered with eschar (dead tissue). Per the wound evaluation, the resident's wound was assessed to be unstageable. Review of the most recent wound evaluation for Resident #6 revealed on 01/05/2021 the facility wound nurse assessed the residents wound to be a stage four (4) and his/her wound measurements were as follows: 13.1 cm in length, 4.5 cm X 3.9 in width and 4.2 cm in depth. Review of Resident #6's physician orders revealed no evidence an order was obtained to treat and/or monitor Resident #6's pressure sore until 12/28/2020 (4 days after readmission) at 11:41 AM. Continued review of Resident #6's physician orders indicated staff were directed to cleanse unstageable wound to coccyx with normal saline, pat dry, skin prep to peri wound and apply Santyl to necrotic area of wound, apply 4X4, cover with foam dressing. The medical record provided no evidence treatment was provided to Resident #6's pressure sore until 5:55 PM on 12/28/2020. Interview with Licensed Practical Nurse (LPN) #3, on 01/12/2021 at 12:30 PM, also the Unit Manager (UM) where Resident #6 resided, revealed she worked on 12/24/2020 and was aware that Resident #6 was being readmitted with a pressure sore. However, the UM stated she left the facility before the resident returned to the facility on [DATE] and did not report back to work until 12/28/2020. She stated when she reported back to work on 12/28/2020 she found out there was an issue with treatment orders therefore, she contacted the residents' physician on 12/28/2020 and obtained treatment and monitoring orders for his/her pressure sore. The UM also stated she found out there was issues with contacting Resident #6's provider to obtain orders when he/she was readmitted on [DATE] and also stated she felt like the holidays was a factor. The UM stated if staff were unable to obtain treatment orders for newly identified pressure sores, they should have contacted the Medical Director and initiated treatment for [REDACTED]. Observations of Resident #6's pressure sore was attempted on 01/11/2021 at 4:00 PM; however, the resident refused. An interview related to care and treatment of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #6, on 01/12/2021 at 11:50 AM, revealed she readmitted Resident #6 back to the facility on [DATE], and she was aware that the resident had a pressure sore to his/her coccyx when she readmitted the resident back to the facility. The LPN stated she worked the 6:30 AM-7:00 PM shift on 12/24/2020 and had attempted to reach the Nurse Practitioner (NP) to inform her of the resident's pressure sore, (unable to recall exact times), and to obtain orders to treat the area; however, the NP did not return her call before the end of her shift. LPN #6 stated she was not trained on what actions to take, if she was unable to reach the residents primary care provider when needed. Therefore, the LPN stated she informed the oncoming nurse (Registered Nurse {RN} #3) of the need for treatment orders for Resident #6's pressure sore. LPN #6 also stated she was not trained on how to evaluate, assess or stage pressure sores in the facility. Interview with RN #3, on 01/11/2021 at 9:55 PM, revealed she worked the 6:30 PM-7:00 AM shift on 12/24/2020 when Resident #6 was readmitted to the facility. The RN stated LPN #6 informed her that treatment orders were needed for the resident's pressure sore and therefore she contacted the NP. The RN was unable to recall what time she contacted the NP; however, stated it was when I came on shift. The RN stated the NP was informed that the resident had returned to the facility with a pressure sore and the NP informed the RN that she didn't know what to order, and she would be there on Monday (3 days away) to look at it, or to have the wound nurse look at it. The RN stated she was unable to obtain orders to treat the resident's unstageable pressure sore, and acknowledged that having a resident in the facility with a pressure sore and no orders to treat or monitor the wound was not a standard of practice. RN #3 also stated she had not been trained how to evaluate, assess or stage pressure sores in the facility. The RN stated she felt if she was able to provide more information to the NP related to the residents wound, it may have facilitated orders to be received and treatment provided to the residents pressure sore sooner. Interview with the facility Wound Nurse, RN #2 on 01/11/2021 at 4:05 PM, revealed staff were expected to assess and notify the physician to obtain treatment orders for pressure sores when they are identified. The RN also stated she had not evaluated Resident #6's wound until 12/29/2020 (5 days after admission) because she had been off work due to illness in her family around the Christmas holiday. She stated when she assessed the residents wound on 12/29/2020, it was an unstageable area; however, when she reevaluated the residents wound on 01/05/2021 the eschar (dead tissue) had been removed with the treatment provided, and therefore she was able to determine Resident #6's pressure sore to be a stage four (4) wound. Interview with the NP on 01/12/2021 at 4:15 PM revealed staff informed her on 12/24/2020 (unable to recall exact time) that Resident #6 had returned to the facility with a pressure sore, and stated she had not provided staff with orders to treat the residents pressure sore. The NP stated she don't go by what they tell me, I prefer seeing it in reference to giving verbal orders to treat pressure sores, and also stated she didn't want to give treatment orders without looking at the wound. The NP also stated she informed staff that the wound nurse could also evaluate the resident's pressure sore, and make recommendations on treatment; however, the NP was not aware that the wound nurse was off during that time due to family illness. Interview with the DON on 01/12/2021 at 4:30 PM revealed she had been the DON for approximately one (1) month and thought staff had been trained to assess pressure sores in the facility. The DON stated she expected staff to inform the physician and/or the NP when a resident developed or was readmitted with a pressure ulcer. Per the DON, she expected staff to obtain treatment orders and implement a monitoring process, no longer than twenty-four hours after pressure sores were identified in the facility. The DON also stated she felt like the time taken to obtain treatment orders for Resident #6's pressure sore was okay because it was Christmas Eve and we weren't here. She also stated Resident #6's wound was an unstageable wound on readmission and was later assessed to be a stageable wound and she wasn't sure treatment would have mattered to the residents pressure sore, however stated a dressing would have been better. The DON also stated the facility had no process in place to direct staff on what actions they should take, if they were unable to reach the residents primary care provider. Interview with the Administrator on 01/12/2021 at 4:50 PM revealed she would have expected staff to contact Resident #6's primary care provider and obtain treatment and monitoring orders for the residents pressure sore when he/she was readmitted to the facility on [DATE] as required.

Based on interview, record review and review of the facility policy, it was determined that the facility failed to ensure the resident representative was informed and/or notified of scheduled resident care plan meetings for two (2) of eight (8) sampled residents (Resident #3 and Resident #4). Interviews and record reviews revealed no evidence that Resident #3 and Resident #4's representatives were informed of care plan meetings, to ensure they were included in the development and implementation of the resident's person centered care plan. The findings include: Review of the facility policy titled, Care Planning-Interdisciplinary Team, dated 08/01/2013, revealed the resident, the resident's family and/or resident's legal representative/guardian or surrogate were encouraged to participate in the development of and revisions to the resident's care plan. The policy also stated every effort would be made to schedule care plan meetings at the best time of the day for the resident and family. (a)Review of Resident #4's medical record revealed the facility admitted the resident on 09/26/2018 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed resident was not interviewable with a Brief Interview for Mental Status (BIMS) score of five (5). Review of the Care Plan Meeting Calendar for June-November 2020 revealed care plan meetings were held for Resident #4 on 07/22/2020 at 2:00 PM and on 10/14/2020 at 1:45 PM. Review of Resident #4's progress notes for July-November 2020 revealed a Social Service note for 07/22/2020 that stated, Care plan for resident, family not in attendance today and a Social Service note for 10/14/2020 that stated, Care plan for resident, family not in attendance today. Interview with Resident #4 Representative, on 01/10/2021 at 2:30 PM, revealed no notification letters were received to inform her of the care plan meetings. The Representative also stated she received no calls alerting her to the care plan meetings for Resident #4. She further stated that in November 2020 she received a call from the facility about Resident #4 having weight loss. The Representative stated the facility asked if she would like to assist with feeding related to the resident's weight loss, but no care plan meetings were mentioned. (b)Review Resident #3's medical record revealed the facility admitted the resident on 09/13/2019 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed the resident was interviewable with a Brief Interview for Mental Status score of fifteen (15). Review of the facility Care Plan Meeting Calendars for months of June-December 2020 revealed Care Plan meetings were held for Resident #3 on 08/05/2020 at 1:15 PM and on 12/02/2020 at 1:00 PM. Review of Resident #3 progress notes for August-December 2020 revealed no documentation that the resident representative was notified of the care plan meetings. Interview with Resident #3's Representative, on 01/12/2021 at 12:10 PM, revealed she had not received notification letters of care plan meetings in about a year. The Representative stated the last call she received about a care plan conference was early spring 2020. Resident #3 Representative further stated that since the pandemic she had received no calls about care plan meetings or when she could meet, when she should call, or when the facility would call her for a care plan conference. Interview with MDS Coordinator #2, on 01/07/2021 at 2:20 PM, revealed a list of residents requiring a care plan meeting was compiled each month by her and sent in a calendar format to the Human Resources Director for letters to be mailed to each resident representative. The MDS Coordinator #2 stated that each month a copy of the care plan calendar she completes is given to the Human Resource Director in the front office and the Human Resource Director then sends invitation letters to the families, also the Social Services Director calls them. When asked if she recalled the last care plan meeting for Resident #3, she stated she was unsure of the date of Resident #3's last meeting, but it would have been in December 2020. Interview with the Receptionist, on 01/07/2021 at 2:50 PM, the MDS Coordinator #2 sent a calendar to her each month listing which residents needed letters sent for care plan meetings. Each name was highlighted on the calendar to indicate each family was mailed a letter and the list was then given back to the Human Resource Manager for confirmation. When asked if there was a follow up phone call or way to know the representatives received the letter, the Receptionist responded, We didn't follow up to make sure the letters were received by the families. They are not sent certified and we don't call them to see if they were received. Interview with the Human Resources Director, on 01/07/2021 at 2:50 PM, revealed no follow up process was in place to ensure resident representatives were receiving the letter notifications of care plan meetings. When asked to explain the process used to notify resident representatives of care plan meetings and her role, the Human Resource Director stated she got the schedule from the MDS Coordinator #2 each month, the Receptionist then mailed out the letters to the resident representatives, and the names were highlighted as the letters are sent out. When asked if there was a process to confirm the letters were received or if there was a follow up, she stated that they don't follow up with phone calls, but the social worker would call the resident representative if the resident was a late add on to the list after letters were sent. Interview with the Social Services Director, on 01/07/2021 at 2:45 PM, revealed MDS Coordinator #2 gave her a copy of the care plan calendar each month. When asked to explain the notification process and her role, the Social Services Director stated she was given a copy of the care plan calendar each month and the Receptionist sent care plan notification letters out to the families. The Social Services Director also stated she notified the residents in person and gave them a copy of the notification letter. The Social Services Director stated there was no verification system in place to ensure the representative received the notification letter and she stated the letters were not sent as certified letters. When asked if she spoke to Resident #3's representative in December 2020, she responded, I spoke to Resident #3's representative in November 2020, but I am unsure if I spoke to him/her in December. The Social Services Director stated she does not keep a record of when she speaks with resident representatives, unless she had made a progress note that she spoke to the resident representative. Interview with the Director of Nursing (DON), on 01/12/21 at 4:30 PM, revealed a monthly Care Plan Calendar was sent to the receptionist and letters were sent out based on what residents were on the calendar. The DON stated there was no follow up in place to ensure the resident representatives received the care plan notification letters. Interview with the Administrator, on 01/12/20 at 4:55 PM, revealed notification letters were sent to resident representatives based on the monthly Care Plan Meeting Calendar to notify the representatives of the care plan meetings. However, the Administrator stated the facility did not have a system to verify notification.

Based on observation, interview, and review of facility policy, it was determined the facility failed to provide housekeeping services necessary to maintain a clean, comfortable, and homelike environment on one (1) of two (2) resident floors. Observations on 11/30/2020 at 10:15 AM, 11:48 AM and 3:00 PM, revealed the hallway floors were dirty and soiled on unit two of the second floor of the facility. The findings include: Review of the facility policy, Housekeeping Services, dated 06/06/2003, revealed in resident care areas, cleaning of non-carpeted floors and other horizontal surfaces, will be done daily and more frequently if spillage or visible soiling occurs. Observation on 11/30/2020 at 10:15 AM, revealed a dried pink sticky substance in front of room [ROOM NUMBER], a dried brown substance in front of room [ROOM NUMBER], a dried brown sticky substance in front of room [ROOM NUMBER], a dried pink sticky substance in front of room [ROOM NUMBER], a dried brown sticky substance in front of room [ROOM NUMBER], a dried yellow liquid in front of room [ROOM NUMBER], and a foamy wet white substance in front of room [ROOM NUMBER]. Observation on 11/20/2020 at 11:48 AM and 3:00 PM revealed the soiled areas of the hallway were still present and had not been cleaned. Interview with State Registered Nurse Aide (SRNA) #2, on 11/30/2020 at 2:07 PM, revealed she was working on unit two of the second floor, and had identified some areas with dried substances on the floor. She further stated that often she was expected to clean up areas such as spills; however, she was unable to clean due to providing resident care. The SRNA stated she had not cleaned the soiled areas identified due to limited time. Interview with SRNA #3, on 11/30/2020 at 2:25 PM, revealed she had identified soiled substances on the floor; however, she had not cleaned the areas. She further revealed that housekeeping was responsible for cleaning the floors in the hallway; however, she had not seen housekeeping till around 12:00 PM. Interview with Administrator, on 11/30/2020 at 4:25 PM, revealed the regular housekeeper wasn't working, and they had not been able to find coverage. She further stated she had observed unit two prior to this interview and identified the hallway floors as being atrocious. Further interview on 12/01/2020 at 3:08 PM, revealed that she was aware the regular housekeeper was not available for work; however, was unable to get coverage to ensure the second floor was cleaned until approximately 1:00 PM - 2:00 PM.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to address the monitoring of hydration status for three (3) of twenty seven (27) sampled residents (Resident #174, #12, and #28). The findings include: Review of the facility's policy titled, Using The Care Plan, revised 08/01/2013, revealed the care plan would be used in developing the resident's daily care routines and would be available to staff who had the responsibility for the provision of care or services to the resident. 1. Review of a closed record for Resident #174 revealed the facility admitted the resident on 10/10/2013 with [DIAGNOSES REDACTED]. Review of Resident #174's care plan, revealed on 09/27/2018, the facility developed a care plan for the resident for hydration. Further review of the care plan, revealed interventions included to encourage fluids daily, keep water at bedside, monitor laboratory tests as ordered by the physician, administer medications as ordered by the physician, and to monitor intakes and outputs as ordered. Review of a Registered Dietician (RD) assessment dated [DATE], revealed Resident #174 had been assessed to require thirteen hundred and eighty six (1386) milliliters (ml) of fluid per day of fluid. Review of physician's orders [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was assessed to have severely impaired cognition. Further review of the MDS revealed the resident required the limited assistance of one (1) person for eating. Review of the fluid intake records for Resident #174, revealed the facility documented the resident had not met his/her fluid requirement on 09/01/2020 with 840 ml, 09/02/2020 with 960 ml, 09/03/2020 with 600 ml, 09/04/2020 with 720 ml, 09/05/2020 with 1200 ml, 09/06/2020 with 420 ml, 09/07/2020 with 840 ml, 09/08/2020 with 720 ml, 09/09/2020 with 840 ml, 09/10/2020 with 1080 ml, 09/11/2020 with 840 ml, 09/13/2020 with 960 ml, 09/15/2020 with 1080 ml, 09/16/2020 with 1080 ml, 09/17/2020 with 1080 ml, 09/18/2020 with 1080 ml, 09/20/2020 with 480 ml, 09/21/2020 with 1200 ml, 09/22/2020 with 480 ml, 09/23/2020 with 480 ml, 09/24/2020 with 840 ml, 09/25/2020 with 720 ml, 09/26/2020 with 180 ml, 09/27/2020 with 720 ml, 09/28/2020 with 502 ml, 09/29/2020 with 600 ml, 09/30/2020 with 1080 ml, 10/01/2020 with 840 ml, 10/02/2020 with 840 ml, 10/03/2020 with 100 ml, 10/04/2020 with 840 ml, 10/05/2020 with 210 ml, 10/06/2020 with 180 ml, 10/07/2020 with 540 ml, and 10/08/2020 with 180 ml. The fluid intake records for Resident #174 revealed the resident had not met daily fluid requirements for thirty seven (37) out of thirty eight (38) days. Review of the nurses notes for Resident #174, revealed an entry dated 10/05/2020 at 1:03 PM which stated resident very lethargic this morning, does awaken with some effort. Advanced Registered Nurse Practioner (ARNP) notified to evaluate the resident. The nurses note further revealed the ARNP ordered laboratory blood tests, a CBC (complete blood count) and BMP (basic metabolic panel) to be drawn on 10/06/2020. The nurses notes also revealed an entry dated 10/06/2020 at 3:17 PM, which revealed the laboratory tests completed for Resident #174 had critical results and the ARNP had been notified with new orders received to administer a 500 ml bolus of normal saline intravenously and then continue administering normal saline intravenously at 100 ml per hour for 2000 ml, and to hold [MEDICATION NAME] (diuretic) and [MEDICATION NAME] (medication to treat heart failure) for the resident for three (3) days, and to recheck a BMP (blood laboratory test) for the resident on 10/08/2020. The nurses note further revealed the resident's responsible party had been notified. Review of laboratory reports for Resident #174 dated 10/06/2020 at 5:19 AM, revealed the resident had a Blood Urea Nitrogen (BUN) level of 156 (normal 7-25 mg/dl); Creatinine level of 4.2 (normal 0.6-1.3 mg/dl); BUN/Creat Ratio of 37 (normal 6-25). Further review of Resident #174's laboratory reports dated 10/08/2020 at 7:32 AM, revealed the resident had a BUN of 126, Creatinine level of 3.6, and BUN/Creatinine Ratio of 35. Further review of Resident #174's nurses notes, revealed an entry dated 10/07/2020 at 3:03 PM, revealed the resident's physician had assessed the resident. A nurses note dated 10/08/2020 at 2:15 PM, revealed the ARNP saw the resident and due to the intravenous line being out and staff were unable to restart the intravenous line, the resident was sent to the acute care hospital. The nurses note further revealed the resident's laboratory tests revealed the resident still had dehydration. Interview conducted with State Registered Nursing Assistant (SRNA) #5 on 10/22/2020 at 10:15 AM, revealed she was required to review care plans at the beginning of every shift. The SRNA stated she was responsible for documenting the fluid intakes in the computer every shift. The SRNA stated she was required to notify the nurse if the resident was not eating or drinking as well. The SRNA stated Resident #174 had been declining and the nurses were aware. Interview conducted with SRNA #4 on 10/22/2020 at 10:20 AM, revealed she was required to review the care plan at the beginning of every shift. The SRNA stated she was required to document resident's fluid intake in the computer. The SRNA stated if the resident did not eat or drink well, she was required to notify the nurse. The SRNA stated the nurses were aware Resident #174 was not eating or drinking well. Interview conducted with Licensed Practical Nurse (LPN) #4 on 10/22/2020 at 10:45 AM, revealed she was not sure where to look to find what fluid requirements a resident required. The LPN stated she did not look daily to ensure residents were meeting their daily fluid requirements. The LPN stated the weekly nursing assessment which she completed on the computer automatically populated the fluid requirement needs of the resident and she was required to look back for the previous week. The LPN stated she probably should have notified the physician and the RD, but she had not and did not know why she had not. Interview conducted with LPN #1 on 10/22/2020 at 10:55 AM, revealed she was unable to state where fluid requirements were documented. The LPN stated she did not check resident's fluid requirements daily. The LPN stated she just asked the SRNAs if the resident was drinking okay. The LPN stated she was required to check the care plans at the beginning of every shift and was expected to follow it. Interview conducted with the MDS Coordinator on 10/23/20 at 3:00 PM, revealed. she was responsible for the development of resident's care plans. The MDS Coordinator stated she utilized physician's orders [REDACTED]. The MDS Coordinator stated Resident #174 had a care plan developed for hydration and staff were expected to follow the care plan. The MDS Coordinator stated staff were required to review care plans at the beginning of every shift prior to providing care for the residents. Interview conducted with the Corporate Nurse (CN) who was the liaison for the Director of Nursing (DON) who was unavailable due to sickness on 10/23/2020 at 3:05 PM, revealed staff were required to review care plans at the beginning of every shift and prior to providing care for the residents. The CN stated if the resident was not meeting the fluid requirements the physician would be notified.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents maintained sufficient fluid intake to maintain proper hydration and health for five (5) out of twenty seven (27) sampled residents (Resident #174, #12, #28, #72, and #55). The findings include: Review of the facility's policy titled, Hydration Fluid Volume Policy and Protocol, revised [DATE], revealed the facility would provide each resident with sufficient fluid intake to maintain proper volume and hydration for health. The policy revealed each resident's fluid requirements would be calculated by a Registered Dietician (RD) and re-evaluated based on the resident's needs. Review of the facility policy titled, Hydration Policy and Protocol, revision date ,[DATE], revealed Each resident will have a head to toe physical assessment by a licensed nurse upon admission including the evaluation for signs and symptoms of dehydration If a resident is assessed to show symptom of de-hydration they will have an interdisciplinary hydration assessment completed. Each resident must have an interdisciplinary hydration assessment completed within fourteen (14) days of admission. Reassessment will be done based on resident clinical status. The fluid requirement (estimated fluid need) for each resident is calculated by the registered dietician and re-evaluated based on resident's needs. The total of the estimated fluid need volume is offered via the meal trays, snacks, and water at bedside. In Addition: These risk factors for dehydration include, but are not limited to: a.) Residents with Foley Catheters, b.) Resident with gastrostomy tubes. c.) Resident receiving intravenous fluids, d.) residents who are on ordered fluid restriction. Abnormal laboratory test values will be reviewed and monitored as an indicator of dehydration along with physical assessment. Further review of the policy revealed under Interventions/Strategies to Maintain Hydration: 1. Ensure that resident receives daily required fluid intake. 1. A review of a closed record for Resident #174 revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #174's care plan, revealed on [DATE], the facility had developed a care plan for the resident for hydration. Further review of the care plan, revealed interventions to encourage fluids daily, keep water at bedside, monitor laboratory tests as ordered by the physician, administer medications as ordered by the physician, monitor intakes and outputs as ordered. A review of a RD assessment dated [DATE], revealed Resident #174 had been assessed to require thirteen hundred and eighty six (1386) milliliters (ml) of fluid per day of fluid. A review of physician's orders for Resident #174, revealed an order dated [DATE], to encourage fluids every shift. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident was assessed to have severely impaired cognition. Further review of the MDS revealed the resident required the limited assistance of one (1) person for eating. A review of the fluid intake records for Resident #174, revealed the facility documented the resident had not met his/her fluid requirement on [DATE] with 840 ml, [DATE] with 960 ml, [DATE] with 600 ml, [DATE] with 720 ml, [DATE] with 1200 ml, [DATE] with 420 ml, [DATE] with 840 ml, [DATE] with 720 ml, [DATE] with 840 ml, [DATE] with 1080 ml, [DATE] with 840 ml, [DATE] with 960 ml, [DATE] with 1080 ml, [DATE] with 1080 ml, [DATE] with 1080 ml, [DATE] with 1080 ml, [DATE] with 480 ml, [DATE] with 1200 ml, [DATE] with 480 ml, [DATE] with 480 ml, [DATE] with 840 ml, [DATE] with 720 ml, [DATE] with 180 ml, [DATE] with 720 ml, [DATE] with 502 ml, [DATE] with 600 ml, [DATE] with 1080 ml, [DATE] with 840 ml, [DATE] with 840 ml, [DATE] with 100 ml, [DATE] with 840 ml, [DATE] with 210 ml, [DATE] with 180 ml, [DATE] with 540 ml, and [DATE] with 180 ml. The fluid intake records for Resident #174 revealed the resident had not met daily fluid requirements for thirty seven (37) out of thirty eight (38) days. A review of the nurses notes for Resident #174, revealed an entry dated [DATE] at 1:03 PM which stated resident very lethargic this morning, does awaken with some effort. Advanced Registered Nurse Practioner (ARNP) notified to evaluate the resident. The nurses note further revealed the ARNP ordered a CBC and BMP (laboratory blood tests) to be drawn on [DATE]. The nurses notes also revealed an entry dated [DATE] at 3:17 PM, revealed the laboratory tests which had been completed for Resident #174 had critical results and the ARNP had been notified with new orders received to administer a 500 ml bolus of normal saline intravenously and then continue administering normal saline intravenously at 100 ml per hour for 2000 ml. The ARNP also ordered to hold [MEDICATION NAME] (diuretic) and [MEDICATION NAME] (medication to treat heart failure) for the resident for three (3) days, and to recheck a BMP (blood laboratory test) for the resident on [DATE]. The nurses note further revealed the resident's responsible party had been notified. A review of laboratory reports for Resident #174 dated [DATE] at 5:19 AM, revealed the resident had a Blood Urea Nitrogen (BUN) level of 156 (normal ,[DATE] mg/dl); Creatinine level of 4.2 (normal 0XXX,[DATE].3 mg/dl); BUN/Creat Ratio of 37 (normal ,[DATE]). Further review of Resident #174's laboratory reports dated [DATE] at 7:32 AM, revealed the resident had a BUN of 126, Creatinine level of 3.6, and BUN/Creatinine Ratio of 35. Further review of Resident #174's nurses notes, dated [DATE] at 3:03 PM, revealed the resident's physician had assessed the resident. A nurses note dated [DATE] at 2:15 PM, revealed the ARNP saw the resident and due to the intravenous line being out and staff were unable to restart the intravenous line, the resident was sent to the acute care hospital. The nurses note further revealed the resident's laboratory tests revealed the resident still had dehydration. A interview conducted with State Registered Nursing Assistant (SRNA) #5 on [DATE] at 10:15 AM, revealed she was responsible for documenting the fluid intakes in the computer every shift. The SRNA stated she was required to notify the nurse if the resident was not eating or drinking as well. The SRNA stated Resident #174 had been declining and the nurses were aware. A interview conducted with SRNA #4 on [DATE] at 10:20 AM, revealed she was required to document resident's fluid intake in the computer. The SRNA stated if the resident did not eat or drink well, she was required to notify the nurse. The SRNA stated the nurses were aware Resident #174 was not eating or drinking well. A interview conducted with Licensed Practical Nurse (LPN) #4 on [DATE] at 10:45 AM, revealed she was not sure where to look to find what fluid requirements a resident required. The LPN stated she did not look daily to ensure residents were meeting their daily fluid requirements. The LPN stated the weekly nursing assessment which she completed on the computer automatically populated the fluid requirement needs of the resident and she was required to look back for the previous week. The LPN stated she probably should have notified the physician and the RD regarding Resident #174's fluid intake, but she had not and did not know why she had not. The LPN stated she had been trained on signs and symptoms of dehydration such as poor skin turgor, dry mucus membranes, abnormal laboratory values. The LPN stated she was required to notify the physician if the resident exhibited any signs or symptoms of dehydration. Interview conducted with LPN #1 on [DATE] at 10:55 AM, revealed she was unable to state where fluid requirements were documented. The LPN stated she did not check resident's fluid requirements daily. The LPN stated she just asked the SRNAs if the resident was drinking okay. The LPN stated she had been trained on signs and symptoms of dehydration such as poor skin turgor, dry mucus membranes, abnormal laboratory values. The LPN stated she was required to notify the physician if the resident exhibited any signs or symptoms of dehydration. Interview conducted with the ARNP for Resident #174 on [DATE] at 3:15 PM, revealed the resident had been declining the last few months. The ARNP stated she expected the staff to monitor intakes and if the resident was not meeting fluid intakes she would have expected staff to notify her. The ARNP stated staff had told her on [DATE] the resident was not drinking. The ARNP could not recall who it had been that had reported the resident was not drinking. The ARNP stated she should have been notified of the resident not meeting his/her fluid requirements because the resident could have died . Interview conducted with the Registered Dietician (RD) on [DATE] at 11:04 AM, revealed after COVID 19 began she had only been back seeing residents at the facility since [DATE]. The RD revealed prior to [DATE], she had been working from home using the computer system to review residents nutritional status. The RD stated after returning to the facility in [DATE], when she comes into the facility she receives a list of referrals to see, such as those with decreased intake, weight loss, wounds, and if they have a MDS assessment coming up. The RD stated she reviewed everyone on the referral list. The RD stated if the resident was not on the list she would not reviewed their intakes. The RD stated if a resident had not met fluid needs for three (3) consecutive days she expected to be notified. The RD stated she would have expected Resident #174 to have been on the list for her to review and the resident was not on the list. The RD stated she had not been aware Resident #174 was not meeting his/her fluid requirements and should have been notified. Interview conducted with Resident #174's physician on [DATE] at 12:14 PM, revealed, he monitored fluid intakes when he visited the resident every month. The physician stated he had been aware the resident was not meeting his/her fluid requirements. The physician stated the resident not eating or drinking as well was a natural progression of his/her disease process. The physician stated the resident was at the end stage of his/her disease process and decreased fluid intake was unavoidable as the resident was entering the palliative phase. An interview conducted with the Corporate Nurse (CN) who was the liaison for the Director of Nursing (DON) who was unavailable due to sickness on [DATE] at 3:05 PM, revealed staff were required to review care plans at the beginning of every shift and prior to providing care for the residents. The CN stated if the resident was not meeting the fluid requirements the physician would be notified. The CN stated prior to the survey, the facility had not identified any concerns with residents fluid intakes not being monitored. The CN stated the nurses look at labs every day, but do not monitor strict intake and outputs on every resident just the residents that show signs and symptoms of dehydration and are at high risk for dehydration based on their policy. The CN stated only if a resident showed signs and symptoms of dehydration would a nurse be expected to notify the physician and RD for dehydration. 2. Record review revealed the facility admitted Resident #12 on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #12 Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the facility did not attempt a BIMS interview due to the resident being rarely/never understood. The facility determined the resident's cognition to be severely impaired, and the resident rarely/never made decisions regarding task of daily living. Further review of the MDS revealed the resident was assessed to be totally dependent on staff for eating and mobility. Review of Resident #12 Dietary Consultants Comprehensive Nutritional Assessment, dated [DATE] revealed the resident was assessed for estimated ml/fluid per day need of 2,112 to 2,535 ml's. Review of the facility Look Back Report for [DATE] thru [DATE] revealed Resident #12 averaged 1,401 ml of fluid per day. On [DATE], Resident #12 consumed 360 ml, on [DATE] only 680 ml and on [DATE] the resident consumed only 480 ml of fluid. Review of Acute Monitoring nursing notes for Resident #12 dated [DATE] at 1:46 AM revealed in bed on right side t/r (turn and reposition) per staff of 2 max assist eating at meals with no difficulty skin recoil good, mucous membranes moist pink no s/s of dehydration. Further review on nursing notes revealed Acute Monitoring note on [DATE] at 11:40 AM Residents daughter called concerning resident. Asked about labs and urine, informed family member that they were pending but that the labs should be back today. Family member stated they wanted the resident sent out to the ER. Resident was sent to ER. Review of Discharge Summary for Resident #12 dated [DATE] revealed labs on [DATE] BUN 50 (Blood urea nitrogen - a medical test that measures the amount of urea nitrogen found in blood. Normal range for BUN is ,[DATE] mg), Creatinine 1.13 (normal is 0XXX,[DATE].2.) Resident #12 was admitted and upon discharge the labs for [DATE] were BUN 14 and Creatinine 0.47. [DIAGNOSES REDACTED]. Further review of the hospital discharge summary revealed Important issues to note: Patient will need frequent reminders for oral hydration and would recommend to try and keep at least ,[DATE] cc of fluid daily. Review of Resident #12 Care plan, with a target date of [DATE], revealed Resident #12 was care planned with a focus Potential for Altered Nutrition related to Diabetes, Impaired cognition, vitamin D deficiency, [MEDICAL CONDITION], and Dysphagia with Intervention Resident to be offered 240 ml fluids every 2 hours. Further investigation revealed the intervention was put into place on [DATE]. The resident also had an intervention for I (in's) and O (out) as ordered. Observation on [DATE] at 9:58 AM revealed Resident #12 in Geri Chair neatly dressed with no fluids at bedside. Attempted interview with resident at this time revealed the resident did not respond to any questions. Observation on [DATE] at 12:30 PM of Resident #12 revealed the resident in Geri Chair with staff totally assisting the resident to eat. Resident ate 100% of meal and drank 240 ml of fluids. Observation on [DATE] at 9:10 AM of Resident #12 revealed the resident in bed on back with eyes closed, no fluids at bedside. Interview with family member of Resident #12 on [DATE] at 3:30 PM revealed the family member had concerns due to the resident being hospitalized in March with dehydration. The family member said prior to COVID shut down the family came to the facility daily and fed the resident and encouraged the resident to drink and was concerned that since they were no longer at the facility the resident was not drinking enough. Interview on [DATE] at 9:10 AM with State Registered Nursing Assistant (SRNA) #1 revealed Resident #12 was total assist with all activities of daily living, which included eating and drinking. The SRNA stated the resident would not be able to pick up a glass and drink it but that they did keep a pitcher of fluids at the bedside and offer the resident fluids throughout the day. The SRNA went into Resident #12 room and returned with a pitcher and stated The pitcher of water was sitting on the roommate's overbed table, the roommate is not supposed to have a pitcher because the roommate was on thicken liquids. The SRNA took the pitcher out of the room and replaced it with a clean one. The SRNA further revealed that they only chart fluids that the resident intakes during meals. Interview on [DATE] at 9:30 AM with SRNA #2 revealed Resident #12 should have a pitcher of water. She further stated that the nurses offer the resident fluids every couple of hours. She stated the resident eats and drinks well. Interview on [DATE] at 10:08 AM with Licensed Practice Nurse (LPN) #1 revealed Resident #12 is a total assist and there are orders for her to be offered by nursing staff 240 ml of fluids every 2 hours. The LPN stated that sometime the resident refuses the fluids but mostly drinks what is offered. The LPN was unable to find the fluid needs of the resident and stated they do not calculate fluid needs daily and rely on SRNA to inform them if a resident is not eating or drinking well. Interview on [DATE] at 11:00 AM with the Administrator and Corporate Nurse (CN) who was the liaison for the Director of Nursing revealed they look at labs everyday. They stated they do not do strict intake and outputs on every resident just the resident that show signs and symptoms of dehydration based on their policy. When asked if someone tallies up the daily fluid intake on each resident they replied only if they met the criteria stated in the policy. The administrator was looking at weekly skin assessment for Resident #12 during the interview and stated they all say skin turgor good and mucus membranes moist. Interview on [DATE] at 11:04 AM with the facility Dietician revealed due to COVID concerns she was just getting back into the facility, and had been doing assessment via point click care (computer system). She stated that she was given a list of residents to look at or who need assessments. Per the Dietician, the lists of residents includes referrals for decreased intake, weight loss, wound, or a resident on the MDS schedule. The Dietician stated those are the residents she see when she visits the facility. The facility Dietician stated, If resident had not met fluids needs in 3 days I would expect the facility to reach out to me. I would expect the facility was monitoring the fluid intake. I was not made aware that Resident #12 had not met fluid needs back in March. Interview on [DATE] at 12:14 PM with Resident #12 physician revealed, he monitored fluid intake when he visited the resident every month. He further revealed that the estimated fluid needs for Resident #12 were too high based on the resident's [DIAGNOSES REDACTED]. He further stated that he would expect the facility to notify the MD or the Nurse Practitioner within ,[DATE] days of resident's not meeting their fluid needs. Interview on [DATE] at 10:30 AM with Clinical Coordinator, Nurse Consultant revealed that the facility had identified concerns with hydration and had started doing inservices and education on the problem. Interview on [DATE] at 10:30 AM with Corporate Nurse (CN) who was the liaison for the Director of Nursing revealed the facility had identified concerns with hydration and had reassessed everyone in the building for hydration needs and that they had started education for staff on hydration. When asked if their computer system tallies the total fluid intake on residents they said it did not. 3. Review of the medical record revealed the facility admitted Resident #55 on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. The assessment further noted the resident was sometimes able to make himself/herself understood and that the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the care plan, undated, revealed the facility had assessed the resident to be at risk for dehydration and added an intervention to encourage fluid intake. Review of the Weekly Nursing assessment revealed Resident #55's daily fluid needs was 1300 - 1500 milliliters per day. Review of Resident #55's intake records for [DATE] through [DATE], revealed the resident met his/her fluid needs one (1) day ([DATE]) out of this fifteen (15) day observation period. Observation of Resident #55 on [DATE] at 10:10 AM, revealed the resident had liquids available at bedside. The resident's lips and skin appeared moist and there were no visible signs of dehydration. Further review of Resident #55's record revealed no evidence the physician or dietician was notified of the resident not meeting their daily fluid needs in [DATE]. 4. Review of the medical record revealed the facility admitted Resident #28 on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed a BIMS score of 11 indicating moderately impaired cognition. The assessment further noted the resident was able to make self himself/herself understood and that the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the resident's comprehensive care plan revealed no intervention to address Resident #28's fluid/hydration status. Interview with the Dietician on [DATE] at 11:58 AM revealed in [DATE], she assessed Resident #28 to need 1600 mls of fluid daily. Review of Resident #28's intake report for [DATE] to [DATE], revealed the resident did not meet his/her assessed hydration needs any day throughout this fifteen (15) day observation period. Observation of Resident #28 on [DATE] at 10:08 AM, revealed the resident had liquids available at bedside. The resident's lips and skin appeared moist and there were not visible signs of dehydration. Further review of Resident #28's record revealed no evidence the physician or dietician was notified of the resident not meeting their daily fluid needs in [DATE]. 5. Review of the medical record revealed the facility admitted Resident #72 on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS, dated [DATE], revealed a BIMS score of 07 indicating severely impaired cognition. The assessment further noted the resident is sometimes understood and that the resident was totally dependent upon one (1) staff person for eating and drinking. Review of the care plan, undated, revealed the facility had assessed the resident to be at risk for dehydration and added an intervention to encourage fluid intake. Further review of the record for Resident #72 revealed the resident minimum fluid needs to be ,[DATE] according to the hydration assessment completed on [DATE]. Review of intake report for [DATE] to [DATE], revealed the resident did not meet his/her assessed hydration needs any day throughout this observation period. Observation of Resident #72 on [DATE] at 10:18 AM, revealed the resident had liquids available at bedside. The resident's lips and skin appeared moist and there were not visible signs of dehydration. Further review of Resident #72's record revealed no evidence the physician or dietician was notified of the resident not meeting their daily fluid needs in [DATE]. Interview on [DATE] at 11:04 AM with the facility Dietician revealed due to COVID concerns they were just getting back into the facility, and had been doing assessment via point click care (computer system). She stated that she was given a list of residents to look at or do assessments on. Per the Dietician, the lists included referrals of residents with decreased intake, weight loss, wound, and residents on the MDS schedule. The facility dietician stated, If resident had not met fluids needs in 3 days I would expect the facility to reach out to me. I would expect the facility was monitoring the fluid intake

Based on observation, interview and review of facility policy, the facility failed to ensure controlled drugs were stored in a permanently affixed compartment as required in one (1) of two (2) refrigerators in the medication rooms. Observation of the second floor medication room revealed a controlled medication for Resident #63 in the refrigerator. However, the medication was not stored in permanently affixed locked narcotic box. The findings include: Review of the facility policy titled Medication Dispensing Controlled Substances, undated revealed that all controlled substances will be stored under double lock, separate from other medications. Observation of the second floor medication room on 10/21/2020 at 4:56 PM revealed the medication Dranabinol (is a man-made form of tetrahydrocannabinol (THC), a psychoactive substance found in cannabis) 10 mg (milligram) ordered twice daily labeled Controlled for Resident #63 located in the refrigerator in the second floor medication room. The medication (Dranabinol) was lying on top of other medications and not stored in the permanently affixed locked narcotic box. Interview with Licensed Practical Nurse (LPN) #1 on 10/21/2020 at 4:56 PM revealed the medication should have been stored in the locked narcotic box; however, the packaging would not fit into the locked box. Interview with the Clinical Coordinator/Director of Nursing Liaison on 10/23/2020 at 2:47 PM revealed controlled medication should be under double lock.

Based on observation, interview, record review, and review of the facility policy, it was determined the facility failed to ensure one (1) of two (2) residents (Resident #55) who received respiratory care out of a sample of twenty-seven (27) residents received respiratory care consistent with professional standards of practice and the comprehensive care plan. Resident #55 was observed on 10/21/2020 and 10/22/2020, receiving oxygen via nasal cannula at two (2) liters per minute (LPM). Review of the physician orders revealed an order dated 02/08/2019 for oxygen to be delivered via nasal cannula at three (3) LPM. The findings include: Review of the facility policy, Oxygen Use, undated, revealed no guidance for monitoring oxygen for proper flow rate setting. Interview on 10/23/2020 at 2:48 PM with Clinical Coordinator/Director of Nursing Liaison revealed nursing staff on the floor are responsible to check oxygen for proper flow rate every shift. She further revealed if observed on the incorrect setting the nurse would complete a respiratory assessment on the patient and notify the physician. Observation of Resident #55 on 10/21/2020 at 9:27 AM revealed the resident was lying in bed, receiving oxygen via nasal cannula. Observation of the oxygen concentrator revealed the setting was at two (2) LPM. Observation on 10/21/2020 at 10:27 AM revealed the oxygen remained at two (2) LPM. Further observation on 10/22/2020 at 9:43 AM and 10/22/2020 at 9:49 AM, revealed the oxygen concentrator setting was at 2.5 LPM. Review of the medical record revealed Resident #55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/23/2020, revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. The MDS further revealed the resident was on oxygen therapy. Review of the physician orders for Resident #55 revealed an order dated 02/08/2019, which stated the resident was to receive oxygen at three (3) LPN via nasal cannula for [DIAGNOSES REDACTED]. Review of the care plan for Resident #55, revealed the facility identified that the resident had [DIAGNOSES REDACTED]. Review of the Treatment Administration Record (TAR), dated October 2020, revealed staff were required to check the resident's oxygen saturation every shift and check to ensure oxygen was set at three (3) LPM. Review of the TAR further revealed on 10/21/2020, staff initialed that the task was completed. Interview with Licensed Practical Nurse (LPN) #1 on 10/21/2020 at 10:50 AM, confirmed that Resident #55 oxygen concentrator was set at two (2) LPM. Further interview revealed that Resident #55 was ordered to receive oxygen at three (3) LPM; however, she was unaware why the settings were incorrect. She also stated that Resident #55 was unable to adjust the setting of the concentrator. She further revealed that she checks the oxygen every shift to ensure the correct setting. Interview with LPN #2 on 10/22/2020 at 9:49 AM, confirmed that Resident #55 oxygen was set at 2.5 LPM. She further revealed that the resident was ordered oxygen at three (3) LPM. Continued interview revealed the nursing staff was responsible for checking every shift to ensure oxygen was set at the correct settings. Interview with the Clinical Coordinator/Director of Nursing Liaison on 10/23/2020 at 2:48 PM revealed she was able to identify an assessment and physician notification was completed on 10/22/2020 related to observation of oxygen on the incorrect setting. However, she was unable to provide documentation that a respiratory assessment and/or physician notification had occurred on 10/21/2020.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure residents were safe from accidents for one (1) of twenty-seven (27) sampled residents. Resident #59 was assessed by the facility to need nectar thicken liquids and was noted to have access to thin liquids. The findings include: Review of the facility policy titled, Dysphagia Diets , not dated, revealed The National Dysphagia Diet provides overall guidelines for managing Dysphagia. Further review revealed, Four levels of liquids, Thin, Nectar-like, Honey-like, Spoon-thick. The Speech Language Pathologist is responsible for evaluating and treating an individual with dysphagia. The policy defined Nectar-like as The beverage coats and drips off a spoon similar to unset gelatin. Record review revealed the facility admitted Resident #59 on 07/27/2020 with [DIAGNOSES REDACTED]. Review of Resident #59 Minimum Data Set (MDS) assessment dated [DATE] revealed the facility did not attempt a BIMS interview due to the resident being rarely/never understood. The facility determined the resident's cognition to be severely impaired, and the resident rarely/never made decisions regarding task of daily living. Further review of Resident # 59 MDS revealed the resident was assessed on their admission MDS, dated [DATE] in section K (Swallowing, Nutritional Status) to hold food in mouth/cheeks or residual food in mouth after meals. The facility also assessed the resident with coughing or choking during meals or when swallowing medications. These areas where not assessed on the resident's quarterly MDS. Further review of the resident's MDS also revealed under section G (Functional Status) to require extensive assist of one staff member for eating as well as for walking. The facility had also assessed the resident to be a wander and had a wander bracelet around their ankle. Review of Resident #59's care plan with a target date of 11/02/2020, revealed the resident was care planned for Elopement Risk related to: wandering Alzheimer's. The resident was also care planned for Potential for Altered Nutrition related to impaired cognition [MEDICAL CONDITION], vitamin deficiency, dysphagia with intervention for Diet per MD order. Puree Nectar thicken liquids and observe for the following: Dysphagia pocketing choking coughing, drooling, holding food in mouth. Review of Speech Therapy note dated 08/24/2020 revealed, Pt (Patient) presents with decreased control and s/s (signs/symptoms) aspiration noted with trials of thin liquids and ST (Speech Therapy) recommends pt continue nectar thick liquids at this time. Observation of Resident #59 on 10/21/2020 at 9:25 AM revealed the resident shared a room with Resident #12 who was totally dependent on staff for all activities of daily living. A picture of thin liquids was observed on Resident #59 bedside table. Observation of Resident #59 on 10/21/2020 at 10:46 AM revealed Resident #59 going into another resident's room, staff redirected. Observation of Resident #59 on 10/22/2020 at 9:13 AM revealed Resident #59 standing next to roommate's bedside table with pitcher of thin liquids. The resident grabbed the handle of the pitcher but staff redirected the resident. Observation of Resident #59 on 10/22/2020 at 3:08 PM revealed the resident in another resident's room with pitcher in hand in the process of taking the pitcher to their mouth. Staff stopped the resident before the resident could take a drink from the pitcher. Interview on 10/22/2020 at 9:01 AM with State Registered Nursing Assistant (SRNA) #3 revealed Resident #59 was assisted with all meals, mostly due to their cognition; you have to tell them to eat. The SRNA stated the resident would be able to pick up a glass and put it to their mouth. The SRNA stated that she had never seen the resident take a drink out of another resident's glass. Interview on 10/21/2020 at 9:10 AM with State Registered Nursing Assistant (SRNA) #1 revealed while the SRNA was looking for a water pitcher for another resident stated, The pitcher of water was sitting on the Resident #12 overbed table, Resident #59 is not suppose to have a pitcher because they are on thicken liquids. Interview on 10/22/2020 at 10:07 AM with SRNA #11 revealed the resident is assisted with meals but will occasionally pick up food and drink without assist. We try to keep an eye on them and keep them out of other resident's room. The SRNA continued by saying she had seen the resident pick up stuff that someone set down at the nursing station, such as a soda can. Interview on 10/22/2020 at 10:15 AM with Licensed Practice Nurse (LPN) #6 revealed Resident #59 was assisted with meals and was on a nectar thicken liquids. The LPN stated she had seen the resident pick up a cup and drink out of it. However, the LPN stated she had never known of the resident to drink out of a cup that was not thicken liquids. She further stated if Resident #59 drank thin liquids they would assess the resident and inform the MD. Interview on 10/23/2020 at 1:30 PM with Clinical Coordinator, Nurse Consultant revealed that the expectation is that staff will ensure that all residents are kept safe from any accidents and they had already started training staff. The Nurse Consultant stated the resident wanders and it is a concern.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to notify the physician and the responsible party (RP) for one (1) of three (3) sampled residents (Resident #2) when the resident experienced a change in condition and when there was a need to alter treatment. Observations on 06/11/19 revealed Resident #2's wound dressing to his/her lower extremity was wet in appearance. Resident #2's bed linen was also wet and a light brown stain, dry in appearance, was also observed on the resident's bed linen. Resident #2 and his/her family member stated concerns had been voiced related to his/her wound dressing and bed linen being always wet with drainage; however, staff had not notified the resident's physician nor altered the resident wound dressing frequency as requested. In addition, staff was observed to provide wound care to Resident #2's right lower extremity on 06/11/19. Observation of the resident's wound care revealed there were two open areas, with reddened wound edges and a foul odor was also observed. Interview with Resident #2's family member revealed she had not been notified of the change in the resident's skin condition, and stated she thought that the facility was treating intact blisters on the resident's leg. The findings include: Review of the policy titled Change in a Resident's Condition, dated 08/01/13, revealed the facility would promptly notify the resident, the attending physician, and his/her representative of changes in the resident's medical condition. The policy defined a significant change of condition as something that would not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions. Review of Resident #2's medical record revealed the facility admitted the resident on 02/19/19 with [DIAGNOSES REDACTED]. Review of Resident 2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of thirteen (13), which indicated the resident was cognitively intact. Review of Resident #2's physician orders [REDACTED]. Interview with Resident #2 on 06/11/19 at 10:45 AM revealed the resident's wound continuously drained fluid and his/her wound dressing and bed linens stayed wet all the time. The resident stated that multiple requests had been made for staff to change the dressing more often, in attempts to keep the wound dry and stated, It feels awful to feel like you're laying in wetness all the time. They don't take good care of my legs like they should. Interview with Resident #2's family member on 06/11/19 at 9:00 PM revealed she visited the facility daily and there's always liquid coming from (his/her) legs. The family member stated the resident's bed linens are always soaked from all of the drainage. She also stated concerns had been voiced to staff about the amount of drainage observed on the resident's wound dressings and linens and also stated she couldn't imagine how any wound could heal with drainage covering it all the time. She stated she was not aware that the resident had developed open wounds on his/her lower extremities, but stated she should have been notified. The family member stated Charge Nurse #1 had notified her today (06/11/19) that the doctor had ordered the resident a shot because of an open wound. Interview with Licensed Practical Nurse (LPN) #1 on 06/11/19 at 12:24 PM revealed she had provided care to Resident #2 on 06/10/19 and identified that the blistered areas had changed to an open wound. She stated she had not notified the resident's family member but she should have. She also acknowledged Resident #2's wound always drained fluid and that the resident had voiced complaints because his/her dressing stayed wet all the time. LPN #2 also stated she should have notified the physician about possibly changing the dressing more often because if it was kept clean and dry it could have helped the healing process. Interview with Physician #1 on 06/12/19 at 11:20 AM revealed he had not been notified of the wound drainage and staff should have consulted him related to Resident #2's dressing and bed linen being wet with drainage frequently. He stated obviously if something is staying wet all the time, our goal should be to keep it clean and dry and change it more often.

Based on observation, interview, and record review it was determined the facility failed to provide dressing changes to non-pressure skin conditions in accordance with professional standards of practice for one (1) of three (3) sampled residents (Resident #1). Observations and interviews with Resident #1 and staff on 06/11/19 revealed State Registered Nurse Aide (SRNA) #1 had performed a physician ordered treatment to a non-pressure skin condition located on the resident's left lower extremity. Interviews with Administrative staff on 06/11/19 revealed non-licensed staff were not permitted to conduct assessments of abnormal skin conditions for facility residents. The findings include: Interview with the Director of Nursing (DON) on 06/12/19 at 2:00 PM revealed the facility had no policy related to professional standards of practice for care provided in the facility. Review of the Kentucky Board of Nursing (KBN) Decision Tree for Delegation to Unlicensed Assistive Personnel (UAP), last revised in (MONTH) (YEAR), revealed the UAP should only accept delegated acts for which they are competent to perform. Further review of the KBN decision tree for delegation of tasks also revealed licensed nurses cannot delegate tasks that require assessment, planning, evaluation, and nursing judgement to UAP. Review of Resident #1's medical record revealed the facility admitted the resident on 12/27/16 with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required limited assistance of one (1) staff member with transferring, ambulation, and toileting. Resident #1 was assessed to have a Brief Interview for Mental Status (BIMS) score of eleven (11), indicating the resident was interviewable. Review of Resident #1's physician orders [REDACTED].#1 directed staff to obtain a culture of Resident #1's wound that was present to the resident's lower extremity. Continued review of the medical record revealed staff obtained the wound culture on 06/01/19. Review of the results of Resident #1's wound culture dated 06/03/19 revealed the resident was diagnosed with [REDACTED]. Review of Resident #1's physician orders [REDACTED]. Review of Resident #1's Medication Administration Record [REDACTED]. Observation and interview with Resident #1 on 06/11/19 at 1:00 PM revealed the resident stated SRNA #1 had already changed my dressing today. Observation of the resident's dressing revealed SRNA #1 had initialed and dated Resident #1's dressing on 06/11/19. Interview with SRNA #1 on 06/11/19 at 1:15 PM revealed she was directed by Kentucky Medication Aide (KMA) #2 to apply the dressing to the non-pressure skin area that required treatment on Resident #1's left lower extremity. Interview with Kentucky Medication Aide (KMA) #2 on 06/11/19 at 9:30 PM revealed Licensed Practical Nurse (LPN) #3 had delegated Resident #1's dressing change for her to complete on 06/11/19. However, the KMA stated when she attempted to do the treatment for [REDACTED].#1 had bathed him/her. KMA #2 stated she honored the resident's wishes and she informed LPN #1 that SRNA #1 was going to perform the treatment for [REDACTED]. Continued interview with KMA #2 also revealed Administrative staff had informed her (unable to recall exact date) that KMAs were going to be responsible to conduct dressing changes for abnormal skin conditions which included anything up to a Stage 1. However, the KMA acknowledged she was not licensed to conduct any type of assessment or evaluation for residents in the facility. Interview with LPN #3 on 06/11/19 at 4:15 PM revealed she had been directed by Administrative staff (unable to recall who) that she could delegate dressing changes to KMAs in the facility on any area requiring treatment, as long as the skin condition was not related to pressure or stasis ulcers. She acknowledged Resident #1's dressing change was conducted by unlicensed personnel in the facility and stated she had not assessed the resident's wound on 06/11/19. The LPN also stated she should not have documented on Resident #1's MAR indicated [REDACTED]. Interview with the DON on 06/12/19 at 2:00 PM revealed licensed nurses were not permitted to delegate tasks which required a nursing assessment, including dressing changes to abnormal skin conditions in the facility. She also stated it was not a standard of practice for nurses to document tasks they had not completed on the resident's MAR.

Based on interview, review of the facility's Grievance Tracking Form, and review of facility policy, it was determined the facility failed to ensure residents were free from abuse for three (3) of thirty-three (33) sampled residents (Residents #13, #52, and #231). On 02/05/19, Resident #13 informed Kentucky Medication Aide (KMA) #1 that he/she did not want a rectal suppository (laxative). However, KMA #1 administered the rectal suppository against the resident's wishes. The resident stated the suppository made his/her belly hurt and made the resident weak. Interview with KMA #1 on 02/06/19 revealed she acknowledged that Resident #13 had refused the rectal suppository; however, he/she stated she (KMA #1) gave it anyway . Resident #13 reported the allegation to Licensed Practical Nurse (LPN) #4 on 02/05/19; however, LPN #4 failed to take action to protect Resident #13 from any further potential abuse. No action was taken to protect residents from abuse until 02/06/19, when the State Survey Agency reported the allegation to the Administrator and KMA #1 was suspended. In addition, in (MONTH) (YEAR) (exact date unknown), Resident #52 reported that State Registered Nurse Aides (SRNAs) #1 and #2 stated that Resident #231 creeped them out and sounded like a creaky door in a haunted house. However, the facility failed to take action to protect residents from further potential abuse. On 01/22/19, Resident #52 reported to the Ombudsman that SRNA #2 had mocked Resident #52's speech/insulted the resident. The Ombudsman immediately reported the allegation to the Administrator on 01/22/19. However, there was no evidence that the Administrator reported or investigated the allegation and no evidence that action was taken to ensure residents were protected from further potential abuse. The facility's failure to ensure residents were free from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/14/19 and was determined to exist on 01/22/19 at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610). The facility was notified of the Immediate Jeopardy on 02/14/19. An acceptable Allegation of Compliance was received on 02/27/19, which alleged removal of the Immediate Jeopardy on 02/16/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/16/19, prior to exit on 03/27/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Reporting abuse to facility management, dated 11/02/17, revealed residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility defined verbal abuse as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance to describe residents, regardless of their age, ability to comprehend, or disability. Further, the facility stated mental abuse included but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. Review of the policy section titled, Abuse Investigations, dated 08/01/13, revealed employees accused of abuse would be suspended immediately pending investigation. 1. Review of Resident #13's medical record revealed the facility admitted the resident on 09/14/15 with [DIAGNOSES REDACTED]. Review of Resident #13's Annual Minimum Data Set Assessment ((MDS) dated [DATE], revealed the resident was totally dependent on two (2) staff members for bed mobility, transfers, and toileting. Further review revealed the facility assessed the resident to be interviewable, with a Brief Interview for Mental Status (BIMS) score of fourteen (14). Review of Resident #13's physician's orders [REDACTED]. During an interview with Resident #13 on 02/06/19 at 5:00 PM, the resident stated, Please make them quit giving me those enemas. They're killing me and making me weak. Last night I told her, 'No, no, no!' and she told me, 'Yes, yes, yes!' and rolled me over and put it in me anyway. Further interview with the resident revealed prior to receiving the rectal suppository the night before, the resident told the staff member that his/her bowels had moved and I didn't need it. Resident #13 further stated that he/she tried to kick (the staff member) but I couldn't, to keep the staff member from administering the rectal suppository. However, the staff member rolled the resident over and administered the suppository against the resident's wishes. The resident stated the suppository made my belly hurt. Further interview revealed the resident stated he/she felt abused and violated as a result of receiving the rectal suppository, and stated, Wouldn't you, if someone did you that way? Interview with KMA #1 on 02/06/19 at 5:50 PM confirmed that Resident #13 did not want her to administer a rectal suppository on 02/05/19. The KMA stated the resident even told her that his/her bowels had already moved. KMA #1 stated she had been trained regarding the facility's abuse policy and realized she should not force residents to take medications, but the KMA stated, It was on my MAR (the resident's Medication Administration Record) to give, so I gave it anyway. The KMA acknowledged the resident stated, No, no, no! because the resident did not want the suppository; however, the KMA told the resident, Yes, yes, yes and rolled the resident over and gave the rectal suppository. KMA #1 stated, I probably shouldn't have done that, should I? Review of Resident #13's Bowel and Bladder Elimination Record for (MONTH) 2019 revealed prior to receiving the suppository on 02/05/19, the resident had two (2) large bowel movements, on 02/04/19 at 2:35 PM and 02/05/19 at 2:04 AM. Further review of the record revealed after the suppository was administered on 02/05/19 at 9:00 PM, the resident had large bowel movements on 02/06/19 at 6:06 AM and 11:00 AM. Review of a facility incident report/investigation dated 02/06/19, revealed no documented evidence the facility took any action to protect residents from further potential abuse until after the State Survey Agency reported the allegation to the Administrator on 02/06/19; KMA #1 was suspended. Review of the facility's final investigation, completed on 02/10/19, revealed the facility substantiated that abuse occurred on 02/05/19 when KMA #1 gave Resident #13 a rectal suppository against the resident's wishes. The facility also terminated KMA #1's employment. Interview with the Administrator on 02/06/19 at 6:00 PM revealed that administering a rectal suppository against a resident's wishes was abusive. 2. Review of Resident #231's closed medical record revealed the facility admitted the resident on 12/18/18 with [DIAGNOSES REDACTED]. Review of Resident #231's Minimum Data Set ((MDS) dated [DATE] revealed the resident required extensive assistance of two (2) staff members for bed mobility, toileting, and transfers. Further review revealed the resident was cognitively impaired and the Brief Interview for Mental Status (BIMS) could not be conducted. Continued review of Resident #231's medical record revealed the resident was discharged home on[DATE] and no longer resided in the facility when the investigation was conducted. Interview with Resident #52 on 02/06/19 at 10:00 AM, who the facility assessed to have no cognitive impairment, revealed sometime during the first week of (MONTH) (exact date unknown) State Registered Nurse Aide (SRNA) #1 and SRNA #2 were providing care for Resident #231. Resident #52 stated he/she heard SRNA #1 state, (Resident #231) creeps me out. According to Resident #52, SRNA #2 replied that Resident #231 reminds me of a creaky door in a haunted house when (the resident) grinds (his/her) teeth like that. Interview with SRNA #1 on 02/06/19 at 9:30 PM revealed that he stated Resident #231 creeps me out. He also stated that SRNA #2 replied, Yes, (the resident) does me too. (The resident) reminds me of a creaky door in a haunted house when (the resident) grinds (his/her) teeth like that. SRNA #1 stated he knew that Resident #52 heard what the SRNAs said while caring for Resident #231 and knew that the resident was bothered by the comments. SRNA #1 stated that Resident #52, . hasn't liked me since (he/she) heard me say that about (his/her) roommate. Review of SRNA #2's personnel file revealed the SRNA was terminated on 02/02/19. Attempts were made on 02/06/19, 02/07/19, and 02/09/19 to interview SRNA #2; however, attempts were unsuccessful. Interview with the Administrator on 02/13/19 at 10:20 AM revealed she had no knowledge of the allegation of verbal abuse regarding Resident #231. The interview further revealed no action was taken to protect residents from further potential abuse. 3. Review of Resident #52's medical record revealed the facility admitted the resident on 11/27/18 with [DIAGNOSES REDACTED]. ALS is a disease that causes the death of neurons that control voluntary muscles. It causes muscle weakness, muscle wasting, and muscle spasms throughout the body due to the degeneration of neurons. Individuals affected by the disorder may ultimately lose the ability to initiate and control all voluntary movement. The disease affects the individual's speech causing slurred and nasal speech, quiet speech, or trouble speaking/forming words), Hypertension, [MEDICAL CONDITION], Moderate Protein Calorie Malnutrition, and Anxiety Disorder. Review of Resident #52's Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident required extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. The resident was assessed to be interviewable, with a Brief Interview for Mental Status (BIMS) score of fifteen (15). Interview with Resident #52 on 02/06/19 at 10:00 AM revealed on 01/22/19, State Registered Nurse Aide (SRNA) #2 called Resident #52 Honey. The resident stated that he/she told the SRNA that his/her name was not Honey. Resident #52 stated SRNA #2 then mocked my slow ALS speech and stated, O-k-a-y, (M-r./M-s.) (resident's last name). Resident #52 stated he/she felt verbally abused and reported the incident to the State Ombudsman, who stated she reported the incident to the Administrator. An interview was attempted with SRNA #2, who was no longer employed at the facility, on 02/06/19, 02/07/19, and 02/09/19. However, the attempts to speak with the SRNA were unsuccessful. She ended her employment with the facility without notice on 02/02/19. Continued interview with Resident #52 on 02/06/19 at 10:00 AM, revealed after he/she reported the allegation to the Ombudsman regarding SRNA #2, the SRNA continued to work at the facility. Although Resident #52 stated SRNA #2 never cared for him/her again, the resident stated if he/she heard the SRNA's voice in the hallway it made him/her so nervous, I was shaking. Interview with the Ombudsman on 02/12/19 at 11:45 AM confirmed that Resident #52 reported to her that when he/she heard SRNA #2's voice in the hallway, it made the resident so nervous, Resident #52 was shaking. Review of a Grievance Tracking Form dated 01/22/19, revealed the Ombudsman reported that Resident #52 did not want SRNA #2 to provide care for him/her. The Administrator documented that the SRNA was loud in the residents' room, and in the hallways; tone is rude and the SRNA failed to answer the call bell as quickly as she should; and the SRNA had referred to the resident as Honey instead of his/her given name. According to the Grievance Tracking Form, a conference was held with SRNA #2 and, She would not be assigned to care for (Resident #52) in the future. Interview with the Administrator on 02/13/19 at 10:20 AM revealed she acknowledged that on 01/22/19, the Ombudsman reported that SRNA #2 was rude to Resident #52, but denied that the Ombudsman reported that the SRNA mocked Resident #52's speech. According to the Administrator, the only action that was taken was instructing SRNA #2 to only go in the resident's room in case of an emergency. **The facility alleged the following actions removed Immediate Jeopardy on 02/16/19: 1. Resident #52 told the Office of Inspector (OIG) surveyor and the surveyor reported to the facility on [DATE], that State Registered Nurse Aides (SRNAs) #1 and #2 made comments in front of Resident #52 about Resident #52's roommate that Resident #52 found offensive. Per the surveyor, the resident stated that SRNA #2 verbally abused the resident by mocking him/her. The allegation of SRNA #2 mocking the resident was thoroughly investigated. Two (2) different staff members interviewed the resident. The resident did not verbalize mocking, but rather that the approach of SRNA #2 was rude, loud, and upsetting to the resident. Resident #52 articulated that it was the roommate that was mocked. The resident stated this occurred in December. An investigation was initiated on 02/14/19, by the Administrator regarding SRNAs #1 and #2, and both were reported to appropriate agencies, including the state agency, APS, the Ombudsman, and the physician. The investigation resulted in SRNA #1 being terminated on 02/14/19, and SRNA #2 was no longer employed with the facility as of 02/01/19. 2. On 02/06/19, Resident #13 reported to the OIG surveyor that on 02/05/19, he/she refused a treatment but the employee, Kentucky Medication Aide (KMA) #1, provided the treatment. The KMA was suspended and terminated on 02/10/19. The Administrator completed an investigation on 02/10/19. The investigation is maintained in the Administrator's file and was reported to the appropriate agencies, including the state agency, APS, and Ombudsman, as well as the physician and Resident Representative. Psychosocial assessments completed daily during the investigation were negative for signs and symptoms of distress or mental anguish. 3. An investigation was initiated by the Administrator regarding Resident #231 on 02/14/19 because Resident #52 told the OIG surveyor that SRNAs #1 and #2 made comments about Resident #231 that were offensive. The allegation was reported to the appropriate agencies, including the state agency, APS, Ombudsman, and physician. SRNA #1 was terminated on 02/14/19 and SRNA #2 was no longer employed at the facility as of 02/01/19. The resident was discharged on [DATE]. 4. Residents with a BIMS score of eight (8) or higher were interviewed on 02/06/19, 02/13/19, and 02/15/19 by the Quality Assurance (QA) RN, who was trained by the Vice President (VP) of Clinical Services, to determine if they had any allegations of abuse, neglect, or treatments provided against their wishes. Residents with a BIMS score below eight (8) had a head-to-toe assessment on 02/06/19 and 02/15/19 by the QA RN and Unit Managers to assess for injuries of unknown origin, abuse, or neglect. There were no concerns noted. The staff involved in the allegation could not be reached for statements and were no longer employed at the facility. The two (2) Staffing Coordinators were interviewed related to the allegations by the Assistant Administrator, trained by the VP (Vice President) of Clinical Services. The interviews revealed that neither Staffing Coordinator had ever had anything inappropriate reported to them regarding this. During the Resident Rights training, on 02/14/19 and 02/15/19, all other staff were given an opportunity to report any inappropriate abuse activity, with no one reporting any issues. All residents were reviewed by the VP of Clinical Services for recent changes in their Patient Health Questionnaire-9 (PHQ9) scores; current and previous scores were reviewed on 02/15/19 to assess for potentially related psychosocial changes. Four (4) residents with minimal declines in PHQ9 scores were noted upon this review. These four (4) residents were followed up on 02/15/19 by Social Services, trained by the VP of Clinical Services, for any indication of depression, anxiety, or symptoms indicating psychosocial decline. Social Services will continue to evaluate these residents weekly for four (4) weeks with outcomes being reviewed in weekly QA. 5. An in-service was conducted on 02/06/19 on Abuse, Neglect, and Resident Rights by the Assistant Administrator, trained by the VP of Clinical Services. Another in-service was conducted on 02/13/19 and 02/14/19 by the QA RN (who was trained by the VP of Clinical Services) on Abuse, Neglect, Reporting Abuse, and Resident Rights. This training covered identification of and reporting of abuse along with inappropriate communication with residents such as mocking and also residents' right to refuse treatment. Staff members trained included licensed staff, nurse aides, department heads, and ancillary staff including activities, maintenance, and housekeeping. A post-test was completed by staff members upon completion of the training to ensure competency on Abuse, Neglect, Reporting, and Resident Rights. All staff members passed the test. 6. Quality Assurance meetings were held on 02/08/19 and 02/12/19. The meeting on 02/14/19 included the Medical Director (via phone), Administrator, Assistant Administrator, a corporate nurse, VP of Clinical Services, and the DON. A Quality Assurance meeting will be held weekly for four (4) weeks and monthly thereafter, to review audits and determine compliance. The following will be conducted: (a) Two (2) residents with a BIMS score of eight (8) or higher will be interviewed daily to ensure no abuse, neglect, or violation of Resident Rights. These audits will be completed daily for four (4) weeks, then weekly for four (4) weeks, and then monthly if no continued issues. (b) Two (2) residents with a BIMS score below eight (8) will have a head-to-toe assessment daily to ensure no injuries of unknown origin, abuse, or neglect. These audits will be completed daily for four (4) weeks, then taken to weekly for four (4) weeks, and then monthly if no continued issues. The residents for these audits are being selected by two (2) categories of characteristics: BIMS score of eight (8) and/or higher is the first category, and the other category of residents is those with a BIMS of seven (7) or less. By process of elimination, the residents who have already had audits completed are excluded, and the next residents are picked. This was intended to make sure, as time progresses, that all residents will be included. The results will be reviewed daily as they are done, by the Administrator or DON, to ensure no issues were identified. In addition, an extra administrative nurse has been present every day for at least eight (8) hours, seven (7) days a week, going between the two (2) units observing care, checking staff and residents to identify problems, and serving as an additional resource. ***The State Survey Agency determined the following removed Immediate Jeopardy on 02/16/19, as alleged by the facility: 1. Review of the investigation, dated 02/14/19, revealed an investigation was immediately initiated regarding allegations made by Resident #52, involving SRNAs #1 and #2. The review also revealed the allegations were reported to the appropriate agencies on 02/14/19. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a final termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in on 02/10/19. Review of an Employee Conference Form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. Further review of the investigation, dated 02/14/19, revealed an addendum, dated 02/27/19, stating Resident #52 was interviewed by the Assistant Administrator and Director of Nursing. The interview revealed the resident stated SRNA #2 did not mock him/her, she mocked the resident's roommate, Resident #231. The resident also stated SRNA #2 was loud, rude, and upsetting to him/her. Resident #52 continued to reside in the facility. Interview with Resident #52 on 03/06/19 at 10:00 AM, revealed the resident stated, Everything is wonderful. The resident further stated they had had some kinks but it was better now. 2. Review of the investigation dated 02/06/19, involving Resident #13, alleged KMA #1 administered a suppository after the resident had stated he/she did not want it. The allegation was reported by the SSA Surveyor to the Administrator. The investigation revealed KMA #1 was removed from the facility on 02/06/19 at 6:06 PM after the report was made at 6:00 PM. The allegation was reported to the appropriate agencies, the physician, and the resident's representative on 02/06/19. Upon conclusion of the investigation, KMA #1 was terminated on 02/10/19. Resident #13 continued to reside in the facility. Interview with Resident #13 on 03/04/19 at 7:00 PM, revealed everything was okay and he/she stated he/she had no incidents of being forced to do anything against his/her will. 3. Resident #231 no longer resided in the facility. The resident was discharged home on[DATE]. The investigation, initiated on 02/14/19, revealed an allegation reported by Resident #52 regarding overhearing SRNAs #1 and #2 making offensive comments about Resident #231. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in for work on 02/10/19. Review of the Employee Conference form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. 4. Review of interview questionnaires completed on 02/15/19, revealed thirty-seven (37) residents with BIMS scores of eight (8) or higher were interviewed related to staff forcing them to have a treatment completed/take a medication and being abused in the facility. Review of the interviews revealed all thirty-seven (37) residents interviewed denied being forced to have a treatment completed/take a medication or being abused in the facility. Review of head-to-toe assessments conducted of residents with a BIMS score below eight (8) revealed none of the seventy-three (73) residents assessed were identified to have any suspicious injuries or injuries of unknown origin. Review of statements from both staffing coordinators revealed they had no knowledge of any reports of abuse or inappropriate behaviors regarding SRNA #1 and SRNA #2. Further review of a computer-generated listing of residents and PHQ-9 scores, dated 02/15/19, revealed four (4) residents were identified as having minimal declines in PHQ-9 scores. Clinical record review revealed Social Services followed up on these four (4) residents weekly. Interview with the Assistant Administrator/Social Services on 03/05/19 at 3:15 PM, revealed she had been visiting with and assessing the four (4) residents identified with slight declines in PHQ-9. She stated all but one (1) of the residents had now returned to baseline PHQ-9 scores. She also added that most of the declines were related to a decrease in appetite. 5. Review of training records revealed documentation that the Vice President of Clinical Services trained the Assistant Administrator on 01/28/19, the DON on 01/28/19, and the QA Nurse on 02/11/19. Further review revealed evidence via sign-in sheet, of in-services on Abuse, Reporting, and Protection and Resident Rights, on 02/06/19, 02/13/19, and 02/14/19. The data also revealed evidence of posttests with passing scores. Interviews on 03/04/19 with second shift employees, with four (4) SRNAs at 6:39 PM, 6:40 PM, 6:50 PM, and 6:55PM, two (2) Registered Nurses (RNs) at 6:34 PM and 6:50 PM, and one (1) KMA at 7:05 PM revealed they had been provided with education on types of abuse, protection of residents, and reporting of abuse immediately as well as residents' rights. The employees also stated they had to take a posttest. Interviews on 03/05/19, with first shift employees, included two (2) housekeeping staff members at 1:50 PM and 1:54 PM, two (2) maintenance staff members at 1:58 PM, one (1) dietary staff member at 2:19 PM, one (1) office staff member at 2:20 PM, two (2) SRNAs at 2:07 PM and 2:15 PM, two (2) nurses at 2:05 PM and 2:09 PM, and one (1) activities staff member at 2:10 PM, revealed all had received education on types of abuse, protection of resident and reporting of abuse immediately, as well as resident rights. The employees also stated they had to take a posttest. Interview with the DON on 03/06/19 at 9:44 AM, revealed no staff were allowed to work or clock in until education on abuse and resident rights had been done. Further review of training records revealed evidence of education on Abuse and Resident Rights provided on 02/21/19 and 02/25/19 by the VP of Clinical Services. 6. Review of the Quality Assurance (QA) agenda and sign-in sheets revealed meetings were conducted on 02/08/19, 02/12/19, and 02/14/19. Further review revealed QA meetings were held on 02/21/19 and 02/27/19. Review of audit interviews for residents with BIMS scores of eight (8) or higher revealed two (2) interviews were performed daily beginning on 02/16/19. Review of the audits for skin assessments on residents with BIMS scores less than eight (8) revealed two (2) were performed daily starting on 02/16/19. Interview with the DON on 03/06/19 at 9:44 AM, revealed she and the acting Administrator reviewed those audits daily. Documentation revealed the extra administrative nurse present daily for at least eight (8) hours a day was initiated on 02/16/19 and continued for every weekend through 03/07/19.

Based on observation, interview, record review, review of a Grievance Tracking Form, and review of facility policy, it was determined the facility failed to ensure allegations of abuse were reported for three (3) of thirty-three (33) sampled residents (Residents #13, #52, and #231). Resident #13 stated he/she refused a rectal suppository (laxative) on 02/05/19. However, staff held the resident over and administered the suppository even though the resident was trying to kick to get away and shouting No, no, no! Interview with Kentucky Medication Aide (KMA) #1 on 02/06/19 revealed she acknowledged Resident #13 refused the rectal suppository; however, the KMA stated, I gave it anyway . In addition, Resident #52 reported an allegation of verbal abuse related to State Registered Nurse Aides (SRNAs) #1 and #2's treatment of [REDACTED]. There was no documented evidence that staff reported the allegation to the Administrator or to state agencies. On 01/22/19, Resident #52 also reported to the State Ombudsman that SRNA #1 verbally abused Resident #52. The Ombudsman stated she reported the allegation to the Administrator. However, there was no evidence that the Administrator reported the allegations to state agencies as required. The facility's failure to ensure allegations of abuse were reported as required has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/14/19 and was determined to exist on 01/22/19 at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610). The facility was notified of the Immediate Jeopardy on 02/14/19. An acceptable Allegation of Compliance was received on 02/27/19, which alleged removal of the Immediate Jeopardy on 02/16/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/16/19, prior to exit on 03/27/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Reporting Abuse Process, dated 11/03/17, revealed all suspected violations of abuse, neglect, exploitation, or mistreatment would be promptly reported to facility management. Further review of the policy revealed the Administrator would immediately report allegations of abuse to appropriate state agencies and other entities as may be required by law, no later than two (2) hours after the allegation was made. 1. Review of Resident #13's medical record revealed the facility admitted the resident on 09/14/15, with [DIAGNOSES REDACTED]. Review of Resident #13's Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was totally dependent on two (2) staff members for bed mobility, transfers, and toileting. Further review revealed the facility assessed the resident to be interviewable, with a Brief Interview for Mental Status (BIMS) score of fourteen (14). During an interview with Resident #13 on 02/06/19 at 5:00 PM, the resident stated, Please make them quit giving me those enemas. They're killing me and making me weak. Further interview with the resident revealed that the night before, staff had administered a rectal suppository even though the resident told staff that his/her bowels had moved and he/she didn't need it. Resident #13 stated the staff member rolled him/her over and administered the suppository anyway. The resident further stated he/she felt abused and violated as a result of receiving the rectal suppository, and stated, Wouldn't you, if someone did you that way? Interview with SRNA #1 on 02/06/19 at 9:30 PM revealed on 02/05/19, he heard Resident #13 tell Licensed Practical Nurse (LPN) #4 that someone gave the resident a suppository that the resident did not want. After Resident #13's report to the LPN, the SRNA stated he told LPN #4 that the resident had routine, regular bowel movements and stated, I don't know why (the resident's) getting them anyway. The SRNA stated he did not report the incident to anyone, because he witnessed the resident report the incident to LPN #4, and assumed the LPN would report the incident. Interview with LPN #4 on 02/08/19 at 2:30 PM revealed she provided care to Resident #13 during the evening shift on 02/05/19. However, LPN #4 denied that Resident #13 told her that someone had given him/her a rectal suppository against his/her wishes. Interview with KMA #1 on 02/06/19 at 5:50 PM confirmed that Resident #13 did not want the KMA to administer a rectal suppository on 02/05/19. The KMA stated she had been trained regarding the facility's abuse policy and realized she should not force residents to take medications, but the KMA stated, It was on my MAR (the resident's Medication Administration Record) to give, so I gave it anyway. The KMA acknowledged that the resident yelled No, no, no! However, the KMA stated she rolled the resident over and gave the rectal suppository. Interview with the Administrator on 02/06/19 at 6:00 PM, revealed staff had not reported Resident #13's allegation of abuse to the Administrator or to state agencies. Review of a facility investigation revealed the allegation of abuse regarding Resident #13 was not reported to the Administrator and to state agencies until 02/06/19, after the State Agency reported the allegation to the Administrator. 2. Review of Resident #231's closed medical record revealed the facility admitted the resident on 12/18/18 with [DIAGNOSES REDACTED]. Review of Resident #231's Minimum Data Set ((MDS) dated [DATE], revealed the resident required extensive assistance of two (2) staff members for bed mobility, toileting, and transfers. Further review revealed the resident was cognitively impaired and the Brief Interview for Mental Status (BIMS) could not be conducted. Continued review of Resident #231's medical record revealed the resident was discharged home on[DATE] and no longer resided in the facility when the investigation was conducted. An interview was conducted on 02/06/19 at 10:00 AM with Resident #52 (Resident #231's roommate), who had a BIMS score of fifteen (15) and was interviewable according to a 12/09/18 Minimum Data Set (MDS) Assessment. The interview revealed that sometime during the first week of (MONTH) (exact date unknown) SRNA #1 stated, (Resident #231) creeps me out. According to Resident #52, SRNA #2 replied that Resident #231, Reminds me of a creaky door in a haunted house when (the resident) grinds (his/her) teeth like that. Resident #52 stated he/she reported the incident to staff (did not recall to whom he/she reported). Interview with SRNA #1 on 02/06/19 at 9:30 PM confirmed that he stated Resident #231 creeps me out. He also confirmed that SRNA #2 replied, Yes, (the resident) does me too. (The resident) reminds me of a creaky door in a haunted house when (the resident) grinds (his/her) teeth like that. SRNA #1 stated that Resident #52 hasn't liked me since (he/she) heard me say that about (his/her) roommate. Review of SRNA #2's personnel file revealed the SRNA terminated her employment at the facility on 02/02/19. Attempts were made on 02/06/19, 02/07/19, and 02/09/19 to interview SRNA #2; however, attempts were unsuccessful. Interview with Licensed Practical Nurse (LPN) #1 on 02/09/19 at 8:00 PM revealed staff (unable to recall who) reported to her in early (MONTH) (YEAR) (exact date unknown) that Resident #52 overheard SRNAs #1 and #2 talking about Resident #231. The SRNAs stated that Resident #231 creeped them out and reminded them of a screechy door in a haunted house. LPN #1 stated she reported the allegation of verbal abuse to the Administrator immediately. According to LPN #1, the Administrator stated she would look into it. LPN #1 further stated no one had discussed/asked about the abuse allegation since she reported it to the Administrator. However, interview with the Administrator on 02/13/19 at 10:20 AM revealed LPN #4 did not report the allegation and she was not aware that the incident occurred. There was no documented evidence that the facility reported the resident's allegation to state agencies as required by the facility's policy. 3. Review of Resident #52's medical record revealed the facility admitted the resident on 11/27/18 with [DIAGNOSES REDACTED]. It's a disease which causes the death of neurons that control voluntary muscles. It causes muscle weakness, muscle wasting, and muscle spasms throughout the body due to the degeneration of neurons. Individuals affected by the disorder may ultimately lose the ability to initiate and control all voluntary movement. The disease affects the individual's speech causing slurred and nasal speech, quiet speech, or trouble speaking/forming words.), Hypertension, [MEDICAL CONDITION], Moderate Protein Calorie Malnutrition, and Anxiety Disorder. Review of Resident #52's admission Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident to be interviewable, with a BIMS score of fifteen (15). Interview with Resident #52 on 02/06/19 at 10:00 AM revealed on 01/22/19, SRNA #2 called the resident Honey. The resident told the SRNA that his/her name was not Honey. Then SRNA #2 mocked my slow ALS speech and stated, O-k-a-y, (M-r./M-s.) (resident's last name). Resident #52 stated he/she felt verbally abused and reported the incident to the State Ombudsman, who stated she reported the incident to the Administrator. Interview with the Ombudsman on 02/12/19 at 11:45 AM, revealed she reported to the Administrator on 01/22/19 that SRNA #2 had mocked Resident #52's slow speech pattern that was related to his/her disease progression. However, review of a Grievance Tracking Form dated 01/22/19, revealed the Ombudsman reported that Resident #52 did not want SRNA #2 to provide care for him/her because the SRNA was loud in the resident's room, and in the hallways; the SRNA had referred to the resident as Honey instead of his/her given name, and the SRNA's tone is rude and the SRNA failed to answer the call bell as quickly as she should. There was no evidence the Administrator documented that the resident alleged that the SRNA mocked the resident's slow speech or that the allegation was reported to state agencies as required by the facility's policy. Interview with the Administrator on 02/13/19 at 10:20 AM revealed she acknowledged that on 01/22/19 the Ombudsman reported that SRNA #2 was rude to Resident #52, but denied that the Ombudsman reported that the SRNA mocked Resident #52's speech. In addition, interview with the Administrator revealed no evidence that the allegation was reported to state agencies as required. **The facility alleged the following actions removed Immediate Jeopardy on 02/16/19: 1. Resident #52 told the Office of Inspector (OIG) surveyor and the surveyor reported to the facility on [DATE], that State Registered Nurse Aides (SRNAs) #1 and #2 made comments in front of Resident #52 about Resident #52's roommate that Resident #52 found offensive. Per the surveyor, the resident stated that SRNA #2 verbally abused the resident by mocking him/her. The allegation of SRNA #2 mocking the resident was thoroughly investigated. Two (2) different staff members interviewed the resident. The resident did not verbalize mocking, but rather that the approach of SRNA #2 was rude, loud, and upsetting to the resident. Resident #52 articulated that it was the roommate that was mocked. The resident stated this occurred in December. An investigation was initiated on 02/14/19, by the Administrator regarding SRNAs #1 and #2, and both were reported to appropriate agencies, including the state agency, APS, the Ombudsman, and the physician. The investigation resulted in SRNA #1 being terminated on 02/14/19, and SRNA #2 was no longer employed with the facility as of 02/01/19. 2. On 02/06/19, Resident #13 reported to the OIG surveyor that on 02/05/19, he/she refused a treatment but the employee, Kentucky Medication Aide (KMA) #1, provided the treatment. The KMA was suspended and terminated on 02/10/19. The Administrator completed an investigation on 02/10/19. The investigation is maintained in the Administrator's file and was reported to the appropriate agencies, including the state agency, APS, and Ombudsman, as well as the physician and Resident Representative. Psychosocial assessments completed daily during the investigation were negative for signs and symptoms of distress or mental anguish. 3. An investigation was initiated by the Administrator regarding Resident #231 on 02/14/19 because Resident #52 told the OIG surveyor that SRNAs #1 and #2 made comments about Resident #231 that were offensive. The allegation was reported to the appropriate agencies, including the state agency, APS, Ombudsman, and physician. SRNA #1 was terminated on 02/14/19 and SRNA #2 was no longer employed at the facility as of 02/01/19. The resident was discharged on [DATE]. 4. Residents with a BIMS score of eight (8) or higher were interviewed on 02/06/19, 02/13/19, and 02/15/19 by the Quality Assurance (QA) RN, who was trained by the Vice President (VP) of Clinical Services, to determine if they had any allegations of abuse, neglect, or treatments provided against their wishes. Residents with a BIMS score below eight (8) had a head-to-toe assessment on 02/06/19 and 02/15/19 by the QA RN and Unit Managers to assess for injuries of unknown origin, abuse, or neglect. There were no concerns noted. The staff involved in the allegation could not be reached for statements and were no longer employed at the facility. The two (2) Staffing Coordinators were interviewed related to the allegations by the Assistant Administrator, trained by the VP (Vice President) of Clinical Services. The interviews revealed that neither Staffing Coordinator had ever had anything inappropriate reported to them regarding this. During the Resident Rights training, on 02/14/19 and 02/15/19, all other staff were given an opportunity to report any inappropriate abuse activity, with no one reporting any issues. All residents were reviewed by the VP of Clinical Services for recent changes in their Patient Health Questionnaire-9 (PHQ9) scores; current and previous scores were reviewed on 02/15/19 to assess for potentially related psychosocial changes. Four (4) residents with minimal declines in PHQ9 scores were noted upon this review. These four (4) residents were followed up on 02/15/19 by Social Services, trained by the VP of Clinical Services, for any indication of depression, anxiety, or symptoms indicating psychosocial decline. Social Services will continue to evaluate these residents weekly for four (4) weeks with outcomes being reviewed in weekly QA. 5. An in-service was conducted on 02/06/19 on Abuse, Neglect, and Resident Rights by the Assistant Administrator, trained by the VP of Clinical Services. Another in-service was conducted on 02/13/19 and 02/14/19 by the QA RN (who was trained by the VP of Clinical Services) on Abuse, Neglect, Reporting Abuse, and Resident Rights. This training covered identification of and reporting of abuse along with inappropriate communication with residents such as mocking and also residents' right to refuse treatment. Staff members trained included licensed staff, nurse aides, department heads, and ancillary staff including activities, maintenance, and housekeeping. A post-test was completed by staff members upon completion of the training to ensure competency on Abuse, Neglect, Reporting, and Resident Rights. All staff members passed the test. 6. Quality Assurance meetings were held on 02/08/19 and 02/12/19. The meeting on 02/14/19 included the Medical Director (via phone), Administrator, Assistant Administrator, a corporate nurse, VP of Clinical Services, and the DON. A Quality Assurance meeting will be held weekly for four (4) weeks and monthly thereafter, to review audits and determine compliance. The following will be conducted: (a) Two (2) residents with a BIMS score of eight (8) or higher will be interviewed daily to ensure no abuse, neglect, or violation of Resident Rights. These audits will be completed daily for four (4) weeks, then weekly for four (4) weeks, and then monthly if no continued issues. (b) Two (2) residents with a BIMS score below eight (8) will have a head-to-toe assessment daily to ensure no injuries of unknown origin, abuse, or neglect. These audits will be completed daily for four (4) weeks, then taken to weekly for four (4) weeks, and then monthly if no continued issues. The residents for these audits are being selected by two (2) categories of characteristics: BIMS score of eight (8) and/or higher is the first category, and the other category of residents is those with a BIMS of seven (7) or less. By process of elimination, the residents who have already had audits completed are excluded, and the next residents are picked. This was intended to make sure, as time progresses, that all residents will be included. The results will be reviewed daily as they are done, by the Administrator or DON, to ensure no issues were identified. In addition, an extra administrative nurse has been present every day for at least eight (8) hours, seven (7) days a week, going between the two (2) units observing care, checking staff and residents to identify problems, and serving as an additional resource. ***The State Survey Agency determined the following removed Immediate Jeopardy on 02/16/19, as alleged by the facility: 1. Review of the investigation, dated 02/14/19, revealed an investigation was immediately initiated regarding allegations made by Resident #52, involving SRNAs #1 and #2. The review also revealed the allegations were reported to the appropriate agencies on 02/14/19. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a final termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in on 02/10/19. Review of an Employee Conference Form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. Further review of the investigation, dated 02/14/19, revealed an addendum, dated 02/27/19, stating Resident #52 was interviewed by the Assistant Administrator and Director of Nursing. The interview revealed the resident stated SRNA #2 did not mock him/her, she mocked the resident's roommate, Resident #231. The resident also stated SRNA #2 was loud, rude, and upsetting to him/her. Resident #52 continued to reside in the facility. Interview with Resident #52 on 03/06/19 at 10:00 AM, revealed the resident stated, Everything is wonderful. The resident further stated they had had some kinks but it was better now. 2. Review of the investigation dated 02/06/19, involving Resident #13, alleged KMA #1 administered a suppository after the resident had stated he/she did not want it. The allegation was reported by the SSA Surveyor to the Administrator. The investigation revealed KMA #1 was removed from the facility on 02/06/19 at 6:06 PM after the report was made at 6:00 PM. The allegation was reported to the appropriate agencies, the physician, and the resident's representative on 02/06/19. Upon conclusion of the investigation, KMA #1 was terminated on 02/10/19. Resident #13 continued to reside in the facility. Interview with Resident #13 on 03/04/19 at 7:00 PM, revealed everything was okay and he/she stated he/she had no incidents of being forced to do anything against his/her will. 3. Resident #231 no longer resided in the facility. The resident was discharged home on[DATE]. The investigation, initiated on 02/14/19, revealed an allegation reported by Resident #52 regarding overhearing SRNAs #1 and #2 making offensive comments about Resident #231. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in for work on 02/10/19. Review of the Employee Conference form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. 4. Review of interview questionnaires completed on 02/15/19, revealed thirty-seven (37) residents with BIMS scores of eight (8) or higher were interviewed related to staff forcing them to have a treatment completed/take a medication and being abused in the facility. Review of the interviews revealed all thirty-seven (37) residents interviewed denied being forced to have a treatment completed/take a medication or being abused in the facility. Review of head-to-toe assessments conducted of residents with a BIMS score below eight (8) revealed none of the seventy-three (73) residents assessed were identified to have any suspicious injuries or injuries of unknown origin. Review of statements from both staffing coordinators revealed they had no knowledge of any reports of abuse or inappropriate behaviors regarding SRNA #1 and SRNA #2. Further review of a computer-generated listing of residents and PHQ-9 scores, dated 02/15/19, revealed four (4) residents were identified as having minimal declines in PHQ-9 scores. Clinical record review revealed Social Services followed up on these four (4) residents weekly. Interview with the Assistant Administrator/Social Services on 03/05/19 at 3:15 PM, revealed she had been visiting with and assessing the four (4) residents identified with slight declines in PHQ-9. She stated all but one (1) of the residents had now returned to baseline PHQ-9 scores. She also added that most of the declines were related to a decrease in appetite. 5. Review of training records revealed documentation that the Vice President of Clinical Services trained the Assistant Administrator on 01/28/19, the DON on 01/28/19, and the QA Nurse on 02/11/19. Further review revealed evidence via sign-in sheet, of in-services on Abuse, Reporting, and Protection and Resident Rights, on 02/06/19, 02/13/19, and 02/14/19. The data also revealed evidence of posttests with passing scores. Interviews on 03/04/19 with second shift employees, with four (4) SRNAs at 6:39 PM, 6:40 PM, 6:50 PM, and 6:55PM, two (2) Registered Nurses (RNs) at 6:34 PM and 6:50 PM, and one (1) KMA at 7:05 PM revealed they had been provided with education on types of abuse, protection of residents, and reporting of abuse immediately as well as residents' rights. The employees also stated they had to take a posttest. Interviews on 03/05/19, with first shift employees, included two (2) housekeeping staff members at 1:50 PM and 1:54 PM, two (2) maintenance staff members at 1:58 PM, one (1) dietary staff member at 2:19 PM, one (1) office staff member at 2:20 PM, two (2) SRNAs at 2:07 PM and 2:15 PM, two (2) nurses at 2:05 PM and 2:09 PM, and one (1) activities staff member at 2:10 PM, revealed all had received education on types of abuse, protection of resident and reporting of abuse immediately, as well as resident rights. The employees also stated they had to take a posttest. Interview with the DON on 03/06/19 at 9:44 AM, revealed no staff were allowed to work or clock in until education on abuse and resident rights had been done. Further review of training records revealed evidence of education on Abuse and Resident Rights provided on 02/21/19 and 02/25/19 by the VP of Clinical Services. 6. Review of the Quality Assurance (QA) agenda and sign-in sheets revealed meetings were conducted on 02/08/19, 02/12/19, and 02/14/19. Further review revealed QA meetings were held on 02/21/19 and 02/27/19. Review of audit interviews for residents with BIMS scores of eight (8) or higher revealed two (2) interviews were performed daily beginning on 02/16/19. Review of the audits for skin assessments on residents with BIMS scores less than eight (8) revealed two (2) were performed daily starting on 02/16/19. Interview with the DON on 03/06/19 at 9:44 AM, revealed she and the acting Administrator reviewed those audits daily. Documentation revealed the extra administrative nurse present daily for at least eight (8) hours a day was initiated on 02/16/19 and continued for every weekend through 03/07/19.

Based on interview, record review, and review of the facility's grievance tracking form and the facility's policy, it was determined the facility failed to ensure allegations of abuse were investigated for two (2) of thirty-three (33) sampled residents (Residents #52 and #231). Resident #52 reported an allegation of verbal abuse related to State Registered Nurse Aides (SRNAs) #1 and #2's treatment of [REDACTED]. However, the facility failed to investigate the allegation and failed to take action to protect residents from further potential abuse. On 01/22/19, Resident #52 reported that SRNA #2 mocked/insulted Resident #52. The Administrator documented that the resident had a grievance and did not want SRNA #2 in his/her room, but failed to investigate the allegation and failed to protect residents from further potential abuse. According to the grievance, the Administrator asked that SNRA #2 only go in the resident's room in case of an emergency. The facility's failure to ensure allegations of abuse were investigated has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/14/19 and was determined to exist on 01/22/19 at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610). The facility was notified of the Immediate Jeopardy on 02/14/19. An acceptable Allegation of Compliance was received on 02/27/19, which alleged removal of the Immediate Jeopardy on 02/16/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/16/19, prior to exit on 03/27/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's Abuse Investigations policy dated 08/01/13, revealed all reports of alleged abuse/neglect would be promptly and thoroughly investigated by facility management. The policy also stated the administrator would provide a written report of the results of all abuse investigations and actions taken to the state survey and certification agencies, within five (5) working days of the reported incident. The policy further stated employees accused of abuse would be suspended immediately pending investigation and would be terminated should the allegation be found to be true. Review of Resident #52's medical record revealed the facility admitted the resident on 11/27/18 with [DIAGNOSES REDACTED]. It is a disease which causes the death of neurons that control voluntary muscles. It causes muscle weakness, muscle wasting, and muscle spasms throughout the body due to the degeneration of neurons. Individuals affected by the disorder may ultimately lose the ability to initiate and control all voluntary movement. The disease affects the individual's speech causing slurred and nasal speech, quiet speech, or trouble speaking/forming words.), Hypertension, [MEDICAL CONDITION], Moderate Protein Calorie Malnutrition, and Anxiety Disorder. Review of Resident #52's Admission Minimum Data Set ((MDS) dated [DATE] revealed the facility assessed the resident to be interviewable, with a Brief Interview for Mental Status (BIMS) score of fifteen (15). 1. Interview with Resident #52 on 02/06/19 at 10:00 AM revealed that during the first week of (MONTH) (YEAR) (exact date unknown) SRNA #1 and SRNA #3 were caring for the resident's roommate at the time (Resident #231). According to Resident #52, SRNA #1 stated, (Resident #231) creeps me out. SRNA #2 replied that Resident #231 Reminds me of a creaky door in a haunted house when (the resident) grinds (his/her) teeth like that. Resident #52 stated she reported the incident to staff (did not recall to whom he/she reported). Review of Resident #231's closed medical record revealed the facility admitted the resident on 12/18/18, with [DIAGNOSES REDACTED]. Review of Resident #231's Minimum Data Set ((MDS) dated [DATE], revealed the resident required extensive assistance with activities of daily living and was cognitively impaired. Interview with Licensed Practical Nurse (LPN) #1 on 02/09/19 at 8:00 PM revealed in early (MONTH) (YEAR), staff (unable to recall who) reported an allegation of abuse regarding Resident #231. The staff member alleged that SRNAs #1 and #2 were providing care for Resident #231 and stated that the resident creeped them out and reminded them of a screechy door in a haunted house. LPN #1 stated she reported the allegation of verbal abuse to the Administrator immediately and the Administrator stated she would look into it. LPN #1 further stated that no one had discussed/asked about the abuse allegation since she reported it to the Administrator, and the staff continued to work at the facility. However, interview with the Administrator on 02/13/19 at 10:20 AM revealed the Administrator denied that LPN #4 had reported the allegation and there was no documented evidence of an investigation or that residents were protected from further potential abuse. Interview with SRNA #1 on 02/06/19 at 9:30 PM revealed he recalled the incident as stated by Resident #52; however, the SRNA revealed the incident was not investigated and he continued to work at the facility. An interview was attempted with SRNA #2 on 02/06/19, 02/07/19, and 02/09/19; however, attempts to speak with the SRNA were unsuccessful. 2. Continued interview with Resident #52 on 02/06/19 at 10:00 AM revealed on 01/22/19, SRNA #2 called Resident #52 Honey. The resident stated he/she told the SRNA that his/her name was not Honey. Then SRNA #2 mocked my slow ALS speech and said, O-k-a-y, (M-r./M-s.) (resident's last name). Resident #52 stated he/she reported the incident to the State Ombudsman, who stated she reported the incident to the Administrator. However, according to the resident, facility staff never asked about/investigated the incident and the SRNA continued to work at the facility. According to SRNA #2's personnel file, the SRNA continued to work at the facility until 02/02/19, when the SRNA resigned. A review of a Grievance Tracking Form dated 01/22/19, revealed the Ombudsman reported that Resident #52 did not want SRNA #2 to provide care for him/her because the SRNA was loud in the resident's room, and in the hallways; the SRNA had referred to the resident as Honey instead of his/her given name, and the SRNA's tone is rude and the SRNA failed to answer the call bell as quickly as she should. There was no evidence the Administrator documented that the resident alleged that the SRNA mocked the resident's slow speech. Further review revealed the corrective action was a conference with the employee and SRNA #2 would not be assigned to care for (Resident #52) in the future. Interview with the Administrator on 02/13/19 at 10:20 AM revealed she acknowledged that on 01/22/19, the Ombudsman reported that SRNA #2 was rude to Resident #52, but denied that the Ombudsman reported that the SRNA mocked Resident #52's speech. Further interview with the Administrator revealed she did not discuss the allegation with Resident #52, and did not interview any other residents or staff. The Administrator stated that after the Ombudsman reported the resident's concerns, she asked SRNA #2 to only go in the resident's room in case of an emergency. **The facility alleged the following actions removed Immediate Jeopardy on 02/16/19: 1. Resident #52 told the Office of Inspector (OIG) surveyor and the surveyor reported to the facility on [DATE], that State Registered Nurse Aides (SRNAs) #1 and #2 made comments in front of Resident #52 about Resident #52's roommate that Resident #52 found offensive. Per the surveyor, the resident stated that SRNA #2 verbally abused the resident by mocking him/her. The allegation of SRNA #2 mocking the resident was thoroughly investigated. Two (2) different staff members interviewed the resident. The resident did not verbalize mocking, but rather that the approach of SRNA #2 was rude, loud, and upsetting to the resident. Resident #52 articulated that it was the roommate that was mocked. The resident stated this occurred in December. An investigation was initiated on 02/14/19, by the Administrator regarding SRNAs #1 and #2, and both were reported to appropriate agencies, including the state agency, APS, the Ombudsman, and the physician. The investigation resulted in SRNA #1 being terminated on 02/14/19, and SRNA #2 was no longer employed with the facility as of 02/01/19. 2. On 02/06/19, Resident #13 reported to the OIG surveyor that on 02/05/19, he/she refused a treatment but the employee, Kentucky Medication Aide (KMA) #1, provided the treatment. The KMA was suspended and terminated on 02/10/19. The Administrator completed an investigation on 02/10/19. The investigation is maintained in the Administrator's file and was reported to the appropriate agencies, including the state agency, APS, and Ombudsman, as well as the physician and Resident Representative. Psychosocial assessments completed daily during the investigation were negative for signs and symptoms of distress or mental anguish. 3. An investigation was initiated by the Administrator regarding Resident #231 on 02/14/19 because Resident #52 told the OIG surveyor that SRNAs #1 and #2 made comments about Resident #231 that were offensive. The allegation was reported to the appropriate agencies, including the state agency, APS, Ombudsman, and physician. SRNA #1 was terminated on 02/14/19 and SRNA #2 was no longer employed at the facility as of 02/01/19. The resident was discharged on [DATE]. 4. Residents with a BIMS score of eight (8) or higher were interviewed on 02/06/19, 02/13/19, and 02/15/19 by the Quality Assurance (QA) RN, who was trained by the Vice President (VP) of Clinical Services, to determine if they had any allegations of abuse, neglect, or treatments provided against their wishes. Residents with a BIMS score below eight (8) had a head-to-toe assessment on 02/06/19 and 02/15/19 by the QA RN and Unit Managers to assess for injuries of unknown origin, abuse, or neglect. There were no concerns noted. The staff involved in the allegation could not be reached for statements and were no longer employed at the facility. The two (2) Staffing Coordinators were interviewed related to the allegations by the Assistant Administrator, trained by the VP (Vice President) of Clinical Services. The interviews revealed that neither Staffing Coordinator had ever had anything inappropriate reported to them regarding this. During the Resident Rights training, on 02/14/19 and 02/15/19, all other staff were given an opportunity to report any inappropriate abuse activity, with no one reporting any issues. All residents were reviewed by the VP of Clinical Services for recent changes in their Patient Health Questionnaire-9 (PHQ9) scores; current and previous scores were reviewed on 02/15/19 to assess for potentially related psychosocial changes. Four (4) residents with minimal declines in PHQ9 scores were noted upon this review. These four (4) residents were followed up on 02/15/19 by Social Services, trained by the VP of Clinical Services, for any indication of depression, anxiety, or symptoms indicating psychosocial decline. Social Services will continue to evaluate these residents weekly for four (4) weeks with outcomes being reviewed in weekly QA. 5. An in-service was conducted on 02/06/19 on Abuse, Neglect, and Resident Rights by the Assistant Administrator, trained by the VP of Clinical Services. Another in-service was conducted on 02/13/19 and 02/14/19 by the QA RN (who was trained by the VP of Clinical Services) on Abuse, Neglect, Reporting Abuse, and Resident Rights. This training covered identification of and reporting of abuse along with inappropriate communication with residents such as mocking and also residents' right to refuse treatment. Staff members trained included licensed staff, nurse aides, department heads, and ancillary staff including activities, maintenance, and housekeeping. A post-test was completed by staff members upon completion of the training to ensure competency on Abuse, Neglect, Reporting, and Resident Rights. All staff members passed the test. 6. Quality Assurance meetings were held on 02/08/19 and 02/12/19. The meeting on 02/14/19 included the Medical Director (via phone), Administrator, Assistant Administrator, a corporate nurse, VP of Clinical Services, and the DON. A Quality Assurance meeting will be held weekly for four (4) weeks and monthly thereafter, to review audits and determine compliance. The following will be conducted: (a) Two (2) residents with a BIMS score of eight (8) or higher will be interviewed daily to ensure no abuse, neglect, or violation of Resident Rights. These audits will be completed daily for four (4) weeks, then weekly for four (4) weeks, and then monthly if no continued issues. (b) Two (2) residents with a BIMS score below eight (8) will have a head-to-toe assessment daily to ensure no injuries of unknown origin, abuse, or neglect. These audits will be completed daily for four (4) weeks, then taken to weekly for four (4) weeks, and then monthly if no continued issues. The residents for these audits are being selected by two (2) categories of characteristics: BIMS score of eight (8) and/or higher is the first category, and the other category of residents is those with a BIMS of seven (7) or less. By process of elimination, the residents who have already had audits completed are excluded, and the next residents are picked. This was intended to make sure, as time progresses, that all residents will be included. The results will be reviewed daily as they are done, by the Administrator or DON, to ensure no issues were identified. In addition, an extra administrative nurse has been present every day for at least eight (8) hours, seven (7) days a week, going between the two (2) units observing care, checking staff and residents to identify problems, and serving as an additional resource. ***The State Survey Agency determined the following removed Immediate Jeopardy on 02/16/19, as alleged by the facility: 1. Review of the investigation, dated 02/14/19, revealed an investigation was immediately initiated regarding allegations made by Resident #52, involving SRNAs #1 and #2. The review also revealed the allegations were reported to the appropriate agencies on 02/14/19. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a final termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in on 02/10/19. Review of an Employee Conference Form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. Further review of the investigation, dated 02/14/19, revealed an addendum, dated 02/27/19, stating Resident #52 was interviewed by the Assistant Administrator and Director of Nursing. The interview revealed the resident stated SRNA #2 did not mock him/her, she mocked the resident's roommate, Resident #231. The resident also stated SRNA #2 was loud, rude, and upsetting to him/her. Resident #52 continued to reside in the facility. Interview with Resident #52 on 03/06/19 at 10:00 AM, revealed the resident stated, Everything is wonderful. The resident further stated they had had some kinks but it was better now. 2. Review of the investigation dated 02/06/19, involving Resident #13, alleged KMA #1 administered a suppository after the resident had stated he/she did not want it. The allegation was reported by the SSA Surveyor to the Administrator. The investigation revealed KMA #1 was removed from the facility on 02/06/19 at 6:06 PM after the report was made at 6:00 PM. The allegation was reported to the appropriate agencies, the physician, and the resident's representative on 02/06/19. Upon conclusion of the investigation, KMA #1 was terminated on 02/10/19. Resident #13 continued to reside in the facility. Interview with Resident #13 on 03/04/19 at 7:00 PM, revealed everything was okay and he/she stated he/she had no incidents of being forced to do anything against his/her will. 3. Resident #231 no longer resided in the facility. The resident was discharged home on[DATE]. The investigation, initiated on 02/14/19, revealed an allegation reported by Resident #52 regarding overhearing SRNAs #1 and #2 making offensive comments about Resident #231. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in for work on 02/10/19. Review of the Employee Conference form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. 4. Review of interview questionnaires completed on 02/15/19, revealed thirty-seven (37) residents with BIMS scores of eight (8) or higher were interviewed related to staff forcing them to have a treatment completed/take a medication and being abused in the facility. Review of the interviews revealed all thirty-seven (37) residents interviewed denied being forced to have a treatment completed/take a medication or being abused in the facility. Review of head-to-toe assessments conducted of residents with a BIMS score below eight (8) revealed none of the seventy-three (73) residents assessed were identified to have any suspicious injuries or injuries of unknown origin. Review of statements from both staffing coordinators revealed they had no knowledge of any reports of abuse or inappropriate behaviors regarding SRNA #1 and SRNA #2. Further review of a computer-generated listing of residents and PHQ-9 scores, dated 02/15/19, revealed four (4) residents were identified as having minimal declines in PHQ-9 scores. Clinical record review revealed Social Services followed up on these four (4) residents weekly. Interview with the Assistant Administrator/Social Services on 03/05/19 at 3:15 PM, revealed she had been visiting with and assessing the four (4) residents identified with slight declines in PHQ-9. She stated all but one (1) of the residents had now returned to baseline PHQ-9 scores. She also added that most of the declines were related to a decrease in appetite. 5. Review of training records revealed documentation that the Vice President of Clinical Services trained the Assistant Administrator on 01/28/19, the DON on 01/28/19, and the QA Nurse on 02/11/19. Further review revealed evidence via sign-in sheet, of in-services on Abuse, Reporting, and Protection and Resident Rights, on 02/06/19, 02/13/19, and 02/14/19. The data also revealed evidence of posttests with passing scores. Interviews on 03/04/19 with second shift employees, with four (4) SRNAs at 6:39 PM, 6:40 PM, 6:50 PM, and 6:55PM, two (2) Registered Nurses (RNs) at 6:34 PM and 6:50 PM, and one (1) KMA at 7:05 PM revealed they had been provided with education on types of abuse, protection of residents, and reporting of abuse immediately as well as residents' rights. The employees also stated they had to take a posttest. Interviews on 03/05/19, with first shift employees, included two (2) housekeeping staff members at 1:50 PM and 1:54 PM, two (2) maintenance staff members at 1:58 PM, one (1) dietary staff member at 2:19 PM, one (1) office staff member at 2:20 PM, two (2) SRNAs at 2:07 PM and 2:15 PM, two (2) nurses at 2:05 PM and 2:09 PM, and one (1) activities staff member at 2:10 PM, revealed all had received education on types of abuse, protection of resident and reporting of abuse immediately, as well as resident rights. The employees also stated they had to take a posttest. Interview with the DON on 03/06/19 at 9:44 AM, revealed no staff were allowed to work or clock in until education on abuse and resident rights had been done. Further review of training records revealed evidence of education on Abuse and Resident Rights provided on 02/21/19 and 02/25/19 by the VP of Clinical Services. 6. Review of the Quality Assurance (QA) agenda and sign-in sheets revealed meetings were conducted on 02/08/19, 02/12/19, and 02/14/19. Further review revealed QA meetings were held on 02/21/19 and 02/27/19. Review of audit interviews for residents with BIMS scores of eight (8) or higher revealed two (2) interviews were performed daily beginning on 02/16/19. Review of the audits for skin assessments on residents with BIMS scores less than eight (8) revealed two (2) were performed daily starting on 02/16/19. Interview with the DON on 03/06/19 at 9:44 AM, revealed she and the acting Administrator reviewed those audits daily. Documentation revealed the extra administrative nurse present daily for at least eight (8) hours a day was initiated on 02/16/19 and continued for every weekend through 03/07/19.

Based on observation, interview, and a review of facility policy it was determined the facility failed to ensure the right to refuse treatment was honored for one (1) of thirty-three (33) sampled residents (Resident #13). Interview with Resident #13 on 02/05/19, revealed the resident refused a rectal suppository (laxative). However, staff held the resident on his/her side and administered the suppository without the resident's consent. Resident #13 stated he/she had a bowel movement prior to receiving the suppository and the suppository made his/her belly hurt. Further interview with the resident revealed the resident was upset and felt violated because staff administered the suppository against his/her wishes. The facility's failure to ensure that residents had the right to refuse treatment and that they were free from abuse has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/14/19 and was determined to exist on 01/22/19 at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610). The facility was notified of the Immediate Jeopardy on 02/14/19. An acceptable Allegation of Compliance was received on 02/27/19, which alleged removal of the Immediate Jeopardy on 02/16/19. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on 02/16/19, prior to exit on 03/27/19, which lowered the scope and severity to D level at 42 CFR 483.10 Resident Rights (F578) and 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600, F609, and F610), while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Rights of Residents, not dated, revealed residents should be treated with consideration, respect, and with full recognition of dignity and individuality. The policy also stated residents had the right to participate in planning their care and treatment, and had the right to refuse treatment in the facility. Interview with Resident #13 on 02/06/19 at 5:00 PM revealed the resident stated to the State Surveyor, Please make them quit giving me those enemas. They're killing me and making me weak. Last night I told her (staff member) 'No, no, no!' and she told me 'Yes, yes, yes!' and rolled me over and put it in me anyway. According to Resident #13, staff came to the resident's room on 02/05/19 and stated they were going to administer a suppository. Resident #13 stated he/she informed the staff member that he/she had a bowel movement and stated, I didn't need it. The resident stated the staff member rolled him/her over and gave the suppository anyway. Further interview revealed the resident stated he/she tried to kick the staff in an attempt to keep the staff member from administering the suppository; however, he/she could not stop the staff member. Resident #13 stated the suppository made my belly hurt. Review of Resident #13's medical record revealed the facility admitted the resident on 09/14/15. The resident had [DIAGNOSES REDACTED]. Review of Resident #13's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was totally dependent on two (2) staff members for bed mobility, transfers, and toileting. The facility assessed the resident to be interviewable, with a Brief Interview for Mental Status (BIMS) score of fourteen (14). Review of Resident #13's physician's orders [REDACTED]. Review of Resident #13's Medication Administration Record [REDACTED]. Interview with KMA #1 on 02/06/19 at 5:50 PM, revealed she was responsible for administering Resident #13's medications on the evening of 02/05/19. KMA #1 acknowledged that Resident #13 didn't want the suppository and even told me (his/her) bowels had already moved. However, KMA #1 stated the rectal suppository was ordered for the resident so she gave it anyway. The KMA stated that Resident #13 was yelling, No, no, no! before she gave it; however, the KMA stated she told the resident, Yes, yes, yes! and administered the suppository against the resident's wishes. KMA #1 added, I probably shouldn't have done that, should I? Interview with the Administrator on 02/06/19 at 6:00 PM and the Director of Nursing (DON) on 02/11/19 at 2:10 PM revealed residents had the right to refuse care and treatment. The DON stated Resident #13 had the right to refuse medications and treatment and KMA #1 should have honored the resident's right. The Administrator also stated that KMA #1 should not have administered a rectal suppository against Resident #13's wishes. **The facility alleged the following actions removed Immediate Jeopardy on 02/16/19: 1. Resident #52 told the Office of Inspector (OIG) surveyor and the surveyor reported to the facility on [DATE], that State Registered Nurse Aides (SRNAs) #1 and #2 made comments in front of Resident #52 about Resident #52's roommate that Resident #52 found offensive. Per the surveyor, the resident stated that SRNA #2 verbally abused the resident by mocking him/her. The allegation of SRNA #2 mocking the resident was thoroughly investigated. Two (2) different staff members interviewed the resident. The resident did not verbalize mocking, but rather that the approach of SRNA #2 was rude, loud, and upsetting to the resident. Resident #52 articulated that it was the roommate that was mocked. The resident stated this occurred in December. An investigation was initiated on 02/14/19, by the Administrator regarding SRNAs #1 and #2, and both were reported to appropriate agencies, including the state agency, APS, the Ombudsman, and the physician. The investigation resulted in SRNA #1 being terminated on 02/14/19, and SRNA #2 was no longer employed with the facility as of 02/01/19. 2. On 02/06/19, Resident #13 reported to the OIG surveyor that on 02/05/19, he/she refused a treatment but the employee, Kentucky Medication Aide (KMA) #1, provided the treatment. The KMA was suspended and terminated on 02/10/19. The Administrator completed an investigation on 02/10/19. The investigation is maintained in the Administrator's file and was reported to the appropriate agencies, including the state agency, APS, and Ombudsman, as well as the physician and Resident Representative. Psychosocial assessments completed daily during the investigation were negative for signs and symptoms of distress or mental anguish. 3. An investigation was initiated by the Administrator regarding Resident #231 on 02/14/19 because Resident #52 told the OIG surveyor that SRNAs #1 and #2 made comments about Resident #231 that were offensive. The allegation was reported to the appropriate agencies, including the state agency, APS, Ombudsman, and physician. SRNA #1 was terminated on 02/14/19 and SRNA #2 was no longer employed at the facility as of 02/01/19. The resident was discharged on [DATE]. 4. Residents with a BIMS score of eight (8) or higher were interviewed on 02/06/19, 02/13/19, and 02/15/19 by the Quality Assurance (QA) RN, who was trained by the Vice President (VP) of Clinical Services, to determine if they had any allegations of abuse, neglect, or treatments provided against their wishes. Residents with a BIMS score below eight (8) had a head-to-toe assessment on 02/06/19 and 02/15/19 by the QA RN and Unit Managers to assess for injuries of unknown origin, abuse, or neglect. There were no concerns noted. The staff involved in the allegation could not be reached for statements and were no longer employed at the facility. The two (2) Staffing Coordinators were interviewed related to the allegations by the Assistant Administrator, trained by the VP (Vice President) of Clinical Services. The interviews revealed that neither Staffing Coordinator had ever had anything inappropriate reported to them regarding this. During the Resident Rights training, on 02/14/19 and 02/15/19, all other staff were given an opportunity to report any inappropriate abuse activity, with no one reporting any issues. All residents were reviewed by the VP of Clinical Services for recent changes in their Patient Health Questionnaire-9 (PHQ9) scores; current and previous scores were reviewed on 02/15/19 to assess for potentially related psychosocial changes. Four (4) residents with minimal declines in PHQ9 scores were noted upon this review. These four (4) residents were followed up on 02/15/19 by Social Services, trained by the VP of Clinical Services, for any indication of depression, anxiety, or symptoms indicating psychosocial decline. Social Services will continue to evaluate these residents weekly for four (4) weeks with outcomes being reviewed in weekly QA. 5. An in-service was conducted on 02/06/19 on Abuse, Neglect, and Resident Rights by the Assistant Administrator, trained by the VP of Clinical Services. Another in-service was conducted on 02/13/19 and 02/14/19 by the QA RN (who was trained by the VP of Clinical Services) on Abuse, Neglect, Reporting Abuse, and Resident Rights. This training covered identification of and reporting of abuse along with inappropriate communication with residents such as mocking and also residents' right to refuse treatment. Staff members trained included licensed staff, nurse aides, department heads, and ancillary staff including activities, maintenance, and housekeeping. A post-test was completed by staff members upon completion of the training to ensure competency on Abuse, Neglect, Reporting, and Resident Rights. All staff members passed the test. 6. Quality Assurance meetings were held on 02/08/19 and 02/12/19. The meeting on 02/14/19 included the Medical Director (via phone), Administrator, Assistant Administrator, a corporate nurse, VP of Clinical Services, and the DON. A Quality Assurance meeting will be held weekly for four (4) weeks and monthly thereafter, to review audits and determine compliance. The following will be conducted: (a) Two (2) residents with a BIMS score of eight (8) or higher will be interviewed daily to ensure no abuse, neglect, or violation of Resident Rights. These audits will be completed daily for four (4) weeks, then weekly for four (4) weeks, and then monthly if no continued issues. (b) Two (2) residents with a BIMS score below eight (8) will have a head-to-toe assessment daily to ensure no injuries of unknown origin, abuse, or neglect. These audits will be completed daily for four (4) weeks, then taken to weekly for four (4) weeks, and then monthly if no continued issues. The residents for these audits are being selected by two (2) categories of characteristics: BIMS score of eight (8) and/or higher is the first category, and the other category of residents is those with a BIMS of seven (7) or less. By process of elimination, the residents who have already had audits completed are excluded, and the next residents are picked. This was intended to make sure, as time progresses, that all residents will be included. The results will be reviewed daily as they are done, by the Administrator or DON, to ensure no issues were identified. In addition, an extra administrative nurse has been present every day for at least eight (8) hours, seven (7) days a week, going between the two (2) units observing care, checking staff and residents to identify problems, and serving as an additional resource. ***The State Survey Agency determined the following removed Immediate Jeopardy on 02/16/19, as alleged by the facility: 1. Review of the investigation, dated 02/14/19, revealed an investigation was immediately initiated regarding allegations made by Resident #52, involving SRNAs #1 and #2. The review also revealed the allegations were reported to the appropriate agencies on 02/14/19. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a final termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in on 02/10/19. Review of an Employee Conference Form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. Further review of the investigation, dated 02/14/19, revealed an addendum, dated 02/27/19, stating Resident #52 was interviewed by the Assistant Administrator and Director of Nursing. The interview revealed the resident stated SRNA #2 did not mock him/her, she mocked the resident's roommate, Resident #231. The resident also stated SRNA #2 was loud, rude, and upsetting to him/her. Resident #52 continued to reside in the facility. Interview with Resident #52 on 03/06/19 at 10:00 AM, revealed the resident stated, Everything is wonderful. The resident further stated they had had some kinks but it was better now. 2. Review of the investigation dated 02/06/19, involving Resident #13, alleged KMA #1 administered a suppository after the resident had stated he/she did not want it. The allegation was reported by the SSA Surveyor to the Administrator. The investigation revealed KMA #1 was removed from the facility on 02/06/19 at 6:06 PM after the report was made at 6:00 PM. The allegation was reported to the appropriate agencies, the physician, and the resident's representative on 02/06/19. Upon conclusion of the investigation, KMA #1 was terminated on 02/10/19. Resident #13 continued to reside in the facility. Interview with Resident #13 on 03/04/19 at 7:00 PM, revealed everything was okay and he/she stated he/she had no incidents of being forced to do anything against his/her will. 3. Resident #231 no longer resided in the facility. The resident was discharged home on[DATE]. The investigation, initiated on 02/14/19, revealed an allegation reported by Resident #52 regarding overhearing SRNAs #1 and #2 making offensive comments about Resident #231. SRNA #2 was no longer employed at the facility as of 02/01/19. Review of the personnel file for SRNA #2 revealed a termination date of 02/07/19. Review of the time detail sheet revealed SRNA #2 last clocked in for work on 02/01/19. Review of the time detail sheet revealed SRNA #1 last clocked in for work on 02/10/19. Review of the Employee Conference form, dated 02/14/19, revealed SRNA #1 was terminated on 02/14/19. 4. Review of interview questionnaires completed on 02/15/19, revealed thirty-seven (37) residents with BIMS scores of eight (8) or higher were interviewed related to staff forcing them to have a treatment completed/take a medication and being abused in the facility. Review of the interviews revealed all thirty-seven (37) residents interviewed denied being forced to have a treatment completed/take a medication or being abused in the facility. Review of head-to-toe assessments conducted of residents with a BIMS score below eight (8) revealed none of the seventy-three (73) residents assessed were identified to have any suspicious injuries or injuries of unknown origin. Review of statements from both staffing coordinators revealed they had no knowledge of any reports of abuse or inappropriate behaviors regarding SRNA #1 and SRNA #2. Further review of a computer-generated listing of residents and PHQ-9 scores, dated 02/15/19, revealed four (4) residents were identified as having minimal declines in PHQ-9 scores. Clinical record review revealed Social Services followed up on these four (4) residents weekly. Interview with the Assistant Administrator/Social Services on 03/05/19 at 3:15 PM, revealed she had been visiting with and assessing the four (4) residents identified with slight declines in PHQ-9. She stated all but one (1) of the residents had now returned to baseline PHQ-9 scores. She also added that most of the declines were related to a decrease in appetite. 5. Review of training records revealed documentation that the Vice President of Clinical Services trained the Assistant Administrator on 01/28/19, the DON on 01/28/19, and the QA Nurse on 02/11/19. Further review revealed evidence via sign-in sheet, of in-services on Abuse, Reporting, and Protection and Resident Rights, on 02/06/19, 02/13/19, and 02/14/19. The data also revealed evidence of posttests with passing scores. Interviews on 03/04/19 with second shift employees, with four (4) SRNAs at 6:39 PM, 6:40 PM, 6:50 PM, and 6:55PM, two (2) Registered Nurses (RNs) at 6:34 PM and 6:50 PM, and one (1) KMA at 7:05 PM revealed they had been provided with education on types of abuse, protection of residents, and reporting of abuse immediately as well as residents' rights. The employees also stated they had to take a posttest. Interviews on 03/05/19, with first shift employees, included two (2) housekeeping staff members at 1:50 PM and 1:54 PM, two (2) maintenance staff members at 1:58 PM, one (1) dietary staff member at 2:19 PM, one (1) office staff member at 2:20 PM, two (2) SRNAs at 2:07 PM and 2:15 PM, two (2) nurses at 2:05 PM and 2:09 PM, and one (1) activities staff member at 2:10 PM, revealed all had received education on types of abuse, protection of resident and reporting of abuse immediately, as well as resident rights. The employees also stated they had to take a posttest. Interview with the DON on 03/06/19 at 9:44 AM, revealed no staff were allowed to work or clock in until education on abuse and resident rights had been done. Further review of training records revealed evidence of education on Abuse and Resident Rights provided on 02/21/19 and 02/25/19 by the VP of Clinical Services. 6. Review of the Quality Assurance (QA) agenda and sign-in sheets revealed meetings were conducted on 02/08/19, 02/12/19, and 02/14/19. Further review revealed QA meetings were held on 02/21/19 and 02/27/19. Review of audit interviews for residents with BIMS scores of eight (8) or higher revealed two (2) interviews were performed daily beginning on 02/16/19. Review of the audits for skin assessments on residents with BIMS scores less than eight (8) revealed two (2) were performed daily starting on 02/16/19. Interview with the DON on 03/06/19 at 9:44 AM, revealed she and the acting Administrator reviewed those audits daily. Documentation revealed the extra administrative nurse present daily for at least eight (8) hours a day was initiated on 02/16/19 and continued for every weekend through 03/07/19.

Based on observation, interviews, record review, and review of facility policy, it was determined the facility failed to utilize the Resident Assessment Instrument (RAI) to conduct a comprehensive and accurate assessment of residents' functional capacity for one (1) of thirty-three (33) sampled residents (Resident #13). The facility admitted Resident #13 on 09/14/15, with no deficits in range of motion (ROM). Review of Resident #13's Minimum Data Set assessments conducted from 09/26/15 through 12/05/18, revealed the resident was never assessed to have any limitations with Range of Motion (ROM) to the upper or lower extremities. However, observations conducted on 02/20/19 and 02/21/19, and interviews with facility staff and Resident #13, revealed the resident had limited range of motion (ROM) to his/her bilateral upper and lower extremities. The findings include: Review of the facility's policy titled, Resident Assessment Instrument-Basic Process, dated 08/01/13, revealed the purpose of the assessment was to describe the resident's capability to perform daily life functions and to identify significant impairments in their functional capacity. Information obtained from the residents' assessments, were to be utilized to plan care which allowed the resident to reach his/her highest practicable level of functioning. Review of Resident #13's medical record revealed the facility admitted the resident on 09/14/15, with [DIAGNOSES REDACTED]. Review of Resident #13's Minimum Data Set (MDS) assessments completed from 09/26/15 through 12/05/18, revealed the resident was never assessed to have any limitations with Range of Motion (ROM) to the upper or lower extremities. Review of Resident #13's MDS assessment dated [DATE], revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. The facility also assessed the resident to have no functional limitations in range of motion to the upper or lower extremities. Review of Resident #13's Comprehensive Care Plan, revised 01/31/19, revealed the facility documented that the resident had an ADL self-care performance deficit and mobility deficit related to weakness and [MEDICAL CONDITION]. Further review of Resident #13's care plan revealed the goal developed for the resident was to improve his/her current level of functioning related to bed mobility, transfers, dressing, toilet use, and personal hygiene by the next scheduled review. The interventions developed to meet the stated goal included staff observing for any declines in the resident's function, observing for any signs and symptoms of contractures, and providing gentle ROM during care. Interview with the Restorative Nurse on 02/11/19 at 2:30 PM, and 02/21/19 at 12:05 PM, and continued review of Resident #13's medical record revealed in (MONTH) (YEAR), Resident #13 was placed on a restorative ROM program because staff reported it was more difficult getting (Resident #13) out of bed. Continued interview with the Restorative Nurse revealed on 08/25/18, she again initiated a restorative program for Resident #13 at the request of the resident's Power of Attorney (POA), because the POA believed the resident was not getting out of bed often enough. The Restorative Nurse stated restorative nursing staff were to perform ROM to the resident's upper and lower extremities. Further interview with the Restorative Nurse revealed on 12/13/18, staff reported a small decline in the resident's ROM abilities, stating the resident was more difficult to transfer from bed. However, the Restorative Nurse stated she had never assessed Resident #13's ROM/functional abilities, including prior to initiating/discontinuing restorative therapy for the resident or when staff reported a decline in the resident's functioning. In addition, the nurse stated she had not referred the resident to Therapy. Observation of Resident #13 on 02/20/19 at 12:45 PM, during the noon meal, revealed the resident had visible contractures to the fingers on the left hand, and the resident required total assistance from staff for eating. Interview with Resident #13 on 02/21/19 at 1:00 PM revealed the resident had not been able to get out of bed or sit up in a chair for a long time. The resident stated his/her left lower leg and hip hurts so bad when I'm sitting up; I can't sit up anymore. An observation was made on 02/21/19, at 11:30 AM of the Physical Therapist and the Occupational Therapist conducting a ROM assessment for Resident #13. The observation revealed the resident had limited ROM to the left shoulder, right elbow, bilateral wrists, left thumb, and left index finger. The observation also revealed Resident #13 had limited ROM to both hips, which resulted in a limited ability for the resident's left lower extremity to be internally rotated. The resident's ROM was also limited in both knees and ankles. Interview with Licensed Practical Nurse (LPN) #3 on 02/20/19 at 3:20 PM revealed she had completed Resident #13's most recent MDS assessment dated [DATE]. She stated she had been trained to conduct complete and accurate assessments, which included evaluating the resident's ROM abilities. However, the LPN stated there had been times that she had completed MDS assessments without properly evaluating the residents, which included their ROM abilities. She acknowledged that Resident #13's MDS assessment was inaccurate and she did not recall whether she had evaluated the resident's ROM abilities when she completed the resident's MDS assessment dated [DATE]. Interview with the MDS Coordinator, who also functions as the Restorative Nurse, on 02/21/19 at 12:05 PM revealed she expected staff completing the MDS assessments in the facility to perform a complete and accurate assessment of the resident's ROM/functional abilities. She also stated the MDS Coordinator should have accurately assessed and coded the resident's ROM and functional abilities. Interview with the Director of Nursing (DON) on 02/12/19 at 2:10 PM revealed she had not identified concerns with accuracy of residents' MDS assessments, and there was no system in place to ensure MDS assessments were coded accurately. The DON stated staff were expected to conduct thorough assessments of residents, and MDS data was expected to be accurate related to the resident's ROM and current functional ability. Interview with the Interim Administrator on 03/06/19 at 10:50 AM, revealed the MDS Coordinator should complete a thorough assessment of the resident's abilities, in order to complete an accurate MDS assessment and develop an appropriate plan of care to ensure the resident's highest level of functioning was maintained.

Based on interview, record review, and review of the facility's policies, it was determined that the facility failed to provide services to meet professional standards of practice for one (1) of thirty-three (33) residents (Resident #52). Interview with Resident #52 revealed on 12/06/18 he/she reported that he/she felt drugged and requested a drug screen because he/she believed the facility had administered the wrong medication. However, the facility failed to assess the resident to ensure a medication error/change in condition had not occurred. On 12/19/18, Resident #52 stated that staff attempted to administer the wrong medication again. However, the resident kept the medication and did not take it. The resident reported his/her concerns about the medication to the Assistant Administrator/Social Services Director (AA/SSD), who determined that staff borrowed [MEDICATION NAME] (treats high blood pressure) medication from another resident and attempted to administer the medication to Resident #52, even though it was the incorrect dosage. The findings include: Review of the facility's policy titled, Medication Administration-General Guidelines, last revised on 12/18/12, revealed medications were to be administered in accordance with good nursing principles and practices. The policy stated borrowing medications from one resident to another when medications were not available was not permitted in the facility. The policy stated residents should be observed when administering medications, to ensure the medications were completely ingested. Medications should be administered without unnecessary interruption, and in accordance with physician orders and to the right resident. Residents were to be identified before medications were administered by checking their identification band, the photograph attached to the medical record, and/or calling the resident by name. The policy did not address how staff were to ensure the right medications were administered to the right resident. 1. Review of Resident #52's medical record revealed the facility admitted the resident on 11/27/18 with [DIAGNOSES REDACTED]. Review of Resident #52's Admission Minimum Data Set ((MDS) dated [DATE], revealed the resident required extensive assistance of two (2) staff members for bed mobility, transfers, and toileting. The facility assessed the resident to be interviewable, with a Brief Interview for Mental Status (BIMS) score of fifteen (15). Review of Resident #52's Physician's Orders for (MONTH) (YEAR) and (MONTH) 2019 revealed the resident's physician prescribed medications that included [MEDICATION NAME] 5 milligram (mg) tablets (treats anxiety), [MEDICATION NAME] 2.5 mg tablets (treats high blood pressure), [MEDICATION NAME] 800 mg (for pain), and [MEDICATION NAME] Syrup 400 mg (to treat respiratory secretions). Further review revealed the resident had no Physician's Orders for any type of narcotic pain medication. 1. A. Interview with Resident #52 on 02/06/19 at 10:00 AM revealed on 12/06/18 Kentucky Medication Aide (KMA) #1 attempted to administer a medication that didn't look like mine. Resident #52 stated the KMA assured the resident it was his/her medication so I took it, and within 30 minutes I felt drugged. Resident #52 stated he/she felt like he/she had taken a narcotic pain medication. The resident stated he/she reported the possible medication error to the Assistant Administrator and requested a drug screen. However, the facility did not conduct a drug screen and to the resident's knowledge, no further action was taken. Resident #52 stated staff stated they were going to leave his/her medications in the blister packs, so the resident could tell that he/she was getting the correct medication; however, the resident stated staff did not always follow that plan. Interview with the Assistant Administrator on 02/11/19 at 1:20 PM confirmed Resident #52 reported on 12/06/18 that staff administered the wrong medication to him/her and it made the resident feel funny. Interview with State Registered Nurse Aide (SRNA) #3 on 02/07/19 at 4:30 PM and SRNA #4 on 02/09/19 at 8:00 PM revealed they provided care to Resident #52 in (MONTH) (YEAR) (exact date unknown) when the resident alleged that KMA #1 had given him/her the wrong medications. SRNA #3 stated Resident #52 was more sleepy than usual, the resident's speech was more slurred, and the resident appeared to be high. SRNA #4 stated the resident didn't act like (himself/herself) and (the resident) could barely talk. The SRNAs stated they obtained Resident #52's vital signs and reported the resident's allegation and the change in the resident's condition to Registered Nurse (RN) #2. Interview with RN #2 on 02/11/19 at 10:15 AM revealed she denied that staff reported a change in Resident #52's condition or that the resident felt drugged due to allegedly receiving the wrong medication. Review of Resident #52's Social Services Progress Notes dated 12/06/18 at 1:58 PM, revealed the resident informed the Assistant Administrator/Social Services Director (AA/SSD) that he/she was afraid (he/she) was getting the wrong medication in the facility. Further review of the note revealed nursing staff ensured the resident that (he/she) was receiving medication as ordered by the physician. Further review of the documentation revealed in the future the resident's medications would be left in the blister packs to assure the resident that he/she was receiving the correct medications. According to the Note, the AA/SSD discussed the intervention with the resident and the resident feels more comfortable with this. Further review of Resident #52's medical record revealed no documentation the facility assessed the resident to determine whether the resident received the incorrect medication and/or had a change in condition. 1. B. Continued interview with Resident #52 on 02/06/19 at 10:00 AM revealed on 12/19/18, KMA #1 attempted to administer a medication that was not ordered for him/her again. However, the resident stated he/she did not take the medication. Resident #52 stated he/she kept the medication and reported the error to the Assistant Administrator. Review of the Social Services (SS) Progress Notes dated 12/19/18 revealed the AA/SSD documented that upon entering Resident #52's room, the resident removed a medication cup out of the night stand drawer that had two (2) pills in it, and the resident informed me that the medication technician had given (him/her) the wrong medication. Further review revealed the resident stated that one of the pills was [MEDICATION NAME] (anti-[MEDICAL CONDITION] pain medication) and the little pink pill was supposed to be (his/her) [MEDICATION NAME] (blood pressure medication) but the resident didn't think it was (his/her [MEDICATION NAME]). Further review of the SS Progress Notes revealed the AA/SSD took the two (2) medications to nursing staff, who confirmed that KMA #1 had attempted to administer the wrong dose of [MEDICATION NAME] to Resident #52. Interview with the AA/SSD on 02/11/19, at 1:20 PM confirmed that on 12/06/18, she instructed staff to leave the resident's medications in the packages until the medication was administered to the resident so that the resident could see what medications he/she was receiving. However, she stated she did not follow up or monitor to ensure staff were implementing the intervention or to ensure the resident was receiving the correct medications. Continued interview with the AA/SSD revealed on 12/19/18, Resident #52 reported that KMA #1 had attempted to give him/her the wrong medication again. The AA/SSD stated that this time the resident did not take the medications and kept them in his/her drawer. During further interview, the AA/SSD stated nursing staff compared the medication to the medications prescribed for the resident. She stated staff confirmed that the medication in the cup that the KMA attempted to administer was not prescribed for the resident and she notified the Administrator immediately. Interview with KMA #1 on 02/09/19 at 6:45 PM revealed she was aware that Resident #52 alleged that he/she had gotten something for pain other than [MEDICATION NAME]. However, the KMA stated no one had ever spoken with her related to the incident. Further interview revealed she was administering Resident #52's medications on 12/19/18, and identified that the resident was out of [MEDICATION NAME] 2.5 mg tablets, ordered to be administered daily at 8:00 AM. She informed the Unit Coordinator (UC) that the resident did not have a [MEDICATION NAME] available and the UC went to another cart, got a pill, and stated here's one to give the resident. The KMA stated she did not ensure the medication was the correct medication or dose, and stated, She's the nurse. I trusted it was the right medication, so I just gave it to the resident. The KMA stated she continued to administer medications to residents until a day or so later, after the medication error. An interview was attempted with the UC on 02/09/19 and 02/13/19; however, attempts were unsuccessful. Interview with the Director of Nursing (DON) on 02/11/19 at 2:10 PM revealed she was aware that Resident #52 had alleged that KMA #1 had administered the wrong medication to him/her on 12/06/18. She also stated that after the incident, staff were required to leave the resident's medications in the packages until the medications were administered so that the resident could observe the packages and see that he/she was receiving the correct medications. However, the DON stated she was not monitoring to ensure staff were implementing the plan. The DON further stated she was not aware the resident had requested a drug screen. The DON also confirmed that staff did not assess the resident or investigate whether the resident received the wrong medication in (MONTH) (YEAR). The DON stated she was also aware that on 12/19/18, KMA #1 attempted to administer the wrong dose of [MEDICATION NAME] to Resident #52. However, the resident caught the error and didn't take the medication. The DON stated KMA #1 continued to administer medications and no action had been taken to ensure the KMA and the Unit Coordinator were competent to administer medications. Interview with the Administrator on 02/13/19 at 10:20 AM, revealed she denied that the Assistant Administrator or DON reported that Resident #52 alleged that he/she received the wrong medication on 12/06/18. The Administrator stated she was notified that KMA #1 had taken the wrong medication to Resident #52 on 12/19/18, but the resident identified the medication error and did not take the medication. She stated she did not identify a concern with the incident because the medication was not ingested and confirmed no further action was taken to ensure KMA #1 and the Unit Coordinator were competent with administering medications.

Based on observation, interviews, record review, and review of facility policy, it was determined the facility failed to ensure one (1) of thirty-three (33) sampled residents (Resident #13), who entered the facility without limited range of motion, did not experience a reduction in range of motion that was avoidable. Resident #13 was admitted to the facility on [DATE], without any deficits in range of motion (ROM). In (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) declines in Resident #13's functional abilities/ROM were reported to the Restorative Nurse. The Restorative Nurse implemented restorative programs for the resident when the declines were reported, consisting of restorative aides providing ROM to the resident. However, the Restorative Nurse never physically assessed the resident to determine the most appropriate ROM program for the resident, the extent of the decline experienced by the resident, to evaluate if the restorative program was effective, or if a referral needed to be made to Occupational/Physical Therapy. In addition, interviews with staff and Resident #13 revealed staff had not consistently provided the restorative programs to Resident #13 due to a lack of staffing in the facility. Observations of Resident #13 on 02/20/19 revealed the resident had visible contractures to the fingers on the left hand, and required total assistance of staff for eating. Further, an assessment of Resident #13 conducted by the Occupational Therapist and Physical Therapist on 02/21/19 revealed the resident had limited ROM to the left shoulder, right elbow, bilateral wrists, left thumb, and left index finger. Resident #13 also had limited ROM to bilateral hips, knees, and ankles. Interview with the Physical Therapist that conducted the assessment revealed the resident had experienced a significant decline in ROM and functional ability. The findings include: Review of the facility's policy titled, Restorative Nursing Care Protocol, not dated, revealed restorative nursing care would be available to all residents and include interventions and goals to restore or prevent further impairments for the residents. The policy also stated a licensed nurse would supervise the restorative program and would conduct periodic evaluations of the resident's progress toward their restorative goal. Review of Resident #13's medical record revealed the facility admitted the resident on 09/14/15, with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #13's Minimum Data Set (MDS) assessments completed from 09/26/15 through 12/05/18, revealed the resident was never assessed to have any limitations with Range of Motion (ROM) to the upper or lower extremities. Review of Resident #13's MDS assessment dated [DATE], revealed the facility assessed Resident #13 to have a Brief Interview for Mental Status (BIMS) score of fourteen (14), indicating the resident was cognitively intact. The facility also assessed the resident to require extensive assistance of one (1) staff member for eating and total assistance of two (2) staff members for bed mobility, transfers, and toileting. Further review of the MDS assessments revealed the resident had no functional limitations in range of motion to the upper or lower extremities. Review of Resident #13's care plan (undated) revealed the facility had implemented (date unknown) a restorative therapy program for the resident consisting of limited active ROM to the bilateral upper extremities and passive ROM to the bilateral lower extremities. Further review of the care plan revealed staff determined on 01/31/19, that Resident #13 had met his/her goal of maintaining ROM functioning, as evidenced by no contractures, and therefore, staff discontinued the resident's restorative therapy program on 01/31/19. Review of Resident #13's Comprehensive Care Plan, revised on 01/31/19, revealed the facility documented that the resident had an ADL self-care performance deficit and mobility deficit related to weakness and [MEDICAL CONDITION]. Further review of the care plan revealed the goal developed for the resident was to improve his/her current level of functioning related to bed mobility, transfers, dressing, toilet use, and personal hygiene by the next scheduled review. The interventions developed to meet the stated goal included staff observing for any declines in the resident's function, observing for any signs and symptoms of contractures, and providing gentle ROM during care. However, review of Resident #13's Bedside Kardex Report (utilized by direct care staff to provide care to the resident) printed 02/11/19, revealed the Kardex did not direct staff to provide gentle ROM during care as outlined on the resident's comprehensive care plan. Observation of Resident #13 on 02/20/19 at 12:45 PM, during the noon meal, revealed the resident had visible contractures to the fingers on the left hand, and the resident required total assistance of staff for eating. Interview with Resident #13 on 02/21/19 at 1:00 PM revealed the resident had not been able to get out of bed or sit up in a chair for a long time. The resident stated he/she had previously enjoyed getting out of the room and talking to other residents, and really liked playing bingo. However, the resident stated his/her left lower leg and hip hurts so bad when I'm sitting up, I can't sit up anymore. The resident also stated he/she had not had any therapy for years, and that no one has worked with me to get me stronger. The resident also stated staff had not worked with my arms and legs in at least a year. Review of Resident #13's Physical Therapy (PT) Notes revealed they had not received a request for an evaluation and possible treatment of [REDACTED]. Review of Resident #13's Occupational Therapy (OT) Notes revealed they had not received a request for an evaluation and possible treatment of [REDACTED]. Interview with the Restorative Nurse on 02/11/19 at 2:30 PM, and 02/21/19 at 12:05 PM, and continued review of Resident #13's medical record, revealed in (MONTH) (YEAR) Resident #13 was placed on a restorative ROM program because staff reported it was more difficult getting (Resident #1) out of bed. However, the Restorative Nurse stated she did not make any referrals for the resident to have therapy evaluations performed to determine if the resident's condition warranted therapy services. The Restorative Nurse stated she did initiate a restorative program for Resident #13 which consisted of restorative staff providing ROM to the resident's upper and lower extremities. However, the Restorative Nurse stated that although she developed the program for Resident #13, she had not assessed the resident's functional status or ROM ability prior to formulating the plan. The Restorative Nurse stated Resident #13 continued to receive restorative services until she discharged the resident from the program on 07/09/18, due to staff reporting that the resident was maintaining ROM levels and was getting out of bed easier. However, RN #1 stated she did not assess the resident's functional status or ROM ability prior to discontinuing restorative services for the resident. Continued interview with the Restorative Nurse on 02/21/19 at 12:05 PM, revealed on 08/25/18, she again initiated a restorative program for Resident #13 at the request of the resident's Power of Attorney (POA), because the POA believed the resident was not getting out of bed often enough. The Restorative Nurse stated restorative nursing staff were to perform ROM to the resident's upper and lower extremities. However, she stated she had not assessed the resident's functional status or ROM abilities prior to formulating the restorative plan for Resident #13. Continued interview with the Restorative Nurse and review of the resident's medical record revealed [REDACTED]. However, the Restorative Nurse was unable to elaborate on the decline the resident had experienced, because she stated she did not assess the resident for the decline or implement any new interventions or make any modifications to the resident's restorative program. Continued interview with the Restorative Nurse revealed the resident was discharged from Restorative Therapy on 01/31/19. The Restorative Nurse stated she discontinued the resident's restorative care because The aides reported (Resident #13) was back to normal. However, she stated she did not assess the resident's functional status or ROM abilities prior to discharging the resident from restorative services. Interview with State Registered Nurse Aide (SRNA) #3 on 02/07/19 at 4:30 PM and SRNA #6 on 02/10/19 at 3:50 PM revealed both staff members were routinely assigned to care for residents on the second floor where Resident #13 resided. The SRNAs stated there had not been a restorative nurse for the floor in months. The SRNAs stated they had been instructed to do restorative nursing care on their assigned residents; however, they stated the facility had been short-staffed for six months at least, and they had been unable to complete restorative therapy for the residents who required the services. The SRNAs stated residents had complained because they were not being walked or receiving therapy and exercises as they were assessed to require. The aides stated, We can't answer their call lights like we're supposed to; how can we do restorative when we're working short all the time? It's impossible. Interview with SRNA #5 on 02/11/19 at 1:20 PM revealed she was the restorative aide for the first floor of the facility, and she had never provided restorative care to the residents on the second floor of the facility. She stated she got pulled to the second floor at times, due to the facility's short staffing, but she had worked as a regular aide and had not provided restorative therapy. SRNA #5 stated the facility had been short-staffed for at least six months. The SRNA stated SRNAs on the floor were supposed to do the restorative therapy. She stated, That's impossible because we're working short a lot. SRNA #5 also stated multiple residents had complained about not receiving their restorative therapy. Further interview with the Restorative Nurse on 02/11/19 at 2:30 PM and on 02/21/19 at 12:05 PM revealed she had been responsible for the facility's restorative program for approximately one (1) year. The Restorative Nurse stated she never assessed Resident #13's functional status or ROM abilities because no one ever told me to do an assessment for residents on the restorative program. The Restorative Nurse stated she relied on the Unit Coordinators (UC) and nurse aides to inform her of any changes in a resident's ROM and/or functional abilities. The Restorative Nurse also stated she had never referred Resident #13 for therapy evaluations despite nursing assistants and the resident's POA reporting declines in the resident's ROM and functioning abilities, because she had never been trained to make referrals to the therapy departments. In addition, the Restorative Nurse stated there had not been a designated restorative aide for the second floor for a while now. The Restorative Nurse stated she was aware that some residents had complained that they were not receiving restorative services as outlined in their plan of care due to a lack of staff. An observation was made on 02/21/19, at 11:30 AM of the Physical Therapist and the Occupational Therapist conducting a ROM assessment for Resident #13. The observation revealed the resident had limited ROM to the left shoulder, right elbow, bilateral wrists, left thumb, and left index finger. The observation also revealed Resident #13 had limited ROM to both hips, which limited the internal rotation of the resident's left lower extremity. The resident's ROM was also limited in both knees and ankles. Interview with the Occupational Therapist (OT) on 02/12/19 at 3:35 PM and on 03/05/19 at 8:50 AM revealed she had voiced concerns to the Administrator (exact dates unknown) due to restorative nursing care not being provided to residents on the second floor of the facility. However, the Occupational Therapist stated the Administrator had taken no action to correct the problem. Further interview with the Occupational Therapist revealed the facility had no process for monitoring residents with ROM deficits, or those at risk for developing deficits in ROM in the facility. She stated residents received evaluations from Therapy only when referrals were received. She stated she expected the restorative nursing staff to assess residents receiving restorative therapy, especially if staff had reported declines in the resident's functional ability. She also stated that if staff identified deficits in a resident's ROM or functional abilities, referrals to Therapy should be made, to ensure preventative measures were implemented in order to prevent a decline in the resident's functional ability and prevent possible contractures. Interview with the Physical Therapist on 02/21/19 at 3:30 PM revealed Resident #13 had experienced a significant decline in ROM and functional ability since the resident's last evaluation by the PT department in (MONTH) (YEAR). The Physical Therapist acknowledged the facility had no system in place for conducting periodic evaluations of residents with deficits or for residents at high risk for decline in their ROM or functioning ability. The Physical Therapist stated they evaluated residents when they received a referral. However, the Physical Therapist stated she had not received a referral for Resident #13 since (YEAR). The Physical Therapist stated the significant ROM deficits in the resident's left lower extremity was a probable contributing factor to the pain experienced by Resident #13, especially when out of bed or sitting in an upright position. The Physical Therapist stated that residents assessed to have ROM deficits or who were at risk for ROM deficits should receive some sort of maintenance care to prevent further decline and maintain the resident's highest level of functioning. Interview with the Interim Administrator on 03/06/19 at 10:50 AM revealed the Restorative Nurse should conduct physical assessments of the resident prior to initiating/discontinuing a restorative program. In addition, the Interim Administrator stated the Restorative Nurse should also assess a resident if any declines or changes in their functioning were reported. The Interim Administrator stated each time a decline in Resident #13's ROM or functional abilities was reported to the Restorative Nurse, she should have assessed the resident to evaluate the decline and to ensure an effective plan was implemented to prevent further declines from occurring, including referrals to Therapy as warranted.