Every finding on record at Bluegrass Care & Rehabilitation Center

Based on interview, record review, review of Mosby's Clinical Nursing Skills and Techniques, 11th edition, review of Kentucky Board of Nursing (KBN) standards, and review of the facility's documents and policies, the facility failed to ensure services provided met professional standards of practice for 1 of 26 sampled residents, Resident (R) 133.The facility discharged R133 on 12/30/2025, and R133 was given a medication that belonged to a different resident, R71.The findings include:Review of the facility's policy titled, Discharge Medication, last revised 04/14/2024, revealed a physician's order was required to discharge a resident with medications before they would be dispensed. Per the policy, the licensed nurse would reconcile the resident's pre-discharge medications with his/her post-discharge medications prior to the resident leaving the facility. Further review revealed a licensed nurse shall review medication instructions with the resident and/or representative as applicable before the resident left the facility.Review of the facility's policy titled, Medication Administration, dated 01/2025, revealed, Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnosis or condition, the nurse calls provider pharmacy for clarification prior to the administration of the medication. If necessary, the nurses contacts with the prescriber for clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. The policy also revealed, Medications supplied for one resident are never administered to another resident.Review of www.KBN.ky.gov website's Accountability and Responsibility of Nurses in Accordance with Kentucky Revised Statute (KRS) 314.021(2) revealed, Nurses are responsible and accountable for making decisions that are based upon the individuals' educational preparation and current clinical competence in nursing and requires licensees to practice nursing with reasonable skill and safety. Nursing practice should be consistent with the Kentucky Nursing Laws, established standards of practice, and be evidence based.Review of Mosby's Safe Medication Administration Guide, from Mosby's Clinical Nursing Skills and Techniques, 11th edition at www.elsevier-elibrary.com, revealed, Always adhere to the 5 rights of medication administration when transcribing, preparing, administering, and documenting medications: Right patient, Right drug, Right route, Right dose, and Right time.1. Review of R133's Face Sheet revealed the facility admitted R133 on 12/29/2025 with a primary diagnosis of atherosclerotic heart disease of native coronary artery status post-surgical intervention.Review of R133's discharge Minimum Data Set [MDS], dated 12/30/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, indicating R133 was cognitively intact.Review of the facility's Summary of Investigation, dated 12/30/2025, revealed R133 was discharged on 12/30/2025, and R133's grandson arrived for the discharge and told staff he was in a hurry being on his lunch break. Per the investigation, Licensed Practical Nurse (LPN) 2 gathered medications from Kentucky Medication Aide (KMA) 3 to put in R133's belongings bag. It further stated LPN2 was obtaining paperwork to go over with the resident and family, but they left before LPN2 could review the paperwork with the resident and grandson. The investigation revealed R133 was sent home with her medications as well as Keppra (seizure medication) that belonged to R71. Per the investigation, R133 reported ingesting the medication that belonged to R71, thinking it was hers. The investigation stated R71 was reimbursed for the medication.Review of LPN2's Witness Statement, dated 12/31/2025, revealed LPN2 was preparing to discharge R133 and asked KMA3 to place medications in a bag for R133 to take home. Per the statement, that bag was handed to R133's grandson. Further review revealed LPN2 was going around the desk at the nurse's station to print the discharge summary, and R133 and her grandson left the facility before LPN2 could complete the discharge.Review of KMA3's Witness Statement, dated 12/31/2025, revealed LPN2 asked her for R133's medications. Further review revealed she opened the medication cart and handed R133's medications to LPN2 over the medication cart.Review of R133 Orders revealed she had no order for Keppra. Furthermore, R133 had no orders for medications to be sent home with her upon her discharge (per facility policy). 2. Review of R71's Face Sheet revealed the facility admitted R71 on 06/01/2023 with a diagnosis of nontraumatic acute subdural hemorrhage, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and epilepsy.Review of R71's Orders revealed an order for Keppra 1000 milligrams (mg) to be administered twice a day for epilepsy.During an interview on 07/13/2026 at 11:00 AM with the Ombudsmen, she stated R133's family called her after they had gone home with the medication. The Ombudsman stated they told her the resident had taken one of the pills that did not belong to her. She stated they told her they called the facility, and the facility asked them to bring it back. However, stated she instructed them not to. She stated she never saw the medication and was unsure how it was packaged. She stated R133 did not have any ill effects from taking the Keppra. During an interview on 07/14/2026 at 3:30 PM with LPN2, she stated R133's discharge was so fast because the family member picking up the resident was in a hurry. LPN2 stated the KMA bagged up the medications and gave them to the resident while she was trying to get the paperwork together. She stated the resident left before she had a chance to go over paperwork and verify the medications. LPN2 stated medications were usually double checked by another nurse before they were given to the resident, however, that time they were not. During an interview on 07/14/2026 at 3:34 PM with the Social Services Director (SSD), she stated R133 had a planned discharge, and she arranged the follow-ups. However, she stated she had no part in the medications being given to the resident. She stated the resident left fast, and she was made aware of the wrong medication being given to the resident the following day. During an interview on 07/15/2026 at 9:25 AM with R133 and R133's representative, they stated R133's grandson came to get her, and he was rushed because he had just started a new job and could not be late. R133 stated she did not remember any names of staff, but she saw one girl obtain her medication from the medication cart and hand it to another girl. She stated that girl then handed them to her grandson. She stated no one went through the medications with her or her grandson to ensure they were the correct medications. R133 stated she assumed they were all hers and took her doses later that day once she returned home. She stated she realized she had a skid, (a prepackaged sealed blister pack with individual doses) with another resident's name (R71) after she had already taken the medication. She stated she made her daughter aware, and they then called the facility and spoke to the unit manager that night (12/30/2030) to make them aware. They stated someone from the facility called them the following day to ask them to return the medications. However, they refused. R133's representative stated they called R133's primary care provider and made them aware, and they just had to monitor for any side effects at home. R133 and her representative stated R133 did not suffer from any adverse effects from taking the wrong medication. R133 stated she never took a picture of the medication she received and just recently discarded it all. During an interview on 07/15/2026 at 10:00 AM with the former Assistant Director of Nursing (ADON), she stated (from what she remembered) the resident left with her grandson before the discharge was completed. She stated she was made aware of the situation the following day, on 12/31/2025, and she called to follow up with the resident. She stated she asked them to bring the medications back to the facility, however they would not. She stated she then offered to come to the residents' home, and R133 refused for them to do that also. The former ADON stated she ended up sending R133's discharge paperwork to R133 via certified mail. She stated she was unsure who handed the medications to the resident's grandson, but she thought the KMA did this while LPN2 was working on the discharge paperwork. The State Survey Agency (SSA) Surveyor left a message for KMA3 on 07/15/2026 at 10:37 AM to contact her. However, KMA3 did not return the call, and KMA3 was out of the facility. During an interview on 07/16/2026 at 3:34 PM with the Director of Nursing (DON), she stated she started working at the facility in May 2026 and did not know any details regarding this incident. She stated she was not sure what the process was for residents discharging with their medications from the facility. She stated she would expect residents to be given the correct medications. During an interview on 07/16/2026 at 4:26 PM with the Administrator, she stated R133 wanted to go home. She stated Physical Therapy's evaluation found R133 was very high functioning and safe to discharge home. The Administrator stated R133 called for a family member to come and pick her up. She stated the family member who came to get her had been at work, came on a break, and was in a rush to get the resident home and get back to work. The Administrator stated LPN2 was working to get her paperwork completed, and another staff member was working to get the medications. She stated medications were not normally sent home with the resident upon discharge because they got called into the resident's pharmacy. However, the Administrator stated since the discharge was not originally planned, and the medications had not been sent to the pharmacy, the medications were sent with the resident so she would not miss any doses. She stated it was her expectation that KMAs did not leave the medications with the resident and/or their representatives before the nurse had verified the medications were correct. The Administrator stated it was important to ensure the right medications were given to the correct resident and to ensure the resident understood their discharge instructions.

Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, Resident (R) 99.R99 had been discharged to the hospital and upon her return on 06/25/2025 her Baseline Care Plan (BCP) documented R99 was assessed as not verbalizing or exhibiting signs of pain but was at risk for pain. Review of R99's Comprehensive Care Plan (CCP) revealed no active care plan for pain had not been initiated until 07/23/2025, after State Survey Agency requested it. Review of R99's Medication Administration Record (MAR) dated 07/01/2025-07/24/2025 revealed she had been medicated with Tramadol for pain once on 7/17/2025, once on 07/18/2025, and once on 07/20/2025.The findings include:Review of the facility policy titled, Comprehensive Care Plans, (CCP) dated 02/09/2024 and as last reviewed on 01/31/2025 revealed the facility would develop and implement a comprehensive person-centered care plan for each resident the included measurable objectives and time frames to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment.Review of R99's Minimum Data Set (MDS) Assessment schedule revealed the facility admitted her on 04/13/2023, with diagnoses of cirrhosis (chronic liver damage), heart failure, atrial fibrillation (a rapid irregular heart rate), diabetes, anemia, neurogenic bladder (lack of bladder control). R99 was discharged to the hospital as a return anticipated on 06/19/2025 and readmitted to the facility on [DATE].Review of R99's MDS Quarterly assessment dated [DATE] for pain revealed R99 had been on a scheduled pain regimen, had received as needed pain medication and a pain assessment interview was conducted and R99 was assessed as pain being present occasionally, occasionally affecting her sleep, occasionally interfered with day-to-day activities and was a 04/10 on the pain scale indicating moderate pain.Review of R99's MDS Quarterly assessment dated [DATE] Brief Interview for Mental Status (BIMS) assessment revealed a score of 12 out of 15 indicating moderate cognitive impairment.Review of R99's 48-hour Baseline Care Plan (BCP) dated 06/25/2025 upon her return from the hospital revealed R99 was not verbalizing or exhibiting signs of pain but was at risk for pain.Review of R99's Clinical Orders, dated 06/26/2025 revealed she had an active order for Tramadol (a pain medication) 50mg tablet orally every 6 hours as needed.Review of R99's Medication Administration Record (MAR) dated 07/01/2025-07/25/2025 revealed she had received a dose of Tramadol for pain once on 7/17/2025, once on 07/18/2025, and once on 07/20/2025.Review of R99's CCP on 07/23/2025 revealed she did not have an active plan for pain.Review of R99's CCP on 07/24/2025 revealed plan for pain had been added with a start date of 07/23/2025.During an interview on 07/25/2025 at 11:04 AM with MDS Nurse1 (MDS1), she stated she had been at the facility for four months and the MDS nurses did not complete resident BCPs, the nurse that admitted the resident completed them. MDS1 also stated R99 had been at the hospital and had returned so a BCP would have been completed, but R99 would not trigger for MDS to complete a CCP until her next comprehensive assessment which would have been due 3 months after her previous assessment. R99's previous significant change of condition assessment dated [DATE] was her last one and her next comprehensive assessment would not be due until 10/03/2025 unless she had another change of condition or discharged from the facility and returned. MDS1 stated anything necessary to provide for the immediate care and needs of the resident should be documented on the BCP by the admitting nurse so the resident's needs would be met. Lastly, MDS1 stated R99 should have had a care plan for potential for pain initiated when she returned to the facility and was assessed as being at risk for pain, or a care plan for pain management when she required the Tramadol be given to her for complaints of pain.During an interview on 07/25/2025 at 10:15 AM with Licensed Practical Nurse (LPN) 5 he stated he had been at the facility since 10/2024 but had been a unit manager here prior to Covid, had left and had come back. LPN5 stated when completing a BCP for a resident, information received from the hospital during report would include how the resident transferred, took medications, diet and fluid consistency, toileting habits, how the resident communicated, possession of hearing aids/dentures/and glasses, pain medication last dose, use of oxygen and need for dialysis. The BCP checklist was completed from this information and the CNA Kardex (paper) was also generated so staff would know what the resident care needs were. He stated floor nurses did not complete the comprehensive care plan but had access to it and could add to/edit it. Stated staff used the BCP and the Resident Profile/admission assessment as a guide to care for the resident until the CCP was completed which was done by MDS. LPN5 did not know if the information on the BCP populated into the CCP. LPN5 stated the BCP should accurately capture all the resident needs for staff to effectively and safely care for the resident and any inaccurate or missed resident information could cause the resident harm.During an interview on 07/25/2025 at 10:54 AM with the MDS2 nurse, she stated she had been doing MDS assessments since November of 2024 and the MDS nurse had seven days to update the CCP after a resident had a significant change of condition assessment completed. MDS2 also stated MDS assessments should be as accurate as possible for reimbursement and resident care planning. MDS2 confirmed that since R99 was at the hospital and had returned, the 5 day look back for pain would not have triggered tor MDS to develop a pain care plan for her. MDS2 further stated nursing should have developed a pain care plan for her if she began showing signs or had complaints of pain or had needed to be medicated for pain. Lastly MDS2 stated resident care plans drove resident care and should be current and accurate.During an interview with the Administrator (Admin) on 07/25/2025 at 11:38 AM she stated the purpose of the BCP was to guarantee all the resident's needed for care were in place. The admitting nurse would get a telephone report about the resident from the hospital and would then complete the admission observation form, which was in the admission packet, when the resident arrived. The admission assessment would include information from the residents' discharge summary and the summary was used to generate all the resident orders into system, including medications, so they could be dispensed. The BCP was completed using a systems approach and included things like communication, vision, hearing, cognition, special equipment, activities of daily living, oxygen, dialysis, etc. The Administrator stated resident orders were received, approved by the physician and entered into the system before the resident arrived. The Administrator further stated the BCP did not populate to CCP, but the MDS nurse would complete the CCP by using the resident's admission orders, the BCP, the discharge summary, the residents' history and physical, and the Certified Nurse Aide (CNA) Kardex and had 14 days from the resident's admission to complete.

Based on observation, interview, record review and review of the facility's policy, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care which included the minimum healthcare information necessary to properly care for a resident, Resident (R)144 and R154.R144 was admitted with diagnoses of dysarthria which was not documented with any goals or interventions/strategies for staff to use when communicating with R144.R154 was admitted with needs for dialysis and oxygen therapy which were not accurately documented on his baseline care plan. The findings include: Review of the facility policy titled, “Baseline Care Plan Policy”, dated effective 09/23/2022 and as last reviewed on 01/31/2025 revealed a baseline care plan was developed and implemented to promote continuity of care and communication among facility stakeholders to increase resident safety and safeguard against adverse events that are most likely to occur right after admission. Review of the policy guidelines revealed the baseline care plan would be developed and implemented within 48 hours of a resident’s admission and would include initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and preadmission screening and resident review (PASRR) if applicable. 1) Review of R154’s “Face Sheet”’ revealed the facility admitted him on 02/20/2025 with diagnoses to include fracture of the right femur, end stage renal disease (ESRD) with dependence on renal dialysis, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF) and respiratory failure with hypoxia. Review of R154’s, “Progress Note” dated 02/20/2025 at 4:47 PM revealed he was alert and oriented to person, place, time and event and was able to make his needs known. Review of R154’s hospital discharge note dated 02/20/2025 documented he had chronic respiratory failure due to COPD and had used oxygen at home and at the hospital set at 2-4 liters per nasal cannula. Further review of the hospital discharge note revealed R154 had ESRD and was being followed by nephrology and had hemodialysis (HD) on Mondays, Wednesdays and Fridays each week. Review of R154's, “Clinical Orders” dated 02/21/2025 revealed orders for oxygen therapy at 2 Liters via nasal cannula continuously and Dialysis on Monday, Wednesday and Friday. Review of R154’s 48-Hour Baseline Care Plan” (BCP) dated 02/20/2025 completed by Licensed Practical Nurse (LPN)1 revealed she had not checked the box for Oxygen usage and had checked the box marking R154 was not receiving dialysis. Licensed Practical Nurse (LPN2) who completed the BCP for R154 was no longer employed at the facility and no current phone number could be provided. Review of R154’s care plan dated 02/21/2025 revealed plans of care had been initiated for social isolation, depression and insomnia, drug related side effects related to psychotropic medications for depression and insomnia, plans for discharge and advance directive/code status. However, further review revealed no care plan for R154 to address the needs for dialysis or usage of oxygen. During an interview on 07/23/2025 at 11:04 AM with the MDS Nurse 1, she stated she had been at the facility for four months and did not complete baseline care plans, the admission nurse for the resident being admitted would complete them. During an interview on 07/25/2025 at 10:15 AM with LPN5 he stated when completing a BCP for a resident, information received from the hospital during report would include how the resident transferred, took medications, diet and fluid consistency, toileting habits, how the resident communicated, possession of hearing aids/dentures/glasses, pain medication and last dose, use of oxygen and need for dialysis. LPN5 further stated staff used the BCP and the Resident Profile/admission assessment as a guide to care for the resident until the CCP was completed which was done by MDS. LPN5 did not know if the information on the BCP populated into the CCP. LPN5 stated the BCP should accurately capture all the resident needs for staff to effectively and safely care for the resident and any inaccurate or missed resident information could cause the resident harm. During an interview on 07/25/2025 at 11:00 AM with Registered Nurse (RN)4 she stated the 48-hour BCP was completed after receiving report from the hospital and after the resident arrived at the facility. RN4 stated if a resident required oxygen and dialysis that should be accurately documented on the BCP. She further stated if the BCP was not correct, there could be a negative outcome or situation of harm for the resident. During an interview on 07/25/2025 12:03 PM with the Director of Nursing (DON) she stated her expectation for MDS was to make sure the resident was care planned per regulation and was personalized to each resident. The DON stated orders, family interviews, and the hospital discharge summary all drove the care plans and the BCP was just a snapshot of the residents' immediate needs for care. She further stated the corporate nurse came in and reviewed care plans once a week to make sure there was a BCP in place until MDS completed the Comprehensive Care Plan (CCP) with the comprehensive assessment which was due fourteen (14) days after admission. The DON stated it was her expectation the admission nurse would code the resident assessment and the BCP correctly to promote accurate resident care, but sometimes the nurses were in a hurry and could make an error because “we are all human”. During an interview with the Administrator (Admin) on 07/25/2025 at 11:38 AM she stated she had previously been the facility DON since 2019 and took over as Administrator in November of 2024. The Admin stated the purpose of the BCP was to guarantee all the resident needed for care were in place. The admitting nurse would get a telephone report about the resident from the hospital and would then complete the admission observation form, which was in the admission packet, when the resident arrived. The admission assessment would include information from the residents discharge summary and the summary was used to generate all the resident orders into system, including medications, so they could be dispensed. The BCP was completed using a systems approach and included things like communication, vision, hearing, cognition, special equipment, activities of daily living, oxygen, dialysis, etc. The Admin stated resident orders were received, approved by the physician and entered into the system before the resident arrived. The Admin further stated the BCP did not populate to CCP but the MDS nurse would complete the CCP by using the resident’s admission orders, the BCP, the discharge summary, the residents history and physical, and the Certified Nurse Aide (CNA) Kardex and had 14 days from the resident’s admission to complete. Lastly, the Admin stated in the case of R154, her expectation was his need for oxygen therapy and for dialysis be captured correctly on his BCP to prevent the possible error of him not receiving the proper care. 2) Review of the facility's policy titled, Resident Rights, revision date 01/31/2025, revealed all residents have the right to be treated with dignity and respect. All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life. The policy further stated, when providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with and access to persons and services inside and outside the facility. Review of R144's Face Sheet revealed the facility admitted R144 on 07/17/2025 with diagnoses to included cerebral infarction, unspecified, dysphasia (impairment of the power to speak or to understand speech) following cerebral infarction, and Alzheimer's disease, unspecified. Review of R144's admitting MDS assessment on 07/24/2025 revealed his BIMS score was 6 out of 15 indicating moderative cognitive impairment. Review of R144's 48-hour baseline care plan dated 07/17/2025 at 11:29 PM revealed the section titled, Communication Goal: Resident communication with staff will be understood. Resident's communication is understood was marked yes. There was no place to indicate on the 48-hour care plan to indicate speech difficulties or communication issues with R144. Observation on 07/22/2025 at 10:41 AM revealed R144 was laying in his bed with the head elevated. R144's eyes were closed and the top sheet was pulled to his waist. During interview at the time of observation, R144 attempted to answer questions from State Surveyor, but was not able to clearly speak his responses other than yes or no. R144 could possibly answer with one-word answers but struggled to enunciate words clearly or effectively. Observation on 07/22/2025 at 10:49 AM of R144 trying to communicate with State Registered Nurse Aide (SRNA)1 revealed SRNA1 was struggling to understand what R144 was trying to tell him. R144 appeared to become frustrated because on SRNA1 not understanding R144's need. Interview on 07/24/2025 at 8:31 AM with SRNA1 he stated he could understand R144 when R144 does not get upset or excited. SRNA1 stated he usually can help R144 with whatever he needs. SRNA1 was asked if he struggles understanding R144 and SRNA1 stated, Yes, it can be challenging at times. SRNA1 was asked, Do you feel that you can understand R144 enough to meet his needs? SRNA1 stated, Most of the time. There are times when R144 is upset or excited, it is hard to know what he needs. Interview on 07/24/2025 at 10:23 AM with Nurse Practitioner (NP) she stated she did not assess R144 initially on admission. The NP stated when a resident was admitted to the facility, the nurses would notify the therapy practitioner to implement concerns regarding speech. Then the speech therapist would come and evaluate the resident to determine if they qualified for services. Review of nursing progress notes dated 07/20/2025 at 11:34 AM entered by NP she stated R144's dysarthria (speech disorder characterized by difficulty in articulating words due to damage or dysfunction in the nerves and muscles that control speech) had significantly worsened an hour before at the previous living facility, before arriving to the Emergency Department (ED). During an interview on 07/24/2025 at 3:50 PM with LPN3, she stated she was one of two nurses who assisted in completing the 48-hour baseline care plan for R144. LPN1 stated she and another nurse were asking R144 questions, and the other was completing a skin assessment. LPN1 stated R144 did not do a lot of talking. During an interview on 07/24/2025 at 4:01 PM with LPN4, she stated R144's speech was pretty jumbled. LPN4 stated she could not recall if R144 could make his needs known at that time. LPN4 stated R144 was beginning to get upset about losing the ability to speak. LPN4 stated she could not remember if R144 was able to speak more than one word at a time. During an interview on 07/24/2025 at 10:40 AM with DON, she stated residents who are admitted to the facility have a 48-hour baseline care plan implemented upon arrival. The DON was asked if the 48-hour care plan instrument used adequately assessed residents who have dysphasia. The DON stated the nurses were able to communicate with R144. During an interview on 07/24/2025 at 3:01 PM with the Administrator, she stated she was familiar with R144. She stated nurses use the 48-hour care plan as a baseline for determining a resident's immediate needs. She stated once the baseline care plan was completed, the MDS nurse completed their assessment on R144. The Administrator stated the care plan did not address R144's dysphagia. The Administrator also provided a copy of a document titled, SRNA Care Plan Record, with R144's name, room number, and other significant information to dictate care for all SRNAs. Not documented under speech were three areas; Aphasic/Doesn't Talk, Clear, or Mumbles. None of the three items were marked indicating impaired speech. This document was reviewed and signed on 07/17/2025 by the DON. The Administrator state the document was not an accurate assessment of R144 because staff who did not know him would not be informed of his speech difficulties. The Administrator stated it was her expectation the 48-hour assessments and the SRNA care plan records would be completed accurately and meet the needs of the residents.

Based on interview and record review, the facility failed to accurately reflect with the Minimum Data Set (MDS) assessment, the resident's status for 1 of 29 sampled residents. (Resident (R)15). The Significant Change MDS dated [DATE] and the Quarterly MDS dated [DATE], did not document R15 as receiving Hospice Care. The findings include:Review of R15's Face Sheet revealed the facility admitted R15 on 03/16/2025 with diagnoses to include Acute Respiratory Failure, Dementia, and Anxiety. Review of R15's medical record revealed the resident started on Hospice care on 3/10/2025.Review of the Significant Change MDS dated [DATE] and the Quarterly MDS dated [DATE] revealed no documented evidence the facility coded R15 as receiving Hospice care in section O. During an interview with the MDS Nurse, on 07/24/2025 at 1:04 AM, she stated there were two places for coding Hospice care. She stated in section J under prognosis if a resident has less than six months to live, that would be checked, but Hospice care should be checked under section O for R15 and neither MDS assessment was coded in section O for Hospice care. During an interview with the Director of Nursing (DON) on 07/25/2025 at 12:03 PM, she stated it was her expectation that the MDS records would accurately reflect each resident. During an interview with the Administrator on 07/25/2025 at 12:15 PM, she stated it was her expectation that MDS assessments should reflect R15's Hospice care to be accurate.

Based on observation, interview, record review, and facility policy review, the facility failed to store medications and biologicals in accordance with professional standards for 2 of 6 residents observed for medication administration, Resident (R) 121 and R122 and 2 of 2 medication refrigerators. The findings include: Review of the facility's policy titled, Medication Administration, revised 06/24/2024, revealed the facility's nursing staff was to administer medications at the time they were prepared. 1, Review of R121's Face Sheet revealed the facility admitted the resident on 08/24/2024 with diagnoses including acute COVID, muscle weakness, and unspecified dementia. Review of R121's Medication Administration Record (MAR) for 08/01/2024 through 08/30/2024 revealed that on 08/30/2024, Certified Medication Aide (CMA) 11 documented he gave famotidine 20 milligrams (mg, for heartburn), losartan 100 mg (for high blood pressure), metformin 500 mg (for diabetes to lower blood sugar), polyethylene glycol 17 G (for constipation), and tamsulosin 0.4 mg (for urinary retention), all administered by mouth for morning medication administration. Review of R122's Face Sheet revealed the facility admitted the resident on 08/29/2024 with diagnoses including respiratory failure, urinary tract infection, and depression. Review of R122's MAR for 08/01/2024 through 08/30/2024 revealed CMA11 documented he gave cefdinir 300 mg (antibiotic), docusate sodium 100 mg (stool softener), doxycycline monohydrate 100 mg (antibiotic), ferrous sulfate 325 mg (iron supplement for anemia), furosemide 40 mg (diuretic), pantoprazole 40 mg (antiacid), potassium chloride 20 milliequivalents (mEq, supplement), prednisone 20 mg (steroid), ropinirole 2 mg (to treat restless leg syndrome), sertraline 25 mg (antidepressant), and ertugliflozin 5 mg (for diabetes to lower blood sugar), all administered by mouth for morning medication administration. Observation on 08/30/2024 at 11:22 AM revealed CMA11 prepared medications for R122, but when he went to administer the medications, he found R122 was not in her room. Further observation revealed CMA11 stated he would look for R122 in the therapy gym and would return in a few minutes. Continued observation at 11:25 AM revealed CMA11 returned with the same medication cup in his hand and placed it in the top drawer of the medication cart alongside a second cup labeled with R121's room number. Observation on 08/30/2024 at 11:27 AM revealed CMA11 removed a medication cup from the top drawer of the medication cart labeled with R121's room number and handed it to R121. Per observation, CMA11 assisted R121 to bring the cup to the resident's mouth to take the medications. Continued observation revealed the North Unit Manager (NUM) walked by and saw the prepared medication cup for R122 in the top drawer of the medication cup while R121 was attempting to swallow his pills. The NUM told CMA11 that storing prepared medications in the medication cart was not an acceptable practice, and those medications would need to be discarded. Additional observation revealed CMA11 told the NUM the pills had been in the locked medication cart. Per observation, the NUM educated CMA11 that he should look for the resident prior to pulling the resident's medications to see if the resident was available and wanted their medicines. In an interview on 08/30/2024 at 2:21 PM, CMA11 stated he placed R121's medications in the top of the medication cart because when he went to give the medications, the resident was in the bathroom and asked him to come back. In further interview, CMA11 stated he went to find R122 after preparing her medications, but the resident was not in the therapy gym or the dining room, so he also placed her medications in the cart. In continued interview, CMA11 stated pulling medications took a long time, and he did not want to get behind schedule by pulling medications twice. Additionally, CMA11 stated the NUM educated him that he should have discarded any medications he was not able to promptly administer. In an interview on 08/30/2024 at 11:36 AM, the NUM stated it was not an acceptable practice for nurses or CMAs to store prepared medications in a locked drawer of the medication cart if the resident was not available. She further stated her expectations for medication storage were for staff to keep the medications in the pharmacy sleeves until they confirmed with the resident that they were available and wanted to take all their medications. In continued interview, the NUM stated storing prepared medication cups in the top drawer of the medication cart increased the chances for a medication error and would make it difficult for a resident to exercise their right to refuse any particular medication. In an interview on 08/30/2024 at 3:24 PM, the Director of Nursing (DON) stated if a nurse or CMA had a cup of medications prepared for a resident and they were unable to find them quickly in their room, the therapy gym, or other location, they should discard the medications and pull them when the resident returned. In an interview on 08/30/2024 at 4:51 PM, the Administrator stated she did not see a problem with staff having a labeled medication cup in the top drawer if it was for only one resident and the cart was locked. She further stated she did not believe it was acceptable to store prepared medication cups in the top drawer for more than one resident. 2. Review of the facility's policy titled, Storage of Medication, dated 01/2023, revealed medications and biologicals were stored properly, following manufacturers or provider pharmacy recommendations to maintain their integrity and to support safe effective drug administration. Per the policy, outdated, contaminated, discontinued, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from pharmacy. Observation on 08/26/2024 at 3:55 PM of the medication room refrigerator on the South Hall revealed R34's Magic Mouthwash expired 08/24/2024. During interview with Licensed Practical Nurse (LPN) 3 at the time of the observation, she stated if a resident received expired medications the medication might not be effective, and there could potentially be harm to the resident. Observation on 08/26/2024 at 4:05 PM of the medication room refrigerator on the North Hall revealed the following six expired doses of the antibiotic Daptomycin 300 mg/106 milliliters (ml) for R106. Two doses expired on 08/10/2024, and four doses expired on 08/24/2024. Further observation revealed the following six expired doses of the antibiotic Daptomycin 450 mg/109 ml for R211. All six expired doses expired on 08/25/2024. Additional observation revealed R18's Magic Mouthwash expired 08/20/2024. During interview with LPN4 at the time of the observation, she stated she checked the expiration date and the rate. She stated she was supposed to check to verify the medications were not expired. She stated if she used expired medications, the resident could have a reaction. During interview with the DON on 08/28/2024 at 10:01 AM, she stated she was not made aware of expired medications. She stated the nurses checked to see if the medications were expired prior to using the medications. During interview with the Administrator on 08/28/2024 at 10:35 AM, the Administrator stated her expectation was for the staff to follow the facility's policy and remove any expired medications.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to implement enhanced barrier precautions (EBP) related to medication administration and resident care for 1 of 28 residents in EBP, Resident (R) 53. Observation on 08/30/2024 revealed Licensed Practical Nurse (LPN) 3 failed to don (put on) a gown and gloves when providing direct resident care to R53 related to application of a medication patch and taking a blood pressure. The findings include: Review of the facility's policy titled, Enhanced Barrier Precautions, dated 03/25/2024, revealed EBPs were indicated for residents who had chronic wounds and or indwelling medical devices regardless of multi-drug resistant organism (MDRO) status. Observation on 08/30/2024 at 9:12 AM of the signage on R53's door revealed it informed all care givers everyone must clean their hands, including before entering and when leaving the room. It also stated, providers and staff must wear gloves and gown for the following high-contact resident care activities. The activities listed were dressing; bathing/showering; transferring; changing linens; providing hygiene; changing briefs or assisting with toileting; device care or use with a central line, urinary catheter, tube feeding, or tracheostomy; and wound care for any skin opening requiring a dressing. Further observation on 08/30/2024 at 9:12 AM of medication administration revealed LPN3 prepared medication to administer to R53 who had a suprapubic catheter in place. After the medication was brought into R53's room, LPN3 took R53's blood pressure without donning a gown or gloves. She started the administration of crushed medication mixed with pudding in medicine cups. She then administered the polyethylene glycol to R53. At that point, the Infection Prevention (IP) Nurse entered the room and spoke to LPN3 about proper donning of gown and gloves when providing care. LPN3 stated she thought that gown and gloves were only necessary when providing physical (dressing change, catheter care) care to R53. The IP then re-educated LPN3 on the purpose and indications of when to don personal protective equipment (PPE, gown and gloves) for residents with EBP. After receiving education, LPN3 donned gown and gloves. LPN3 applied two lidocaine patches on R53's right lateral chest and lateral abdomen. During an interview with the IP Nurse on 08/30/2024 at 11:14 AM, she stated she was also the Staff Development Nurse and expected nursing staff to understand when to use PPEs in relation to EBPs. She stated, That is why I came to [R53's] room when I was informed [LPN3] had not donned a gown and gloves when taking vitals [blood pressure] or administering medications. She stated she knew when the new policy was enacted in May 2024, she provided education to the entire staff on when the regulations were changed. She stated now that there had been an identified gap in education for the staff, she would be reeducating all staff. The IP Nurse stated when the facility had a skills fair in December for nurses and aides, she tested staff to make sure they had been educated properly. She stated, Obviously there was a breakdown with that one staff member, but it could happen to other staff. I want to make sure all staff know how improper practice can negatively impact residents. During an interview on 08/30/2024 at 3:35 PM with the Director of Nursing (DON), she stated she expected nursing staff who administered medication to a resident who was in EBP to don gloves and gown when obtaining a resident's blood pressure. She also stated nursing staff should don gown and gloves when administering transdermal patches. She stated re-education for staff would be necessary to prevent further incidents. During an interview on 08/30/2024 at 4:43 PM with the Administrator, she stated she expected nursing staff to wear gloves and gowns when caring for residents in EBPs. She also stated the nursing staff needed follow-up education to ensure the safety of all residents when providing care.

Based on interview, record review, and review of the facility's policy, the facility failed to send a copy of the transfer or discharge notice to a representative of the Office of the State Long-Term Care (LTC) Ombudsman for 1 of 4 residents investigated for the discharge process, Resident (R) 111. The findings include: Review of the facility's policy titled, Transfer /Discharge Policy, dated 03/24/2024, revealed the facility must notify the Ombudsman of a facility-initiated transfer or discharge notice to a representative of the Office of the State LTC Ombudsman. Review of R111's Face Sheet revealed the facility admitted the resident on 10/23/2021 with diagnoses of renal and perinephric abscess, schizoaffective disorder (bipolar type), and dementia in other diseases classified elsewhere with behavioral disturbances. Further review revealed R111 was discharged on Friday, 11/12/2021 at 2:39 PM. Review of R111's Discharge Note, dated 11/10/2021 at 4:14 PM and signed by the Physician's Assistant, revealed R111 would be going back to the group home where he lived prior to hospitalization and coming to the facility. The note stated R111 would have 24/7 (around the clock) care there. Per the note, R111 had remained medically stable during his stay at the facility, completed his intravenous antibiotic, and was safe to return back to his group home. Review of Notification of Discharge, from the Social Services Director (SSD), revealed no Ombudsman notification was completed for R111's 11/12/2021 discharge. During an interview with the SSD on 08/30/2024 at 11:29 AM, she stated she would wait until the end of each month and send an email to the Ombudsman with all the discharges from the month. She stated, in regard to R111, when she looked through the records, there was no documentation of notification of the 11/12/2021 discharge sent to the Ombudsman. During an interview on 08/30/2024 at 4:43 PM with the Administrator, she stated Social Services sent a monthly discharge list to the Ombudsman for the previous month, the first of the next month. She stated, in this situation, that procedure was not followed.

Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a Baseline Care Plan within 48 hours for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 30 sampled residents, Resident (R) 212. The facility admitted R212 on 08/21/2022 after a fall that resulted in a vertebrae fracture and facial bruises. R212's care plan for pain was not developed within 48 hours. Cross reference F697 The findings include: Review of R212's Face Sheet revealed the facility admitted the resident on 08/21/2024 with diagnoses which included displaced fracture of sixth cervical vertebra, need for assistance with personal care, and diabetic nephropathy. Review of the facility's policy titled, Comprehensive Care Plans, last revised 02/09/2024, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs. Review of R212's 48-Hour Care Plan, dated 08/22/2024 at 2:25 PM , revealed no documented evidence the facility implemented interventions for pain. Observation on 08/26/2024 at 1:36 PM revealed R212 was sitting in the wheelchair, and she had bruising around both eyes and was wearing a neck brace. During interview at the time of the observation, R212 stated she slipped on a rug in the kitchen and fell , hitting her head and back on the counter. She stated her pain was mainly in her right arm. R212 stated she was having pain and asked for pain medication this morning, but the nurse told her it was not available. R212 stated the pain was bad; but, she was not crying and was able to eat breakfast and lunch. Review of R212's Medication Administration Record (MAR) revealed R212 did not receive pain medication of oxycodone 5 mg (an opioid pain reliever) until 08/26/2024 at 3:30 PM. Continued inteview with R212 on 08/26/2024 at 3:00 PM revealed she was given Tylenol when her narcotic pain medication was not availble and it helped somewhat. During interview on 08/26/2024 at 2:48 PM with Licensed Practical Nurse (LPN) 2/Unit Manager who documented R212's care plan, she stated she developed the 48-hour care plans with the resident's record, family, or the resident. She stated the care plan was an observation, and she answered each individual question on the care plan. She stated when she came to the pain section, she asked R212 if she was in any pain, and since R212 stated, No, she clicked No on the care plan. She stated she made a mistake, and she should have clicked Yes and addressed pain on the care plan. During interview with the Administrator on 08/28/2024 at 10:35 AM, she stated when a resident was having pain she expected staff to provide pain relief. She also stated she expected the staff to follow the facility's care plan policies.

Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 2 residents investigated for pain management, Resident (R) 212. R212 did not receive oxycodone (an opioid pain reliever) as scheduled on 08/26/2024 because the nurse said it was unavailable. However, the medication was in the facility's emergency medication kit (EMK). The findings include: Review of the facility's policy titled, Ordering and Receiving Controlled Medications, dated 01/2023, revealed in an emergency situation, verbal authorization could be given by the prescriber to the pharmacist for a new order as described by state law. Review of the facility's policy titled, Medication Administration, last revised 06/24/2024, revealed medications were administered as prescribed in accordance with the manufacturer's specifications and good nursing principles and practices. Review of R212's Face Sheet revealed R212 was hospitalized due to a fall from 08/16/2024 to 08/21/2024. The facility admitted the resident on 08/21/2024 with diagnoses of displaced fracture of the sixth cervical vertebra, need for assistance with personal care, and type 2 diabetes. Review of R212's Orders, revealed R212 had an order for oxycodone (opioid pain medication) 5 milligram (mg) related to pain, twice a day as needed (PRN). Review of the EMK revealed the kit contained six oxycodone 5 mg tablets. Observation on 08/26/2024 at 1:36 PM revealed R212 was sitting in the wheelchair, she had bruising around both eyes and was wearing a neck brace. During interview at the time of the observation, the resident stated she was having pain and asked for pain medication this morning, but the nurse told her it was not available. R212 stated the pain was bad; but, she was able to eat breakfast and lunch. During interview with Licensed Practical Nurse (LPN) 2/Unit Manager on 08/26/2024 at 2:48 PM, she stated R212 received oxycodone at 8:30 PM on 08/25/2024. She stated Advanced Practice Registered Nurse (APRN) 1 was at the facility this morning, but she did not think to ask her for a one-time order for oxycodone. She also stated she did not think to take the oxycodone from the EMK. During interview with APRN1 on 08/27/2024 at 8:56 AM, she stated she was called on 08/26/2024 in the morning to write a stat prescription for oxycodone to be given to R212. She stated she then went into R212's room and interviewed R212. She stated R212 told her she was having continued moderate pain in the right arm. APRN1 stated she told R212 the provider, who specializes in pain management would be in that morning to evaluate and treat the pain. Review of the House Stock Kit Withdrawal Log revealed on 08/26/2024 at 3:15 PM oxycodone 5 mg was removed for R212 by LPN2/Unit Manager and Certified Nurse Aide/Certified Medication Technician (CNA/CMT2). Review of R212's Medication Administration Record (MAR) revealed R212 received oxycodone 5 mg on 08/26/2024 at 3:30 PM. During interview with the Director of Nursing (DON) on 08/28/2024 at 10:01 AM, she stated the pain medication for R212 should have been taken from the EMK and given to R212 on 08/26/2024 in the morning when the resident requested the medication. During interview with the Administrator on 08/28/2024 at 10:35 AM, she stated she expected all staff to know what was in the EMK. The Administrator stated when a resident was having pain she expected staff to provide pain relief.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure residents were protected from abuse by another resident, Resident #2, for two (2) of six (6) sampled patients, Resident #3 and Resident #4. On 03/31/2021, Resident #2 pushed Resident #3 and Resident #3 fell against the wall causing a cut on the back of the head. Resident #3 was sent to the emergency room and found to have no serious injury. On 04/04/2021, Resident #2, using his/her fist, punched Resident #4 in the back. Resident #4 had no apparent injuries. The findings include: Review of the facility's policy titled, Abuse, Neglect, and Misappropriation of Property, last revised 05/08/2019, revealed it was the organization's intention to prevent the occurrence of abuse. Review of the facility's document Resident Rights, undated, revealed the resident had the right to be free from physical abuse. Review of Resident #2's medical record revealed the facility admitted the resident, on 07/28/2018, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed after the incident with Resident #3, on 03/31/2021, Resident #2 was placed on one-to-one (1:1) supervision, until it was discontinued, on 04/02/2021. Further, after the incident with Resident #4, on 04/04/2021, Resident #2 was placed on one-to-one (1:1) supervision, until it was discontinued on 04/05/2021. Per Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further, Resident #2 was evaluated for a possible urinary tract infection (UTI), but the results were negative. Additional review revealed, on 04/05/2021, a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's Quarterly Minimum Data Set (MDS) Assessment, dated 03/15/2021, revealed the resident had a Brief Interview for Mental Status score of ninety-nine (99), which indicated the resident was unable to complete the interview because of limitations. Per assessment, the resident had a memory problem and was moderately impaired with decision making. The Assessment stated the resident needed one (1) person physical assistance with locomotion on the unit. In addition, it stated the resident had no behaviors of physical or verbal symptoms toward others. 1. Review of the facility's Initial Self-Reported Incident Form, signed and dated by the Administrator, on 03/31/2021, revealed an employee witnessed Resident #2 hit Resident #3 in the chest causing the resident to fall backward and hit his/her head on the hand rail in the hallway. Per report, Resident #3 received a small gash to the back of the head, was treated by nurses on-site, and was sent to a local emergency room for further evaluation. In addition, the report stated Resident #2 was placed on one-to-one (1:1) supervision, and Resident #3 was moved to a room closer to the Nurse's Station for additional observation. Review of the facility's Five (5) Day Follow-Up Report, signed and dated by the Administrator, on 04/06/2021, revealed actions taken since the incident occurred, on 03/31/2021. Per report, some of the actions included a psychiatric medication review and behavior assessment, on 04/01/2021, resulting in a medication recommendation, which was approved by the Physician. In addition, Social Services did a follow-up interview with both Resident #2 and Resident #3 and neither could recall anything about the incident. Continued review of the report revealed a referral for inpatient psychiatric services was sent to a facility approximately twenty-five (25) miles away, and Resident #2 had been accepted for admission to that facility. Observation with the Unit Manager, on 04/06/2021 at 2:25 PM, revealed Resident #3 had a superficial scab to the back of her/his head, measuring about 0.5 inches by 0.1 inches. In addition, interview with Resident #3 at the same time revealed he/she did not remember the event. Review of Resident #3's medical record revealed the facility admitted the resident, on 07/11/2019, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's Quarterly MDS Assessment, dated 01/19/2021, revealed the resident had a BIMS score of eight (8), indicating moderate cognitive impairment. The Assessment stated the resident needed set-up assistance with locomotion on the unit when using a wheelchair. In addition, it stated the resident had no behaviors of physical or verbal symptoms toward others. Interview with the Restorative Aide, on 04/06/2021 at 3:15 PM, revealed she witnessed Resident #2 hit Resident #3 in the torso, and Resident #3 fell against the wall and hit his/her head. The Aide stated she notified the Resident's nurse, but did not know if a report was made. Interview with Registered Nurse (RN) #1, on 04/06/2021 at 4:00 PM, revealed she was in the conference room, on 03/31/2021, with the Unit Manager, when she was told there had been an incident with Resident #2 hitting Resident #3. She stated, when she arrived at the location, there were several staff members present, and Resident #3, who was alert, was on the floor with a open area and bruising to the back of his/her head. In addition, she stated there was blood on the wall where the resident had hit his/her head. RN #1 stated Resident #3's head was cleaned and ice was applied to the wound. In addition, she stated the resident had no deficits and that Resident #2 was going to be evaluated at an inpatient psychiatric facility. Interview with Licensed Practical Nurse #3, on 04/06/2021 at 4:05 PM, revealed, on 03/31/2021, she was sitting at the Nurse's Station when she heard a loud noise. She stated Resident #3 was in the hallway on the floor and had a small laceration, approximately 0.2 inches by 0.8 inches, and the laceration was bleeding. LPN #3 stated Resident #3 was sent to the emergency room for evaluation. 2. Review of the facility's Initial Self-Reported Incident Form, signed and dated by the Administrator, on 04/04/2021, revealed, on 04/04/2021, an employee witnessed Resident #2 hit Resident #4 on the back when passing by Resident #4. Per report, Resident #4 then grabbed Resident #2's shirt and pulled his/her hair. Per report, the residents were immediately separated, and Resident #2 was placed on one-to-one (1:1) supervision. Review of the facility's document BGCR Incident Report (IR), dated 04/04/2021, and signed by the RN Weekend Supervisor and two (2) additional nurses, revealed, on 04/04/2021 at 2:15 PM, Resident #4 was in a wheelchair going to another resident's room. Per IR, Resident #2 walked past Resident #4, swung and hit the resident in the back; Resident #4 then grabbed Resident #2's shirt and pulled him/her down so Resident #4 could pull Resident #2's hair. Per IR, the three (3) staff members had to untangle the two (2) residents from one another. Interview with the RN Weekend Supervisor, on 04/07/2021 at 1:34 PM, revealed she confirmed the incident, on 04/04/2021 around 2:00 PM. She stated she came around the corner of the hallway and saw the two (2) nurses with Resident #2 and Resident #4. Review of Resident #4's medical record revealed the facility admitted the resident, on 02/20/2017, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed the resident had a BIMS score of eight (8) to twelve (12), indicating moderate cognitive impairment. In addition, review of the record revealed Resident #4 did not sustain any injuries from the incident with Resident #2, and there were no new Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Resident #4, on 04/06/2021 at 2:45 PM, revealed the resident was alert and oriented to person, place, and time. The resident stated he/she liked the food and the music at the facility, and no one had yelled at or hurt him/her. Interview with the Social Services Director, on 04/07/2021 at 2:00 PM, revealed she was in the hallway, on 04/04/2021, and saw Resident #2 hit Resident #4 in the back. She stated Resident #4 then pulled Resident #2's hair. The Director stated she attempted to discuss the incident with Resident #4, but she would not talk about the incident. Interview with Resident #2, on 04/06/2021 at 2:10 PM, revealed he/she had never hit anyone. During the interview, it was noted the resident was alert but only oriented to name. Interview with the Director of Nursing (DON), on 04/07/2021 at 1:18 PM, revealed all department managers did daily rounds to ensure abuse or neglect of residents did not occur. She stated she had an open door policy which encouraged staff to inform her if he/she thought abuse had occurred. The DON stated Resident #2 was placed on one-to-one (1:1) supervision after both incidents, and after the second incident, psychiatry was called and [MEDICATION(S)] ([MEDICATION(S)]) was suggested, which Resident #2 was now taking. She also stated inpatient psychiatric services had been recommended for Resident #2, and the facility was waiting for the green light to transfer him/her there. The DON stated she expected staff to follow the facility's policy on abuse and expected there to be no abuse at the facility.

Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, to properly prevent and/or contain COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observation of the lunch meal pass revealed resident hand hygiene was not performed prior to meals in four (4) of eleven (11) sampled residents' rooms. Observation revealed two (2) of eleven (11) sampled residents were not social distancing. Resident #1 was observed entering and exiting multiple residents' rooms for visits. Resident #10, who was in Droplet Isolation Precautions, was observed sitting within two (2) feet of the open doorway while residents and staff passed by in the hallway. Observation revealed (5) of eleven (11) sampled residents were in the hallway without masks or wore masks inappropriately with no staff reinforcement. Resident #1 was wearing the mask under the chin. Resident #2 was in Droplet Isolation Precautions and was in the hallway without a mask. Resident #10 was in Droplet Isolation Precautions and was sitting within two (2) feet of the doorway without a mask. Resident #6 and Resident #11 were in the hallway without a mask. Observation revealed two (2) staff members inappropriately wearing a fit tested N95 respirator/mask and multiple staff members not performing hand hygiene after touching their face masks and eye protection (goggles). The findings include: 1. Review of the facility's policy, Novel Coronavirus (COVID-19), dated 08/18/2020, revealed the purpose of the guideline was to provide clarification for steps the facility would take regarding the Novel Coronavirus (COVID-19) and ensure the health and safety of the facility's residents to meet the standards required to help each resident attain or maintain his/her highest level of well-being. Further review revealed residents were to perform frequent hand hygiene. Review of the facility's policy, Handwashing/Hand Hygiene, dated August 2015, revealed residents would be encouraged to practice hand hygiene frequently. Observation of meal pass, on 01/06/2021 at 11:44 AM, revealed no hand hygiene was performed for Residents #6, #7, #8, and #9 prior to the meal. Interview with Hospitality Aid (HA) #1, on 01/06/2021 at 2:40 PM, revealed hand hygiene was to be performed on residents prior to meals. Interview with Licensed Practical Nurse (LPN) #3, on 01/06/2021 at 4:02 PM, revealed the meal process involved assisting residents with hand hygiene prior to the meal. Further interview revealed proper resident hand hygiene was necessary for infection control practices. Interviews, on 01/06/2021, with State Registered Nurse Aide (SRNA) #1 at 1:39 PM, SRNA #2 at 2:04 PM, SRNA #3 at 2:16 PM, LPN #1 at 3:15 PM, and LPN #2 at 3:41 PM, revealed infection control interventions for residents included hand hygiene before meals, after using the bathroom, and when visibly soiled. Interview with the Infection Preventionist Registered Nurse (IPRN), on 01/06/2021 at 4:28 PM, revealed residents were to receive hand hygiene prior to meals. Further interview revealed all staff had received education on hand hygiene and had been tested for competency in this area and were expected to assist the residents with hand hygiene frequently per policy. Interview with the Director of Nursing (DON), on 01/06/2021 at 6:22 PM, revealed hand hygiene was expected to be performed frequently on all residents per policy. 2. Review of the facility's policy, Novel Coronavirus (COVID-19), dated 08/18/2020, revealed residents were to practice social distancing. Further review revealed residents were to be reminded by staff to practice social distancing, which included no hand shaking, no hugging, and staying six (6) feet apart. Review of the facility's policy, Isolation-Initiating Transmission-Based Precautions, dated August 2019, revealed Transmission-Based Precautions could include Contact Precautions, Droplet Precautions, or Airborne Precautions. Review of the facility's policy, MED-PASS, Inc. Transmission-Based Precautions, dated August 2016, revealed for Droplet Isolation Precautions, to maintain a separation of roommates, visitors, and staff for at least three (3) feet. Review of Resident #1's medical record revealed the facility admitted the resident, on 08/19/2018, with [DIAGNOSES REDACTED]. Review of Resident #10's medical record revealed a physician's orders [REDACTED]. Observation, on 01/06/2021 at 9:16 AM, revealed Resident #1 entered multiple residents' rooms on the South Hall. Further observation revealed Resident #1 remained in room [ROOM NUMBER], another resident's room, until the State Survey Agency Surveyor contacted staff inquiring about the identity of Resident #1. Furthermore, Resident #1 was in room [ROOM NUMBER] for five (5) minutes, less than three (3) feet apart from the resident that lived in room [ROOM NUMBER], in violation of the facility's policy. Observation, on 01/06/2021 at 11:37 AM, revealed Resident #10 was sitting less than two (2) feet from the open doorway, in violation of the facility's policy. Interviews, on 01/06/2021 with SRNA #1 at 1:39 PM, SRNA #2 at 2:04 PM, and LPN #1 at 3:15 PM, revealed infection control interventions for residents included social distancing. Interview with LPN #2, on 01/06/2021 at 3:41 PM, revealed the door to a resident's room, who was on Droplet Isolation Precautions, was to be closed to prevent the spread of infection. Interview with the Director of Nursing (DON), on 01/06/2021 at 6:22 PM, revealed social distance location marks had been placed in the common area, and staff was expected to monitor residents. Further interview revealed a Droplet Isolation Precaution resident's room door should be kept closed, and the curtains were to be pulled if the door was open. 3. Review of the facility's policy, Personal Protective Equipment, dated October 2018, revealed visitors and residents who were asked to comply with Transmission-Based Precautions were educated on the proper use of personal protective equipment (PPE) and provided with equipment at no charge. Review of Resident #2's medical record revealed the facility admitted the resident, on 06/21/2019, with [DIAGNOSES REDACTED]. Additional review of Resident #2's medical record revealed a physician's orders [REDACTED].#4, who tested positive for COVID-19 on 12/29/2020. Observation, on 01/06/2021 at 9:16 AM, revealed Resident #1 moving throughout the South Unit with his/her mask under his/her chin. Observation, on 01/06/2021 at 9:27 AM, revealed Resident #11 in the South Unit hallway not wearing a mask. Further observation revealed a staff member approached and spoke with Resident #11, but did not assist with applying a mask to the resident. Observation, on 01/06/2021 at 9:36 AM, revealed a Droplet Isolation Precaution sign on the doorway of room [ROOM NUMBER], and no one inside the room. Interview with HA #1, on 01/06/2021 at 9:37 AM, revealed Resident #2 lived in room [ROOM NUMBER] and was on Droplet Isolation Precautions because his/her roommate (Resident #4) recently tested COVID positive. Further observation revealed Resident #2 in the hallway not wearing a mask. Observation, on 01/06/2021 at 11:37 AM, revealed Resident #10, who was on Droplet Isolation Precautions, was sitting less than two (2) feet from the doorway with no mask on while staff and residents passed by the doorway. Observation, on 01/06/2021 at 11:46 AM, revealed Resident #6 wandering through the North Unit hallway without a mask. Multiple staff members were at the nurse's station and did not assist Resident #6 with applying a mask. Interviews, on 01/06/2021 at 1:39 PM with SRNA #1, and SRNA #3 at 2:16 PM, revealed Resident #2 frequently left his/her room without wearing a mask and often required assistance. Interviews, on 01/06/2021 with SRNA #1 at 1:39 PM, SRNA #2 at 2:04 PM, SRNA #3 at 2:16 PM, LPN #1 at 3:15 PM, and LPN #2 at 3:41 PM, revealed infection control interventions for the residents included reminders and assistance with wearing a mask. Interview with the DON, on 01/06/2021 at 6:22 PM, revealed residents on Droplet Isolation Precautions were required and expected to wear a mask. Further interview revealed staff had been trained on reapplying and monitoring resident mask usage and were expected to enforce proper mask wearing. 4. Review of the facility's policy, Personal Protective Equipment, dated October 2018, revealed training on the proper donning, use, and disposal of PPE was provided upon orientation and at regular intervals. Further review revealed visitors and residents who were asked to comply with Transmission-Based Precautions were educated on the proper use of PPE and provided with equipment at no charge. Review of the facility's policy, Infection Control Policy and Procedure Manual for Donning PPE, dated August 2007, revealed mask and respirators were to fit snugly to the face and below the chin, and the ties or elastic bands were to be secured at the middle of the head and neck. In addition, the policy stated the front of the mask or respirator was contaminated - DO NOT TOUCH! Review of the facility's policy, Handwashing/Hand Hygiene, dated August 2015, revealed the facility considered hand hygiene the primary means to prevent the spread of infections. Further review revealed all personnel would follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Review of the facility's policy, Novel Coronavirus (COVID-19), dated 08/18/2020, revealed anytime stakeholders touched their masks with their hands, they must immediately wash their hands. Observation, on 01/06/2021 at 10:15 AM, revealed a staff member in the Center Hallway wearing a N95 mask without the bottom strap secured over the head. Further observation, at 11:41 AM, revealed another staff member on the North Unit wearing a N95 mask without the bottom strap secured over the head. Interview with the Regional Administrator, on 01/06/2021 at 11:42 AM, revealed the mask should be worn with both straps secured in place because if not worn properly, the mask did not provide protection. Interview with the Administrator and the DON, on 01/06/2021 at 9:00 AM, revealed staff were to wear fit tested N95 or KN95 masks and eye protection when entering resident care units. Further interview with the DON, on 01/06/2021 at 6:22 PM, revealed all staff and visitors were required to wear their masks appropriately, and the expectation for the fit tested N95 masks was that both straps were to be worn over the head according to the guidelines. Observation, on 01/06/2021, during the facility tour, revealed multiple staff members touching their masks and eye protection without performing hand hygiene. Further observations revealed SRNA #1 at 1:39 PM, SRNA #3 at 2:16 PM, and HA #1 at 2:40 PM, touched their masks and eye protection without performing hand hygiene afterwards. Interview with the Dietary Director, on 01/06/2021 at 3:07 PM, revealed he observed dietary staff when auditing them for compliance with infection control practices. In addition, he stated he would provide on-the-spot, or immediate, education if improper PPE use or hand hygiene practices were observed during these audits. Interview with LPN #1, on 01/06/2021 at 3:15 PM, revealed N95 or KN95 masks/respirators and eye protection were required to be worn before entering the units. Further interview revealed hands were to be sanitized after touching the face mask and eye protection. Interview with LPN #2, on 01/06/2021 at 3:41 PM, revealed hand hygiene was to be performed after touching your face. Interview with LPN #3, on 01/06/2021 at 4:02 PM, revealed hand hygiene was to be performed after touching masks or goggles (eye protection). Interview with the IPRN, on 01/06/2020 at 4:28 PM, revealed staff had received hand hygiene competencies and was expected to perform hand hygiene after touching their face or adjusting their mask and eye protection. Continued interview with the DON, on 01/06/2021 at 6:22 PM, revealed training on infection control requirements was provided to staff through one-on-one education and competency check offs. Further interview revealed the expectation was for staff to follow infection control practices.

Based on interview, record review, review of the facility's policies, and review of the Center for Disease Control (CDC) guidelines, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections to properly prevent and/or contain COVID 19 for one (1) of three (3) sampled residents (Resident #2). On 04/29/2020 at 3:00 PM, Resident #2 was admitted to the facility and placed in droplet precautions. However, observations on 04/30/2020 at 3:15 PM, revealed no isolation disposal receptacles in the resident's room for doffed Personal Protective Equipment (PPE). Additionally, observations on 04/30/2020 at 3:30 PM, revealed State Registered Nurses Assistant (SRNA) #2 enter Resident #2's room to lay doffed PPE on the foot of the bed without donning PPE. Further, observations on 04/30/2020 at 3:40 PM revealed SRNA #3 enter Resident #2's room without donning PPE to place isolation receptacles in the resident's room and SRNA #2 enter Resident #2's room without donning PPE to dispose of previously doffed PPE in the isolation receptacles. The findings include: Review of the facility's Novel Coronavirus (COVID-19) policy, dated 03/04/2020, revealed Long Term Care facilities should ensure all staff are using appropriate Personal Protective Equipment (PPE) when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE. Additionally, full PPE should be worn per CDC guidelines for the care of any resident with known or suspected COVID-19. Further, all new residents admitted to the facility will be placed in droplet precautions for seven (7) to fourteen (14) days. Review of the facility's Coronavirus (COVID-19) Pandemic Plan Information, revised 03/06/2020, revealed the purpose of the policy was to provide a safe and healthy workplace for all employees. The pandemic policy for coronavirus outlines our overall response based on CDC guidelines. This will be part of our emergency preparedness plan. This plan will guide you through steps to take to safeguard employees, and residents while ensuring Principle Long Term Care's ability to maintain essential operations. Prevention steps for people confirmed to have, or being evaluated for coronavirus include placing the resident on contact isolation (Droplet Precautions). Review of the facility's Isolation-Categories of Transmission-Based Precautions (TBP) policy, dated October 2018, revealed TBP were initiated when a resident was at risk for transmitting an infection. Additionally, TBP were additional measure to protect staff, visitors and other residents from becoming infected. Further, when entering a Droplet Precautions or TBPs resident room, a mask, gloves, gown and goggles should be worn. Review of a laminated Center for Disease Control (CDC), Use PPE When Caring for Patients with Confirmed or Suspected COVID-19, procedure sheet that was taped to a resident's doorframe revealed the CDC sheet stated PPE must be donned correctly before entering the patient area; must remain in place and be worn correctly for the duration of work in the patient area. Additionally PPE should not be adjusted during patient care; and PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. Further, the CDC sheet listed step by step how to don and doff PPE: including disposal of PPE after doffing in a receptacle. Review of the facility's Education and Training records, dated 04/01/2020, revealed nursing staff received ongoing training and education regarding the Donning and Doffing PPE, COVID-19 Infection Control, and Handwashing to include when to wear PPE, handwashing and sanitizing, respiratory hygiene and strategies for minimizing the spread of COVID-19. Review of Resident #2's medical record revealed the facility admitted the resident on 04/29/2020 with [DIAGNOSES REDACTED]. Review of Resident #2's Admission Assessment, dated 04/29/2020, revealed the facility assessed the resident as being oriented to person, place and time. Further review revealed the facility assessed the resident as having no respiratory abnormalities. Review of Resident #2's Progress Note, dated 04/29/2020 at 3:00 PM, revealed the resident was admitted to facility after an acute hospital stay for Acute Hypoxic [MEDICAL CONDITION], Right Sided Pneumonia, [MEDICAL CONDITION], and Bilateral Pleural Effusions, status [REDACTED]. Additionally, the resident had received intravenous and oral antibiotics. Continued review revealed the resident stated his/her only problem was weakness. Further, the resident was alert, oriented, and able to elaborate on questions asked. Observations, on 04/30/2020 at 3:15 PM, revealed Resident #2's door was open and the resident was at the foot of the bed sitting in a wheelchair, with his/her feet resting on the floor and his/her head nodded down ward. The call light was within reach and the resident was mumbling incoherent words. Outside of the room, there were two (2) PPE carts; one (1) plastic cart, which contained gloves, hand sanitizer, and shoes coverings and the other, a metal cart that contained designated staff, face shields and cotton gowns. Continued observation revealed a laminated Center for Disease Control (CDC), Use PPE When Caring for Patients with Confirmed or Suspected COVID-19, procedure sheet taped to the left side of the doorframe. The CDC sheet stated PPE must be donned correctly before entering the patient area; must remain in place and be worn correctly for the duration of work in the patient area. Additionally PPE should not be adjusted during patient care; and PPE must be removed slowly and deliberately in a sequence that prevents self-contamination. Further, the CDC sheet listed step by step how to don and doff PPE: including disposal of PPE after doffing in a receptacle. Observations, on 04/30/2020 at 3:25 PM, revealed Resident #2's call light above the doorway was on. SRNA #2 stood at the resident's doorway and asked how she could assist the resident. The resident stated he/she need the wheelchair food rest. SRNA #2 stated she would be in to assist shortly. Continued observation revealed SRNA #2 donned PPE in the hallway outside of Resident #2's room; sanitized hands, donned a mask, sanitized hands, donned shoe coverings, sanitized hands, donned gloves, sanitized hands, donned gown, and donned face shield. SRNA #2 donned PPE out of sequence; she donned her gloves before gown. Additional observation revealed SRNA #2 enter Resident #2's room and assisted the resident with care. Continued observation revealed after assisting the resident with care, SRNA #2 walked to the resident's doorway and removed her foot coverings and gloves and laid the soiled PPE on the foot of the bed by the doorway. She then sanitized her hands and removed her gown, laid the soiled gown on the bed and sanitized her hands. SRNA #2 then stepped outside of Resident #2's room, into the hallway and removed her face shield, which she laid on top of the plastic PPE cart in the hallway. SRNA #2 then sanitized her hands and removed her facemask, sanitized her hands again and donned another facemask. Further, at 3:30 PM, SRNA #2 stepped back into Resident #2's room to lay the used facemask on the end of the bed. Continued observations on 04/30/2020 at 3:30 PM, revealed SRNA #2 ask SRNA #3, who was also standing in the hallway, to ask the nurse what to do since there was no designated isolation receptacle in Resident #2's room to place the doffed PPE. SRNA #2 sanitized the face-shield she previously laid on the plastic PPE cart and SRNA #3 went to the nurses' station. SRNA #3 returned and stated Licensed Practical Nurse (LPN) #1 directed her to sanitize and move the receptacles in the room across the hallway to Resident #2's room. Additional observations at 3:40 PM revealed SRNA #3 sanitized the receptacles and moved them out of the room across the hallway and into Resident #2's room; however, SRNA #3 did not don PPE when she entered Resident #2's room to place the receptacles. Further, SRNA #2 stepped back into Resident #2's room to place previously doffed PPE, which she had laid on the foot of the bed, into the receptacles without donning PPE. Interview with SRNA #2, on 04/30/202 at 4:11 PM, revealed she had worked at the facility for five (5) years. Additionally, the facility had provided recent and ongoing training and education related to COVID-19, TBP, PPE and Infection Control procedures. Per interview, she was trained by the facility to don and doff PPE correctly by CDC guidelines; to don PPE in a specific sequence including shoe coverings, glove, gown, mask and face shield when providing care to residents in droplet precautions; to doff PPE and dispose of it in designated isolation receptacles in resident rooms. Per interview, she should have referred to the CDC sheet by the resident's door for correct PPE donning sequencing if she had any questions/concerns and there should have been a designated isolation receptacle in Resident #2's room for immediate disposal of doffed PPE. She stated she was nervous and today was her first day working with the residents in droplet isolation. SRNA #2 stated it was important to maintain CDC Guidelines related to donning and doffing PPE to ensure staff do not bring germs in the hallway and contaminate other residents or staff. Further, it was the Unit Coordinator/LPN#1's responsibility to ensure isolation rooms had designated receptacle for doffed PPE. Interview with SRNA #3, on 04/30/2020 at 4:21 PM, revealed she had worked at the facility for nine (9) months. Additionally, the facility had provided training related to COVID-19, isolation precautions, PPE and infection control policy and procedures. Per interview, the Unit Coordinator/LPN #1 provided daily discussions about updates with infection control guidelines, policy and procedures. Per interview, she should have donned PPE before entering Resident #2's room to place the isolation receptacles; but working with these guidelines was new to her and she made a mistake and was not thinking when she entered Resident #2's room to place the receptacles. Further, when working in resident care areas for residents in isolation precautions for COVID-19, it was important to ensure we are wearing PPE per CDC Guidelines to decrease the risk of spreading it to other staff and residents. Interview with LPN #1/ Unit Coordinator for the North hallway, on 04/30/2020 at 4:30 PM revealed he had worked at the facility for seven (7) months. Per interview, he had received training on COVID-19 by the Director of Nursing (DON) including isolation precautions, when to wear PPE, handwashing and sanitizing, respiratory hygiene and strategies for minimizing the spread of COVID-19. Continued interview revealed he received daily morning updates from the DON on changes to Guidelines, Policy and Procedure and shared those updates with direct care staff. Per interview, isolation/droplet precaution rooms should have designated receptacles for doffed PPE; however, he was uncertain why Resident #2's room did not have designated isolation receptacles until 04/30/2020 at 3:40 PM, twenty-four (24) hours after admission. Further, anytime a staff member enters an isolation room, PPE should be donned. His expectation of SRNA #2 and SRNA #3 was for PPE to be donned each time before entering a resident's room and to be doffed each time before exiting a resident's room in the designated receptacles; not maintaining guidelines for infection control increased the risk and source of cross contamination to other residents and staff. Interview with the DON, on 04/30/2020 at 4:39 PM, revealed it was her expectation that staff should don and doff PPE per facility policy and CDC Guidelines each time they enter an isolation room. Additional interview revealed isolation rooms should have designated receptacles for disposal of PPE per facility policy and CDC Guidelines. Per interview, the facility changed isolation rooms within the last week and the receptacles must not have made it into the new isolation rooms with the move; however, LPN #1/Unit Coordinator should have noticed the receptacles were not present upon admitting Resident #2 into the room on 04/29/2020. Further, it was important to maintain Infection Control Policy and Procedure to prevent transmission of disease. Continued interview revealed her surveillance and audit process did not identify problems/concern with staff donning and doffing PPE per CDC Guidelines; however, the audit did not include checking isolation rooms for receptacles. Interview with the Administrator, on 05/01/2020 at 2:00 PM, revealed he had worked at the facility for five (5) weeks. Additionally he expected staff to maintain facility policy and regulation related to infection control practices specific to donning and doffing PPE and the use of designated receptacles in isolation rooms. Further, he stated it was important to maintain infection control practices to reduce chances of spreading contagious diseases.

Based on observation, interview, record review, review of the facility's investigation and review of the facility's Policy, it was determined the facility failed to ensure the residents have the right to and the facility promotes and facilitates resident self-determination through support of resident choice for one (1) of four (4) sampled residents (Resident #1). On 01/04/2020, [ENTITY] #1 attempted to deny Resident #1's right to refuse administration of a supplement. The findings include: Review of the facility's Resident Right Policy, dated 08/16/2018, revealed all residents have the right to be treated with respect and dignity. Per the policy, these rights will be promoted and protected by the facility. Continued Review revealed when providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them with a dignified existence, through self-determination, and communication with and access to persons and services inside and outside the facility. Review of the facility's Investigating Abuse, Neglect and Misappropriation Policy, dated 05/08/2019, revealed it was the policy of the facility that each resident had the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Continued review revealed the facility has a zero tolerance concerning any type of abuse or neglect of its residents or misappropriation of their property. All allegations and reports of resident abuse, neglect, mistreatment, and misappropriation of resident property shall be promptly and thoroughly investigated. Review of the facility's investigation, undated, revealed the facility received an anonymous report on 01/24/2020 that [ENTITY] #1 was observed being inappropriate with the resident when administering medication on 01/04/2020. Continued review of the investigation revealed, [ENTITY] #1 was suspended during the facility's investigation. Per the investigation, the resident was unable to recall the incident related to cognition. Per the investigation Registered Nurse (RN) #1 and State Registered Nursing Assistant (SRNA) #4 both stated [ENTITY] #1 attempted to administer liquid nutritional supplement to Resident #1, who at the time had his/her lips pursed and was shaking his/her head in a no motion. Per the report, [ENTITY] #1 continued to verbally que Resident #1 to drink the supplement until intervention from SRNA #4 occurred. Review of the medical record revealed the facility admitted Resident #1 on 06/17/2016 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 01/01/2020, revealed the facility assessed the resident, as having a Brief Interview of Mental Status (BI[CONDITION]) score of ninety-nine (99) due to the interview could not be conducted. Further review of Minimum Data Set (MDS) revealed Resident #1 was assessed to have severe cognitive impairment. Observation of Resident #1, on 02/18/2020 at 12:00 PM, revealed the resident to be alert sitting up in a wheelchair in the facility's dayroom. Resident #1 was pleasant, and reactive to vocal communication, but was unable to respond in an oriented and clear sounding manner. Further observation revealed RN #2 was administering a scheduled dose of [MEDICATION NAME] to Resident #1. Resident #1's medication was crushed and placed in Pro Med supplement solution. Upon delivery of the medication, Resident #1 was able to identify the straw and cup, and could maneuver his/her head into a drinking position. Resident #1 was able to consume all of the supplement within a four (4) minute time frame with small breaks in between sips. Interview with Resident # 1, on 02/18/2020 at 12:10 PM, could not be conducted due to cognitive status. Interview with [ENTITY] #1, on 02/18/2020 at 1:00 PM, revealed he could not remember the exact date or medication being given, but Resident # 1 was just inside the dining hall and he attempted to give him/her Pro Med supplement. He stated during the first attempt to administer the Pro Med, Resident #1 would not open his/her lips and began shaking his/her head in a no motion. [ENTITY]#1 stated, he did place the straw in Resident #1's mouth but was vocally instructing the resident to drink. [ENTITY] # 1 revealed he asked two (2) times before SRNA #4 came over and intervened. [ENTITY] #1 stated residents do have the right to refuse medication consumption. [ENTITY] #1 stated he was suspended and later terminated due to the incident. Interview with SRNA #4, on 02/18/2020 at 10:30 AM, revealed [ENTITY] #1 was attempting to provide a supplement to Resident #1 on 01/04/2020. Continued interview revealed she noticed Resident #1 was closing his/her lips and shaking his/her head in a no manner. Further interview revealed SRNA #4 did not see [ENTITY] #1 forcing the supplement into Resident #1 mouth, but he was becoming frustrated with Resident # 1's refusal to take the supplement. At this point SRNA #4 intervened and redirected [ENTITY] #1 who walked off in frustration. Resident #1 was able to consume the supplement after redirection and short rest period. Interview with RN #1, on 02/18/2020 at 11:30 AM, revealed she overheard the incident when SRNA# 4 redirected [ENTITY] #1. Per interview, she did not see [ENTITY] #1 administering the supplement as her back was turned. RN #1 stated after [ENTITY] #1 left, Resident #1 did not appear in distress and was able to consume the supplement after redirection. Further interview revealed Resident #1 can at times refuse to drink or eat, but at no point in her memory has she had to waste medication due to the resident refusing. Resident #1 is able to be redirected after pauses in most instances. Further RN #1 stated she reported the incident to the Weekend Nursing Supervisor. Attempted interview with Weekend Nursing Supervisor, on 02/18/2020; however, she is no longer employed with the facility and did not return telephone calls. Interview with RN #2, on 02/18/2020 at 12:00 PM, revealed Resident #1 is mostly pleasant but can become anxious or frustrated. Resident #1 does require some assistance for meals, and daily living activities. Further interview revealed Resident #1 will at times not want to drink his/her supplement for medication administration but no instances where medicine had to be wasted due to outright refusal. After simple redirection and approach, the resident will consume the supplement and medication. Further interview revealed all residents have the right to self-determination in all aspects of care. Interview with RN #3, on 02/18/2020 at 12:00 PM, revealed Resident #1 requires assistance with meals and activities of daily living. Per interview, Resident #1 will at times will require redirection and additional attempts to administer his/her supplements; however, he/she has not refused them. Per interview, all residents have the right to self-determination in all care. Interview with the Unit Manager, on 02/18/2020 at 2:45 PM, revealed the incident was thoroughly investigated after allegation was presented. Abuse was unsubstantiated, but Resident #1 had the right to refuse to drink his/her supplement and not be pressed to do so. All residents within the facility have the right to self-determination. Interview with the Director of Nursing, on 02/18/2020 at 3:00 PM, revealed the initial report concerning [ENTITY] #1 and Resident #1 was called to her on 01/04/2020 as medicine being distributed in the dining hall by the Weekend Supervisor. [ENTITY] #1 was coached by the supervisor and no other mention of the incident was encountered until the anonymous report was called in by compliance department. The facility initiated an investigation, which concluded no abuse was substantiated, and [ENTITY] #1 was terminated due to conduct against company values. Further interview revealed Resident #1 and all Residents have the right to self-determination in all aspects of care. Per interview, in this particular case Resident #1 had the right to refuse consumption of his/her supplement and should not have been pressed by the [ENTITY] to consume it. She stated it was her expectation that all staff respect the Rights of Residents. Resident #1 is now care planned for such behaviors and all staff have been educated on Resident Rights. Interview with the Administrator, on 02/18/2020 at 3:30 PM, revealed after the incident was reported, an immediate investigation was conduct with the conclusion no abuse had occurred; however, residents have the right to choose. Per interview, [ENTITY] #1 was terminated for conduct not in line with our facility values. Resident #1's right to self-determination was violated due to [ENTITY] #1 verbally pressing Resident #1 to consume his/her medication supplement after Resident #1 expressed refusal. All residents have the right of self-determination in all aspects of care, and it was her expectation that her staff follow the facility's policies while upholding those rights. Further interview revealed Resident #1's Comprehensive Care Plan was updated concerning the incident and all staff were educated and will continue to have on going education concerning all aspects care in accordance to facility values.

Based on interview, record review and review of facility policy, it was determined the facility failed to ensure five (5) of five (5) sampled residents were free from misappropriation of resident property (Residents #3, #5, #6, #7, and #8) Resident #3's family paid the facility in cash $2,000.00 for room and board and also gave the facility $[AGE].00 cash for the resident's account in 09/2019. However, the money was not deposited into the resident's account and the cash receipts for the funds were torn out of the facility Receipt Book. The facility was unaware of the missing funds until Resident #3 was again billed for room and board for 09/2019, and the son brought in copies of cash receipts showing $2,0[AGE].00 dollars was received by the facility on 09/05/19. In addition, Staff interviews and record review revealed the facility Receipt Book showed receipts for cash payments for deposit for Residents #5, #6, #7, and #8's accounts; however, review of the residents' accounts revealed no documented evidence the cash payments were deposited. The findings include: Review of facility Abuse, Neglect and Misappropriation of Property, Policy, dated 05/08/19, revealed Misappropriation of Property is defined as deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's trust accounts and/or resident's trust petty cash. If Misappropriation was identified, there will be notification to the Compliance, Internal Audit and Legal for investigation purposes. 1. Review of Resident #3's medical record revealed the facility admitted the resident on 04/05/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 11/10/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) of eight (8) out of fifteen (15) indicating moderate cognitive impairment. Review of the facility Investigation, dated 12/12/19, revealed Resident #3's son provided a copy of a receipt, dated 09/05/19, for a total of $2,000.00 dollars in cash deposit for room board and a copy of a receipt dated 09/05/19 for $[AGE].00 dollars for the resident's personal account. Per the Investigation, review of Resident #3's personal account by the Regional Business Office Consultant, revealed these funds were not deposited in the resident's account. Further review of the Investigation, revealed the Regional Business Office Consultant reviewed all cash collections from 07/2018 to current date and compared receipts to resident accounts to validate the cash payments were deposited into the residents' accounts and irregularities in other residents' accounts were discovered. Per the Investigation, the facility notified the residents' families, Law Enforcement, Corporate Compliance and Internal Audits. Review of the facility Receipt Book, on 12/04/19, revealed the page for the cash receipt for $2,000.00 for room and board and the cash receipt for the $[AGE].00 was missing. Review of Resident #3's Resident Statement (financial statement), revealed there was no documented evidence the money was deposited. Phone interview was attempted on [DATE] at 2:02 PM, with Resident #3's Power of Attorney (POA), and a message was left with no return phone call. Interview with the Administrator, on 12/12/19 at 10:24 AM and 3:30 PM, revealed Resident #3's family had paid for room and board for the month of 09/2019 with cash and also gave $[AGE].00 cash for the resident to spend. Per interview, when the facility again charged the Resident #3 for room and board for 09/2019, the resident's son brought in copies of cash receipts showing $2,000.00 dollars was received for room and board and $[AGE].00 dollars was received for the resident's personal account on 09/05/19. The Administrator stated the facility started an investigation and found the cash receipts for Resident #3's $2,000.00 room and board and $[AGE].00 dollars for spending money dated 09/05/19, were missing and the page pertaining to the cash receipts had been torn out, indicating misappropriation. Further interview revealed the facility notified the family that the $2,0[AGE].00 dollars would be reimbursed to Resident #3's account, and the family verbalized understanding. Further interview and record review with the Administrator, on 12/12/19 at 3:30 PM, revealed the facility Investigation revealed other irregularities for Residents #5, #6, #7, and #8's accounts, indicating misappropriation. 2. Review of Resident #5's medical record revealed the facility admitted the resident on 05/23/17 with diagnose including Diabetes Mellitus Type 2, Hypertension, and Cognitive Communication Deficit. Resident #5's cash receipt dated 03/22/19, revealed cash was received for $50.00 dollars for the resident's personal account and $2,000.00 dollars for room and board. However, Resident #5's Resident Statement, revealed the $2,050.00 was not deposited into the resident's account. 3. Review of Resident #6's medical record revealed the facility admitted the resident on 05/30/19 with [DIAGNOSES REDACTED]. Resident #6's cash receipt, dated 07/10/19, revealed $400.00 dollars was provided to the facility for the resident's room and board. However, Resident #6's Resident Statement revealed the funds were not deposited into the resident's account. 4. Review of Resident #7's medical record revealed the facility admitted the resident on 04/25/19 with diagnose including Cerebral Infarction of the Right Dominant Side with [MEDICAL CONDITION] and [MEDICAL CONDITION], Hypertension, and Depression. Resident #7's cash receipt, dated 0[DATE], revealed the resident paid $3[AGE].00 dollars for room and board; however, the Resident Statement, revealed the funds were not deposited into the resident's account. 5. Review of Resident #8's medical record revealed the facility admitted the resident on [DATE] with [DIAGNOSES REDACTED]. Resident #8's cash receipt dated 09/30/19, revealed $100.00 dollars was provided for the resident's personal account; however, the Resident Statement, revealed the funds were not deposited into the resident's account. Interview on 12/12/19 at 11:52 AM, with the Business Office Manager (BOM), revealed the resident or family received a cash receipt when paying for room and board or depositing cash for personal use by the resident into the resident's interest bearing saving account. Further interview revealed the facility obtained a money order or check for the cash deposit for room and board or resident personal use and made a deposit into the resident's personal interest bearing account. Per interview, the residents were able to draw money for spending from their personal interest bearing savings accounts. Further, the money deposited for room and board was left in the resident's interest-bearing savings account until time to pay for room and board and then the money was moved into the resident's checking account for payment. Phone interview on [DATE] at 2:15 PM, with the alleged Perpetrator/former Business Office Manager (BOM), revealed he had been terminated on 10/11/19 and the facility had not contacted him concerning any resident's cash missing. Per interview, the process for handling cash was to provide a receipt to the resident or family for their records. He stated the cash was then put into the safe until the facility could get a check or money order to deposit into the resident's account. Interview on 12/12/19 at 1:50 PM, with the Consultant Regional Business Office Auditor, revealed the process for receiving cash from the residents/or their responsible parties was to write a receipt for the cash and then to obtain a money order to deposit the money into the resident's account. She further stated she normally audited residents' accounts every quarter; however, due to the new computer program she was unable to audit the residents' accounts for two (2) quarters or eight (8) months. Per interview, her audit of the account ledger with comparison to the receipt book, revealed cash received was not deposited into the Resident #3, #5, #6, #7 and #8's interest bearing saving accounts and it was the facility's fault for not handling the funds correctly Continued interview with the Administrator, on 12/12/19 at 10:24 AM and 3:30 PM, revealed there was notification to Cooperate Legal, Financial Audit, Office of Inspector General, Police, and Resident #3, #5, #6, #7 and #8's families on 12/04/19 related to misappropriation of resident funds. Per interview, the alleged perpetrator was the former BOM, and he was terminated. Further, the Consultant Regional Business Office Auditor reviewed all cash collections from 07/2018 to current date 12/12/19, and compared receipts to resident accounts to validate the cash payments were deposited in the resident's account. She stated follow up internal audits were planned by the Internal Audit Department.

Based on interview, review of the Resident Trust Fund Authorization form, and review of Resident Statements (financial statements), it was determined the facility failed to establish and maintain a system that assures generally accepted accounting principles and proper bookkeeping techniques, in order to maintain the ongoing balance for each resident's personal funds entrusted to the facility on the resident's behalf for three (3) of three (3) sampled residents (Residents #1, #2 and #4). Although Residents #1, #2 and #4 signed the facility Resident Trust Fund Authorization, authorizing the facility to handle the resident trust funds, the facility failed to pay the residents' supplemental insurance premiums to cover dental, audiology and vision on a monthly basis. As a result, the funds stayed in the residents' accounts until the money was withdrawn in large amounts to pay for delinquent supplemental insurance premiums. Interviews with Resident #1 and Resident #2, revealed the facility's failure to withdraw money from their accounts monthly to pay the supplemental insurance premiums which resulted in account balances not being accurate as to how much money was left to spend when reviewing financial statements. The findings include: Review of the Life Insurance Company form, titled Living Care Facility Resident Application for Individual Insurance, revealed coverage for dental, vision and audiology was offered for a monthly premium. Per the Application, residents select the type of coverage and selected who received the bill as the facility or the residents' legal representative for payment. Review of the facility Resident Trust Fund Authorization, dated 11/2013, revealed the form gave authorization for the Administrator of the facility, or any other person authorized by the Administrator to handle resident trust funds for Social Security or other checks made payable to the resident, and to deposit them into the facility's resident trust bank account. Further review revealed the form gave authorization to apply the resident trust funds to charges, which the resident owed for services and supplies, provided during the resident's stay. Review of the facility Investigation, dated [DATE], signed by the Administrator, revealed after Resident #1 questioned his/her financial statements, and after review of the resident's financial statements, it was discovered the Business Office accounting system had not paid Resident #1's supplemental insurance premiums on a monthly basis in order to cover dental, and vision. Resident #1 had utilized a portion of the funds for personal use prior to the facility identifying that the resident's insurance premiums had not been paid. Per the Investigation, Resident #1 requested to cancel the dental and vision insurance and verbalized understanding that the cancellation of the insurance premium would not affect his/her $40.00 allowance. Further review of the Investigation, revealed there was an ongoing investigation related to other residents' accounts. 1. Review of Resident #1's medical record revealed the facility readmitted the resident on 05/31/19 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BI[CONDITION]) of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Review of the Resident Trust Fund Authorization, dated 11/2013, revealed Resident #1 signed the form on 06/04/15, authorizing the facility to handle his/her resident trust funds. Review of Resident #1's application to the Insurance Company, titled Living are Facility Resident Application for Individual Insurance dated 02/27/19, revealed Resident #1 selected coverage for dental, and vision with monthly premiums and selected the facility to receive the bill for payment. Review of Resident #1's Resident Statement, revealed the most recent withdrawals for supplemental insurance premiums was on 07/17/19 for $144.00 and on 09/05/19 for $287.00. Review of Resident #1's supplemental Premium Statement, dated 10/25/19, with due date of 11/01/19, revealed the account was still $[AGE]1.00 dollars past due. Per the Statement, premiums were $144.00 a month for dental and vision coverage. Interview on 12/12/19 at 9:51 AM, with Resident #1, revealed when he/she received his/her Quarterly Resident Statements in the past (specific dates unknown), he/she had a substantial account balance for spending; however, when he/she asked to withdraw money (date unknown), he/she was told by the Business Office Manager (BOM), there was only $40.00 left in the account for the month. Resident #1 stated he/she spoke with the Administrator about the situation and was told the facility had withdrawn money to pay the supplemental insurance premiums, which were behind as the facility had not been paying the premiums monthly. 2. Review of Resident #2's medical record revealed the facility admitted the resident on 02/08/19 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed the resident as having a BI[CONDITION] score of fourteen (14) out of fifteen (15) indicating intact cognition. Review of the facility form titled Resident Trust Fund Authorization, dated 11/2013, revealed Resident #2 signed on 10/13/15, authorizing the facility to handle his/her resident trust funds. Review of Resident #2's application to the Insurance Company form titled Living are Facility Resident Application for Individual Insurance dated 07/18/18, revealed Resident #2 selected coverage for vision, and dental, with monthly premiums, and selected the facility to receive the bill for payment. Review of Resident #2's Resident Statement, revealed the most recent withdrawal for supplemental insurance premiums was on 07/17/19 for $1,000 dollars; on 0[DATE] for $1,555.00 dollars; and on 09/05/19 for $110 dollars. Review of Resident #2's supplemental Premium Statement, dated 10/25/19, with due date of 11/01/19, revealed the account was still $410.00 dollars past due. Per the Statement, premiums were 205.00 per month for vision, dental, and audiology supplemental insurance. Interview on 12/12/19 at 1:30 PM, with Resident #2, revealed when he/she reviewed his/her Quarterly Resident Statements, he/she assumed the total of the funds was available to spend; however, when he/she reviewed it on a later date, there was less money and he/she was concerned over where the money had gone. Per interview, he/she found out the facility had withdrawn money for the supplemental insurance premiums which the facility failed to withdraw monthly. Resident #2 stated he/she was upset the premiums were not paid on time because this resulted in his/her account balances not being accurate when reviewing his/her financial statements. Per interview, after discussion with the Administrator, he/she felt it was the facility's fault for not paying the premiums timely and therefore, the facility should not have withdrawn large amounts of money from his/her account to pay for the premiums. 3. Review of Resident #4's medical record revealed the facility readmitted the resident on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 10/19/19, revealed the facility assessed the resident as having a BI[CONDITION] score of twelve (12) out of fifteen (15) indicating moderate cognitive impairment. Review of the facility form titled Resident Trust Fund Authorization, dated 11/2013, revealed Resident #4 signed on 02/23/18, authorizing the facility to handle his/her resident trust funds. Review of Resident #4's application to the Insurance Company form titled Living are Facility Resident Application for Individual Insurance dated 07/18/18, revealed Resident #4 selected coverage for dental, and vision with a monthly premium, and selected the facility to receive the bill for payment. The insurance premium payments were $144.00 dollars monthly. Review of Resident #4's Resident Statement, revealed the most recent payment for the supplemental insurance premium was withdrawn on 09/05/19, in the amount $205.00 dollars. Review of Resident #4's supplemental Premium Statement, dated 10/25/19, with due date of 11/01/19, revealed the resident owed #144.00 for the month and owed a past due payment of $576.00 dollars. Resident #4 was out of the facility at the time of the Survey, and was unavailable for interview. Interview on 12/12/19 at 11:52 AM, with the Business Office Manager (BOM), revealed she had been at the facility in her position for one (1) month, and therefore was still trying to sort out the concern with the facility not paying the supplemental insurance premiums monthly for the residents. Per interview, the residents' financial statements combined the interest bearing savings accounts with the checking accounts. She stated all the money the residents received from Medicaid was deposited into the residents' interest bearing savings account, and when the premiums or other expenses were due, the money was transferred to their checking accounts. The BOM stated residents received a copy of the quarterly financial statement, which itemized the deposits and expenditures for the resident funds with interest. Further interview with the BOM, revealed the facility was not aware the premiums for Residents #1, #2 and #4 were not paid timely until the facility began the investigation related to Resident #1's concerns related to his/her Resident Statement. Continued interview revealed Resident #1's supplemental insurance premiums were delinquent, and when the delinquent payments were paid from the resident's account, this left the resident's account balance at $40.00 dollars for monthly allowance for September 2019. Per interview, this caused the resident to be concerned that he/she did not have as much money to spend as he/she thought he/she had. Additional interview with the BOM, revealed Resident #2's supplemental insurance premium payments were not paid for a few months, and therefore when the premium was paid, the account balance was adjusted and this upset Resident #2 who thought he/she had more money to spend as per her Resident Statement prior to the withdrawals in July and September 2019. Further, the facility was in the process of reviewing Resident #4's accounts as well as all residents' accounts and it would likely take a month to make sure all supplemental insurance premiums were up to date and to make adjustments in residents' accounts. Continued interview with the BOM, revealed she created a new form with the current residents' account balance. Per interview, this form listed the amount of spending money available to the resident from the residents' interest bearing savings account. The BOM stated some residents received money from friends and family, which allowed the account to build up with savings so this new form would reflect the money available for the resident to spend. Interview on 12/12/19 at 1:50 PM, with the Consultant Regional Business Office Auditor, revealed it was her practice to take a percentage of the Resident Fund Accounts for audits. However, she stated she had not audited the business office books for two (2) quarters or about eight (8) months due to computer program upgrades. She stated she did not know the facility had not been paying the residents' supplemental insurance premiums monthly. Per interview, residents received a combined quarterly statement of checking and interest bearing savings account, and the facility provided the financial statements (Resident Statements) to residents assessed as cognitively intact. Continued interview revealed the facility planned to reimburse the money taken out of Resident #1, Resident #2 and Resident #4's account to pay the insurance premiums for the year. She further stated the corporate office would perform an audit from last year to present of all the residents' accounts to review for any other unidentified concerns, and the audit would identify the total amount owed to the residents' accounts. Interview on 12/12/19 at 10:24 AM, with the Administrator, revealed Medicaid sent money to the facility for each Medicaid recipient. Per interview, the Medicaid money covered services, and the insurance premiums. She stated the residents had a balance of $40.00 dollars to spend for the month. Further interview revealed Resident #1 had questioned her about his/her Resident Statement and also Resident #2 had not received his/her dentures that were to be covered by the supplemental insurance. Per interview, after investigating, it was concluded the facility had not been paying the supplemental insurance premiums payments on a monthly basis. She stated the facility requested the supplemental insurance company to send bills in order for the premiums to be paid out of the residents' checking accounts. Per interview, the money for the delinquent premiums for Residents' #1, #2 and #4 was then withdrawn from their accounts. Further interview with the Administrator, revealed on [DATE], Resident #1 requested money from his/her account and was informed his/her supplemental premiums were not submitted for payment for the year and the money that remained in the resident's account; other than, the $40.00 for the month was for the premiums. Per interview, the resident then requested the supplemental insurance to be canceled. She stated the insurance company provided services up to September 2019 for Resident #1. Continued interview with the Administrator, revealed on [DATE], Resident #2 was informed his/her supplemental insurance payments were not submitted each month for payment. Per interview, Resident #2 wanted to keep the current insurance. Further, Resident #2's premiums were paid up to date and he/she would receive his/her dentures. Additional interview with the Administrator, revealed on [DATE], Resident #4 was informed his/her supplemental insurance premiums were not submitted for payment each month. Per interview, Resident #4 verbalized appreciation and understood the facility would cover the cost of the money spent for the insurance premiums and put the money back into the resident's account. Further interview with the Administrator, revealed the facility planned to reimburse Resident #1, Resident #2, and Resident #4 for the money spent on supplemental insurance premiums for the year. Continued interview revealed after a full audit of all residents' accounts, the facility would be reimbursing money paid by the residents for delinquent supplemental insurance premiums for the year.

Based on observation, interview, and review of facility policy, it was determined the facility failed to prepare food under sanitary conditions. Observation on 11/18/19, during initial kitchen tour, revealed there was an accumulation of dust behind the production equipment and in front of the cook's preparation table. Further observation revealed the fry pan which was stored under the cook's table was not stored in such a way as to prevent dust or other accumulation of particles onto the cooking surface. The findings include: Review of the facility Cleaning Schedules Policy, dated 08/31/18, revealed the Food and Nutrition Service's staff shall maintain the sanitation of the Food and Nutrition Service's Department through compliance with written, comprehensive cleaning schedules developed for the community by the Director of food and Nutrition Services or other clinically qualified nutrition professional. Review of the facility form, titled Daily Cleaning Schedule, dated 11/2019, revealed it did not address scheduled or assigned cleaning behind equipment. Observation on 11/18/19 at 9:20 AM, of kitchen during initial tour, revealed there was an accumulation of dust behind the production equipment including the oven, stove, and convection oven near the front of the cook's preparation table. In addition the fry pan which was stored under the cook's table was not turned upside down to prevent dust or other accumulation of particles onto the cooking surface. Interview on 11/20/19 at 2:40 PM, with Dietary Aide/Assistant Manager #1, revealed the dust accumulation from behind the equipment in front of the cook's table could get into the food and cause cross contamination. Interview on 11/20/19 at 2:42 PM, with Dietary aide #2, revealed dust in the kitchen could accumulate and contaminate the residents' food. Further interview revealed the pans on the cook's shelf were to be stored upside down in order to prevent dust or other particles from falling into the pans and causing cross contamination. Interview on 11/20/19 at 2:45 PM, with the Dietary Manager, revealed dust accumulation could contaminate food during food production. Further, all pans on the cook's shelf were to be stored upside down in order to prevent accumulation of dust or other particles, which could contaminate residents' food. Interview on 11/21/19 at 10:20 AM, with the Director of Nursing (DON), revealed it was her expectation the kitchen be sanitary, and in good working condition. Further, if there was an accumulation of dust in the kitchen, the dust could contaminate food during preparation. Interview on 11/21/19 at 10:15 AM, with the Administrator, revealed it was her expectation for Dietary Staff to keep the kitchen clean for resident food production.

Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to develop and implement a Comprehensive Care Plan (CCP) for each resident, that includes measurable objectives to meet a residents needs for one (1) of twenty-three (23) sampled residents (Resident #30). Although Resident #30 had a contracture of the right hand, there was no documented evidence the CCP was developed and implemented with interventions to address the resident's limited ROM. (Refer to F-688) The findings include: Review of the facility Policy, titled Comprehensive Care Plans, dated 07/19/18, revealed a person centered care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs and is developed for each resident. Per review, the CCP will include how the facility will assist the resident to meet his/her needs, goals and preferences. Further, the CCP will describe the services to be provided to maintain or attain the residents highest practicable physical, mental, and psychosocial wellbeing; include identified problem areas; and aid in preventing or reducing decline in functional status/level. Review of Resident #30's Clinical Record revealed the facility admitted the resident on 01/28/15 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan (CCP), initiated 06/14/19, revealed Resident #30 required assistance with Activities of Daily Living (ADLs) related to Decreased Mobility, [MEDICAL CONDITION] with Right [MEDICAL CONDITION]. The goal revealed the resident would maintain current level of function through next review. The interventions included: keep call light within reach; Physical therapy to evaluate and treat as indicated; Praise resident efforts; left side of bed against wall per choice; high back wheelchair for mobility; and staff to provide assistance for transfers. All of these interventions were initiated on 06/14/19. Review of the Annual Minimum Data Set (MDS) Assessment, dated 09/05/19, revealed the facility assessed Resident #30 as having a Brief Interview for Mental Status (BIMS) score of five (15) out of fifteen (15) indicating intact cognitively. Further, the facility assessed the resident as requiring extensive assistance of two (2) staff for all Activities of Daily Living (ADLs). Per the MDS Assessment, the resident had Limitations in Functional Range of Motion (ROM) to one (1) upper extremity and one (1) lower extremity. Observation of Resident #30, on 11/18/19 at 3:23 PM, revealed the the resident had a rolled wash cloth positioned inside his/her right hand between the palm and the resident's contracted digits. In addition, the resident's right hand had moderate swelling to the digits. No splint or brace was noted in the room. Interview with Resident #30, on 11/18/19 at 3:23 PM, revealed no staff member including the therapy staff, did anything for his/her contracture of the right hand. Further, he/she stated his/her hand did have pain at times, especially when the wash cloth was not placed in his/her palm. Continued interview with Resident #30, on 11/20/19 at 3:14 PM, revealed staff was not involved with assisting him/her with Range of Motion (ROM) to his/her contracted right hand. Resident #30 stated he/she was interested in any therapy or device that would prevent further decline or contracture in his/her right hand as he/she only used the wash cloth for his/her hand contracture. However, there was no documented evidence the CCP was developed and implemented with interventions to address the resident's limited ROM to the right hand. (Refer to F-688). Review of Resident #30's State Registered Nurse Aide (SRNA) Kardex (Care Plan), on 11/21/19, revealed no documented evidence of interventions for Range of Motion or a device related to the contracture of the resident's right hand. Furthermore, record review revealed no documented evidence Resident #30 was receiving ROM or a device to the right hand contracture. Interview with State Registered Nurse Aide (SRNA) #1, on 11/21/19 at 10:00 AM, revealed he was often assigned to Resident #30. SRNA #1 stated he did not have a guide or any plan to show him how to assist Resident #30 with ROM to his/her hand and he just placed a dry rolled wash cloth in his/her hand for comfort at the resident's request. Interview with Licensed Practical Nurse (LPN) #1, on 11/21/19 at 10:45 AM , revealed he was assigned to Resident #30. Per interview, LPN #1 was not aware of a plan to address Resident #30's needs related to limited range of motion or related to his/her hand contracture. He stated Resident #30 was not currently receiving Restorative Nursing or orthotic/splinting care to prevent further decline in range of motion of the hand. Further interview revealed the resident's CCP should have addressed the resident's limited ROM. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 11/21/19, after Surveyor intervention, revealed Resident #30's right hand contracture placed the resident at risk for decreased skin integrity. Recommendations included Occupational Therapy five (5) times a week for four (4) weeks. Short term goals included the resident participating in determining appropriate orthotic to right hand with tolerating wear up to two (2) hours with no signs or symptoms skin irritation or redness; and resident participating in determining/implementing self ROM for right hand to prevent further loss in function and maintain skin integrity. Further review revealed long term the resident would participate in wearing orthotic four (4) hours per day with no signs or symptoms of skin irritation and would participate in the Restorative Nursing Program. Interview with the Occupational Therapist (OT) /Rehabilitation Manager, on 11/21/19 at 9:35 AM, revealed residents with contractures should be re-evaluated for further treatment based on change in function, skin impairment and change in measurement of contracture and each resident with contractures should have an individualized plan of care to maintain current level of function and prevent further decline. Continued interview revealed Resident #30 was evaluated this morning and recommendations were written for Occupational Therapy with Orthotic Use and to be referred to Restorative Nursing when therapy was discontinued. Interview with the Unit Manager (UM), on 11/21/19 at 11:30 AM, for the unit in which Resident #30 resided, revealed Resident #30 should have had a CCP developed and implemented related to the contracture of the right hand in order to prevent further decline. Interview is with MDS Coordinator, on 11/21/19 at 1:00 PM, revealed the Comprehensive Care Plan was important to communicate resident needs to the staff. Per interview, it was important to develop and implement the Care Plan related to a resident's Range of Motion limitations in order to prevent worsening contractures. Further, the CCP was a guide for staff to utilize in providing care to residents and should be accurate to ensure residents received optimal care. Interview with the Director of Nursing (DON), on 11/21/19 at 1:45 PM , revealed residents with contractures should have a Plan of Care in place to address the need for ROM and/or splints as applicable in order to prevent decline in ROM. Per interview, Resident #30 should have had a CCP developed and implemented related to limited ROM of his/her contracted right hand. Interview with the Administrator, on 11/21/19 2:00 PM, revealed it was her expectation the CCP address contractures and limitations in range of motion, with interventions to prevent further decline. Per interview, this was important because staff utilized the CCP as a guide in providing necessary care.

Based on observation, interview, and record review, it was determined the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one (1) of five (5) sampled residents reviewed for limited Range of Motion (ROM) out of a total of twenty-three (23) sampled residents (Resident #30). Observation on 11/18/19, revealed Resident #30 had a rolled wash cloth positioned inside his/her right hand between the palm and the resident's contracted digits, and the resident's right hand had moderate swelling to the digits. Interview with the resident during the observation revealed staff did not perform ROM for his/her contracture of the right hand, nor did the resident have a device/splint for the right hand. (Refer to F-656) The findings include: Interview with the Administrator, on 11/21/19 at 1:00 PM, revealed the facility did not have a policy related to evaluating residents for Range of Motion/Contracture, or related to Restorative Nursing. Review of Resident #30's Medical Record revealed the facility admitted the resident on 01/28/15 with [DIAGNOSES REDACTED]. Review of Resident #30's Comprehensive Care Plan (CCP), initiated 06/14/19, revealed the resident required assistance with Activities of Daily Living (ADLs) related to Decreased Mobility, [MEDICAL CONDITION] with Right [MEDICAL CONDITION]. The goal stated the resident would maintain current level of function through next review. Interventions included: keep call light within reach; Physical therapy to evaluate and treat as indicated; Praise resident efforts; left side of bed against wall per choice; high back wheelchair for mobility; and staff to provide assistance for transfers. All interventions were initiated on 06/14/19. Review of Resident #30's Occupational Therapy (OT) Evaluation, dated dated 04/04/17, revealed recommendations for the resident to transition to a RNP to maintain/prevent further decline in contracture and for ROM. However, there was no documented evidence the CCP was developed and implemented related to RNP interventions, nor was there documented evidence of interventions for ROM, or related to a device/splint to prevent further contracture to the resident's right hand. (Refer to F-656). Review of Resident #30' s Annual Minimum Data Set (MDS) Assessment, dated 09/05/19, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (15) out of fifteen (15) indicating intact cognitively. Additionally, the facility assessed the resident as requiring extensive assistance of two (2) staff for all Activities of Daily Living (ADLs). Per the Assessment, the resident had Limitations in Functional Range of Motion (ROM) to one (1) upper extremity and one (1) lower extremity. Review of Resident #30's State Registered Nurse Aide (SRNA) Kardex (Care Plan), on 11/21/19, revealed no documented evidence of interventions for RNP or related to interventions for Range of Motion or a device related to the contracture of the resident's right hand. Furthermore, record review revealed no documented evidence Resident #30 was participating in a Restorative Nursing Functional Maintenance Program nor was there evidence the resident was receiving ROM or a device to the right hand contracture. Observation of Resident #30, on 11/18/19 at 3:23 PM, revealed the resident was sitting up in bed, and had a rolled wash cloth positioned inside his/her right hand between the palm and the resident's contracted digits. Additionally the resident's right hand had moderate swelling to the digits. No splint or brace was noted. Interview with Resident #30, on 11/18/19 at 3:23 PM, revealed no staff member including therapy staff, did anything for his/her contracture of the right hand. Additionally, he/she stated his/her hand did have pain at times, especially when the wash cloth was not placed in his/her palm. Additional interview with Resident #30, on 11/20/19 at 3:14 PM, revealed restorative nursing was not involved with assisting him/her with Range of Motion (ROM) and staff did not perform ROM on his/her contracted right hand. Per interview, Resident #30 was interested in any therapy or device that would prevent further decline or contracture in his/her right hand as he/she only used the wash cloth for his/her hand contracture. The resident stated he/she knew it probably would not get better, but therapy or a device for his/her hand could possibly prevent pain and prevent the contracture from getting worse. Interview with State Registered Nurse Aide (SRNA) #1, on 11/21/19 at 10:00 AM, revealed he had worked at the facility for three (3) months and was often assigned to Resident #30. SRNA #1 stated he did not have a guide or any plan to show him how to assist Resident #30 with ROM to his/her hand and he just placed a dry rolled wash cloth in his/her hand for comfort at the resident's request as the resident complained of pain if there was no wash cloth in his/her hand. Interview with Licensed Practical Nurse (LPN) #1, on 11/21/19 at 10:45 AM , revealed he had worked at the facility for two (2) years, and was assigned to Resident #30. Additionally, ROM was provided to all residents by nurses, SRNAs, and restorative SRNAs. Further, it was important ROM was provided to residents to ensure they could continue to use their extremities, keep moving, prevent pain, and ensure quality of life. Per interview, if a resident had recommendations from therapy, the CCP should be developed and implemented with interventions specific to the recommendations, but he did not know how long residents were to remain in the RNP. Continued interview revealed there was a Restorative Nursing Binder and certain residents were provided a Plan specific to their needs at least five to seven (5-7) days a week by Restorative Nursing. Per interview, LPN #1 was not aware of a plan to address Resident #30's needs related to limited range of motion or related to his/her hand contracture. Per interview, Resident #30 was not currently receiving Restorative Nursing or orthotic/splinting care to prevent further decline in range of motion of the hand. Review of the Occupational Therapy Evaluation and Plan of Treatment dated 11/21/19, after Surveyor intervention, revealed Resident #30's right hand contracture put the resident at risk for decreased skin integrity. Recommendations were for Occupational Therapy five (5) times a week for four (4) weeks. Short term goals included resident to participate in determining appropriate orthotic to right hand with tolerating wear up to two (2) hours with no signs or symptoms skin irritation or redness; and resident will participate in determining/implementing self ROM for right hand to prevent further loss in function and maintain skin integrity. Per review, long term the resident would participate in wearing orthotic four (4) hours per day with no signs or symptoms of skin irritation and would participate in the Restorative Nursing Program. Interview with the Occupational Therapist (OT) /Rehabilitation Manager, on 11/21/19 at 9:35 AM, revealed when a resident was discharged from skilled therapy and referred to Restorative Nursing Services, training was provided with Restorative Nursing related to specific RNP interventions for that resident. Per interview, residents with contractures should be re-evaluated for further treatment based on change in function, skin impairment and change in measurement of contracture and each resident with contractures should have an individualized plan of care to maintain current level of function and prevent further decline. Per interview, Resident #30 was evaluated this morning and recommendations were written for Occupational Therapy with Orthotic Use and to be referred to Restorative Nursing when therapy was discontinued. Interview with the Unit Manager (UM), on 11/21/19 at 11:30 AM, revealed she was the UM for the unit where Resident #30 resided. Per interview, direct care staff provided ROM to residents when they turned and repositioned them during Activities of Daily Living (ADL) care. Further interview revealed Restorative SRNAs received specific training on ROM, including applying and removing splints/braces, and ambulating residents. Additional interview revealed she was not aware of Resident #30 participating in a RNP. Continued interview revealed the facility should have a policy and procedures in place to maintain resident (s) level of function related to range of motion and contractures to prevent further decline and should have a CCP and SRNA Care Plan to address appropriate interventions. Interview with the Director of Nursing (DON), on 11/21/19 at 1:45 PM , revealed she had worked at the facility since February, 2019. Per interview, staff was to utilize a communication form to notify the therapy department of the need to screen the resident for services if a decline in Activities of Daily Living was noted or a need for therapy was noted such as a contracture. Further, when residents were discharged from therapy with recommendations for RNP, it was her expectation nursing staff follow through with the recommendations. The DON acknowledged, residents with contractures should have a Plan of Care in place to address the need for ROM and/or splints as applicable in order to prevent decline in ROM. Per interview, she was aware Resident #30 had limited ROM and dependent [MEDICAL CONDITION] of the hand, but she was unaware the resident was not wearing an orthotic and was unaware the resident was having pain in his/her contracted hand. Interview with the Administrator, on 11/21/19 2:00 PM, revealed she had been at the facility since (MONTH) (YEAR). Additionally, she stated it was her expectation staff address contractures and limitations in range of motion. Further the Administrator stated she would expect Resident #30 to receive treatment to prevent decline in ROM and orthotic/splinting as needed related to his/her hand contracture.

Based on observation, interview, record review, and review of the facility's Policies, it was determined the facility failed to ensure residents were free from abuse for two (2) of nine (9) sampled residents, Resident #1 and Resident #2. Review of the Facility's Initial Self-Reported Incident Form, dated 09/14/19, revealed while seated together in the commons area, Resident #1 tossed an empty coffee cup towards Resident #2, which struck Resident #2 on the right hand. Further review revealed staff intervened, separated residents, and assessed residents. Staff assessed Resident #2 to have a discoloration to the right hand. Continued review of Facility Initial Self-Report revealed staff initiated increased supervision and made notifications to the resident's families and medical provider. Additional review of Facility Self-Report revealed the facility launched an investigation of incident on 09/14/19 following notification of State Agencies. The findings include: Review of the facility's Policy, titled Abuse, Neglect and Misappropriation of Property, revised 05/08/19, revealed the facility's definition of abuse was any action that caused physical harm, pain or mental anguish to a resident, even if resident was unable to understand the incident. Further review revealed the facility trained all stakeholders, contractors, and volunteers during orientation, of the individual's obligation to comply with reporting requirements of the Affordable Care Act, Section 1150B. Continued policy review revealed the facility educated and trained all stakeholders about signs and symptoms of elder abuse, ways to prevent abuse, and how/when to report knowledge and allegations of suspected abuse with annual and as needed training courses. Review of the facility's Policy, titled Resident Rights, dated 08/16/18, revealed the facility believed, and would promote and protect, the resident's right to be treated with respect and dignity. Further review of the policy, revealed the facility would ensure residents were treated in a manner and in an environment that promoted maintenance or enhancement of his/her quality of life while respecting each resident's right to individuality. Review of the facility's Policy, titled Dementia Care, dated 07/11/18, revealed the facility would provide care and services to enhance the quality of life for residents with dementia. Further policy review revealed facility's goal for residents with dementia was to provide a peaceful, calm, safe and accepting environment while recognizing and upholding resident dignity and individual worth. Continued review of policy, revealed the care and services provided by the facility would be administered in a supportive environment while promoting and recognizing each resident's individual need and preference. Additional review revealed individualized approaches to dementia care would be utilized while focusing on resident care needs while attempting to reduce behavioral expressions of distress in a supportive physical and psychosocial environment. Review of the Facility Initial Self-Reported Incident Form, dated 09/14/19, no time stamp, documented by Licensed Nursing Home Administrator (LNHA), revealed the facility reported Resident #1 tossed an empty coffee cup towards Resident #2, hitting Resident #2's right hand. Further review of Incident Form revealed, staff immediately separated residents and initiated increased supervision for Resident #1. Skin assessment performed on Resident #2, with discoloration noted to right hand. Continued review revealed, notifications made to both resident's families and facility medical provider. Additional review of Incident Form revealed facility initiated an investigation into resident-to-resident altercation. Review of the Facility Investigation Summary, Five (5) Day Follow-Up/Final Report, dated 0[DATE], documented by Clinical Social Worker (CSW), revealed following the investigation, the facility concluded, Resident #2 had been sitting near Resident #1, in the commons area, talking/preaching non-sensical statements, when his/her voice became louder, finally escalating to profanity, as per resident's usual behavior. Further review of the Facility's Investigation Summary, revealed Resident #2's behavior caused Resident #1 to become upset and frustrated, as he/she believed Resident #2 was directing cursing at him/her. Continued review revealed, Resident #1 threw an empty coffee cup towards Resident #2 out of frustration, as he/she remained physically confined to a Geri-chair and was unable to self-mobilize away from the source of distress. Additional review of the Facility Investigation Summary/Five (5) Day Follow-Up/Final Report revealed, the facility re-educated and encouraged Resident #1 to request staff assistance if/when uncomfortable with any situation. Additionally, with his/her spouse approval, facility moved Resident #2 to different unit in an attempt to prevent any further sharing of commons area with Resident #1. Further review revealed the facility notified the Psychiatric Nurse Practitioner of the incident and performed additional resident interviews and skin assessments with no similar concerns or issues identified. Continued review revealed the facility unsubstantiated abuse, stating, Resident #1 had responded with natural frustration to a situation and tried to defend him/herself. Further, the facility believed Resident #2 meant no harm to any specific resident and cursing loudly was just disease process progression. Facility documented their goal was to ensure residents were safe and rights were protected. 1. Review of the clinical record revealed the facility readmitted Resident #1 on 08/14/18 with [DIAGNOSES REDACTED]. Review of Quarterly Minimum Data Set (MDS) Assessment, dated [DATE], revealed the facility assessed Resident #1 as having a Brief Interview for Mental Status (BI[CONDITION]) score of ten (10) out of (15), which indicated moderate cognitive impairment. Further review of Quarterly MDS revealed the facility assessed Resident #1 as requiring total physical assistance of two (2) for bed mobility, transfers and toilet use. Continued MDS review revealed the facility assessed Resident #1 as requiring extensive physical assistance of two (2) for dressing and personal hygiene and required supervision and one (1) person physical assistance with eating. Additional MDS review revealed the facility assessed Resident #1 as requiring total physical dependence of two (2) for bathing and was assessed as having impairment in functional range of motion to both upper and lower extremities on both sides. Review of Resident #1's Comprehensive Care Plan, initiated on 04/22/19, revised on 09/13/19, revealed a focus for resident with verbal behavioral symptoms directed towards others such as threatening, screaming and cursing with history of splashing juice onto another resident. The goal stated resident would not threaten, scream at, or curse, other residents, visitors or staff through next review date of 12/13/19. Interventions included the following: assessment of resident behaviors and whether or not staff intervention necessary; avoidance of over-stimulation (noise, crowding, other aggressive residents); and removal of resident from group activities when behavior unacceptable. Further review revealed focus, initiated on 06/11/19, for resident [MEDICAL CONDITION] drug use related to receiving routine anti-psychotic anti-depressant medications due to [DIAGNOSES REDACTED]. Interventions included the following: Increased supervision for every fifteen (15) for monitoring aggressive behavior; resident to participate in one (1) on one (1) activity with aide until no signs of frustration noted, administration of medication as ordered; provider to attempt dose reduction as indicated; monitor for effectiveness of [MEDICAL CONDITION] medication; and observe for drug-related signs and symptoms of adverse reaction such as [MEDICAL CONDITION], cognitive impairment, decrease in appetite, etc. Interview with Resident #1, on 0[DATE] at 11:00 AM, revealed resident was unable to recall the incident that occurred on 09/14/19 with Resident #2. However, further interview with Resident #1 revealed he/she would not put up with anyone calling him/her filthy names. 2. Review of clinical record revealed the facility readmitted Resident #2 on 06/04/19 with [DIAGNOSES REDACTED]. Review of Quarterly MDS, dated [DATE], revealed the facility assessed Resident #2 as having a BI[CONDITION] score of two (2) out of fifteen (15), which indicated severe cognitive impairment. Further review of the MDS revealed the facility assessed Resident #2 as requiring total physical assistance of two (2) for bed mobility, transfers and toilet use. Continued MDS review revealed the facility assessed Resident #2 as requiring extensive physical assistance of one (1) for dressing, personal hygiene and eating. Additional MDS review revealed the facility assessed Resident #2 as requiring total physical dependence of two (2) for bathing and had no impairment in functional range of motion to either upper or lower bilateral extremities. Review of Resident #2's Comprehensive Care Plan, initiated on 06/19/19, revealed a focus for resident with behavioral problem of hallucinations related to [DIAGNOSES REDACTED]. The goal stated resident would interact appropriately with staff, family members and other residents through next review date of 12/14/19. Interventions included administration of medication as ordered; assessing effect of hallucinations on resident status (nutrition, care, skin, and rest); determining if hallucinations pose danger to resident or others and intervening if necessary; providing safe, quiet, low-stimuli environment and maintaining consistent routine with resident. Further review of care plan revealed focus for resident with [MEDICAL CONDITION] drug use related to anti-depressant and anti-psychotic medications. The goal stated resident would show no medications side effects through next review date of 12/14/19. Interventions included administration of medications as ordered; resident and family education on potential risks/benefits of [MEDICAL CONDITION] drug use; monitor for effectiveness of [MEDICAL CONDITION] medication use; observe for drug-related signs and symptoms of adverse reaction such as [MEDICAL CONDITION], cognitive impairment, decrease in appetite, etc. Observation of Resident #2, on 09/18/19 at 3:05 PM, revealed the resident was resting quietly in bed with eyes closed with spouse at bedside reading a book. Observation of Resident #2, on 0[DATE] at 08:08 AM, and again on 0[DATE] at 10:06 AM, revealed the resident sitting up in a Geri-chair, non-verbal, watching other residents, staff and visitors as they walked by. Resident #2 appeared comfortable, dressed appropriately for the season and well-groomed with hair combed and face shaved. Interview with Resident #2's spouse, on 09/18/19 at 3:11 PM, revealed he/she was notified of the incident between Resident #1 and Resident #2 on 09/14/19, at approximately 7:30 PM or 8:00 PM, by LPN #1 via telephone. Further interview with Resident #2's spouse revealed, he/she was told Resident #1 had thrown an empty coffee cup towards Resident #2, striking his/her right hand which caused discoloration to the area. Continued spouse interview revealed LPN #1 explained to spouse the medical provider was notified with no new orders received. Spouse further added he/she was pleased with resident move to another room. Interview with Licensed Practical Nurse (LPN) #1, on 09/18/19 at 3:15 PM, revealed he was assigned to care for Resident #1 and Resident #2 on 09/14/19 from seven (7) AM to seven (7) PM. Further interview revealed LPN #1 was sitting at South Unit (location of incident) nurse's station, when he heard Resident #2, seated in a Geri-chair, in commons area following dinner; yelling out, as if in pain. Continued interview revealed LPN #1 ran to commons area to investigate yelling and noted Resident #2, in a Geri-chair, doubled over, holding his/her right hand and moaning out, trembling in pain. LPN #1 reported he assessed Resident #2's right hand and noted some bruising/discoloration. Seated nearby, Resident #1 told LPN #1 He/she, referring to Resident #2, called me a [***] . Additional interview with LPN #1 revealed, Resident #2 had been chanting/ preaching/cursing as per his/her usual behavior but was unaware other staff had seated Resident #1, who was easily agitated, near Resident #2 that evening after meal service. LPN #1 reported he made resident family notifications and contacted the medical provider and Director of Nursing following incident. Interview with LPN #2, on 09/18/19 at 3:20 PM, revealed he was also assigned to care for Resident #1 and Resident #2 on 09/14/19 from seven (7) AM to seven (7) PM as he and LPN #1 worked together on the South Unit as a team. Further interview revealed he was at the South Unit nurse's station when he heard Resident #2 yelling out in pain. LPN #2 advised he ran to the commons area to investigate and saw Resident #2 doubled over, holding his/her right hand, moaning and trembling. Continued interview with LPN #2 revealed the residents were immediately separated and he made other staff aware of incident, instructing nursing assistants to keep residents separated from one another the remainder of the shift. Additional interview with LPN #2 revealed LPN #1 performed assessments and made notifications. LPN #2 assisted to separate residents and communicate information to staff. Interview with Clinical Social Worker (CSW), on 0[DATE] at 4:00 PM, revealed she had investigated the incident between Resident #1 and Resident #2 on 09/14/19. Further interview revealed CSW observations of Resident #2 revealed loud sermon-like speaking that would escalate to cursing/name calling that she felt Resident #1 believed was directed towards him/her. Continued interview with CSW revealed her belief was Resident #1 became upset, thinking Resident #2 was cursing him/her, and threw empty coffee cup out of frustration as he/she is in a Geri-chair and unable to move away from source of distress. Additionally, CSW did not substantiate the incident as abuse because she believed neither resident acted maliciously. Interview with the Director of Nursing (DON), on 09/20/19 at 1:35 PM, revealed LPN #1 notified her of incident occurring between Resident #1 and Resident #2 on the evening of 09/14/19. Further interview revealed the DON directed staff to increase supervision of both residents and LPN #1 to perform skin assessment of Resident #2, as had been completed. In addition, the DON reported, she instructed LPN #1 to make notification to both resident's families and facility on-call medical provider. DON reported she contacted LNHA of incident. Continued interview with DON revealed the following Monday, 0[DATE], Resident #2 was moved to another unit, with his/her spouse's approval to prevent any further contact with Resident #1. The DON advised the facility did not substantiate abuse due to lack of Resident #1's intent to harm Resident #2. The DON advised her expectation of all staff would be to keep all residents safe and free from abuse/neglect and to ensure all suspected abuse/neglect was reported immediately. Interview with Licensed Nursing Home Administrator (LNHA), on 09/20/19 at 2:00 PM, revealed the DON notified her of the incident occurring between Resident #1 and Resident #2 on the evening of 09/14/19. Further interview with LNHA revealed she notified state agencies as appropriate after instructions to were provided to staff regarding resident and staff interviews and ensuring resident safety. Continued interview with LNHA revealed the facility unsubstantiated abuse due to the belief that neither Resident #1's physical behavior, nor Resident #2's verbal expressions were directed specifically at one another or other facility residents. LNHA revealed her expectations were staff to provide safety to all residents and to ensure all residents are free from abuse/neglect and misappropriation. LNHA added all suspicions of abuse were to be reported immediately.

Based on observation, interview, and review of the Manufacturer's Preventative Maintenance Recommendations for Dryers, it was determined the facility failed to ensure the resident environment remains as free of accident hazards as is possible. Review of the Manufacturer's (Allied Laundry) Preventative Maintenance Recommendations for Dryers, revealed all dryer fronts should be removed and vacuumed bi-annually. However, interview with the Director of Maintenance revealed Maintenance failed to remove the front center Dryer panels and vacuum the Dryers bi-annually as per the Manufacturer's Recommendations, asserting this maintenance was last completed on the Dryers in (MONTH) of (YEAR). On 08/05/19, staff placed approximately fifty (50) new washcloths with combustible one and one half X one half (1 ½ X ½ ) inch plastic tags in the gas fired dryer and a fire was observed by Laundry Worker #1 in the basket of Dryer 2. Laundry Worker #1 failed to pull the manual fire alarm immediately after the fire was discovered in the basket of dryer #2, but did notify the Director of Housekeeping (DOH) who extinguished the fire with a fire extinguisher. However, the DOH also failed to pull the manual fire alarm immediately. The findings include: Review of the facility Fire Response Policy, undated, revealed any staff member who discovers a fire or potential fire situation within the facility should utilize the RACE procedure which stands for Rescue, Alarm, Confine, and Extinguish. Rescue person in immediate danger; Alarm-pull nearest pull station alarm and announce Code Red; Confine-by closing doors to isolate fire and smoke; Extinguish-attempt to extinguish fire only if the first three (3) parts of the RACE procedure have been completed and the fire appears to be manageable. A laundry policy was requested; however, not submitted for review. Review of the Manufacturer's (Allied Laundry) Preventative Maintenance Recommendations for Dryers revealed all dryer fronts should be removed and vacuumed bi-annually. Interview with the Director of Maintenance (DOM), on 08/06/19 at 8:00 AM, revealed there was no written policy related to how often to remove the front center dryer panels and vacuum; however, facility maintenance staff had received training by Regional Maintenance related to the need to remove the front center dryer panels and vacuum quarterly on 11/14/18. Review of the facility's Training and Testing related to Dryer Maintenance, revealed clothes dryer vents, sensors, and front panels were to be free of lint, properly maintained, and serviced quarterly. The DOM and the Assistant Director of Maintenance (ADOM) signed as receiving this education with post test on 11/14/18. Review of the Long Term Care Facility-Self Reported Form Five (5) Day Follow Up/Final Report and attached facility Investigation, signed by the Administrator, revealed on 08/05/19 at approximately 11:00 AM, the fire alarm was activated and the Fire Code was announced via intercom indicating the fire was located in the laundry department. Staff initiated fire procedure relocating all residents behind smoke doors within the facility. The Fire Department arrived at approximately 11:05 AM. It was identified during the investigation the Laundry Aide identified smoke coming from the second Dryer in the laundry area and the Director of Housekeeping (DOH) was immediately notified. The DOH identified flames inside the second Dryer and utilized the fire extinguisher to extinguish the fire. The Assistant Director of Maintenance (ADOM) then arrived in the laundry and saw smoke, but no flames. The Fire Department arrived, and per their Investigative Report the fire alarm was sounding and upon arrival to the laundry light smoke was noted in the room and an extinguisher had been discharged . There were burned towels noted in the second Dryer. The power and gas were shut off to the machine and the contents were removed and taken outside the building. Per the Fire Department Investigative Report, the damage was to the second Dryer only, the ductwork was checked and it appeared the build up of lint in the machine had ignited. Further review of the facility Investigation, revealed per the facility's lint trap cleaning schedule, the laundry aide removed lint each hour starting at 7:00 AM on 08/05/19 and the maintenance cleaning log revealed the three (3) operable Dryers were serviced (there was no date noted) which included vacuuming under the Dryers, removing the lint trap screen and vacuuming around the drum of the Dryer as well as vacuuming the top of the Dryer to ensure no lint build up was located on the electrical parts of the Dryer. The second Dryer was placed out of order and the Vendor was notified for an evaluation of the equipment. On 08/06/19, the Vendor assessed the Dryer, and stated after his assessment of the machine he could not determine that lint initiated the fire. The Vendor was notified the facility was drying new wash cloths at the time of the fire and the Vendor assessed the wash cloths and stated the fire could have ignited from the washcloth tags and the lint, but he could not determine the true cause of the fire. Continued review of the facility Investigation, revealed after completing interviews with the DOH, Laundry Aide and ADOM, the facility could not identify the pull station was utilized. The alarm monitoring report did not provide details to indicate the fire alarm was initiated via pull station verses smoke detector. The ADOM identified the pull station was not reset to his knowledge. Per the facility Investigation, education was immediately initiated on fire safety procedure for all staff; and all Dryers were cleaned thoroughly to include the front panel. The Maintenance Department will begin cleaning the front panel of the dryers bi-annually per the manufacturer's recommendations. Going forward the laundry staff will remove the tags from the washcloths. Per the Investigation, the facility identified at the time of the alarm, residents were not noted in the laundry areas and no residents were affected by the smoke or identified fire. The cause of the fire could not be determined. Review of the Fire Department Incident Detail Report, revealed on 08/05/19 at 11:00 AM, the alarm sounded and upon arrival at the Center at 11:05 AM, the alarm was sounding and staff led the Fire Department personnel to the laundry room. Per the Report, smoke was noted in the room and an extinguisher had been discharged . A commercial Dryer had burned towels, and the Power and Gas had been shut off to the machine. Further, the contents from the Dryer had been removed from the metal bucket of the Dryer and taken outside. The Exhaust fan was running in the laundry room and the duct work was checked for heat and blockage. Per the Report, it appeared a build up of lint in the machine had ignited and the damage appeared contained to the machine. Further review of the Report, revealed a replacement fire extinguisher was present. Interview on 08/06/19 at 8:00 AM, with the DOM, ADOM, and the Director of Housekeeping (DOH), revealed the Lexington Fire Department had responded to the facility on [DATE] at approximately 11:05 AM due to a fire located in the basket area of Dryer #2. Observation on 08/06/19 at 8:15 AM, of the laundry room, revealed the DOM was in the process of cleaning Dryer 1, Dryer 2. and Dryer #3, as the Life Safety Code Inspector walked into the Laundry room. The DOM took the front panels off all the Dryers for inspection. Dryer 4 which was out of service at the time of inspection revealed a large amount of lint was observed packed in the lower right void under the basket and the electricity to the Dryer was disconnected. Dryer 2 had smoke and burn patterns inside the basket of the dryer. Interview with the DOM, on 08/06/19 at 8:15 AM, revealed he received a call at home on 08/05/19 related to the fire in the laundry room and came to the facility immediately. He stated the Dryer fronts where the basket was located were being removed and cleaned on an annual basis, instead of quarterly as per the facility expectation. He stated the center front on facility Dyers #1, #2, and #3 had last been removed and cleaned sometime in (MONTH) of (YEAR). The DOM stated Dryer #4 was taken out of service in (MONTH) of (YEAR). Per interview, the fire in Dryer 2 was probably a result of lint in the Dryer due to Maintenance staff failing to service the Dryers by taking off the front panels and vacuuming and servicing the machines on a quarterly basis. Per interview, Maintenance staff was responsible to ensure this was done as scheduled; however, he could not say why this service had not been completed. Interview with Laundry Worker #1, on 08/06/19 at 8:25 AM, revealed she was in the process of drying approximately fifty (50) new wash clothes when she observed smoke coming from Dryer #2 on 11/05/19 at approximately 11:00 AM. Per interview, then she observed fire and smoke in the basket area of Dryer #2. She stated, upon discovering the smoke and fire, she ran into the main hallway to alert the Director of Housekeeping (DOH) who immediately extinguished the fire with a fire extinguisher. Laundry Worker #1 stated the wash clothes which she had placed in the Dryer were found to have one and a half X one half inch (1 ½ X ½ inch ) combustible plastic tags affixed to them and she had not noticed this when putting the wash cloths in the Dryer. Further interview revealed she did not pull the manual fire alarm immediately upon discovery of the fire as required by the facility fire response policy. She stated she had received training on fire response; however, she got scared and ran to get her supervisor, who responded to the fire. Review of the education and test dated 05/20/19 revealed Laundry Worker #1 had received training on fire response which included, First step is to pull the fire alarm. Interview with the DOH, on 08/06/19 at 8:45 AM, revealed he was cleaning the main hallway when he was alerted to the fire by Laundry Worker #1. He stated he proceeded to the laundry room after alerting other staff of the fire and extinguished the fire in Dryer #2 with a fire extinguisher. He further stated the smoke that emanated from the basket area upon opening the front of the Dryer set off the smoke alarm system. Per interview, he did not pull the manual fire alarm immediately upon discovery of the fire as required by the facility fire response policy, although he had been trained to do this. Interview with the Assistant Director or Maintenance (ADOM), on 08/06/19 at 9:05 AM, revealed he proceeded to the laundry room after being verbally notified of the fire on 08/05/19. He stated he observed the DOH extinguish the fire and he immediately turned off the Air Conditioning in the laundry area in order to prevent smoke from transferring to other parts of the facility. Per interview, he observed the DOH turn on an exhaust fan, which assisted in clearing out smoke and fire extinguisher powder from the space. He stated the smoke from the fire set off the alarm and no pull stations were reset. Interview with the facility's Dryer Maintenance Vendor, on 08/06/19 at 2:20 PM, revealed it was his opinion the fire was the result of the 1 ½ X ½ inch plastic tags affixed to the new washcloths that had been recently purchased and were being dried after their initial washing. Interview with a Technician from the Alliance Laundry Manufacturer, on 08/07/19 at 3:30 PM, revealed the plastic tags were more likely than lint to have caused the fire inside the basket area as described by witnesses. Interview with the Administrator, on 08/06/19 at 3:00 PM, revealed she was in the facility conference room when she heard the verbal code over the loudspeaker alerting staff of a fire on 08/05/19 at approximately 11:00 AM. She stated she proceeded to the laundry and observed the fire doors closed and heard the alarm sounding. She further stated she proceeded to direct staff and assist the Fire Department to the laundry room upon their arrival. Continued interview revealed it was determined the fire was caused by either the plastic tags on the wash rags being exposed to the heat of the dryer or lint buildup. Further interview revealed it was also determined the facility dryers had not been maintained per the facility's procedure. Additionally, she stated staff had failed to activate the manual pull station immediately upon discovery of the fire which would have the effect of closing all fire doors and alerting the Fire Department in a timelier manner. The Administrator stated she needed to re-educate and utilize training and testing procedures for staff to ensure the Dryers were maintained in compliance with facility policy; to ensure plastic tags were not placed into the fuel fired dryers; and to ensure staff were knowledgeable of the fire response policy. The Administrator stated no residents were evacuated or otherwise effected by this incident. Per interview, she was still in the process of conducting an internal investigation into the incident.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to promptly notify the Physician when there was a significant change in the resident's physical status and a need to alter treatment for one (1) of thirteen (13) sampled residents (Resident #1). On 07/03/14 Resident #1 was noted to have [MEDICAL CONDITION] weeping legs with an open area on the right lower extremity measuring three (3) centimeters (cm) x 0.1 cm on 07/03/14, and the Advanced Registered Nurse Practitioner (ARNP) was notified. [MEDICATION NAME] (antidiuretic medication) was ordered; however, the nurse who notified the ARNP, did not ensure a treatment was ordered for the wound. On 07/24/14 the resident was noted to have an open area to the right shin and left great toe; however, there was no documented evidence the Physician or ARNP was notified of the progression of skin breakdown in order to obtain a treatment order until 07/25/14, when Vaseline Gauze was ordered to the open areas of the lower extremities. The skin on the resident's lower extremities continued to deteriorate and on 07/31/14 the resident was noted to have open areas to the right inner calf and the top of the right foot. On 08/14/14 the resident was noted to have open blisters to the left foot and an open area to the right foot and right leg. However, there was no documented evidence the Physician was notified of the increased number of wounds and the continued deterioration of the wounds after 07/25/14. On 08/27/14, the ARNP was notified of maggots in the large elongated wound on the right calf; however, there was no documented evidence the ARNP was notified of the the increased number of wounds or the deterioration of the wounds until 08/28/14. Observation of a skin assessment on 08/30/14 by the surveyor revealed a total of six (6) open areas to the lower extremities with two (2) of the larger areas on the right calf having eschar at the edges of the wounds. (Refer to F309) The findings include: Review of the facility's "Change in a Resident's Condition or Status" Policy, revised 10/13, revealed the Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or on-call Physician when there has been; a significant change in the resident's physical/emotional/mental condition, or a need to alter the resident's medical treatment. Review of the medical record revealed the facility admitted Resident #1 on 07/02/10. Continued review revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a five (5) out of fifteen (15) indicating the resident was cognitively impaired. Further review revealed the facility assessed the resident as having no arterial or venous ulcers. Review of the monthly July 2014 physician's orders [REDACTED]. Review of the Weekly Skin Integrity Review (WSIR), dated 07/03/14, revealed Resident #1 had two (2) plus [MEDICAL CONDITION] and an open area measuring three (3) centimeters (cm) x 0.1 cm and the diagram on the WSIR revealed the area was on the right shin. Review of the Interdisciplinary Progress Notes, dated 07/03/14 at 10:00 AM, revealed Resident #1's bilateral lower extremities were [MEDICAL CONDITION] and weeping, the ARNP was notified, and a now dose of [MEDICATION NAME] 40 milligrams (mg's) was ordered and given. Review of the physician's orders [REDACTED]. However, there was no indication the nurse had requested a treatment order. Further review of the WSIR dated 07/10/14 revealed Resident #1's skin was dry and there was two (2) plus [MEDICAL CONDITION] and weeping. Review of the WSIR dated 07/17/14, revealed the residents skin was dry and the right lower extremity had weeping and two (2) plus [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Phone interview on 09/05/14 at 11:05 AM, with Licensed Practical Nurse (LPN) #18, who had signed as completing the WSIR's for 07/03/14, 07/10/14, and 07/17/14, revealed she had obtained the physician's orders [REDACTED]. She stated she had notified the ARNP on 07/03/14 of the open area on the resident's leg and the [MEDICAL CONDITION] to the lower extremities, and the ARNP ordered [MEDICATION NAME] and told her to talk to the Wound Nurse about a treatment. Further interview revealed, she had asked the Wound Nurse to assess the leg for a treatment order; however, could not recall if a treatment was ordered and was unsure if the Wound Nurse had assessed the resident. Further interview revealed she could not remember what type of treatment was being performed for the resident's weeping legs during that time period. Review of the Treatment Administration Record (TAR), dated July 2014, revealed there was no treatment orders related to the weeping legs and open area which were noted on 07/03/14, and no indication the Physician/ARNP had been notified of the lack of treatment even though the resident had an open area identified on 07/03/14 and the legs were weeping fluid. Review of the WSIR dated 07/24/14, revealed there was skin breakdown on Resident #1's right shin and left great toe. Interview on 09/04/14 at 9:47 AM, with Registered Nurse (RN) #2/Assistant Director of Nursing (ADON)/Unit Coordinator (UC) for the North Unit who completed this skin assessment, confirmed these areas were open at the time she completed the skin assessment. She further stated she did not call the Physician/ARNP for notification of the areas of skin breakdown and request an order for [REDACTED]. Review of the Interdisciplinary Progress Note, dated 07/25/14 at 10:00 PM, and completed by LPN #19, revealed Resident #1 had open areas to the right lower extremity and left great toe and new orders were received for Vaseline Gauze and dressings to the areas daily and as needed (prn). Phone interview with LPN #19 on 09/05/14 at 11:00 AM, revealed before 07/25/14, the resident just had orders for creams and lotions to the lower extremities for dry cracked skin; however, the day she obtained the treatment order on 07/25/14 the resident had an open area to the left great toe, and open areas to the right shin and the lateral calf which were small and looked like the top layer of skin was gone. Further review of the WSIR dated 07/31/14, completed by LPN #17, revealed Resident #1 had an open area on the resident's right medial calf and top of the right foot and no documentation addressing the resident's left great toe. Review of the WSIR dated 08/14/14 completed by LPN #17, revealed the resident had open blisters to the left foot and also open areas to the right foot and right leg. The WSIR dated 08/14/14, stated treatment nurse notified. Interview with LPN #17 on 09/04/14 at 12:00 PM, revealed the resident had an area on the right calf and the top of the right foot which was not present on the previous WSIR; however, she thought this area was old. She further stated, according to what she could remember and looking at the WSIR for 08/14/14 the resident had an area to the left great toe and new areas to the left 3rd digit and and a new area to the top of the resident's left foot. She stated she called and informed the Wound Care Nurse because the areas to the left 3rd digit and the top of the resident's left foot were new. LPN #17 stated she assumed the Wound Nurse would call the Physician for a treatment order. However, review of the Interdisciplinary Progress Notes and physician progress notes [REDACTED]. Review of the WSIR dated 08/21/14 completed by LPN #18, revealed open areas to the right medial calf, right great toe, and left foot. Further phone interview with LPN #18 on 09/05/14 at 11:00 AM, revealed she was unable to remember just what the wounds looked like on that date; however, she thought there was a treatment order for the wounds. Review of the Nurse's Notes dated 08/27/14 at 2:00 PM, written by LPN #5, revealed the resident's wound was found to have foreign matter in an open area, the wound was cleansed with all foreign matter cleaned out and a treatment was applied. Interview with LPN #5 on 08/29/14 at 2:00 PM, revealed Resident #1 started having weeping in her legs and about a month ago developed open areas to the lower extremities. She stated when starting to remove the bandage on 08/27/14 she noted the resident's wound on the right leg had white round foreign matter which would move and could have been maggots, although she had never seen maggots before. Review of Resident #1's Non Pressure Skin Condition Record, completed by the Wound Nurse, dated 08/28/14, revealed the following; Left Great Toe Metatarsal 1.4 cm Length (L) x 1.7 cm Width (W)-partial thickness, Right Lower Extremity Calf Posterior measuring 13.5 cm L x 5 cm W x 0.3 cm depth-full thickness, serous drainage, and slough described as moist yellow or gray necrotic tissue, Right Great Toe lateral metatarsal 0.8 cm L x 1 cm W-partial thickness, Right Proximal Lower Extremity 2 cm L x 1 cm W-partial thickness, serosanguinous exudate, and slough-moist yellow or gray necrotic tissue, and Right Distal Lower Ext 0.9 cm L x 0.7 cm W-partial thickness. Further review of the Non Pressure Skin Condition Record for each wound revealed an area marked Physician notified 08/28/14. Observation of Resident #1's skin assessment performed by LPN #17 on 08/30/14 at 10:15 AM, revealed the resident had an open area to the left great toe medial base which measured 1.5 cm L x 1.5 cm W and the wound bed was beefy red; an open area to the right great toe medial base which measured 1 cm x 0.9 cm and the wound bed was red; an open area to the right shin with a red wound bed with a yellow center which measured 1.5 cm L x 1 cm W; an open area on the lower shin which had a red wound bed and measured 0.8 cm L x 0.6 cm W; an open area to the right medial/posterior calf which measured 3 cm L x 1.9 cm W with a red wound bed and white middle surrounded by eschar; an area just below the previous area to the right medial/posterior calf which measured 6 cm L x 3.5 cm W x 0.4 cm depth with a red wound bed with yellow/green areas on the wound bed surrounded by eschar; and, an area on the right lower medial/posterior calf which measured 5 cm W x 7 cm L and appeared as scar tissue. Interview, with the Wound Nurse on 08/30/14 at 12:15, and 09/09/14 at 6:50 PM, revealed she had initially seen Resident #1 late June or early July 2014, related to the lower extremities having weeping and [MEDICAL CONDITION]. She stated she did not document her observation and thought the nurses had a treatment in place. She further stated she was not notified of any open areas or any wounds in the resident's lower extremities until 08/27/14 when she was told the resident had a deterioration in the wounds and also had maggots in one of the wounds as she was walking out the door to go to class. Interview on 08/29/14 at 2:50 PM and 09/05/14 at 11:11 AM, with the ARNP revealed she was notified of the staff finding maggots in the Resident #1's wound. She stated she was informed the resident had weeping in the lower extremities earlier this summer and the diuretic had been increased; and she was in to assess the wounds on 09/02/14. She stated the last time she had seen the resident's lower extremities they were "nothing like now". "I was surprised the wounds were that bad". Continued interview revealed a dry dressing would have been sufficient for weeping legs; however, staff needed to notify her of any change in status such as deteriorating wounds or any new wounds. She stated she did not know at what point the wounds worsened because she had not been notified. Further interview revealed the staff was her eyes and ears and she was not notified of the deterioration of the wounds or the numerous wounds until the resident had developed a large elongated wound which was possibly necrotic with maggots. She further stated she did not know if the Attending Physician was notified; however, there was no documentation to support the Physician had been notified. Further interview revealed she would have ordered a wound consult sooner had she been aware of the condition of the residents lower extremities. The resident's Physician was out of the country at the time of the investigation and unavailable for an interview. Interview with the Director of Nursing (DON) on 09/05/14 at 11:20 AM, revealed the Physician was to be notified of any new area of skin breakdown or any change in wound status. She stated at the point a wound was identified, or for any change in a wound, staff should have notified the Physician/ARNP for a treatment order. However, the DON indicated, by reviewing the record for Resident #1, the Physician or ARNP was not kept informed of this resident's change in condition related to wounds.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure the Comprehensive Plan of Care was revised for one (1) of thirteen (13) sampled residents (Resident #1). On 07/03/14 Resident #1 was noted to have [MEDICAL CONDITION] weeping legs with an open area on the right lower extremity measuring three (3) centimeters (cm) x 0.1 cm on 07/03/14, and the Advanced Registered Nurse Practitioner (ARNP) was notified. [MEDICATION NAME] (antidiuretic medication) was ordered; however, the nurse who notified the ARNP, did not ensure a treatment was ordered for the wound. On 07/24/14 the resident was noted to have an open area to the right shin and left great toe; however, there was no documented evidence the Physician or ARNP was notified of the progression of skin breakdown in order to obtain a treatment order until 07/25/14, when Vaseline Gauze was ordered to the open areas of the lower extremities. The skin on the resident's lower extremities continued to deteriorate and on 07/31/14 the resident was noted to have open areas to the right inner calf and the top of the right foot. On 08/14/14 the resident was noted to have open blisters to the left foot and an open area to the right foot and right leg. However, there was no documented evidence the Physician was notified of the increased number of wounds and the continued deterioration of the wounds after 07/25/14. On 08/27/14, the ARNP was notified of maggots in the large elongated wound on the right calf; however, there was no documented evidence the ARNP was notified of the the increased number of wounds or the deterioration of the wounds until 08/28/14. Observation of a skin assessment on 08/30/14 by the surveyor revealed a total of six (6) open areas to the lower extremities with two (2) of the larger areas on the right calf having eschar at the edges of the wounds. Although this resident had multiple ulcers to the lower extremities, and the ulcers were continuing to deteriorate, there was no documented evidence the facility evaluated and revised the Care Plan as the resident's status changed related to the development of venous ulcers to the lower extremities. (Refer to F309) The findings include: Review of the facility "Care Plans-Comprehensive", revised October 2010, revealed Assessments of residents were ongoing and care plans were revised as information about the resident and the resident's condition changed. Further review revealed the Care Planning/Interdisciplinary Team was responsible for the review and updating of care plans when there was a significant change in the resident's condition, when the desired outcome was not met, and at least quarterly. Review of the clinical record revealed the facility admitted Resident #1 on 07/02/10. Further review revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a five (5) out of fifteen (15) which indicated cognitive impairment. Continued review revealed the facility assessed the resident as having no arterial or venous ulcers. Review of the Comprehensive Plan of Care with an onset date of 11/14/11, revealed Resident #1 was at risk for developing skin breakdown and had a history of [REDACTED]. There was several approaches listed including a notation under the approaches, undated, which stated the resident had an open area to the right lower extremity and the left great toe. However, the care plan did not address this resident's actual venous ulcers to the lower extremities with specific individualized interventions in an attempt to heal the venous ulcers, and keep further ulcers from developing. Also, there was no documented evidence the Care Plan had been reviewed and evaluated despite the non healing wounds and despite the development of new wounds. Review of the WSIR, dated 07/03/14, revealed Resident #1 had two (2) plus [MEDICAL CONDITION] and an open area measuring three (3) centimeters (cm) x 0.1 cm and the diagram on the WSIR revealed the area was on the right shin. Review of the Interdisciplinary Progress Notes dated 07/03/14 at 10:00 AM, revealed the resident's bilateral lower extremities were [MEDICAL CONDITION] and weeping, the ARNP was notified, and a now dose of [MEDICATION NAME] (diuretic medication) forty milligrams (40 mg's) was ordered and administered. Continued review of the WSIR dated 07/10/14 revealed Resident #1's skin was dry and there was two (2) plus [MEDICAL CONDITION] and weeping, and the WSIR dated 07/17/14, revealed the residents skin was dry and the right lower extremity had weeping and two (2) plus [MEDICAL CONDITION]. Further review of physician's orders [REDACTED]. There was a notation on the care plan, which stated [MEDICATION NAME] 40 mg po now 07/03/14, and [MEDICATION NAME] per order 07/17/14. However, there was no documented evidence the Care Plan was revised related to the actual new area of skin breakdown which was identified on 07/03/14, or updated related to the actual [MEDICAL CONDITION] and weeping lower extremities. Review of the WSIR dated 07/24/14, revealed there was skin breakdown on Resident #1's right shin and left great toe and interview with Registered Nurse (RN) #2/Assistant Director of Nursing/Unit Coordinator for the North Unit who completed this skin assessment verified these areas were open when she assessed the resident's skin. She stated she did not realize these were new areas that required care plan revision and she did not check the care plan at the time of the assessment to see if it needed to be revised. Review of the Interdisciplinary Progress Note, dated 07/25/14 at 10:00 PM, and completed by LPN #19, revealed Resident #1 had open areas to the right lower extremity and left great toe and new orders were received for Vaseline Gauze and dressings to the areas daily and as needed (prn). There was a notation, undated, on the Care Plan under approaches which stated the resident had an open area to the right lower extremity and to the left great toe and treatment per order. Further review of the WSIR dated 07/31/14 and completed by LPN #17, revealed there was an open area with a diagram indicating areas on the right medial calf and top of the right foot; however, there was no documentation addressing the residents left great toe. Review of the WSIR dated 08/14/14 completed by LPN #17, revealed the resident had open blisters to the left foot and open areas to the right foot and right leg. The diagram indicated there was an old area of skin breakdown on the right medial calf and and an area on the top of the right foot and also new areas to the left foot. However, there was no documented evidence the Care Plan was revised related to the new areas of skin breakdown. Review of the WSIR dated 08/21/14 completed by LPN #18, revealed Resident #1 had open areas to the right medial calf, right great toe, and left foot. Review of the Nurse's Notes dated 08/27/14 at 2:00 PM, written by LPN #5, revealed Resident #1's wound was noted to have foreign matter in an open area, the wound was cleansed with all foreign matter cleaned out and a treatment was applied. Interview with LPN #5 on 08/29/14 at 2:00 PM, revealed the resident started having weeping in the lower extremities and about a month ago developed open areas to the lower extremities. She stated on 08/27/14 she noted the resident's wound on the right leg had white round foreign matter which would move about and could have been maggots. Review of the Non Pressure Skin Condition Record for Resident #1, completed by the Wound Nurse, dated 08/28/14 revealed the following skin assessment; Left Great Toe Metatarsal 1.4 cm Length (L) x 1.7 cm Width (W)-partial thickness, Right Lower Extremity Calf Posterior measuring 13.5 cm L x 5 cm W x 0.3 cm depth-full thickness, serous drainage, and slough described as moist yellow or gray necrotic tissue, Right Great Toe lateral metatarsal 0.8 cm L x 1 cm W-partial thickness, Right Proximal Lower Extremity 2 cm L x 1 cm W-partial thickness, serosanguinous exudate, and slough-moist yellow or gray necrotic tissue, Right Distal Lower Ext 0.9 cm L x 0.7 cm W-partial thickness. Observation of Resident #1's skin assessment performed by LPN #17 on 08/30/14 at 10:15 AM, revealed the resident had an open area to the left great toe medial base which measured 1.5 cm L x 1.5 cm W and the wound bed was beefy red; an open area to the right great toe medial base which measured 1 cm x 0.9 cm and the wound bed was red; an open area to the right shin with a red wound bed with a yellow center which measured 1.5 cm L x 1 cm W; an open area on the lower shin which had a red wound bed and measured 0.8 cm L x 0.6 cm W; an open area to the right medial/posterior calf which measured 3 cm L x 1.9 cm W with a red wound bed and white middle surrounded by eschar; an area just below the previous area to the right medial/posterior calf which measured 6 cm L x 3.5 cm W x 0.4 cm depth with a red wound bed with yellow/green areas on the wound bed surrounded by eschar; and, an area on the right lower medial/posterior calf which measured 5 cm W x 7 cm L and appeared as scar tissue. Interview, with the Wound Nurse on 08/30/14 at 12:15, and 09/09/14 at 6:50 PM, revealed she had seen Resident #1 in late June or early July 2014, related to the lower extremities having weeping and [MEDICAL CONDITION]. Further interview with the Wound Nurse revealed she assessed the wounds on the resident's lower extremities on 08/28/14 and was "surprised" to see five (5) open areas to the lower extremities which she would classify as vascular ulcers (she stated she measured three (3) ulcers as one (1) on the right posterior calf), and the resident also had ulcers on the left and right great toe and right lower extremity posterior and anterior areas. Further interview revealed any nurse could revise the care plan, but she was responsible for revising the care plans for the wounds which she was tracking. She stated there was no care plan in place to indicate this resident had actual stasis ulcers, and she completed a care plan when she became aware of the resident's wounds. Interview, on 08/30/14 at 10:15 AM, LPN #17 stated she knew any nurse could update the care plan but she thought the Wound Care Nurse was following this resident and she would have revised the care plan. Interview, on 08/29/14 at 2:00 PM, with LPN #5 revealed she was aware any nurse could revise the care plan but she failed to look at the care plan to see if it required revision and she thought the Wound Care Nurse was revising the care plans when there were new open areas identified. Interview on 08/29/14 at 2:50 PM and 09/05/14 at 11:11 AM, with the ARNP revealed she was aware Resident #1 had weeping in the lower extremities earlier this summer and the diuretic had been increased; however, she assessed the wounds on 09/02/14 and the previous time she had seen the resident's lower extremities they were "nothing like now". "I was surprised the wounds were that bad". Interview on 09/09/14 at 3:00 PM with the MDS Nurse on the North Unit, revealed she had completed the resident's last MDS on 07/14/14 and the resident had no ulcers and just dry skin to the lower extremities at that time. She stated she obtained information for the MDS from the skin assessments which the Wound Nurse completed and also observed resident's skin during the assessment period. She further stated she revised care plans for the Admission, Quarterly, Yearly, and Significant Change MDS's and the floor nurses were to update the care plans between assessments. Continued interview revealed the wound care plans were to be completed by the Wound Nurse because she tracked the wounds. However, she stated in July 2014, she was still responsible for updating the care plans from physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 09/05/14 at 11:20 AM, revealed there was no Care Plan in place to address this resident's actual stasis ulcers and risk factors with individualized interventions related to the venous ulcers until the Wound Nurse completed a care plan on 08/28/14. The DON stated, usually the Wound Nurse revised the wound care plans, but other staff including the floor nurses or MDS nurses could also revise the care plans.

Based on observation, interview, record review, and review of facility's policy, it was determined the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (1) of four (4) sampled residents who was diagnosed with [REDACTED].#1), out of a total sample of thirteen (13) residents. On 07/03/14 Resident #1 was noted to have [MEDICAL CONDITION] weeping legs with an open area on the right lower extremity measuring three (3) centimeters (cm) x 0.1 cm on 07/03/14, and the Advanced Registered Nurse Practitioner (ARNP) was notified. [MEDICATION NAME] (antidiuretic medication) was ordered; however, the nurse who notified the ARNP, did not ensure a treatment was ordered for the wound. On 07/24/14 the resident was noted to have an open area to the right shin and left great toe; however, there was no documented evidence the Physician or ARNP was notified of the progression of skin breakdown in order to obtain a treatment order until 07/25/14, when Vaseline Gauze was ordered to the open areas of the lower extremities. The skin on the resident's lower extremities continued to deteriorate and on 07/31/14 the resident was noted to have open areas to the right inner calf and the top of the right foot. On 08/14/14 the resident was noted to have open blisters to the left foot and an open area to the right foot and right leg. However, there was no documented evidence the Physician was notified of the increased number of wounds and the continued deterioration of the wounds after 07/25/14. On 08/27/14, the ARNP was notified of maggots in the large elongated wound on the right calf; however, there was no documented evidence the ARNP was notified of the the increased number of wounds or the deterioration of the wounds until 08/28/14. Observation of a skin assessment on 08/30/14 by the surveyor revealed a total of six (6) open areas to the lower extremities with two (2) of the larger areas on the right calf having eschar at the edges of the wounds. Although this resident had multiple ulcers to the lower extremities, and the ulcers were continuing to deteriorate, there was no documented evidence the facility evaluated and revised the Care Plan as the resident's status changed related to the development of venous ulcers to the lower extremities. (Refer to F157, F280) The findings include: Review of the facility's "Pressure Ulcers/Skin Breakdown-Clinical Protocol" Policy, revised 10/2013, revealed the physician would assist staff to determine etiology (for example, arterial or stasis ulcer) and characteristics (necrotic tissue, status of wound bed) of the skin alteration. Further review revealed the Physician would authorize pertinent orders related to wound treatments, including wound cleansing and [MEDICATION NAME] approaches, dressings, and applications of topical agents if indicated for type of skin alteration. Continued review revealed the Physician would evaluate and document the progress of wound healing and would help staff review and modify the care plan especially when wounds were not healing as anticipated or new wounds developed despite existing interventions. Interview with the Director of Nursing on 09/05/14 at 11:20 AM, revealed this was the policy which was to be used for Pressure Ulcers as well Stasis Ulcers. Review of the medical record revealed the facility admitted Resident #1 on 07/02/10. Further review revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) of a five (5) out of fifteen (15) indicating cognitive impairment. Further review revealed the facility assessed the resident as requiring extensive assist of two (2) staff for bed mobility and transfers, and limited assist of one (1) staff for ambulation. Continued review revealed the facility assessed the resident as having no arterial or venous ulcers. Review of the Comprehensive Plan of Care dated 11/14/11, revealed Resident #1 was at risk for developing skin breakdown and had a history of [REDACTED]. There was a notation, that was undated, which stated the resident had an open area to the right lower extremity and the left great toe and treatment per order. Review of the monthly July 1, 2014, physician's orders [REDACTED]. Review of the WSIR, dated 07/03/14, revealed Resident #1 had two (2) plus [MEDICAL CONDITION] and an open area measuring three (3) centimeters (cm) x 0.1 cm and the diagram on the WSIR revealed the area was on the right shin. Review of the Interdisciplinary Progress Notes, dated 07/03/14 at 10:00 AM, revealed the resident's bilateral lower extremities were [MEDICAL CONDITION] and weeping, the ARNP was notified, and a "now" (one time) dose of [MEDICATION NAME] 40 milligrams (mg) was ordered and administered. Review of the physician's orders [REDACTED]. Further review of the WSIR dated 07/10/14 revealed the resident's skin was dry and there was two (2) plus [MEDICAL CONDITION] and weeping. The WSIR dated 07/17/14, revealed the resident's skin was dry and the right lower extremity had weeping and two (2) plus [MEDICAL CONDITION]. Further review of physician's orders [REDACTED]. Phone interview on 09/05/14 at 11:05 AM, with Licensed Practical Nurse (LPN) #18, who had signed as completing the WSIR's for 07/03/14, 07/10/14, and 07/17/14, and had obtained the physician's orders [REDACTED]. She stated she had called the ARNP on 07/03/14 and informed her of the open area on the resident's leg and the [MEDICAL CONDITION] to the lower extremities, and the ARNP ordered [MEDICATION NAME] and instructed her to talk to the Wound Nurse about a treatment. She further stated she had asked the Wound Nurse to assess Resident #1's leg for a treatment order; however, could not recall if a treatment was ordered and was unsure if the Wound Nurse had assessed the resident. LPN #18 stated she could not recall if the resident still had an open area on 07/10/14 and 07/17/14 when she completed the skin assessments; however, the resident's legs were [MEDICAL CONDITION] and she obtained an order for [REDACTED]. Interview, with the Wound Nurse on 08/30/14 at 12:15 PM, and 09/09/14 at 6:50 PM, revealed she had initially seen the resident late June or early July 2014, related to the lower extremities having weeping and [MEDICAL CONDITION]. She stated she did not make a note and thought the nurses had a treatment in place. She further stated she was not notified of any open areas or any changes in the lower extremities until 08/27/14. Review of a Physician's Note dated 07/18/14, written by the Attending Physician, revealed the resident had weeping lower extremity areas that she/he refused to let staff dress. Review of the WSIR dated 07/24/14, revealed a diagram indicating there was skin breakdown on the resident's right shin and left great toe and interview with Registered Nurse (RN) #2/Assistant Director of Nursing/Unit Coordinator for the North Unit who completed this skin assessment, confirmed these areas were open at the time she completed the assessment. She stated these were not pressure ulcers so she did not measure and describe the wounds; however, in hindsight felt she should have measured the wounds. She further stated she did not call the Physician for an order because she thought there was already an order in place. Continued interview revealed she was only assessing the resident's skin due to the facility doing a skin sweep and was not familiar with the resident's wounds at the time. She further stated she had removed Kerlix from the resident's bilateral extremities before assessing the skin and thought the treatment was for Skin Repair to the legs, avoiding the open areas, and Kerlix to the legs bilaterally. However, further review of the TAR dated July 2014, and the physician's orders [REDACTED]. Review of the Interdisciplinary Progress Note for Resident #1, dated 07/25/14 at 10:00 PM, and completed by LPN #19, revealed the resident had open areas to the right lower extremity and left great toe and new orders were received for Vaseline Gauze and dressings to the areas daily and as needed (prn). However, there was no documented evidence of measurement or description of the areas. Review of the physician's orders [REDACTED]. Further review revealed orders to cleanse the open area to the left great toe with Normal Saline, pat dry, and apply Vaseline Gauze and dry dressing every day and prn. Phone interview with LPN #19 on 09/05/14 at 11:00 AM, revealed before 07/25/14, the resident just had orders for creams and lotions to the lower extremities for dry cracked skin; however, the day she obtained the treatment order on 07/25/14 the resident had an open area to the left great toe, and open areas to the right shin and the lateral calf which were small and looked like the top layer of skin was gone. She stated she did not know why she did not measure the areas, but should have measured them. Further review of the WSIR dated 07/31/14 and completed by LPN #17, revealed there was an open area with a diagram indicating areas on the right medial calf and top of right foot and no documentation addressing Resident #1's left great toe. Review of the WSIR dated 08/14/14 completed by LPN #17, revealed the resident had open blisters to the left foot and open areas to the right foot and right leg. The diagram indicated there was an old area of skin breakdown on the right medial calf and and an area on the top of the right foot and new areas to the left foot. The WSIR dated 08/14/14, stated treatment nurse notified. Interview with LPN #17 on 09/04/14 at 12:00 PM, revealed by looking at the WSIR for 07/31/14, the resident had an area on the right calf and the top of the right foot which was not present on the previous WSIR; however, she thought these areas were old. She further stated, according to what she could remember and looking at the WSIR for 08/14/14 the resident had an area to the left great toe and new areas to the left 3rd digit and a new area to the top of the resident's left foot, and she called and informed the Wound Care Nurse because the areas on the left 3rd digit and the top of the resident's left foot were new. Continued interview revealed she assumed the Wound Nurse would call the Physician for a treatment order and also assumed the Wound Nurse was measuring and describing this resident's wounds weekly. LPN #17 stated she used to be wound certified and stasis ulcers were to be measured and described weekly and the Physician was to be notified of any new areas of skin breakdown. However, review of the medical record including Interdisciplinary Progress Notes and physician progress notes [REDACTED]. Review of Resident #1's WSIR dated 08/21/14, completed by LPN #18, revealed a diagram indicating open areas to the right medial calf, right great toe, and left foot; however, no measurements were noted. Further phone interview with LPN #18 on 09/05/14 at 11:00 AM, revealed she was unable to remember just what the wounds looked like on that date; however, she thought there was a treatment already in place for the wounds and thought the Wound Nurse was following Resident #1 for measurements. Review of the Nurse's Notes dated 08/27/14 at 2:00 PM, written by LPN #5, revealed the resident's wound was found to have foreign matter in an open area, wound cleansed with all foreign matter cleaned out and treatment applied. Further review, revealed the ARNP was notified with no new orders, dressing changes to continue daily, and the resident had no signs and symptoms of pain, infection, or deterioration. Interview with LPN #5 on 08/29/14 at 2:00 PM, revealed the resident started having weeping in her legs about a month ago and developed open areas to the lower extremities. She stated on 08/27/14 she noted the resident's wound on the right leg had white round foreign matter which would move and could have been maggots, although she had never seen maggots before. She stated she had RN #2/ADON/UC for the North Unit, come to the room to assess what she had seen. She further stated she took the dressings and the bed linens, and placed them in a red biohazard bag and handed them to the housekeeper to dispose of. LPN #5 stated she flushed the wounds with Normal Saline until they were clean. Continued interview revealed RN #2/ADON/UC called the ARNP and notified her of the white foreign matter, although she (LPN #5) had written the Note stating the ARNP was notified on 08/27/14 at 2:00 PM. Further interview with RN #2/ADON/UC of the North Unit, on 09/04/14 at 9:47 PM, revealed she was asked to come in Resident #1's room on 08/27/14 and she noticed maggots on the bed covers; however, she did not see maggots in the resident's wounds. She stated she had notified the ARNP; however, had LPN #5 make the Note. She stated the ARNP did not give orders or instructions except to clean the wounds. She further stated the staff threw away the bed covers and notified housekeeping to clean and disinfect the room. Interview, with State Registered Nurse Aide (SRNA) #28, on 09/03/14 at 4:00 PM, revealed on 08/27/14, she saw LPN #5 remove the bandage on the resident's leg and maggots rolled out on to the bed spread, mattress. SRNA #28 stated she had never seen maggots before this. She stated she had seen flies and gnats in Resident #1's room daily and was not sure if she or anyone else had reported this. She stated the resident's meal trays stayed in the room longer than they should because the resident refused to allow them to take the tray at times. Interview, with SRNA #41 on 09/03/14 at 4:20 PM, revealed she was assigned to Resident #1 on 08/27/14 when LPN #5 called the SRNA into the resident's room. She stated when LPN #5 opened the dressing on the resident's leg, maggots were everywhere, on the bed linens, and on the floor, and there was about forty (40) of them. Continued interview revealed this was the first time she had seen maggots in the resident's room; however, she had noticed flies in the resident's room this summer as well as the resident had old food and milk at the bedside on occasion. Interview, with SRNA #14 on 09/03/14 at 4:30 PM, revealed she witnessed maggots on the floor while the nurse was cleaning the residents wounds on 08/27/14 and assisted with giving the resident a bed bath afterwards. She stated she had seen flies, gnats, and spiders everywhere and had reported it to a nurse; however, could not remember which nurse. She further stated Resident #1 had flies and gnats in the room at times and she threw away old food which was left at the bedside. Review of Resident #1's Non Pressure Skin Condition Record, completed by the Wound Nurse, dated 08/28/14, revealed the areas were first observed on 08/28/14, including the following; Left Great Toe Metatarsal 1.4 cm Length (L) x 1.7 cm Width (W)-partial thickness, Right Lower Extremity Calf Posterior measuring 13.5 cm L x 5 cm W x 0.3 cm depth-full thickness, serous drainage, and slough described as moist yellow or gray necrotic tissue, Right Great Toe lateral metatarsal 0.8 cm L x 1 cm W-partial thickness, Right Proximal Lower Extremity 2 cm L x 1 cm W-partial thickness, serosanguinous exudate, and slough-moist yellow or gray necrotic tissue, Right Distal Lower Ext 0.9 cm L x 0.7 cm W-partial thickness. Observation of Resident #1's skin assessment performed by LPN #17 on 08/30/14 at 10:15 AM, revealed the resident had an open area to the left great toe medial base which measured 1.5 cm L x 1.5 cm W and the wound bed was beefy red; an open area to the right great toe medial base which measured 1 cm x 0.9 cm and the wound bed was red; an open area to the right shin with a red wound bed with a yellow center which measured 1.5 cm L x 1 cm W; an open area on the lower shin which had a red wound bed and measured 0.8 cm L x 0.6 cm W; an open area to the right medial/posterior calf which measured 3 cm L x 1.9 cm W with a red wound bed and white middle surrounded by eschar; an area just below the previous area to the right medial/posterior calf which measured 6 cm L x 3.5 cm W x 0.4 cm depth with a red wound bed with yellow/green areas on the wound bed surrounded by eschar; and, an area on the right lower medial/posterior calf which measured 5 cm W x 7 cm L and appeared as scar tissue. Interview, with the Wound Nurse on 08/30/14 at 12:15, and 09/09/14 at 6:50 PM, revealed she was not notified of any open areas or any changes in the lower extremities until 08/27/14 when she was told the resident had a deterioration in the wounds and also had maggots in the wound as she was walking out the door to go to class. The Wound Nurse stated she assessed Resident #1's wounds on the lower extremities on 08/28/14 and was surprised to see five (5) open areas to the lower extremities which she would classify as vascular ulcers (she stated she measured three (3) ulcers as one (1) on the right posterior calf), and the resident also had ulcers on the left and right great toe and right lower extremity posterior and anterior areas. Continued interview revealed she was to be notified of any new areas of skin breakdown until 08/27/14, and therefore had not been tracking the resident's wounds with measurements and descriptions of the wounds, and had not been corroborating with the Physician or ARNP related to the wounds. Further interview revealed staff was to fill out a Communication Form to the Wound Nurse and flag it in the skin assessment book which was read daily by the Wound Nurse or the Assistant Director of Nursing in the morning meetings; however, she did not remember being told verbally or by the Communication Form of the resident's wounds. Continued interview revealed any nurse could revise the care plan, but she was responsible for revising the care plans for the wounds which she was tracking. She stated there was no care plan in place to indicate the resident's actual stasis ulcers, and she completed a care plan when she became aware of the residents wounds. Interview, on 08/29/14 at 2:50 PM and 09/05/14 at 11:11 AM, with the ARNP revealed she was notified of the staff finding maggots in Resident #1's wound and staff also said there was a lot of flies in the building this summer. She stated she was aware the resident had weeping in the lower extremities earlier this summer and the diuretic had been increased; however, she saw the wounds on 09/02/14 and the previous time she had seen the resident's lower extremities they were "nothing like now". "I was surprised the wounds were that bad". She further stated the wounds were not pressure ulcers but were venous stasis ulcers related to Peripheral Artery Disease and the resident also had Diabetes Mellitus. The ARNP stated, a dry dressing would have been sufficient for weeping legs; however, staff needed to notify her of any change in status such as deteriorating wounds or any new wounds and she did not know at what point the wounds worsened. She stated the staff was her eyes and ears and she was not notified of the decline in the wounds or the numerous wounds until the resident had a large elongated wound which was possibly necrotic with maggots. Further interview revealed, she was available except from 08/18/14 through 08/25/14 when she was on vacation. She stated she did not know if the Attending Physician was notified of the worsening wounds; however, there was no documentation to support the Physician had been notified. Continued interview revealed the Wound Nurse should have been following Resident #1 to give recommendations for further treatment. She stated the Wound Nurse guided her related to wound treatments because she (Wound Nurse) was aware of the latest treatments available. The ARNP indicated she had ordered a wound consult after she assessed the wounds which she would have done sooner had she been aware of the condition of the residents lower extremities. The resident's Physician was out of the country at the time of the investigation and unavailable for an interview. Interview with the Director of Nursing (DON), on 09/05/14 at 11:20 AM, revealed the Physician was to be notified of any new area of skin breakdown or any change in wound status. She stated at the point a wound was identified, or for any change in a wound, staff should have notified the Physician for a treatment order as well as obtained measurements and documented the measurements and description of the wounds on a Non Pressure Skin Condition Record which was the facility's tracking form for a stasis ulcer. However, she indicated by reviewing the record the Physician or ARNP was not kept informed of this resident's change in condition related to wounds, and the wounds were not being measured weekly. She stated in the morning clinical meeting Monday through Friday they discussed anything which occurred the previous day as well as the new physician's orders [REDACTED]. She stated the ADON's, the Wound Care Nurse, the MDS Nurses, Medical Records, Social Services, Staff Development attended the meetings; however, she was unaware if the Wound Care Nurse would have been at the meeting the day they discussed the new physician's orders [REDACTED]. She stated the nurses were to fill out a communication sheet for the Wound Nurse if there was new or worsened skin breakdown; however, she was unsure if this was done for this resident. Further interview revealed the nurses should have ensured the Wound Nurse was notified of changes in the wound and an appropriate treatment was in place; however, there was no indication the Wound Nurse was following this resident. When reviewing the record, the DON stated there was no skin assessment completed form 07/31/14 through 08/14/14; however, staff had addressed but not measured the resident's wounds on the 08/07/14 weekly summary. Review of the Comprehensive Plan of Care and further interview with the DON, revealed there was no Care Plan in place to address Resident #1's actual stasis ulcers and risk factors as well as individualized interventions related to the ulcers until 08/28/14. She stated usually the Wound Nurse revised the wound care plans, but other staff including the floor nurses or MDS nurses could also revise the care plans.

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on observation, interview, record review, and Fire Emergency Plan and Evacuation Plan review, during the 07/03/14 survey, it was determined the facility failed to have an effective system to ensure the residents' environment remained as free of accidental hazards as possible. The facility failed to ensure a safe path to a public way for three (3) of the facility's eight (8) exits, which the facility detailed as fire evacuation exits. On 06/24/14, the facility began construction by removing the concrete pavement outside the Northwest hallway exit and the Dining room exit, and on 06/27/14 the Southwest exit door had pavement removed, affecting the safe path to a public way. Observation on 06/30/14 revealed the fire exit located at the end of the Northwest hallway had a ramp which led to a three (3) inch drop off from the ramp to gravel and rebar (common steel bar used in construction to reinforce concrete); the fire exit located at the Dining room exit had a concrete pad leading to a three and a half (3.5) inch drop off to gravel and rebar; and, the Southwest hallway had a ramp which led to a four and a half (4.5) inch drop off with gravel. All three (3) of the fire exits remained accessible with no signage posted at the exit doors to alert residents, staff, and visitors these exits were not accessible due to the construction. There was a total of thirty (30) beds on the Northwest hallway and thirty (30) beds on the Southwest hallway which could have potentially affected sixty (60) of the facility's one hundred and twenty-four (124) residents in the event of an emergency evacuation. The facility's failure to ensure the residents' environment remained as free of accidental hazards as was possible was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 06/30/14, and was determined to exist on 06/24/14. The facility was notified of the Immediate Jeopardy on 06/30/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/03/14 with the facility alleging removal of the Immediate Jeopardy on 07/02/14. The Immediate Jeopardy was verified to be removed on 07/02/14, with remaining non-compliance at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure the resident's environment remains as free of accidental hazards as possible; and each resident receives adequate supervision to prevent accidents. The findings include: Review of the facility's, "Disaster Preparedness" Manual, dated January 2005, revealed the fire safety procedure plan, stated in preparing for an evacuation after the fire alarm was sounded, staff was to first check the primary exit route. If it was clear and safe, they were to use that exit if evacuation was ordered. Review of the facility's, "Fire Safety Procedures Orientation Training", undated, revealed under the "evacuation" section, staff was to first check the primary exit route, if it was clear and safe, use that exit if evacuation was ordered. Review of the facility's Map on 06/30/14 at 5:15 PM, posted in the dining room, revealed arrows leading from the dining room to the outside exit as an exit route from the dining room. However, observation on 06/30/14 at 5:15 PM, of the Dining room fire exit door revealed a concrete pad leading to a three and a half (3.5) inch drop off to gravel and rebar (common steel bar used widely in construction to reinforce concrete). Review of the facility's "North Nursing Department Fire Emergency Guidelines" revealed staff was to check the primary exit route, if blocked use the secondary route. Continued review revealed staff were to report to the grassy area south of the parking lot on the south side of the building, and the sidewalk in front of the building. Review of the facility's Map on 06/30/14 at 5:20 PM, posted across from the nurse's station on the north unit, revealed an exit route for the Northwest hallway with arrows pointing towards the exit door at the end of the Northwest hallway leading outside. However, observation on 06/30/14 at 5:20 PM revealed the fire exit at the end of the Northwest hallway had a ramp which led to a three (3) inch drop off from the ramp to gravel and rebar. Review of the facility's, "South Nursing Department Fire Emergency Guidelines", undated, revealed staff was to check the primary exit route, if blocked use the secondary route. Review revealed staff were to report to the grassy area south of the parking lot on the south side of the building, and the sidewalk in front of the building. Review of the facility's Map on 06/30/14 at 5:24 PM, posted across from the nurse's station on the south unit, revealed an exit route for the Southwest hallway with arrows pointing towards the exit door at the end of the Southwest hallway leading outside. However, observation on 06/30/14 at 5:24 PM revealed the fire exit door at the end of the Southwest hallway had a ramp which led to a four and a half (4.5) inch drop off with gravel and rocky uneven surface. Further observation on 06/30/14 at 5:15 PM, 5:20 PM and 5:25 PM revealed there was no signs posted at the Southwest, Northwest, and Dining room exits to alert staff, residents, and visitors these exits were not accessible due to the construction. Interview with the Director of Plant Operations, on 06/30/14 at 2:20 PM, revealed construction began on 06/24/14 with the removal of the concrete pavement outside of the Northwest Hallway and the Dining room exit and on 06/27/14 the concrete pavement was removed outside the Southwest exit door. Continued interview revealed these three (3) exits were not safely accessible in case of an emergency evacuation. Observation of the Southwest hallway exit door, at the time of the interview, revealed the door was access-controlled with magnetic locks and could be released with a manual release device and was operational. Further observation revealed when the green button by the door was pushed, a beeping noise would start and the door would disengage and could be opened within fifteen (15) seconds. Observation on 06/30/14 at 5:15 PM of the dining room fire exit door and at 5:20 PM of the Northeast hallway fire exit doors revealed when the green button by the door was pushed, a beeping noise would start and the door would disengage and could be opened within fifteen (15) seconds. Interview with State Registered Nursing Assistant (SRNA) #1, on 06/30/14 at 3:16 PM, revealed she would have used the Northwest, Southwest, and dining room exits to the outside if an emergency arose which required residents to be evacuated. She stated she was aware of construction going on; however, as far as she knew these exits were not affected. Interview with Housekeeper #1, on 06/30/14 at 3:20 PM, revealed she would use the Northwest, Southwest, and dining room exits to the outside in the case of an emergency evacuation because she had not been told she could not use the exits. Interview, on 06/30/14 at 5:01 PM, with the Social Service Director (SSD) revealed she had sent out a letter to inform families of the construction; however, she did not know the date construction was to start at the time she sent the letter. She viewed the Northwest, Southwest, and dining room exits and stated the residents would not be able to exit these exits due to construction, and this was a safety concern. Review of the letter sent to families by the SSD, revealed a date of 02/19/14, which detailed the renovation at the facility would include fresh paint, flooring, furniture, an expanded gym and the addition of private rooms. However, there was no documented evidence the letter addressed any construction taking place outside the building. Interview, on 06/30/14, at 5:15 PM, with Licensed Practical Nurse (LPN) #4 revealed was not aware these exits could not be used until that day, 06/30/14. Interview, on 06/30/14 at 5:17 PM, with the second shift Supervisor/Registered Nurse (RN) #5 revealed on 06/27/14 she was told not to use the exits to the back of the building, but she thought construction had already began at that time. She stated she did not formally inservice staff not to use those exits; however, did verbally tell some of the staff. Interview, on 06/30/14 at 5:30 PM, with Housekeeper #2 revealed his supervisor told him there was construction in the back of the building; however, he was unaware there was gravel and a drop off at the back exit doors, which included the Northwest, Southwest and dining room doors to the outside. He stated he was not aware of an alternate evacuation plan. Interview, on 06/30/14 at 5:50 PM, with SRNA #4 revealed she became aware there was construction going on "last week" when she saw a piece of construction machinery. She stated she had seen the gravel at the back of the building; however, was unaware there was a drop off from the back exit doors. She stated she was confused because a nurse had told her she could use the back exit doors for an emergency exit; but, the Maintenance Director had told her those exits were inaccessible. Interview, on 06/30/14 at 5:52 PM, with LPN #1 revealed she was not educated until that day, 06/30/14, in regards to not using the Northwest and Southwest exit doors due to construction. Observation of the back side of the building with LPN #1 at the time of the interview, revealed she indicated staff would not be able to take residents out the three (3) exits involved (Northwest, Southwest and dining room exits), and it would be a safety issue for residents to try to evacuate them from those exits. Interview, on 06/30/14 at 5:55 PM, with SRNA #3 revealed she was unaware of the construction taking place in the back of the building until that day, 06/30/14. Interview, on 06/30/14 at 7:30 PM, with LPN #3 revealed she knew there was construction going on, but she had received no new information related to a new evacuation plan, and was unaware of the exits which were inaccessible due to construction. Interview, on 06/30/14 at 5:17 PM, with the Assistant Director of Nursing (ADON)/Unit Manager for the South hall revealed the doors at the back of the building, including the Northwest, and Southwest doors were inaccessible due to the construction. Continued interview revealed if staff were unaware of the blocked exits, this could be a safety issue if there was a fire. Interview, on 06/30/14 at 5:05 PM, with the Director of Nursing (DON) revealed she was told in the "Stand Up Meeting" the morning of 06/17/14, there would be construction to start on 06/18/14, which included repairing concrete; however, the construction was delayed and started on a later date. She stated, in the same meeting they were told to stay clear of the exit doors to the Northwest and Southwest hall exits because the sidewalks were being replaced outside those doors. The DON stated there were two (2) exits in the front of the building, an exit by the therapy department, and also the Northeast and Southeast hallway doors to the outside that could be used in the case of an emergency evacuation. However, she indicated she had not been educated as to the alternate routes to use for emergency evacuation. She stated the Staff Development Nurse inserviced staff related to the construction; but, she was unsure if all staff had been inserviced and instructed to use the alternate routes for emergencies. She stated staff would be unable to get residents' wheelchairs out the exits where the construction was taking place. She indicated these exits would be dangerous for people at risk for falls, and also for residents who were confused and exit seeking. According to the DON, this made it important to ensure staff were aware of which exits led to the construction zones. Interview with the Staff Development Nurse (SDN), on 06/30/14 at 5:30 PM, revealed she was told by the Director of Plant Operations during a morning "Stand Up Meeting", there was construction going on outside and the facility was putting new concrete on the driveway out back. She stated she was told there would be construction workers with machines and they could not use the exits to the back of the building including the dining room exit. Continued interview revealed the DON had asked her to let staff know which doors would be inaccessible due to construction; however she was not told who to inservice and was not told exactly what the new evacuation routes would be. She stated she did an informal verbal inservice at the last "Town Hall Meeting" which was done on payday, Friday on 06/20/14, for the staff who picked up their checks that day. The SDN stated she told staff present, the doors which would be inaccessible due to construction would be the Southwest door, the dining room door and the kitchen door. However, she was unaware there was construction near the Northwest exit door and did not inservice staff related to that door. She stated she also told staff which doors they could use for evacuation of residents. However, she stated she was unaware of the date of the inservice, and was unable to submit the inservice or signatures of staff present from the inservice. Interview with the Administrator, on 06/30/14 at 7:00 PM, revealed she started at the facility on 05/15/14, and was told by the previous Administrator on that date there would be construction which included replacing damaged pavement on the west or back side of the building. She stated during the "morning meetings" she discussed with the managers the construction consisted of tearing up the concrete and re-pouring the concrete at the back of the building; however, they did not discuss the safety aspects related to the construction. She stated no formal education was provided to staff regarding which doors were affected by the construction and which doors were to be used for alternate routes. Further interview with the Administrator and previous Administrator on 07/01/14 at 12:00 PM, revealed residents did not go outside unsupervised and never went past the front porch. However, they stated there was confused and/or exit seeking residents in the building, and residents who were at risk for falls and this would be dangerous if they were to exit on to the construction zone. Continued interview revealed there was a wanderguard system in place to alert staff if a resident, at risk for elopement wearing a wanderguard device, was attempting to exit the building. They stated the wanderguard system affected the front lobby doors and the south side door, but did not affect the Northwest and Southwest Hallway exit doors or the dining room exit door. Further interview revealed once the green button was pushed by the three (3) exit doors leading to the construction zone, there would be a beeping noise and the doors would open within fifteen (15) seconds. They revealed if there was a fire, all the exit doors would disengage and open when pushed. Review of the facility's, "Residents at Risk for Elopement Risk", revealed sixteen (16) residents were at risk in the facility. Review revealed three (3) residents resided on the Southwest Hallway and three (3) residents who resided on the Northwest Hallway. In addition, review of the facility's Roster Matrix revealed nineteen (19) residents who were identified at risk for falls. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 07/03/14, which alleged removal of the Immediate Jeopardy (IJ), effective 07/02/14. Review of the AOC revealed the facility implemented the following: 1. The Regional Nurse Consultant (RNC) inserviced the Administrator and the entire Safety Committee (Human Resources Director/Safety Director, ADON North, Business Office Manager (BOM), Chaplain, Clinical Social Worker (CSW), Rehabilitation (Rehab) Manager, Medical Records Director, Dietary Director, Housekeeping Director, Activity Director, Staff Development Coordinator (SDC), Plant Operations Director, DON, ADON South, MDS LPN, MDS RN and Marketing Director, who were also the Quality Assurance (QA) Committee, on 06/30/14 during a Safety Committee meeting held to discuss the facility's Fire Safety Procedure for alternate evacuation routes due to construction. The education covered construction planning and continued safety of residents. Additionally, the construction plan and assignments, that delineated which staff member was responsible for what piece of the AOC, were dispersed to all departments by the Administrator and the Safety Committee Director. The construction plan included the creation of new routes and temporary exit diagrams, placement of signage outlining the construction plan in appropriate areas that included the front entrance, parking lot entrance and the doors which were closed related to the construction. New signs stating "DO NOT USE" were also placed on the affected doors. 2. Inservices were initiated on 06/30/14 and 07/01/14, by the DON, Assistant Director of Nursing (ADON), Dietary Manager (DM), Staff Development, Business Office Manager (BOM), Housekeeping Director and Rehabilitation (Rehab) Director for all staff, including dietary, housekeeping, therapy, laundry and maintenance. The education consisted of the new evacutation plan and continued safety of residents. Additionally, no employee would be allowed to work until the education was provided and the post test completed to ensure compliance with exit routes. The Administrator maintained an employee roster to crosscheck with the training log to assure no employee was allowed to work until the education was received. One hundred and fifty-five (155) employees of one hundred and sixty-three (163) employees had been educated by 07/01/14. The facility did not utilize agency staff. 3. All residents with a BIMS score of eight (8) or greater on their last MDS were informed of the construction and alternate evacuation routes, as well as, the the new evacuation signs. Forty-eight (48) residents met the criteria and were informed as indicated by the Activity Director and Social Service Director on 06/30/14 and 07/01/14. Responsible Parties of residents, who were frequent visitors to the facility, were notified of the construction and temporary evacuation routes, by telephone by the Chaplain and Marketing Director. Thirty (30) Responsible Parties were notified on 06/30/14 and 07/01/14, with plans to continue notifications daily until all resident families/responsible parties were notified. 4. Signs were placed on the Main Entrance and the employee entrance doors on 06/30/14 by the Maintenance Director to inform all visitors that "Construction is in progress". Also, new temporary exit diagrams (maps) were created for the South West/North West/ Dining Room/Dietary Services/Laundry Area by the Safety Committee on 06/30/14 and posted on all temporary alternate evacuation routes. Signs were created and posted on all "temporarily closed" evacuation exits that stated, "STOP-DO NOT USE" by the Maintenance Director on 06/30/14. 5. The Medical Director was notified of the IJ 07/01/14 by the DON. 6. A QA meeting was held on 07/01/14 to review the new temporary exit diagrams for the South West/North West/Dining Room, Dietary Services and Laundry areas. Signs were created and posted on all areas of temporary alternate evacuation routes. Signs were created and posted on all temporarily closed evacuation exits to "STOP-DO NOT USE". The the entire plan was reviewed with the Medical Director on 07/01/14 during the QA meeting. The Medical Director approved the plan developed by the facility to address the IJ. Another QA meeting was scheduled for 07/09/14. 7. Maintenance was to audit daily beginning 07/01/14, to ensure signage was in place on the Main Entrance and employee entrance door informing all visitors "Construction is in process". The maintenance audit was to include a daily check to ensure the new temporary exit diagrams created for the South West/North West/Dining Room, Dietary Services and Laundry area's remain posted on all temporary alternate evacuation routes and to ensure that signs created and posted on all "temporarily closed" evacuation exits saying "STOP-DO NOT USE" remain in place. The results of the audits will be turned in daily to the Administrator until the construction project is completed. The Administrator was do daily rounds of the signage to assure accuracy of maintenance audits until the project is completed. 8. A staff questionnaire regarding exit routes and evacuation plan was being administered by the Administrator, DON, ADONs, SDC, Dietary Director, BOM, Social Services Director (SSD), Chaplain, Admissions Director, Medical Records Director, and HR Director to five (5) staff members on each shift and different staff members until the immediacy was removed beginning 07/01/14. After the immediacy was removed ten (10) staff questionnaires were to be done daily to ensure continued understanding of exit routes and evacuation plan. All results of the questionnaires were to be reviewed by the Administrator, DON or Regional Nurse Consultant. The Administrator was to review all audits for completeness and accuracy, as well as, conduct "spot checks" of questionnaires to staff to ensure knowledge and accuracy of audits. Results of the staff questionnaires were to be reviewed by the QA Committee weekly to determine the further need of continued education or revision of the facility's plan. The QA Committee was to determine at what frequency the questionnaires for staff would need to continue. Any concerns identified were to be corrected immediately and reported to the Administrator. 9. A RNC has been onsite since 06/30/14, to assist with compliance with staff education, ensure daily audits were completed by the Maintenance Director and turned into the Administrator with no issues identified, and ensure daily staff questionnaires were completed as scheduled to ensure staff were aware of the new exits/evacuation plan. The Vice President (V/P) of Operations or Chief Nurse Executive were in daily contact with the RNC to review the above. Before the construction areas are re-opened, the areas are to be inspected by the Administrator and Maintenance Director to ensure the areas were safe for use. The State Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she and the entire Safety Committee had been inserviced by the RNC on the construction plan, resident safety and the new, temporary evacuation routes and diagrams on 06/30/14 at approximately 8:15 PM. Review of the education information revealed the construction plan which included the creation of new routes and temporary exit diagrams, placement of signage at the front doors, parking lot entrance and doors which were to be closed related to the construction. 2. Review of the education information, including the post tests, provided to all staff, revealed the education included education on the construction plan and new signs posted and included the following statement, "due to the recent construction on the back driveway of the facility, new evacuation routes have been implemented until further notice". Continued review of the education material revealed the alternate evacuation plan was included, as well as, the questions for the post test to ensure competency and understanding. Interviews on 07/02/14 with Certified Occupational Therapy Aide (COTA) #1 at 12:00 PM; the Rehab Manager at 12:02 PM; SRNA #5 at 12:03 PM; SRNA #6 at 1:55 PM; SRNA #7 at 1:58 PM; SRNA #8 at 2:01 PM; SRNA #9 at 2:04 PM; SRNA #10 at 2:07 PM; SRNA #11 at 2:10 PM; Housekeeper #3 at 2:20 PM; Housekeeper #1 at 2:23 PM; Maintenance Assistant #1 at 2:24 PM; Dietary Aide #3 at 2:28 PM; Dietary Aide #1 at 2:32 PM; SRNA #3 at 3:11 PM; SRNA #1 at 3:13 PM; SRNA #12 at 3:15 PM; SRNA #13 at 3:17 PM; SRNA #14 at 3:24 PM; SRNA #15 at 3:26 PM; LPN #8 at 5:30 PM; RN #1 at 5:35 PM; LPN #9 at 5:40 PM; and LPN #10 at 5:45 PM revealed they had been in-serviced on the construction plan and the new, temporary evacuation routes and the new temporary exit diagrams, along with taking a post test to ensure they understood the education material. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she used an employee roster in conjunction with training logs to assure no employee worked without the education, she continued by stating that to ensure accuracy/staff understanding of the education, she would select two (2) completed post tests and re-interview that staff person. Review of documentation revealed the employee roster had been crosschecked against an employee training log to ensure employees had not worked without receiving the education and post test to ensure competency. 3. Review of the education documents revealed all interviewable residents had been educated and a questionnaire was used to ensure resident understanding of the education related to the new evacuation plan and evacuation routes. Interviews with Resident #24 on 07/02/14 at 11:30 AM and Resident #23 at 11:35 AM, revealed they had been educated and completed a questionnaire related to the new construction and new evacuation plans. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had been her assigned task to educate residents with a BIMS of eight (8) or greater on the construction plan and the new temporary evacuation routes while construction was in place. The SSD indicated she had performed her education with interviewable residents on 06/30/14 and 07/01/14. Review of the education documents revealed the same education tool used for interviewable residents had been used to educate residents' responsible parties regarding the construction and new evacuation plans. Record review of phone logs revealed Resident #25's family had been contacted regarding the construction and educated on the temporary evacuation routes. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had also been her assigned task to educate residents' responsible parties on the construction plan and the temporary evacuation routes while construction was in place. The SSD stated she initiated the education for responsible parties on 06/03/14 and 07/01/14. Continued interview revealed she had answered any questions the responsible parties might have had. She indicated she would continue notification and education until all responsible parties/families had been contacted. Further interview revealed she used the facility census sheet to ensure responsible parties of non-interviewable residents received the construction education. 4. Observations, on 07/02/14 at 11:15 AM, revealed the new signage was in place at the Main Entrance and employee entrance doors as alleged on the AOC. Continued observation revealed the new temporary exit diagrams were also posted as alleged. Observation, on 078/02/14 at 11:32 AM, revealed signs stating "STOP-DO NOT USE" were posted on the "temporarily closed" evacuation exits. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed he had placed the new signage and temporary exit diagrams on 06/30/14 at approximately 8:30 PM. 5. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM, revealed he had been notified by the DON of the IJ on 07/01/14. 6. Review of the minutes revealed a QA meeting was held on 07/01/14, and revealed the Medical Director was in attendance via telephone. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM revealed he had been notified by the DON of the IJ on 07/01/14, during the QA meeting. He stated the plan implemented by the facility was a good plan, and he didn't think there was anything he would have added to the plan. Continued interview revealed he provided insight on Quality Measures and acted as a resource for facility staff education as part of his responsibilities as the Medical Director. 7. Review of the daily Maintenance Audit logs beginning 07/01/14 revealed Maintenance was performing daily rounds to verify, by initialing the log, that the Main Entrance and employee entrance door signage remained in place to inform visitors that construction was in progress, the temporary exit diagrams remained posted on all temporary evacuation routes and the "STOP-DO NOT USE" signs remained in place on the temporarily closed evacuation routes. Continued review of the Audit log revealed the Administrator was also initialing the log indicating she had performed walking rounds as verification of the accuracy of the Maintenance audits until the construction process is completed. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed maintenance was performing the daily audits and initialing the log for verification. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she was performing her walking rounds daily of the signage posted and initialing the maintenance audit log. 8. Review of the staff education revealed a questionnaire related to the exit routes and evacuation plan. Review of the completed questionnaires revealed the Administrator, DON, ADON, SDC, Dietary Director, Medical Records Director or HR Director had administered the questionnaire. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she, the DON or RNC had reviewed the questionnaires. She indicated she was performing "spot checks" of questionnaires as per the AOC. The Administrator stated the questionnaire results would be taken to the facility's QA Committee weekly and QA would determine the frequency at which the questionnaires would be used. According to the Administrator, if there were any concerns identified they were to be reported to her. 9. Interview with the RNC on 07/02/14 at 4:45 PM revealed she had been on site daily since 06/30/14. Continued interview revealed she assisted the Administrator in any capacity she needed to ensure compliance with staff education and ensure the daily Maintenance audits were completed accurately and turned into the Administrator. Interview with the Chief Nursing Executive on 07/02/14 at 4:50 PM, via telephone, revealed she was in daily contact with the RNC and facility and acted as a resource when needed. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed prior to the construction areas being re-opened, she and the Maintenance Director will inspect the construction area to ensure it is safe to use and institute re-education for all staff, residents and/or their responsible party.

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on observation, record review, interview, review of the facility's policy and Evacuation Plan, during the 07/03/14 survey, it was determined the facility failed to have an effective system to identify a Quality Assurance (QA) concern, and develop and implement appropriate plans of action. The facility's QA system's failure to develop and implement appropriate plans of action prevented the facility from ensuring effective measures were in place for appropriate evacuation of residents from the Northwest and Southwest hallways and dining room in case of fire or other emergencies, due to the exits not being accessible related to construction. The primary emergency exit routes for the Northwest and Southwest Hallways were the exits at the end of the hallways leading outside per the facility's evacuation plan; however, observation revealed those were the exits inaccessible due to the construction. This could potentially affect sixty (60) residents out of the facility's one hundred and twenty-four (124) residents in the event of an emergency evacuation. In addition, the map posted in the dining room revealed arrows leading to the outside exit, as the emergency exit route from the dining room. Observation revealed there was construction outside the dining room door exit. The facility's QA system failed to identify, develop and implement plans of action to address: the construction outside the facility leaving the three (3) emergency exit doors without a safe path to a public way; the need for a revised evacuation plan in the case of a fire or other emergency related to the three (3) emergency exit doors; and the need to ensure staff was trained and knowledgeable of which fire exits were appropriate for evacuation during the construction. (Refer to F-323, F-490 and F-518) The facility's failure to develop and implement an evacuation plan during construction which affected fire/emergency exits was likely to to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 06/30/14 and determined to exist on 06/24/14. The facility was notified of the Immediate Jeopardy on 06/30/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/03/14 with the facility alleging removal of the Immediate Jeopardy on 07/02/14. The Immediate Jeopardy was verified to be removed on 07/02/14, with remaining non-compliance at 42 CFR 483.75 Administration at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure the residents' environment remains as free of accidental hazards as was possible; and each resident receives adequate supervision to prevent accidents. Based on observation, interview, record review, review of the facility's policy and investigation reports and call light audits, during the 08/01/14 survey, it was determined the facility failed to have an effective system to develop and implement appropriate plans of action to ensure resident grievances were acted upon and resolved regarding call light issues. (Refer to F-166) The findings include: Review of the facility's, "Performance Improvement Plan" Policy, dated February 2009, revealed it was the intent of the facility to conduct an ongoing performance improvement program designed to: systematically monitor and evaluate the quality and appropriateness of resident care; pursue opportunities to improve resident care; resolve identified problems; and identify opportunities for improvement in a timely manner. Further review revealed the Performance Improvement (PI) Committee and the facility would use the risk management approach to establish key quality indicators designed to monitor effectiveness of established systems across departments. Reference F-323, F-490, F-518 1. Review of the facility's, "Disaster Preparedness" Manual, dated January 2005, revealed the fire safety procedure plan noted when preparing for an evacuation when the fire alarm was sounded the primary exit route should be checked first, and if this exit was safe and clear staff should use that exit if evacuation was ordered. Review of the facility's, "North Nursing Department Fire Emergency Guidelines" and "South Nursing Department Fire Emergency Guidelines", both undated, revealed staff was to check the primary exit route and if it was blocked they were to use the secondary route. Observation of the maps posted across from the nurse's station on the North and South units on 06/30/14, revealed the maps had arrows pointing towards the exit doors at the end of the Northwest and Southwest hallways leading to the outside indicating those doors were an exit route. Additionally, review of the map posted in the dining room on 06/30/14, revealed arrows leading from the dining room to the exit door, which led outside the building, as an exit route from the dining room. On 06/30/14 at 2:20 PM, interview with the Director of Plant Operations revealed on 06/24/14 construction started with removal of the concrete pavement outside of the Northwest hallway and the dining room exit, and on 06/27/14 the concrete pavement was removed outside the Southwest hallway exit door. The Director of Plant Operations stated he was not aware of the facility having a revised evacuation plan related to construction. He stated staff, including himself, had not received any formal training related to a new evacuation plan due to construction, even though those three (3) exits were not accessible in case of an emergency evacuation because of the construction. Observations on 06/30/14 from 5:15 PM until 5:24 PM of the dining room exit door revealed a concrete pad leading to a three and a half (3.5) inch drop off which led to rebar (steel bar used in construction to reinforce concrete) and gravel. Observation of the Northwest hallway exit door revealed a ramp leading to a three (3) inch drop off to gravel and rebar. Additionally, observation of the Southwest hallway exit door revealed a ramp leading to a four and a half (4.5) inch drop off to gravel. Interview, on 06/30/14 at 5:05 PM and 07/03/14 at 7:00 PM, with the Director of Nursing (DON) revealed on 06/17/14, she was told construction would be starting on 06/18/14 and they were told to stay clear of the exit doors to the Northwest and Southwest hallways exits because the sidewalks were being replaced outside those doors. However, she had not been educated as to the alternate routes to use for emergency evacuation due to those exits being inaccessible. The DON stated it would be important for the facility to have an alternate evacuation plan and ensure staff were inserviced on this because staff would be unable to get wheelchairs out the exits by the construction. According to the DON, she did not remember bringing up any safety concerns related to the construction in the last QA Meeting. She further stated the facility had no QA Nurse, and all the department heads were responsible for bringing their audits and tracking and trending related to their departments to the QA meetings to discuss findings. Interview with the Staff Development Nurse (SDN) on 06/30/14 at 5:30 PM, revealed she was aware there was construction taking place outside the building as new concrete was being put on the driveway in the back of the building. She stated she was told staff could not use the exits at the back of the building including the dining room exit and she had provided a verbal inservice to some staff, on 06/20/14, related to the construction and which exit doors to use for an emergency evacuation. However, she was unaware there was construction near the Northwest hallway exit door and had not inserviced staff related to the door being inaccessible. She stated she was unaware of the facility having any new formal evacuation plan in case of fire or other emergency prior to or since the construction began. Interview, on 06/30/14 at 7:00 PM, with the Administrator revealed she had been informed on 05/15/14, by the previous Administrator, construction was to begin on 06/17/14 to include replacement of damaged pavement on the back side of the building which was the west side. She stated however, the construction was delayed and did not start until 06/24/14. Per interview, the Administrator had discussed the construction would consist of taking up the old concrete and re-pouring concrete at the back of the building every few days in the morning meetings. However, she stated during those morning meetings they had not discussed any safety aspects related to the construction. The Administrator explained the facility evacuation plan stated if for some reason an exit could not be used, staff were to use another exit; but she stated if all staff was not aware they could not use certain fire exit doors, this could cause a delay in getting residents evacuated from the building in an emergency situation. The Administrator indicated this was her first time having construction in a building as Administrator and therefore, had not thought about needing a new emergency evacuation plan for the facility. She stated in hindsight though she should have ensured there was a new emergency evacuation plan specific to address the three (3) emergency fire exits not available for use during the construction. Per interview the Administrator revealed the last QA meeting was 06/18/14, prior to the initiation of construction. She stated she had told the QA Committee in that meeting, construction was getting ready to start. The QA Committee had discussed the construction; however, they had not identified or discussed any safety aspects related to the fire exit doors which would be inaccessible during the construction. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 07/03/14, which alleged removal of the Immediate Jeopardy (IJ), effective 07/02/14. Review of the AOC revealed the facility implemented the following: 1. The Regional Nurse Consultant (RNC) inserviced the Administrator and the entire Safety Committee (Human Resources Director/Safety Director, ADON North, Business Office Manager (BOM), Chaplain, Clinical Social Worker (CSW), Rehabilitation (Rehab) Manager, Medical Records Director, Dietary Director, Housekeeping Director, Activity Director, Staff Development Coordinator (SDC), Plant Operations Director, DON, ADON South, MDS LPN, MDS RN and Marketing Director, who were also the Quality Assurance (QA) Committee, on 06/30/14 during a Safety Committee meeting held to discuss the facility's Fire Safety Procedure for alternate evacuation routes due to construction. The education covered construction planning and continued safety of residents. Additionally, the construction plan and assignments, that delineated which staff member was responsible for what piece of the AOC, were dispersed to all departments by the Administrator and the Safety Committee Director. The construction plan included the creation of new routes and temporary exit diagrams, placement of signage outlining the construction plan in appropriate areas that included the front entrance, parking lot entrance and the doors which were closed related to the construction. New signs stating "DO NOT USE" were also placed on the affected doors. 2. Inservices were initiated on 06/30/14 and 07/01/14, by the DON, Assistant Director of Nursing (ADON), Dietary Manager (DM), Staff Development, Business Office Manager (BOM), Housekeeping Director and Rehabilitation (Rehab) Director for all staff, including dietary, housekeeping, therapy, laundry and maintenance. The education consisted of the new evacuation plan and continued safety of residents. Additionally, no employee would be allowed to work until the education was provided and the post test completed to ensure compliance with exit routes. The Administrator maintained an employee roster to crosscheck with the training log to assure no employee was allowed to work until the education was received. One hundred and fifty-five (155) employees of one hundred and sixty-three (163) employees had been educated by 07/01/14. The facility did not utilize agency staff. 3. All residents with a BIMS score of eight (8) or greater on their last MDS were informed of the construction and alternate evacuation routes, as well as, the the new evacuation signs. Forty-eight (48) residents met the criteria and were informed as indicated by the Activity Director and Social Service Director on 06/30/14 and 07/01/14. Responsible Parties of residents, who were frequent visitors to the facility, were notified of the construction and temporary evacuation routes, by telephone by the Chaplain and Marketing Director. Thirty (30) Responsible Parties were notified on 06/30/14 and 07/01/14, with plans to continue notifications daily until all resident families/responsible parties were notified. 4. Signs were placed on the Main Entrance and the employee entrance doors on 06/30/14 by the Maintenance Director to inform all visitors that "Construction is in progress". Also, new temporary exit diagrams (maps) were created for the South West/North West/ Dining Room/Dietary Services/Laundry Area by the Safety Committee on 06/30/14 and posted on all temporary alternate evacuation routes. Signs were created and posted on all "temporarily closed" evacuation exits that stated, "STOP-DO NOT USE" by the Maintenance Director on 06/30/14. 5. The Medical Director was notified of the IJ 07/01/14 by the DON. 6. A QA meeting was held on 07/01/14 to review the new temporary exit diagrams for the South West/North West/Dining Room, Dietary Services and Laundry areas. Signs were created and posted on all areas of temporary alternate evacuation routes. Signs were created and posted on all temporarily closed evacuation exits to "STOP-DO NOT USE". The the entire plan was reviewed with the Medical Director on 07/01/14 during the QA meeting. The Medical Director approved the plan developed by the facility to address the IJ. Another QA meeting was scheduled for 07/09/14. 7. Maintenance was to audit daily beginning 07/01/14, to ensure signage was in place on the Main Entrance and employee entrance door informing all visitors "Construction is in process". The maintenance audit was to include a daily check to ensure the new temporary exit diagrams created for the South West/North West/Dining Room, Dietary Services and Laundry area's remain posted on all temporary alternate evacuation routes and to ensure that signs created and posted on all "temporarily closed" evacuation exits saying "STOP-DO NOT USE" remain in place. The results of the audits will be turned in daily to the Administrator until the construction project is completed. The Administrator was do daily rounds of the signage to assure accuracy of maintenance audits until the project is completed. 8. A staff questionnaire regarding exit routes and evacuation plan was being administered by the Administrator, DON, ADONs, SDC, Dietary Director, BOM, Social Services Director (SSD), Chaplain, Admissions Director, Medical Records Director, and HR Director to five (5) staff members on each shift and different staff members until the immediacy was removed beginning 07/01/14. After the immediacy was removed ten (10) staff questionnaires were to be done daily to ensure continued understanding of exit routes and evacuation plan. All results of the questionnaires were to be reviewed by the Administrator, DON or Regional Nurse Consultant. The Administrator was to review all audits for completeness and accuracy, as well as, conduct "spot checks" of questionnaires to staff to ensure knowledge and accuracy of audits. Results of the staff questionnaires were to be reviewed by the QA Committee weekly to determine the further need of continued education or revision of the facility's plan. The QA Committee was to determine at what frequency the questionnaires for staff would need to continue. Any concerns identified were to be corrected immediately and reported to the Administrator. 9. A RNC has been onsite since 06/30/14, to assist with compliance with staff education, ensure daily audits were completed by the Maintenance Director and turned into the Administrator with no issues identified, and ensure daily staff questionnaires were completed as scheduled to ensure staff were aware of the new exits/evacuation plan. The Vice President (V/P) of Operations or Chief Nurse Executive were in daily contact with the RNC to review the above. Before the construction areas are re-opened, the areas are to be inspected by the Administrator and Maintenance Director to ensure the areas were safe for use. The State Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she and the entire Safety Committee had been inserviced by the RNC on the construction plan, resident safety and the new, temporary evacuation routes and diagrams on 06/30/14 at approximately 8:15 PM. Review of the education information revealed the construction plan which included the creation of new routes and temporary exit diagrams, placement of signage at the front doors, parking lot entrance and doors which were to be closed related to the construction. 2. Review of the education information, including the post tests, provided to all staff, revealed the education included education on the construction plan and new signs posted and included the following statement, "due to the recent construction on the back driveway of the facility, new evacuation routes have been implemented until further notice". Continued review of the education material revealed the alternate evacuation plan was included, as well as, the questions for the post test to ensure competency and understanding. Interviews on 07/02/14 with Certified Occupational Therapy Aide (COTA) #1 at 12:00 PM; the Rehab Manager at 12:02 PM; SRNA #5 at 12:03 PM; SRNA #6 at 1:55 PM; SRNA #7 at 1:58 PM; SRNA #8 at 2:01 PM; SRNA #9 at 2:04 PM; SRNA #10 at 2:07 PM; SRNA #11 at 2:10 PM; Housekeeper #3 at 2:20 PM; Housekeeper #1 at 2:23 PM; Maintenance Assistant #1 at 2:24 PM; Dietary Aide #3 at 2:28 PM; Dietary Aide #1 at 2:32 PM; SRNA #3 at 3:11 PM; SRNA #1 at 3:13 PM; SRNA #12 at 3:15 PM; SRNA #13 at 3:17 PM; SRNA #14 at 3:24 PM; SRNA #15 at 3:26 PM; LPN #8 at 5:30 PM; RN #1 at 5:35 PM; LPN #9 at 5:40 PM; and LPN #10 at 5:45 PM revealed they had been in-serviced on the construction plan and the new, temporary evacuation routes and the new temporary exit diagrams, along with taking a post test to ensure they understood the education material. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she used an employee roster in conjunction with training logs to assure no employee worked without the education, she continued by stating that to ensure accuracy/staff understanding of the education, she would select two (2) completed post tests and re-interview that staff person. Review of documentation revealed the employee roster had been crosschecked against an employee training log to ensure employees had not worked without receiving the education and post test to ensure competency. 3. Review of the education documents revealed all interviewable residents had been educated and a questionnaire was used to ensure resident understanding of the education related to the new evacuation plan and evacuation routes. Interviews with Resident #24 on 07/02/14 at 11:30 AM and Resident #23 at 11:35 AM, revealed they had been educated and completed a questionnaire related to the new construction and new evacuation plans. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had been her assigned task to educate residents with a BIMS of eight (8) or greater on the construction plan and the new temporary evacuation routes while construction was in place. The SSD indicated she had performed her education with interviewable residents on 06/30/14 and 07/01/14. Review of the education documents revealed the same education tool used for interviewable residents had been used to educate residents' responsible parties regarding the construction and new evacuation plans. Record review of phone logs revealed Resident #25's family had been contacted regarding the construction and educated on the temporary evacuation routes. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had also been her assigned task to educate residents' responsible parties on the construction plan and the temporary evacuation routes while construction was in place. The SSD stated she initiated the education for responsible parties on 06/03/14 and 07/01/14. Continued interview revealed she had answered any questions the responsible parties might have had. She indicated she would continue notification and education until all responsible parties/families had been contacted. Further interview revealed she used the facility census sheet to ensure responsible parties of non-interviewable residents received the construction education. 4. Observations, on 07/02/14 at 11:15 AM, revealed the new signage was in place at the Main Entrance and employee entrance doors as alleged on the AOC. Continued observation revealed the new temporary exit diagrams were also posted as alleged. Observation, on 078/02/14 at 11:32 AM, revealed signs stating "STOP-DO NOT USE" were posted on the "temporarily closed" evacuation exits. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed he had placed the new signage and temporary exit diagrams on 06/30/14 at approximately 8:30 PM. 5. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM, revealed he had been notified by the DON of the IJ on 07/01/14. 6. Review of the minutes revealed a QA meeting was held on 07/01/14, and revealed the Medical Director was in attendance via telephone. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM revealed he had been notified by the DON of the IJ on 07/01/14, during the QA meeting. He stated the plan implemented by the facility was a good plan, and he didn't think there was anything he would have added to the plan. Continued interview revealed he provided insight on Quality Measures and acted as a resource for facility staff education as part of his responsibilities as the Medical Director. 7. Review of the daily Maintenance Audit logs beginning 07/01/14 revealed Maintenance was performing daily rounds to verify, by initialing the log, that the Main Entrance and employee entrance door signage remained in place to inform visitors that construction was in progress, the temporary exit diagrams remained posted on all temporary evacuation routes and the "STOP-DO NOT USE" signs remained in place on the temporarily closed evacuation routes. Continued review of the Audit log revealed the Administrator was also initialing the log indicating she had performed walking rounds as verification of the accuracy of the Maintenance audits until the construction process is completed. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed maintenance was performing the daily audits and initialing the log for verification. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she was performing her walking rounds daily of the signage posted and initialing the maintenance audit log. 8. Review of the staff education revealed a questionnaire related to the exit routes and evacuation plan. Review of the completed questionnaires revealed the Administrator, DON, ADON, SDC, Dietary Director, Medical Records Director or HR Director had administered the questionnaire. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she, the DON or RNC had reviewed the questionnaires. She indicated she was performing "spot checks" of questionnaires as per the AOC. The Administrator stated the questionnaire results would be taken to the facility's QA Committee weekly and QA would determine the frequency at which the questionnaires would be used. According to the Administrator, if there were any concerns identified they were to be reported to her. 9. Interview with the RNC on 07/02/14 at 4:45 PM revealed she had been on site daily since 06/30/14. Continued interview revealed she assisted the Administrator in any capacity she needed to ensure compliance with staff education and ensure the daily Maintenance audits were completed accurately and turned into the Administrator. Interview with the Chief Nursing Executive on 07/02/14 at 4:50 PM, via telephone, revealed she was in daily contact with the RNC and facility and acted as a resource when needed. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed prior to the construction areas being re-opened, she and the Maintenance Director will inspect the construction area to ensure it is safe to use and institute re-education for all staff, residents and/or their responsible party. Reference F-166 2. Review of the facility's policy titled, "Investigating a Resident Grievance or Complaint", dated December 2010, revealed grievances and/or complaints would be investigated and recorded on the grievance/complaint log. The Policy noted the Administrator would assign the responsibility of investigating grievances and complaints to the Social Services Director (SSD) or designee who would initiate an investigation. The policy revealed the investigation and report were to include a follow-up/recommendation for corrective action, a resolution, date of the resolution and was to be reviewed by the Administrator within three (3) working days of the facility receiving the complaint/grievance. The Policy stated the resident or responsible party was to be notified of the findings. Review of the Resident Council Minutes for April, May, June and July of 2014 revealed the residents had complained of their call bells not being answered timely in the past two (3) months. Interview with residents during the Group Interview and also individual resident interviews revealed they continued to complain of their call bells not being answered timely. However, review of the facility's documentation regarding grievance forms and call light audits revealed no documented evidence the facility had attempted to resolve the residents' grievances regarding call bells, until 06/03/14, even though this had been an ongoing concern expressed by residents since April 2014. Interview with the SSD, on 07/03/14 at 4:08 PM and on 07/25/14 at 7:20 PM, revealed to address the Resident Council's concerns related to their call lights not being answered timely, she developed an audit for call lights to be performed across all shifts and during shift changes. The SSD indicated the call light audits had been initiated "a few months ago". Per interview, on 07/03/14 at 3:42 PM, with the Activities Director, with Registered Nurse (RN) #4/Assistant Director of Nursing (ADON) at 4:35 PM, and at 6:41 PM with the Staff Development Coordinator (SDC) revealed call light audits were being conducted on all shifts. The Activity Director stated residents had voiced concerns in the Resident Council Meetings regarding staff taking a long time to answer their call lights, which were placed on grievance forms and given to the Social Services Director (SSD) to investigate. RN #4/ADON revealed the SSD was responsible for the audits of the call lights and the audits were supposed to be reviewed in the facility's Quality Assurance (QA) meetings. The June 2014 call light audits were reviewed and revealed only the 7:00 AM to 3:00 PM, and 3:00 PM to 11:00 PM shift had been audited. Continued review revealed no documented evidence of call light audits conducted on the 11:00 PM to 7:00 AM shift. Further interview with the SSD, on 07/03/14 at 4:08 PM and on 07/25/14 at 7:20 PM, revealed call light audits had not been completed during the 11:00 PM to 7:00 AM shift because there were not "a lot" of complaints related to the night shift. She stated after becoming aware of problems regarding night shift on 07/03/14, after surveyor intervention, the call light audits had been initiated at that time on night shift. However, the SSD indicated the call light audits should have been done during night shift also, as the QA process had been for audits to be performed across all shifts. Interview, on 07/03/14 at 5:20 PM and 08/01/14 at 9:34 AM with the Director of Nursing (DON), revealed once a week administrative staff discussed with residents how the staff responsible for their care was doing with answering their call lights. The DON reported if a concern was identified, she would talk to residents more often regarding this. Per interview, the DON indicated residents' concerns were why the facility was continuing with the call light audits. She stated the facility had been aware of call lights being an issue related to Resident Council concerns and resident interviews which had been taken to the QA meetings and discussed. The DON stated when concerns were identified and taken to QA and audits implemented, and if the issue continued to be a concern, audits were increased. Per interview, she stated since "most" of the call light concerns had been related to evening shift and weekends the audits had been performed during those timeframe's, and stated the audits had been performed from the information "we had". She reported the SSD analyzed the "findings" of the call light audits and looked for "patterns on when it" took longer for staff to answer the call lights. Interview, on 07/03/14 at 7:25 PM, with the former Administrator and on 07/31/14 at 10:14 PM revealed she had not attended the facility's June 2014 Quality Assurance (QA) Meeting. She stated the facility was conducting call light audits when she became Administrator, and she knew call lights were an issue in the Resident Counsel Meetings. However, the Administrator reported she was not sure if the call light audits were being conducted on night shift. The Administrator indicated the audits may have been more effective if the time it took for each call light to be answered was the focus, instead of looking at the average time for a call light to be answered. She did not think the current QA effort to improve the timeliness of answering call bells had been effective to correct the problem.

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on interview, record review, review of the facility's policy and investigation reports, during the 08/01/14 survey, it was determined the facility failed to have an effective system in place to ensure all allegations of abuse, including neglect, were investigated thoroughly to ensure residents were protected from further neglect for five (5) of thirty-seven (37) sampled residents (Residents #5, #26, #27, #28, #29). (Refer to F-224) On 07/03/14, Resident #26, who resided on the South Unit, rang the call bell for incontinence care assistance at approximately 5:30 AM; however was not assisted until approximately 7:45 AM, (two hours and fifteen minutes later). Interview with the day shift State Registered Nursing Assistant (SRNA), who assisted Resident #26 at 7:45 AM, revealed the resident was soaked with urine and covered in bowel movement. Staff interviews further revealed other residents on the South Unit were also left soaked in urine or soiled with bowel movement the morning of 07/03/14, after day shift reported to work at 7:00 AM. These residents included #5, #27, #28, and #29. Review of the facility's investigation revealed only Resident #26's concern and his/her condition on the morning of 07/03/14 was investigated. There was no documented evidence the facility investigated the conditions of Residents #5, #27, #28 and #29 who reportedly had been left urine soaked and soiled the morning of 07/03/14 and no documented evidence an assessment was performed on Residents #5, #27, #28 and #29, who were assessed by the facility as non-interviewable. In addition, the facility failed to assess other non-interviewable residents on the South Unit for possible neglect through skin assessments and failed to interview all staff who had knowledge of the condition the residents were found in, on 07/03/14 at shift change. Additionally, review of the facility's investigation reports revealed a staff interview which indicated a conflict between SRNA #19 and SRNA #21, who were usually scheduled as the night shift SRNAs for the South Unit, on which all the aforementioned residents resided. Even though the conflict was noted in Registered Nurse (RN) #4's/Assistant Director of Nursing's (ADON) written statement in the facility's investigation, there was no documented evidence the facility investigated and interviewed the two (2) SRNAs about the conflict after becoming aware of it during the investigation, or that the facility followed-up and addressed the conflict issue to ensure residents were protected from possible further neglect. Staff interviewed by the State Survey Agency revealed the conflict impacted resident care during the night shift on the South Unit on 07/03/14. The facility's failure to have an effective system in place to ensure all allegations of abuse, including neglect were investigated thoroughly, and to ensure residents were protected from further neglect was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 07/25/14, and was determined to exist on 07/03/14. The facility was notified of the Immediate Jeopardy on 07/25/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14 with the facility alleging removal of the Immediate Jeopardy on 07/29/14. The Immediate Jeopardy was verified to be removed on 07/29/14, prior to exiting the facility on 08/01/14, with remaining non-compliance at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure an effective system is in place to ensure all allegations of abuse, including neglect are investigated thoroughly, and residents are protected from further neglect. The findings include: Review of the facility's policy titled, "Abuse, Neglect and Misappropriation", dated April 2013 revealed abuse and neglect of residents was prohibited. Review of the Policy revealed staff was to be trained on abuse to include what constituted abuse, neglect or misappropriation of resident property. The Policy revealed all allegations of abuse were to be investigated, and the Administrator/designee was to make all reasonable efforts to investigate and address alleged reports, grievances and concerns. Further review revealed Social Services or the Chaplain were to follow up with the resident to monitor his/her emotional well-being after an incident, and families were to be notified of the outcome of the investigation. Interview, 07/03/14 at 2:26 PM, with Resident #26 revealed early that morning the resident had requested night shift SRNA #19's assistance to get cleaned up as he/she had "pooped" on himself/herself. According to Resident #26, SRNA #19 did not assist him/her as requested , which made the resident feel staff "did not want to change" him/her and feel like he/she "wasn't supposed to be clean". Resident #26 was observed to start crying, and stated he/she did not received assistance to be changed until after day shift SRNAs came to work. Interview with SRNA #9 on 07/03/14 at 2:44 PM, revealed when she reported to work for day shift on 07/03/14, she found several residents "soaked" and/or soiled, and needing to be changed (Residents #5, #26, #27, #28, and #29). Review of the facility's investigation reports, dated 07/03/14 through 07/07/14, revealed only Resident #26's concerns were investigated. There was no documented evidence of Resident #5, Resident #27, Resident #28 or Resident #29 being left wet and/or soiled by night shift staff on 07/03/14 was investigated. Continued review of the investigation report revealed Resident #26 was interviewed on 07/03/14 and had concerns about the care received by night shift staff which he/she had reported to Registered Nurse (RN) #5/Evening Shift Supervisor. Interview, on 07/03/14 at 6:45 PM, with RN #5/Evening Shift Supervisor revealed at approximately 4:08 PM that day she had spoken with Resident #26 who told her SRNA #19 had left him/her "wet and with crap" on him/her. RN#5/Evening Shift Supervisor stated she went to the Director of Nursing (DON) and Social Services Director (SSD) and reported to them what Resident #26 had told her. Continued review of the investigation report revealed staff statements were obtained and two (2) staff interviewed, Licensed Practical Nurse (LPN) #12 and RN #4/ADON indicated SRNA #9 had reported concerns regarding the condition residents were left in by night shift staff on 07/03/14. Review of the written statement for LPN #12 revealed SRNA #9 reported to him her "group" of assigned residents, on the Southeast Hall of the South Unit, were "all wet" when she took over their care. LPN #12 noted in his written statement he told SRNA #9 to "take it to" RN #4/ADON or the DON, and the SRNA "just turned and walked away". Review of RN #4's/ADON's written statement revealed SRNA #9 had stated "late in the day" on 07/03/14 that Resident #26 had reported to her he/she had been "covered in feces up to" his/her waist and no one had changed him/her. RN #4/ADON documented having spoken to SRNA #16 who had sat "one on one" with Resident #26, "since around 6:20" AM. RN #4/ADON noted SRNA #16 told her SRNA #19 (the night shift SRNA) informed her she had not changed Resident #26 because the resident was a two (2) person assist, and she and the "other night shift" aide, SRNA #21 "don't work together". However, continued review of the investigation report revealed no documented evidence SRNA #9 was interviewed by the facility regarding her concerns on 07/03/14. Interview with SRNA #9 on 07/03/14 at 2:44 PM, revealed she had never been interviewed regarding her concerns on 07/03/14, in regards to Resident #5, Resident #26, Resident #27, Resident #28 and Resident #29 being left wet and/or soiled by night shift staff. Even though she had expressed her concerns regarding the residents care to LPN #12 and RN #4/ADON which was documented on their written statements that was part of the investigation conducted 07/03/14 through 07/07/14. Interview, on 07/03/14 at 4:35 PM, with the RN #4/ADON revealed she had not talked directly to SRNA #9; however, indicated she should have. Per interview, RN #4/ADON stated she was not aware of a conflict between SRNA #19 and SRNA #21 at the time of the incident on 07/03/14. She stated if they were not "working well together" it could "impact" resident care. Additionally, review of the facility's investigation report dated 07/03/14 through 07/07/14, revealed staff interviews which indicated a conflict between SRNA #19 and SRNA #21, who were usually scheduled as the night shift SRNAs for the South Unit, on which all the aforementioned residents resided. Even though SRNA #19's phone interview statement revealed she had "difficulty" getting SRNA #21 to help her, and RN #4/ADON's written statement noted SRNA #19 and SRNA #21 didn't "work together", there was no documented evidence the facility interviewed the two (2) SRNAs about the conflict, or that the facility followed-up and addressed the issue to ensure residents were protected from possible further neglect. Interview conducted on 07/23/14 at 9:08 AM, with SRNA #19 revealed the DON had never discussed the incident involving Resident #26, on the morning of 07/03/14, with her. She stated she had never been asked to write a statement about what had occurred, and had never been interviewed by any of the administrative staff. However, review of the investigation report revealed a telephone interview was conducted with SRNA #19 on 07/03/14 by the Human Resources (HR) Director related to Resident #26. Continued interview with SRNA #19 revealed SRNA #21 and she had a conflict between them, and therefore did not work together when assigned as the two (2) SRNAs on the night shift for the South Unit. SRNA #19 stated she had told nurses about the conflict, and had written a grievance about the conflict and put it under the DON's office door. However, she stated nothing had ever been done and she had never been interviewed regarding the conflict. Interview, on 07/23/14 at 4:51 PM, with SRNA #21 revealed no one in the facility had ever discussed the incident involving 07/03/14 with her. Further review of the investigation report, dated 07/07/14, revealed Resident #26's concerns/allegation were unsubstantiated, as there were no findings of abuse or neglect. In addition, review of the investigation report revealed no documented evidence other non-interviewable residents also cared for by SRNA #19 on 07/03/14 had been assessed or their families/responsible parties interviewed. A group interview was held with the HR Director, Social Services Director (SSD) and DON on 07/23/14 at 5:49 PM. Per the SSD, she was responsible for abuse investigations. She stated on 07/03/14 the investigation performed had been "focused" on Resident #26's concerns. The SSD indicated she was unaware of a conflict between SRNA #19 and SRNA #21, even though two (2) staff reported concerns in staff interviews conducted on 07/03/14. The SSD reported the investigation report was reviewed by the former Administrator on 07/07/14, in conjunction with herself and the HR Director. Per the HR Director, she had assisted with the abuse investigation on 07/03/14 by interviewing the staff she thought had been assigned to Resident #26's care that day. She stated she was not sure why she had not interviewed SRNA #9. The HR Director stated she had investigated what she could; but had missed information in staff's statements, obtained during the investigation, including the conflict between SRNA #19 and SRNA #21, and SRNA #9's concerns about resident care. Per the DON, she had not reviewed the investigation after it was completed on 07/07/14, and she should have been more involved in the investigation as it was related to a nursing issue. The DON indicated she was unaware of SRNA #9's concerns reported by other staff in interview on 07/03/14. The DON stated the facility's investigation should have indicated why staff did not take action when SRNA #9 expressed concerns to them. Per interview, the DON indicated she was not sure if non-interviewable residents, cared for by SRNA #19, had been assessed. The DON stated she had not been aware of the conflict between SRNA #19 and SRNA #21 until 07/23/14, when RN #6 reported it to her. According to the DON, RN #6 told her, on 07/23/14, she had thought she "could handle it"; however, the DON stated RN #6 should have reported the conflict to Administration so it could be addressed. Interview, on 07/03/14 at 7:00 PM, with RN #6, the night shift nurse working with SRNA #19 on 07/03/14, revealed there was a personal conflict between SRNA #19 and SRNA #21, who were the SRNAs regularly scheduled on the unit. She stated due to the personal conflict between SRNA #19 and SRNA #21 resident care had been negatively impacted that night. RN #6 revealed she had not reported the information regarding the conflict between SRNA #19 and SRNA #21 to Administration; however, indicated she should have reported the incident. Continued interview with the SSD on 07/23/14 at 5:49 PM, revealed the former Administrator had determined the allegation to be unsubstantiated in regards to Resident #26's concerns from 07/03/14, as the facility hadn't been able to "determine the timeframe" for the resident having been left wet. However, review of the facility's investigation revealed documented evidence staff had expressed concerns regarding the condition residents had been found in the morning of 07/03/14, which included Resident #26 and Resident #29. Additional interview on 07/25/14 at 7:20 PM, with the HR Director and SSD revealed the SSD stated stated skin assessments should have been completed on all non-interviewable residents SRNA #19 had been responsible for from 11:00 PM on 07/02/14, through 7:00 AM on 07/03/14. Per interview, the SSD stated those residents' families or responsible parties should have been interviewed, and nursing staff would have needed to have been involved for residents who couldn't speak for themselves. Per interview, the HR Director revealed because the former Administrator had "led and directed the investigation" she and the SSD had not notified the DON of the results of the investigation. According to the HR Director, had she and the SSD known "more detailed" information "like which residents were left wet" she would have conducted a more thorough investigation. The HR Director stated she had been trained to investigate allegations by her Administrators "in the past throughout the years". She stated she and the Administrators had "gone through investigations", and she had performed interviews "alongside" the Administrators. Per interview, the HR Director stated she had "a lot of hands on training", and had "some" formal training on investigating "on hire". Interview, on 07/31/14 at 10:14 AM, with the former Administrator, who was in charge of the facility until 07/11/14, revealed she had became aware of a conflict between SRNA #19 and SRNA #21 through the DON during the investigation conducted on 07/03/14. She stated as Administrator she should have followed up on the conflict as it could impact resident care if the aides did not work together. She revealed she was not sure anyone addressed the two (2) SNRAs conflict; however, she stated the HR Director or Staff Development Nurse (SDN) should have addressed the conflict. However, interview with the SSD and DON revealed they were not aware of the conflict. The former Administrator stated the DON, the HR Director and SSD had performed the investigation. Per interview, she stated her part of the investigation had been to review it and "come up with findings with the team". According to the former Administrator, she, the DON, the HR Director, and the SSD reviewed the investigation together, and determined the allegation to be unsubstantiated as they were unable to "come up with a conclusion" regarding "how long" Resident #26 had been left wet due to "conflicting statements" from staff. Continued interview revealed she, as the Administrator, did not read or review the investigation; the DON, HR and the SSD verbally talked about the investigation and it was determined the facility "could not prove" Resident #26 "did not receive care". She stated SRNA #9 should have been interviewed regarding her concerns over resident care, if SRNA #9 had told staff about finding other residents wet. The former Administrator stated as part of a "thorough investigation", skin assessments of non-interviewable residents should have been performed. Interview, on 07/25/14 at 8:09 PM, with the Special Projects Administrator for the corporation who owned the facility, revealed any time the facility learned of staff not working well together, it needed to be investigated and to see what was going on during that particular shift. The Special Projects Administrator stated skin assessments should have been performed on the non-interviewable residents, and their families called, as part of the investigation conducted on 07/03/14. However, he stated he had not been in the facility when the investigation had taken place, and had not reviewed the investigation report because he worked for the facility's corporation, and was the acting Administrator in another facility. He stated that when the former Administrator left on 07/11/14, the new Administrator took over. However, he stated the new Administrator was on vacation from 07/18/14 through 07/28/14, therefore he was there to cover for the new Administrator while on vacation. Interview, on 07/31/14 at 11:47 AM, with the current Administrator revealed he had started on 07/09/14, and had taken over as Administrator on 07/11/14. The current Administrator reported the former Administrator discussed with him an investigation which had been initiated on two (2) residents; however, he could not recall the residents. According to the current Administrator, "typically" investigations involved the HR Director, SSD, DON and himself; but indicated if it was a nursing issue it might just be the DON, SSD and himself involved. The current Administrator stated this process was in place before he came to work at the facility. However, interview revealed this process had not been implemented. Further interview with the current Administrator revealed he could not recall for certain if the former Administrator had informed him of the conflict between SRNA #19 and SRNA #21, but indicated he knew there had been "issues" with SRNA #19. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14 that alleged removal of the IJ effective 07/29/14. Review of the AOC revealed the facility implemented the following: 1. The facility opened and investigated the five (5) reported allegations of neglect identified on the 06/30/14 through 07/03/14 Survey for Residents #5, #26, #27, #28, and #29. Initial Reports were completed with the five (5) day follow up reports pending completion of the investigations. The allegations were investigated by the Clinical Nurse Executive, Corporate Nurse Consultant, Special Projects Administrator, Administrator, HR Director, SSD, Corporate Director of Compliance and Signature Care Consultant. 2. One hundred percent (100%) of the resident population received head to toe assessments by the DON, the ADON, MDS Coordinator, Wound Care Nurse, SDC, Evening Nurse Supervisor, Corporate Nurse Consultant and Charge Nurses on 07/23/14. 3. Residents with a BIMS of eight (8) or above were interviewed by the ADON, Admissions Director, Dietary Director, MDS Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, SDC, Supply Coordinator, Quality of Life Director or Chaplain which was completed on 07/25/14 for any abuse, neglect, or misappropriation concerns. 4. Families and responsible parties were interviewed for residents with a BIMS below eight (8) which was initiated on 07/25/14 and as of 07/28/14, thirty-seven (37) of fifty-six (56) had been completed, for any abuse, neglect, or misappropriation concerns. The facility would continue to attempt contacting families and responsible parties daily to identify any concerns until remaining Power of Attorney's (POA's) had been reached. Concerns were addressed per policy and procedure as to reporting requirements and resident protection. 5. Staff was interviewed for any abuse, neglect, or misappropriation concerns by the ADON, Admissions Director, Dietary Director, MDS Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, SDC, Quality of Life Director or Chaplain on 07/25/14. Initial reports were made on the allegations relative to those interviews. 6. Initial Reports were made on 07/25/14 related to the alleged allegations relative to the interviews with residents, families, responsible parties, and staff. Thorough investigations were initiated on 07/25/14 by the Clinical Nurse Executive, Corporate Nurse Consultant, Special Projects Administrator, Administrator, HR Director, SSD, Corporate Director of Compliance and Signature Care Consultant on those residents identified with appropriate follow up reporting on the allegations received. 7. Abuse, neglect and misappropriation audits, assessments, interviews and questionnaires were reviewed by the Special Projects Administrator, DON, Corporate Nurse Consultant or Chief Nurse Executive on 07/27-07/28/14 for any indications of abuse, neglect or misappropriation concerns. 8. The Medical Director was notified of the Immediate Jeopardy on 07/25/14 by the DON and Special Projects Administrator. An Emergency Quality Assurance (QA) Meeting was held on 07/26/14 with the Corporate Director of Risk Management, Clinical Nurse Executive, Corporate Nurse Consultant, Medical Director, Special Projects Administrator, DON, HR Director, SSD and SDC related to the Immediate Jeopardy. 9. The DON, two (2) ADONs, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions, Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse were re-educated on 07/23/14 and the Administrator was re-educated on 07/28/14, upon his return, by the Corporate Nurse Consultant on the Abuse, Neglect and Misappropriation Policy and Procedure which included training, prevention, identification, investigation, protection and reporting, as well as, providing care per residents' individualized care plans. They could not return to work until the abuse, neglect, misappropriation education was provided and post test administered and a one hundred percent (100%) score was obtained on the post test. If a manager did not score a one hundred percent (100%) on post test, the manager was immediately re-educated and a post test was re-administered. 10. The facility's Administrator, DON, ADON's, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse educated stakeholders related to the Abuse, Neglect, and Misappropriation Policy which included training, prevention, identification, investigation, protection and reporting, as well as, providing care per residents' individualized care plans starting on 07/23/14 and continued until 07/28/14. No staff would be allowed to work until this education was provided and the post test administered and a one hundred percent (100%) score obtained. Eighty-seven (87) of ninety-six (96) were completed by 07/28/14. 11. Administrator, DON, ADON's, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse provided education to stakeholders which was initiated on 07/26/14 to nursing staff related to incontinence care and Activities of Daily Living (ADL's) care per the Care Plan and answering call lights. Calls and certified letters had been sent notifying staff they must complete training before returning to work relative to incontinence care and Activities of Daily Living (ADL's) Care per resident individualized Care Plan and answering call lights in a timely manner. 12. Education regarding the Abuse, Neglect and Misappropriation Policy would be included in the orientation process for newly hired staff. No newly hired person would be able to work until this education was provided and a post test administered and one hundred percent (100%) score obtained provided by staff development. 13. Staff assessment of knowledge test regarding abuse, neglect and misappropriation was being administered by the Administrator, DON, ADON's, MDS Coordinator, SDC, Dietary Director, Medical Records Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Care Nurse to five (5) staff members on each shift and different staff members until the immediacy was removed. 14. Ten (10) staff questionnaires would be administered daily to ensure continued understanding of the Abuse, Neglect and Misappropriation Policy. Results of the questionnaires, tests, ten (10) resident skin assessments of residents with a BIMS less than eight (8) per day, ten (10) residents with a BIMS greater than eight (8) interviews would be reviewed daily until the immediacy was resolved by the Administrator, DON, Nurse Consultant or Chief Nurse Executive. Any concerns revealed on the above to include injuries of unknown source would be reported immediately to the Abuse Coordinator, Administrator, DON, Corporate Nurse Coordinator, Regional Vice President of Operations, Special Projects Administrator, or Chief Nurse Executive. 15. Results of the staff questionnaires, resident interviews and skin assessments would be reviewed daily by the Administrator, DON, Nurse Consultant or Chief Nurse Executive with results reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of plan. Based on the evaluation the QA Committee would decide at what frequency the staff questionnaire would need to continue. Concerns identified would be corrected immediately and reported to the Administrator or DON to ensure an investigation of suspected abuse, neglect or misappropriation was investigated/completed and reporting guidelines were met along with any reporting of violation of resident rights. 16. Administrator, DON, ADONs, MDS Coordinator, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Director, Plant Operations Director, Quality of Life Director, Wound Care Nurse, Corporate Nurse Consultant, Regional Vice President or Clinical Nurse Executive would conduct call light audits through direct observation and monitoring tool daily twenty-four (24) hours a day seven (7) days a week on each shift to monitor compliance until the immediacy was removed. Then five (5) call lights daily on each shift (fifteen (15) total) ongoing and reported to QA Committee weekly during immediacy and monthly after immediacy was removed. Charge Nurses would provide direct observation of call light responsiveness and ensure all residents were getting needs met for plan of care each shift. Incontinence care observation would be completed for ten (10) residents daily until the immediacy was removed then ongoing for five (5) residents daily with results being reported to the QA Committee weekly during immediacy and monthly after the immediacy was removed. 17. Human Resources (HR) Director performed an audit of staff files for any abuse, neglect or misappropriation concerns 7/26/14 through 7/27/14 and the items reviewed included coaching, counseling forms, suspension forms, termination forms, abuse registry checks, background checks and licensure to 07/03/14. Results of the audit was given to the Administrator, DON or Corporate Nurse Consultant on 07/27/14, to review for any abuse, neglect or misappropriation concerns that needed reported. None were identified. 18. Information on "Caring for the Caregiver" which addresses the signs of stress and burn out, showing the caregiver ways to cope and reduce stress and useful ways that friends could offer help to the caregiver were posted by the time clock on 07/27/14 by the Special Projects Administrator. 19. A nurse from the regional team or corporate office had been onsite since 07/21/14 and would remain in the facility daily until the Immediate Jeopardy was lifted. The nurses from the regional team home office were assisting with investigations, observing staff treatment of [REDACTED]. The Chief Nurse Executive would be in daily contact with the Corporate Nurse Consultant and would review allegations. 20. Grievances and Resident Questionnaires since 07/23/14 were reviewed by the Administrator, DON, Chief Nurse Executive, HR Director, Admissions Director or Regional Nurse Consultants 07/27/14 through 07/28/14 to determine if any items documented were a reportable event. All issues identified were reported and investigations initiated per the facility's policy and procedure. The Administrator, SSD, or the DON would review daily, the grievances and Incident/Accident Reports, until immediacy was lifted, starting 07/27/14 to determine if there were reportable allegations which had been identified, then daily Monday through Friday during the Morning Stand-Up Meeting. SSD or the DON would report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator would review any allegations of abuse, neglect or misappropriation for reporting to the Office of Inspector General, Adult Protective Services and Ombudsman and appropriate authorities as required by state law. 21. The Administrator, DON, SSD would review and discuss abuse, neglect and misappropriation allegations daily to ensure the resident was protected, the perpetrator was removed from resident care area, reports to the State Survey Agency, APS and Ombudsman were filed timely, and a thorough investigation was completed. The Abuse Coordinator (SSD) would maintain an abuse, neglect and misappropriation investigation log starting on 07/27/14 that would include documentation of the following: validate protection of residents; perpetrator was removed from resident care area; reports to the State Survey Agency and Adult Protective Services (APS) were filed timely; and a thorough investigation was completed. The Abuse Coordinator and one of the following: Administrator, DON, Chief Nurse Executive or Regional Nurse Consultant would review the abuse, neglect and misappropriation log daily until removal of the Immediate Jeopardy, beginning on 07/27/14, to validate protection of the resident, that the perpetrator was removed from the resident care area, that reports to the State Survey Agency and APS and appropriate authorities required by state law, were filed timely, and a thorough investigation had been completed. 22. In the event of any new reports of alleged abuse, neglect, or misappropriation of

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on interviews, record reviews and review of the facility's Daily Staffing Sheets and time clock punches, during the 08/01/14 survey, it was determined the facility failed to have sufficient staffing to ensure residents' care needs were met for residents residing on the facility's two (2) units as evidenced by residents' complaints and concerns of their call lights not being answered timely, and their request for assistance not being provided for seven (7) of thirty-seven (37) sampled residents (Residents #8, #16, #17, #26, #32, #33 and #36), and staff's reports of being short staffed on the night shift. Resident #26 rang his/her call light on 07/03/14, at approximately 5:30 AM for incontinence assistance; however the two (2) State Registered Nursing Assistants (SRNAs), SRNA #19 and SRNA #21, working on the South Unit where the resident resided had a conflict and did not work together to provide care for residents. SRNA #19 did not get SRNA #21 to assist her with Resident #26 because of the conflict, therefore Resident #26 had to wait until approximately 7:45 AM, for assistance to get cleaned up. Additionally interviews with residents revealed their call lights were not answered in a timely manner and their request for assistance was not provided in a timely manner due to the facility's staffing. Also, interviews with staff revealed they were short staffed on night shift, and could not always get resident care provided and call lights answered in a timely manner. After becoming aware of this information on 07/03/14, the facility initiated an investigation and identified a conflict between the two (2) SRNAs normally scheduled on the South Unit who didn't work together to provide care. However, the facility failed to address the interviewed residents' concerns with night shift and failed to address the conflict between the two (2) SRNAs assigned to the unit on the night shift which impacted resident care and left residents at risk for further neglect. (Refer to F-225 and F-226) The facility's failure to have sufficient staffing to ensure residents' care needs were met for residents was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 07/25/14, and was determined to exist on 07/03/14. The facility was notified of the Immediate Jeopardy on 07/25/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14 with the facility alleging removal of the Immediate Jeopardy on 07/29/14. The Immediate Jeopardy was verified to be removed on 07/29/14, prior to exiting the facility on 08/01/14, with remaining non-compliance at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure sufficient staffing to ensure residents' care needs are met for all residents. The findings include: Review of the Census and Condition (CMS-672) Form dated 06/30/14, revealed the facility had a total census of one hundred and six (106) residents of the one hundred and twenty-four (124) total certified beds. Review of the Form revealed: seventy-six (76) residents required one (1) to two (2) staff assist with transfer; twenty-five (25) residents were totally dependent on staff for transfers; ninety (90) residents required assist of one (1) to two (2) staff for toileting; sixteen (16) residents were totally dependent on staff for toileting; eighty-six (86) residents required one (1) to two (2) staff for dressing; and, twenty (20) residents were totally dependent on staff for dressing. Review of the facility's bed listing, floor map and Resident Census for the North and South Units from 06/30/14 through 07/02/14 revealed the South Unit was a sixty (60) bed unit with a census of fifty-one (51) residents; and, the North Unit was a sixty-four (64) bed unit with a census of fifty-five (55) residents during that timeframe. Interview, on 07/23/14 at 5:49 PM, with the Director of Nursing (DON) revealed the facility did not have a policy related to staffing. She stated the Staff Development Coordinator (SDC) completed the daily scheduling of staff, and if there were call-ins the SDC or Evening Shift Supervisor attempted to provide coverage. The DON stated staff was instructed to call her or the Assistant Directors of Nursing (ADONs). She stated she did not get the Daily Assignment Sheets and did not review them, and was not always aware of the actual staffing for the previous day. Continued interview with the DON revealed during the daily clinical meeting the day's staffing was discussed. Per interview, the DON stated for night shift staffing there was no minimum, and the facility staffed four (4) nurses and four (4) State Registered Nursing Assistants (SRNAs), two (2) nurses and two (2) SRNAs on each of the facility's two (2) units, for a total of eight (8) staff at night. She stated staff should call her if there were not two (2) nurses and two (2) SRNAs on each unit during the night shift. Review of the facility's "Attendance" policy, undated, revealed staff were to provide the Supervisor with at least two (2) hours advance notice of his/her inability to report for his/her assigned shift". Interview, on 07/31/14 at 7:14 PM, with the SDC revealed the facility's process was "acuity based" which meant that staffing for the day was based on what activities were occurring in regards to admissions and discharges, whether residents were on intravenous (IV) antibiotics and other such issues. However, she stated she had a "budget" of total nursing staff hours to use, so staffing "basically" always was: for day shift (7:00 AM to 3:00 PM) three (3) nurses per unit, with two (2) as the minimum, and a "goal" of five (5) SRNAs, with four (4) as the minimum; evening shift (3:00 PM to 11:00 PM) three (3) nurses per unit, with two (2) the minimum, and three (3) to four (4) SRNAs minimum; and for night shift (11:00 PM to 7:00 AM) two (2) nurses per unit and two (2) SRNAs. Continued interview with the SDC revealed the day's staffing was reviewed in the morning "clinical" meeting, and call-ins were discussed. She stated if she became aware of staffing being short on a shift she tried to get coverage, or have staff from the previous shift stay over and staff from the next shift come in early. The SDC stated there had been a "problem" with communication on the evening and night shifts related to staffing, and since hiring the Evening Shift Supervisor it was better on that shift. However, she stated the 11:00 PM to 7:00 AM shift was "still" a problem, as sometimes she did not get the call-ins for that shift until she came in the next morning. The SDC indicated six (6) staff on night shift would not be acceptable; and if there was only one (1) SRNA on a unit at night it would be "difficult" to provide the care residents required. Review of the June 2014 Daily Staffing Sheets and Time Clock Punches for the 11:00 PM to 7:00 AM shift and the facility's daily resident census revealed: on 06/05/14 seven (7) staff worked the shift, one (1) nurse and two (2) SRNAs on the South Unit with a resident census of forty-eight (48), and two (2) nurses and two (2) SRNAs on the North Unit with a census of fifty-four (54); on 06/06/14 five (5) staff was present in the facility after 3:00 AM, two (2) nurses assigned on the South Unit, with a resident census of forty-eight (48), and one (1) nurse and two (2) SRNAs on the North Unit with a census of fifty-five (55); on 06/08/14, seven (7) staff worked the shift, two (2) nurses and one (1) SRNA on the South Unit with a resident census of forty-nine (49), and two (2) nurses and two SRNAs on the North Unit with a census of fifty-five (55); on 06/09/14, seven (7) staff worked the shift, two (2) nurses and two (2) SRNAs on the South Unit with a resident census of fifty (50), and one (1) nurse and two (2) SRNAs on the North Unit with a census of fifty-five (55); on 06/13/14, seven (7) staff was present, two (2) nurses and two (2) SRNAs on the North Unit with a census of fifty-eight (58) and one (1) nurse and two (2) SRNAs on the South Unit with a census of fifty-one (51); on 06/14/14, seven (7) staff worked, one (1) nurse, one (1) SRNA/Kentucky Medication Aide (KMA) and two (2) SRNAs on the North Unit with a census of fifty-seven (57), and one (1) nurse and two (2) SRNAs on the South Unit with a census of fifty-one (51); on 06/15/14, seven (7) total staff worked the shift, two (2) nurses and two (2) SRNAs on the South Unit with a resident census of fifty-one (51), and two (2) nurses and one (1) SRNA on the North Unit with a census of fifty-six (56); and, on 06/20/14, six (6) staff were working the shift, one (1) nurse and two (2) SRNAs on the North Unit with a resident census of fifty-six (56), and one nurse and two (2) SRNAs on the South Unit with a census of fifty-one (51). Review of the facility's Roster Sample Matrix, provided by the facility on 06/30/14, revealed the South Unit had forty (40) residents assessed to be incontinent of bladder and/or bowel, and thirty-eight (38) residents assessed to be incontinent of bladder and/or bowel on the facility's North Unit. Interview, on 07/03/14 at 4:45 PM and on 07/23/14 at 9:08 AM, with SRNA #19 revealed she worked the night shift on the South Unit and at times had been the only SRNA assigned to care for residents on the whole unit. She reported at least one (1) night a week she had to work as the only SRNA on the whole unit. SRNA #19 revealed when she worked as the only SRNA on the unit she could only complete two (2) rounds all night, instead of the every two (2) hour rounds that were required. She stated she could not complete the last round on residents who required two (2) person assist as the nurses couldn't help her if she was the only SRNA on the unit. She stated there had been a few times when there was only one (1) nurse and one (1) SRNA working on the unit; however, this had not happened often. Per interview, SRNA #19 stated she had heard there were only two (2) SRNAs in the "whole building" a few nights before. SRNA #19 stated "Administration" know "we need more help"; however, she indicated nothing had been done. SRNA #19 revealed she had not been able to perform incontinence care on Resident #26 and Resident #29 during her last rounds on 07/03/14, as those two (2) residents were two (2) person assist. She stated there was a conflict between her and SRNA #21 and she had not requested SRNA #21's assistance on 07/03/14 due to the conflict. Per interview, she stated she had informed the nurses and they were aware of the conflict; however, nothing had been done so far. SRNA #19 stated there were seven (7) residents who required two (2) person assist on the Southeast hall, of the South Unit she worked on. Interview, on 07/25/14 at 2:48 PM, with SRNA #6, a 7:00 AM to 3:00 PM SRNA, revealed she couldn't always get residents call lights answered as fast as residents needed them answered during her shift, and it was worse on the night shift. She indicated she sometimes came in earlier due to the staffing on night shift. Interview, on 07/24/14 at 9:48 PM, with SRNA #22, a night shift SRNA, revealed she had worked on the North Unit as the only SRNA "several times" before. She stated when there was only one (1) SRNA working the whole unit it wasn't fair to the residents or the SRNA. According to SRNA #22, when the unit was staffed like that, all she could do was try to get all the residents changed, and if residents rang their call lights they would have to wait, if she was in another resident's room and the nurse was busy. Continued interview with SRNA #22 revealed during the times when she was the only SRNA working the unit residents would want to get up out of bed in the morning and she would have to tell them she couldn't get them up. She stated one (1) SRNA could not take care of fifty (50) to sixty (60) residents by themselves; and could only complete about two (2) rounds the whole night, instead of the every two (2) hour rounds. She stated when she worked as the only SRNA on the unit sometimes residents would have to lay wet and soiled, and she couldn't turn residents every two (2) hours like she was supposed to. SRNA #22 reported it wasn't fair to the "poor" residents to be cared for like that, and she would not want her grandparents "treated like that". The SRNA stated she knew SRNA #19 had worked by herself on the South Unit before. Per interview, SRNA #22 stated there had been one (1) time there was only one (1) nurse, one Certified Medication Aide (CMA)/SRNA and herself working the whole unit, and indicated she thought it was 06/06/14. Review of the Daily Staffing Sheets and Time Clock Punches for 06/06/14, on the 11:00 PM to 7:00 AM shift, revealed seven (7) staff present in the entire facility, one (1) SRNA worked the 3:00 PM to 11:00 PM and stayed over until 3:00 AM. Further review of the Staffing Sheets and Time Clock Punches revealed after 3:00 AM, only six (6) staff were present in the facility, four (4) nurses and two (2) SRNAs, (two (2) nurses and an SRNA on each unit). Further interview with SRNA #22 revealed that night was "crazy", and she had called the "on-call" administrative person, Registered Nurse (RN) #4/Assistant Director of Nursing (ADON), who said she would try to get SRNA #22 some help; however, no one showed up to help. She stated also that night on the South Unit there were no SRNAs after 3:00 AM, when the 3:00 PM to 11:00 PM SRNAs who had stayed over to help left to go home. In addition, she stated staffing was a problem at times on both units. SRNA #22 stated all the day shift nurses were aware of the times she had worked by herself on night shift. Interview, on 07/29/14 at 3:20 PM, with SRNA #31 revealed "lately" the facility had been "short staffed", and it depended on staffing on how long it was for residents' call lights to be answered. SRNA #31 stated if they worked "short staffed" it was "harder" to get the work done. According to SRNA #31, sometimes night shift was staffed with only one (1) SRNA on a unit, and staff would have to come in early or stay over to help the night shift SRNA out, "because obviously" they couldn't get all their work done by themselves. In addition, he stated when they worked "short staffed" they couldn't get everything documented in the "Kiosk", (the facility's computer system for SRNAs). SRNA #31 indicated "a lot" of residents complained about their call lights not getting answered in a timely manner, and reported it could take five (5) minutes to fifteen (15) minutes for the SRNAs to be able to answer a call light. Interview, on 07/30/14 at 2:55 PM, with SRNA #18 and SRNA #20 revealed "there could be and should be more" staff, and there should be "staffing ratios" to ensure residents received the care they needed. The SRNAs indicated staff was "short" on "pretty much every shift", and SRNAs had to "hit the ground running" to get everything done. They stated they were aware of there being only one (1) SRNA on night shift at times on a unit. The SRNAs reported day shift staff had to come in early to help out and evening shift would stay over to help out because only one (1) SRNA couldn't care for all the residents on the unit without help. Interview, on 07/25/14 at 9:17 AM, with Licensed Practical Nurse (LPN) #9, a 7:00 PM to 7:00 AM nurse, revealed she recalled one (1) time in June when SRNA #22 had to work by herself on the North Unit. Review of the Time Clock Punches for 06/06/14 revealed on the 11:00 PM to 7:00 AM shift, only six (6) staff present in the facility after 3:00 AM, four (4) nurses and two (2) SRNAs, one of which was SRNA #22. Continued interview with LPN #9, revealed if the nurses didn't help with providing direct care when there was only one (1) SRNA, they wouldn't be able to get their rounds completed, it would be "tough". LPN #9 also stated if there was only one (1) SRNA they wouldn't be able to get residents up for the morning. Interview, 07/25/14 at 1:35 PM, with Registered Nurse (RN) #8, a 7:00 PM to 7:00 AM nurse, revealed there was still a problem with not enough SRNAs in the facility, and reported the facility was "short on them often". RN #8 stated night shift staffing was supposed to be two (2) nurses and two (2) SRNAs on each of the two (2) units, but there were times when there was only one (1) nurse with two (2) SRNAs, or two (2) nurses with only one (1) SRNA on a unit. She stated when the staffing was like that it was hard to get all the work done, and if residents rang their call lights they would have to wait, and at times it might be fifteen (15) to thirty (30) minutes or longer. She stated once when she had been the only nurse, she had refused to "clock in" to work until another nurse was found to help her which did happen and she worked. Review of the Time Clock Punches for 06/05/14, on the 11:00 PM to 7:00 AM shift, revealed RN #8 was one (1) of only two (2) nurses working the shift for that day in the facility with only three (3) SRNAs. Review of the 06/20/14 Time Clock Punches revealed RN #8 was one (1) of only two (2) nurses working that day, with four (4) SRNAs. Continued interview with RN #8 revealed the facility census had been about full that night and the acuity of the residents had made her feel not safe being the only nurse. She stated the SRNAs worked with only one (1) SRNA at night about "every other week". RN #8 stated when that happened it was "pretty hard", and the nurses helped the SRNAs as they could to provide resident care during rounds. According to RN #8, when there was only one (1) SRNA on the unit they couldn't get residents who wanted to get up in the morning up, and that made her feel bad for the residents. However, she stated the work was "too overwhelming" for the SRNAs in the mornings as the nurses had to pass medications and could not help them out as much. She stated residents had to wait for day shift to come in at 7:00 AM to get them up. Further interview revealed residents might also have to "wait a little while" to get their call lights answered, especially in the early morning, between 5:00 AM and 7:00 AM it would take longer. Interview, on 07/24/14 at 7:19 PM, with RN #5/Evening Supervisor, who worked 3:00 PM to 11:00 PM, revealed the staffing for 11:00 PM to 7:00 AM, was supposed to be two (2) nurses and two (2) SRNAs on each of the facility's two (2) units. However, she stated she was aware of times when there were only three (3) nurses in the facility on the night shift but, she stated there was "not a big med pass in the morning", and indicated it was okay. She indicated she attempted to get coverage if there were call-ins. Interview, on 07/26/14 at 10:09 AM, with RN #6 revealed on the North Unit during the month of June she was aware of one (1) SRNA having to work the entire unit by herself for two (2) nights in a row. Review of the Time Clock Punches for 06/19/14 and 06/20/14 revealed on the 11:00 PM to 7:00 AM shift, SRNA #21, who was sometimes pulled to work the North Unit, worked those nights as one (1) of only three (3) SRNAs in the entire facility for that shift. She stated the nurses assisted as well as they could helping do rounds with the SRNAs to get residents cared for, until 5:00 AM when they started their medication pass. RN #6 stated the SRNAs on the South Unit also helped out those two (2) nights, as they could, but had their own residents to care for. After receiving a complaint regarding the lack of care provided by night shift staff on 07/03/14 the facility initiated an investigation. Review of the investigation report dated 07/03/14 through 07/07/14, revealed interviewable residents had been questioned regarding the care received on night shift, 11:00 PM to 7:00 AM, and Resident #16, Resident #8, Resident #17, Resident #26, Resident #36, Resident #32 and Resident #33 all expressed concerns regarding care on night shift. 1. Review of Resident #26's medical record revealed the facility admitted the resident on 07/23/12, with [DIAGNOSES REDACTED]. Review of Resident #26's Annual Minimum Data Set (MDS) Assessment, dated 06/23/14, revealed the facility assessed Resident #26 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #26 as requiring: extensive physical assistance of two (2) staff with his/her Activities of Daily Living (ADLs) of bed mobility, transfers and toileting. Further review of the MDS Assessment revealed the facility assessed the resident to be frequently incontinent of bowel and bladder. Interview, on 07/03/14 at 2:26 PM, with Resident #26 revealed on 07/03/14, during the night shift he/she had "pooped" on himself/herself. Resident #26 stated he/she had requested assistance from SRNA #19, but the SRNA had not helped the resident. Resident #26 stated at times he/she had waited for over an hour for staff to answer his/her call light before. Resident #26 reported he/she had problems with getting staff to answer his/her call light on the night shift, 11:00 PM to 7:00 AM, and the day shift, 7:00 AM to 11:00 PM. 2. Review of Resident #32's medical record revealed the facility admitted the resident on 05/24/13, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 04/13/14, revealed the facility assessed Resident #32 to have a BIMS score of fourteen (14) which indicated no cognitive impairment and the resident was interviewable. Continued review of the MDS Assessment revealed the facility assessed Resident #32 to require extensive assistance of two (2) staffs physical assist with most of his/her ADLs including transfers, bed mobility and toileting. Further review of the MDS Assessment revealed the facility assessed the resident to be frequently incontinent of urine and always continent of bowel. Review of Resident #32's Comprehensive Care Plan, dated June 2014, revealed the resident was care planned for ADL self care deficit related to his/her [DIAGNOSES REDACTED]. Interview, on 07/03/14 at 2:14 PM, with Resident #32 revealed no one answered when he/she pressed his/her call light. Resident #32 stated he/she became incontinent and had to wait while sitting in his/her urine for assistance after ringing the call light. Additional interview, on 07/22/14 at 5:00 PM, on 07/25/14 at 3:30 PM; and, on 07/31/14 at 6:25 PM, with Resident #32 revealed when he/she had to wait to "pee-pee", he/she "wet" his/her self. Resident #32 stated when that happened it made him/her feel "no good, like a baby". Resident #32 revealed he/she had to wait about forty (40) minutes at night for his/her call light to be answered, and at times became incontinent of urine. Resident #32 stated there were not enough staff at night at times. Further interview with Resident #32 revealed he/she had talked to "the people over the building" before; however, nothing had been done and he/she still had to wait for the call light to be answered and "wet" on himself/herself. 3. Review of Resident #33's medical record revealed the facility admitted the resident on 04/22/11, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE], revealed the facility assessed Resident #33 as having a BIMS score of fourteen (14), which indicated no cognitive impairment and the resident was interviewable. Continued review of the MDS revealed the facility assessed the resident to require extensive assistance of two (2) staff to assist with toileting, and to be occasionally incontinent of urine and to have a [MEDICAL CONDITION]. Review of Resident #33's Comprehensive Care Plan, dated 05/19/14, revealed the resident was care planned for requiring assistance with ADLs and for the potential for complications related to his/her incontinence of bowel and bladder. Interview, on 07/03/14 at 2:25 PM, with Resident #33 revealed it took staff "a long time" for staff to answer his/her call light. The resident stated he/she had a "weak bladder" and when he/she had to go to the bathroom, he/she had to go right away. According to Resident #33, during the night it was worse, and he/she had been incontinent of urine waiting for staff to respond to the call light during the night. Resident #33 stated sometimes he/she "wet" on himself/herself while waiting on staff to respond to the call light. Resident #33 stated this made him/her feel "bad". Further interview with Resident #33 revealed "sometimes" he/she became "frustrated" when staff did not come "fast enough" to assist him/her. In an additional interview with Resident #33 on 07/29/14 at 6:30 PM, revealed there was "not enough staff for sure" at night. Resident #33 stated at night sometimes there was only one (1) staff person to help him/her to the bathroom, and he/she needed two (2) because his/her balance was "real bad". Resident #33 reported feeling "frustrated" at times when staff didn't answer his/her call light fast enough to help him/her. Per interview, Resident #33 indicated staff had talked to him/her regarding his/her concerns with night shift; however, no one had followed up with him/her on his/her concerns. 4. Review of Resident #36's medical record revealed the facility admitted the resident on 11/02/11, with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 06/16/14, revealed the facility assessed Resident #36 to have a BIMS score of fourteen (14) which indicated the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #36 to require extensive assistance of two (2) staff for transfer and one (1) staff assist with other ADLs except eating. Further review of the MDS Assessment revealed the facility assessed Resident #36 as being frequently incontinent of urine and always continent of bowels, and requiring a one (1) person assist toileting. Review of the Comprehensive Care Plan, dated 06/17/14, revealed Resident #36 was care planned for ADL self care deficit, and for the potential for complications related to his/her incontinence of bladder. Interview, on 07/24/14 at 2:10 PM, with Resident #36 revealed he/she took himself/herself to the bathroom because he/she had to wait twenty (20) to thirty (30) minutes "sometimes" for his/her call light to be answered. However, Resident #36 stated he/she often had "accidents" in his/her pull up adult brief because his/her bladder was "so bad". Resident #36 stated staff was busy and couldn't get to him/her "right away" at times. Resident #36 revealed "sometimes" the facility was "really short of help at night time", and at times he/she waited twenty (20) to thirty (30) minutes for his/her call light to be answered. 5. Review of Resident #8's medical record revealed the facility assessed Resident #8 to have a BIMS score of fifteen (15) indicating the resident was cognitively intact and interviewable. Interview, on 07/25/14 at 11:20 AM, with Resident #8 revealed during the night shift there was "not enough staff" and "there were 'issues' due to this", such as, call lights not being answered timely. 6. Review of Resident #16's medical record revealed the facility assessed Resident #16 to have a BIMS score of fifteen (15) indicating the resident was cognitively intact and interviewable. Interview, on 07/24/14 at 1:30 PM, with Resident #16 revealed it had taken forty-five (45) minutes at times for his/her call light to be answered. Resident #16 stated there was "just not enough help" in the facility. 7. Review of Resident #17's medical record revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) indicating the resident was cognitively intact and interviewable. Interview on 07/24/14 at 1:49 PM, with Resident #17 revealed the resident had been interviewed about his/her care concerns, but no one had followed up with him/her after concerns were expressed on 07/03/14. According to Resident #17, sometimes he/she still had to wait for as long as thirty (30) minutes for the call light to be answered. Resident #17 stated night shift and weekends were the worst times, because there was not enough staff. Interview, on 07/31/14 at 10:14 AM, with the former Administrator, who was the Administrator from 05/15/14 through 07/11/14 when the current Administrator took over, revealed in the "morning meeting" held Monday through Friday staffing was discussed and the current day's call-ins were reviewed. However, the former Administrator stated the previous days call-ins and actual staffing were not looked at and discussed to identify patterns or trends. She stated the Human Resources (HR) Director had given her a "total number of hours" worked for each department. The former Administrator stated she had never been made aware of only one (1) SRNA working on a unit during the night shift. However, review of the Daily Staffing Sheets and Time Clock Punches for the 11:00 PM to 7:00 AM shift revealed on 06/06/14 five (5) staff was present in the facility after 3:00 AM, only two (2) of which were SRNAs (with a daily census of fifty-five (55) on the North Unit and forty-eight (48) on the South Unit); on 06/08/14, only three (3) SRNAs were present in the facility for the shift (with a daily census of fifty-five (55) on the North Unit and forty-nine (49) on the South Unit); and on 06/15/14, only three (3) SRNAs were present and working the shift (with a daily census of fifty-six (56) on the North Unit and fifty-one (51) on the South Unit). If only three (3) SRNAs were working the shift it would leave one (1) unit with only one (1) SRNA. Continued interview revealed she didn't think last rounds in the morning for night shift for residents requiring two (2) person assist could be completed if there was only one (1) SRNA because the nurse would have to be on the medication cart. Per interview, the former Administrator stated having only one (1) SRNA on a unit on night shift "could negatively impact care". Interview, on 07/31/14 at 7:14 PM, with the SDC revealed she had come in at times and worked the floor as a nurse to pass medications and do treatments, or worked the floor as a nursing assistant when the staffing had been short and she couldn't find coverage. Interview, on 07/31/14 at 11:47 AM, with the current Administrator revealed he had taken over as Administrator on 07/11/14. He acknowledged being aware of staffing issues since taking over, and not having been told there was only one (1) SRNA at times on a unit during the night shift. The current Administrator stated there were vacancies and problems with "call-outs" which the SDC took care of during the day, and the Evening Shift Supervisor took care of in the evenings. He stated the SDC kept a report of "call-outs" which had been in place since he had became Administrator. Further interview revealed the SDC knew what the staffing was for the day, and would know the "call-outs" and find replacement staff. He in

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on interview, record review, and review of the facility's policy, during the 08/01/14 survey, it was determined the facility failed to ensure residents were free from neglect for five (5) of thirty-seven (37) sampled residents (Residents #5, #26, #27, #28, #29). The facility failed to have an effective system in place to ensure the necessary care and services related to incontinence care were provided to residents when needed and upon the residents' request. On 07/03/14, Resident #26 rang the call bell for incontinence care assistance at approximately 5:30 AM; however was not assisted until approximately 7:45 AM, (two hours and fifteen minutes later). Interview with the day shift State Registered Nursing Assistant (SRNA), who assisted Resident #26 at 7:45 AM, revealed the resident was soaked with urine and covered in bowel movement. Staff interviews further revealed other residents were also left soaked in urine or soiled with bowel movement the morning of 07/03/14, after day shift reported to work at 7:00 AM. These residents included #5, #27, #28, and #29. After becoming aware of this information on 07/03/14, the facility initiated an investigation and identified a conflict between the two (2) SRNAs normally scheduled on the South Unit who didn't work together to provide care. However, the facility failed to address the interviewed residents' concerns with night shift and failed to address the conflict between the two (2) SRNAs assigned to the unit on the night shift which impacted resident care and left residents at risk for further neglect. (Refer to F-225 and F-226) The facility's failure to have an effective system to ensure residents were protected from neglect was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 07/25/14, and was determined to exist on 07/03/14. The facility was notified of the Immediate Jeopardy on 07/25/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14 with the facility alleging removal of the Immediate Jeopardy on 07/29/14. The Immediate Jeopardy was verified to be removed on 07/29/14, prior to exiting the facility on 08/01/14, with remaining non-compliance at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure necessary care and services are provided in regards to having an effective system in place to ensure incontinence care is provided timely and upon request and residents are protected from neglect. The findings include: Review of the facility's policy titled, "Abuse, Neglect and Misappropriation", dated April 2013 revealed abuse and neglect of residents was prohibited. Review of the facility's Job Description for the position of SRNA, updated December 2011, revealed licensed nursing personnel were to provide supervision of SRNAs when they performed direct resident care duties. Review of the Job Description revealed SRNA's essential duties and responsibilities included the provision of personal care required by residents daily and as needed. 1. Review of Resident #26's medical record revealed the facility admitted the resident on 07/23/12, with [DIAGNOSES REDACTED]. Review of Resident #26's Annual Minimum Data Set (MDS) Assessment, dated 06/23/14, revealed the facility assessed Resident #26 to have a Brief Interview for Mental Status (BIMS) score of thirteen (13) which indicated the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #26 as requiring: extensive physical assistance of two (2) staff with his/her Activities of Daily Living (ADLs), with bed mobility, transfers and toileting. Further review of the MDS Assessment revealed the facility assessed the resident to be frequently incontinent of bowel and bladder and as being at risk for developing pressure ulcers. Review of the Brand Scale for Pressure Sore Risk, dated 06/23/14 revealed the resident was assessed as having a moderate risk for pressure development. Review of Resident #26's Comprehensive Care Plan, dated 06/16/14, revealed the resident was care planned for ADL assistance and for the potential for altered skin integrity. Interview, on 07/03/14 at 2:26 PM, with Resident #26 revealed on 07/03/14, during the night shift he/she had "pooped" on himself/herself. Resident #26 stated he/she had requested assistance from SRNA #19, who had been assigned to his/her care during the night shift, and SRNA #19 had not assisted with changing the resident after the request. Resident #26 started crying during the interview and stated he/she felt that staff "did not want to change" him/her and felt he/she "wasn't supposed to be clean". Per interview, Resident #26 stated he/she had to wait until day shift came in to get incontinence assistance and get cleaned. Further interview revealed at times he/she had waited for over an hour for staff to answer his/her call light. Resident #26 reported he/she had problems with getting staff to answer his/her call light on the night shift, 11:00 PM to 7:00 AM, and the day shift, 7:00 AM to 11:00 PM. Interview, on 07/03/14 at 7:00 PM, with Registered Nurse (RN) #6, who had worked the night shift from 07/02/14 at 11:00 PM to 07/03/14 at 7:00 AM, revealed at "about 5:30 AM", Resident #26 had requested staff's assistance to get cleaned and changed. Per interview, RN #6 stated she informed SRNA #19 to change Resident #26 as the resident was on intravenous (IV) fluids at seventy-five (75) cc's (cubic centimeters) per hour and this caused the resident to urinate "a lot". RN #6 stated SRNA #19 told her she was getting the residents up, dressed and ready for breakfast and she needed assistance to change Resident #26. According to RN #6, there was a personal conflict between SRNA #19 and SRNA #21, who were the SRNAs regularly scheduled on the unit. According to RN #6, she had assisted SRNA #19 with resident care at approximately 1:30 AM and 3:00 AM. However, RN #6 was passing medication when Resident #26 requested assistance at approximately 5:30 AM and had not assisted SRNA #19 to change the resident. Continued interview revealed the personal conflict between SRNA #19 and SRNA #21 had negatively impacted resident care that night. RN #6 stated, as she was SRNA #19's supervisor, she should have informed SRNA #19 not to get residents out of bed as that was not as important as providing resident care as requested and/or needed. She stated even though she knew Resident #26 had requested assistance, she did not ensure it was provided; however, should have followed up to ensure the resident's needs were met. Further interview with RN #6 revealed it would be "terrible" to be wet or soiled and not be changed. She indicated the facility provided training on neglect as a form of abuse, and by not providing the care Resident #26 requested that morning it was neglect. RN #6 stated she had not reported this information to Administration; however, indicated she should have reported the incident. Interview, on 07/03/14 at 4:45 PM and on 07/23/14 at 9:08 AM, with SRNA #19 revealed early in the morning of 07/03/14, during her last rounds, Resident #26, who was a two (2) person assist, rang the call light and requested incontinence assistance. Continued interview with SRNA #19, revealed she informed Resident #26 as soon as she could get someone to help her she would change him/her. However, she stated she could not get anyone to help her change Resident #26. SRNA #19 stated she asked RN #6 to help her, but she couldn't as she was passing medications. She also asked SRNA #21; however, SRNA #21 "ignored" her. According to SRNA #19, when SRNA #9 and SRNA #6 came to work on the day shift, somewhere around 6:45 AM to 7:00 AM, she told them Resident #26 needed to be changed. SRNA #19 stated she took out her trash after telling the day shift SRNAs and went home without returning to Resident #26's room. Interview with SRNA #9, on 07/03/14 at 2:44 PM and on 07/23/14 at 1:52 PM, revealed upon reporting to work at 7:00 AM that morning she had discovered Resident #26 had soiled himself/herself and needed to be cleaned and changed. According to SRNA #9, she had asked SRNA #19, who had been assigned to the residents on night shift, to assist with cleaning and changing the resident. She stated however, SRNA #19 did not assist and walked away. She stated SRNA #20, who had come in early that morning to escort Resident #26 to an appointment, had cleaned and changed the resident upon arrival. Interview, on 07/03/14 at 2:51 PM and on 07/23/14 at 2:26 PM, with SRNA #20 revealed she had reported to work early the morning of 07/03/14 to escort Resident #26 to his/her doctor's appointment. She stated upon her arrival, Resident #26 had bowel movement on his/her clothing and on the pad of the reclining chair the resident was sitting on. Per interview, she had to work for over an hour to assist the resident in getting cleaned. According to SRNA #20, Resident #26 usually requested assistance when he/she needed it, and this was not normal for the resident. SRNA #20 stated Resident #26 "normally" knows when he/she has to have a bowel movement and goes to the bathroom in the wheelchair with two (2) person assist to stand and transfer. She stated Resident #26 told her the "aide" assigned to his/her care had not checked on him/her all night on 07/02/14 at 11:00 PM to 07/03/14 at 7:00 AM. Additional interview, with SRNA #20 revealed she reported the condition she had found Resident #26 in on 07/03/14 to LPN #8, and had asked her to come look at the resident; however, LPN #8 could not come "right then". Interview, on 07/03/14 at 5:53 PM, with Licensed Practical Nurse (LPN) #8 revealed SRNA #20 also told her Resident #26 was left wet. LPN #8 revealed when she went to Resident #26's room and spoke to him/her, the resident told her staff had not been in his/her room "all night". Interview, on 07/23/14 at 5:27 PM, with SRNA #16 revealed she had sat with Resident #26 early in the morning on 07/03/14. She stated Resident #26 needed to be changed and she was on "light duty" and could not change the resident. SRNA #16 stated she told SRNA #19 Resident #26 needed to be changed, and SRNA #19 informed her she would change Resident #26 when she "got some help". Interview, on 07/23/14 at 3:49 PM, with RN #4/ADON revealed she had became aware of "a problem with night shift" late in the day on 07/03/14. RN #4/ADON stated she had overheard SRNA #9 talking to someone else about Resident #26 being left wet that morning. She stated she could not recall who SRNA #9 was telling, and stated SRNA #9 did not tell her "directly" about Resident #26. RN #4/ADON stated she did not talk to SRNA #9 about what she had overheard her saying; however, indicated she should have. According to RN #4/ADON, she talked to SRNA #16, as she knew she had been sitting with Resident #26 the morning of 07/03/14. She stated SRNA #16 told her SRNA #19 told Resident #26 he/she would have to wait for day shift to come in to change him/her. Interview, on 07/03/14 at 6:45 PM, with RN #5/Evening Shift Supervisor revealed at approximately 4:08 PM that day she had spoken with Resident #26 who told her SRNA #19 had left him/her "wet and with crap" on him/her. RN #5/Evening Shift Supervisor stated she went to the Director of Nursing (DON) and Social Services Director (SSD) and reported to the DON and SSD what Resident #26 had told her. Per interview, RN #5/Evening Shift Supervisor revealed staff should not "knowingly" leave residents wet and soiled as that would be a form of neglect. Further interview with SRNA #9, 07/03/14 at 2:44 PM, revealed several other residents were found "soaked" with urine or soiled on 07/03/14 which included Residents #5, Resident #27, Resident #28, and Resident #29. 2. Review of Resident #5's medical record revealed the facility readmitted the resident on 04/10/14, with [DIAGNOSES REDACTED]. Review of Resident #5's Quarterly MDS Assessment, dated 05/15/14, revealed the facility assessed the resident as having severe cognitive impairment, and to require extensive physical assistance of two (2) staff with his/her ADLs including bed mobility, transfers and toileting. Further review of the MDS Assessment revealed the facility assessed Resident #5 to always be incontinent of bowel and bladder. Continued review of the MDS revealed the resident was assessed as being at risk for pressure ulcers and as having a pressure ulcer. Review of the Brand Scale for Pressure Sore Risk, dated 05/15/14 revealed the resident was assessed as having a moderate risk for pressure. Continued record review revealed Resident #5 had a history of [REDACTED]. Review of Resident #5's Comprehensive Care Plan, dated 06/03/14, revealed the resident was care planned as requiring extensive assistance with bed mobility and for the potential for complications related to his/her incontinence of bowel and bladder. Continued review of the Comprehensive Care Plan revealed the resident was at risk for developing skin breakdown. Review of the interventions revealed treatments were provided from 04/11/14 through 05/26/14 at which time the Stage II was noted as being healed. Additional interview, on 07/23/14 at 12:05 PM, with LPN #8 revealed SRNA #9 had come to her the morning of 07/03/14 and reported Resident #5 being soiled. She stated she had told SRNA #9 to clean and change the resident immediately. Per interview, LPN #8 stated when she went to Resident #5's room, the resident was "pretty wet" but she could not recall if the bed was wet. 3. Review of Resident #27's medical record revealed the facility admitted the resident on 06/14/13, with [DIAGNOSES REDACTED]. Review of Resident #27's Quarterly MDS Assessment, dated 05/21/14, revealed the facility assessed the resident to have severe cognitive impairment, and to require extensive physical assistance of two (2) staff with his/her ADLs including transfers, bed mobility and toileting. Further review of the MDS Assessment revealed the facility assessed the resident to be frequently incontinent of bowel and bladder and as being at risk for developing pressure sores. Review of the Braden Scale for Pressure Sore Risk, dated 05/21/14 revealed the facility assessed the resident as being at a high risk for pressure sore development. Review of Resident #27's Comprehensive Care Plan, dated 05/28/14, revealed the resident was care planned for ADLs and for the potential for complications related to his/her incontinence of bowel and bladder. Continued review of the Comprehensive Care Plan revealed Resident #27 was care planned for the risk of developing skin breakdown and as needing extensive/total assistance with bed mobility. 4. Review of Resident #28's medical record revealed the facility admitted the resident on 03/06/13, with [DIAGNOSES REDACTED]. Review of Resident #28's Quarterly MDS Assessment, dated 03/26/14, revealed the facility assessed the resident to have severe cognitive impairment, and to require extensive physical assistance of two (2) staff for most ADLs including transfers and bed mobility and extensive assist of one (1) staff for toileting. Further review of the MDS Assessment revealed the facility assessed the resident to be frequently incontinent of bowel and bladder and as having no pressure but as being at risk for skin break down. Review of Resident #28's Comprehensive Care Plan, dated 06/03/14, revealed the resident was care planned for ADLs and for the potential for complications related to his/her incontinence of bowel and bladder and for the potential for altered skin integrity. Review of the Pressure Ulcer Braden Scale, dated 06/26/14 revealed the facility assessed the resident to be at moderate risk for skin breakdown. 5. Review of Resident #29's medical record revealed the facility admitted the resident on 09/28/12, with [DIAGNOSES REDACTED]. Review of Resident #29's Quarterly MDS Assessment, dated 07/07/14, revealed the facility assessed the resident to have severe cognitive impairment, and to require extensive physical assistance of two (2) staff with ADLs including transfers, bed mobility and toileting. Further review of the MDS Assessment revealed the facility assessed the resident to be always incontinent of bowel and bladder and as being at risk for the development of pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 07/07/14 revealed the facility assessed the resident as having a mild risk for the development of pressure sores. Review of Resident #29's Comprehensive Care Plan, dated 06/01/14, revealed the resident was care planned for ADLs and for the potential for complications related to his/her incontinence of bowel and bladder. Continued review of the Comprehensive Care Plan revealed the resident was care planned for the potential for altered skin integrity related to decreased physical and cognitive function. Additional interview, on 07/03/14 at 5:53 PM, with LPN #8 revealed on the morning of 07/03/14, after reporting to work at 7:00 AM, SRNA #32 came and got her to look at the condition Resident #29 had been left in by night shift. LPN #8 stated Resident #29 was "beyond soaked" that morning, and indicated it appeared as though the resident had not been changed at all during the night. Interview, on 07/03/14 at 4:45 PM and on 07/23/14 at 9:08 AM, with SRNA #19 revealed she had not been able to perform incontinence care on Resident #29 during her last rounds on 07/03/14 as he/she was also a two (2) person assist. Continued interview with SRNA #19, on 07/03/14 at 4:45 PM and on 07/23/14 at 9:08 AM, revealed there was a conflict between her and SRNA #21 who wouldn't talk to her, and they did not work well together because of this. Per interview at times she had worked the entire South Unit by herself due to SRNA #21 not wanting to work with her. SRNA #19 stated she had informed the nurses and they were aware of the conflict; however, nothing had been done. Further interview with SRNA #19 revealed neglect was a form of abuse, and it was neglect "for residents not to be changed when needed". However, SRNA #19 denied leaving residents wet or soiled, not changed, or unattended. Interview, on 07/23/14 at 4:36 PM, with SRNA #21 revealed she worked on the South Unit. She stated SRNA #19 had not requested her assistance early in the morning of 07/03/14. SRNA #21 stated she and SRNA #19 did not have a "very good" relationship. She stated SRNA #19 did not want to work with her, thought she did not like her, and would not ask her for assistance. SRNA #21 reported SRNA #19 told "everyone" she refused to help her; however, indicated she assists if SRNA #19 asked her. Continued interview with SRNA #21 revealed SRNA #19 would ask the nurses or SRNAs on the North Unit to help her. SRNA #21 stated she just liked to get her work done on her hall and did not socialize "a lot". SRNA #21 indicated if residents were not being changed, ringing their call light for assistance or being left wet it would be abuse in the form of neglect. She stated "no one wants to be left wet". Per interview, SRNA #21 stated if SRNA #19 asked her for assistance she would help her. Interview, on 07/29/14 at 3:20 PM, with SRNA #31 revealed staff was aware of the conflict between SRNA #19 and SRNA #21 which had been going on for "months". SRNA #31 stated SRNA #19 and SRNA #21 complained about each other to other people. Per interview, SRNA #31 stated he/she had not told nurses or other supervisory staff about it. Interview, on 07/30/14 at 2:55 PM, with SRNA #18 and SRNA #20 revealed they were both aware of the conflict between SRNA #19 and SRNA #21. SRNA #20 stated when SRNA #19 and SRNA #21 worked at night they did not work together and did not answer call lights for each other. Both SRNAs stated "everybody" knew about the conflict between the two (2) SRNAs and indicated the conflict impacted resident care. SRNA #20 stated there had been times SRNA #19 had left residents "soaking wet" and with bowel movement on them at the end of her shift. According to SRNA #20, there was no need to tell nurses about the conflict because they knew what was going on. Interview, on 07/24/14 at 9:11 PM with SRNA #4 who worked day shift, revealed she had rounded before on residents who SRNA #19 had been assigned to provide care and had found five (5) residents wet, with their "full" bed wet with urine, which required a complete bed linen change. She stated she did not report this to anyone as she was not usually assigned to work the South Unit. Further interview, on 07/03/14 at 5:53 PM, with LPN #8 revealed she had noticed when a certain SRNA, whose name she could not recall, worked it looked as if rounds were not being performed on night shift. Per interview, LPN #8 revealed she did not tell her supervisor about what Resident #26 had told her, or of the condition other residents had been left in, as she had observed SRNA #9 going to the Staff Development Coordinator (SDC) to tell her about the condition residents had been left in that morning. Further interview with SRNA #9, 07/03/14 at 2:44 PM, revealed she was so upset over the condition the residents had been left in, on 07/03/14 by SRNA #19, she went to the SDC to report the residents being left "soaked" and "soiled". Additional interview with SRNA #9 revealed when she reported the incident of residents being left "soaked" and "soiled" to the SDC on the morning of 07/03/14, the SDC told her to "write it up" and she would take it to the Human Resources (HR) Director. However, SRNA #9 stated she never wrote up the incidents. SRNA #9 stated "almost daily" when she came to work after SRNA #19 had worked the previous shift, she found her residents "wet" and their beds needing to be changed. Per interview, SRNA #9 stated it was "neglect" to leave residents "wet". Interview, on 07/03/14 at 6:41 PM, with the SDC revealed no staff had reported to her that morning the condition residents had been left in, nor had she spoken to residents. However, interviews with SRNA #9 and LPN #8 revealed SRNA #9 had reported the residents' condition to her. The SDC stated if she had been informed of a reportable situation by staff she would have directed them to tell the Assistant Director of Nursing (ADON) and "follow the chain of command". Interview, on 07/03/14 at 2:51 PM and on 07/23/14 at 2:26 PM, with SRNA #20 revealed when reporting to work on day shift at 7:00 AM, in a week's time she had had to change several residents three (3) times out of the week. Further interview with SRNA #20 revealed she had told Registered Nurse (RN) #4/Assistant Director of Nursing (ADON) of her concern regarding residents' care. She reiterated three (3) to four (4) days out of the week finding residents "wet" when she reported to work at 7:00 AM. Interview, on 07/03/14 at 4:35 PM and on 07/23/14 at 3:49 PM, with the RN #4/ADON revealed she was not aware of the incidents involving Resident #5, Resident #26, Resident #27, Resident #28 and Resident #29 which had taken place the morning of 07/03/14 until later that day. She stated a staff member did tell her residents had not been "touched in awhile"; however, the staff person did not tell her which residents were involved and to what extent. The ADON stated her expectation was for night shift and day shift to do rounds on residents prior to night shift leaving the facility. She indicated staff should not leave residents soiled. Interview, on 07/03/14 at 5:20 PM, with the Director of Nursing (DON) revealed she was not made aware of Resident #26 and the other residents having been left wet and soiled by night shift for day shift to change until about an hour before the current interview with the State Survey Agency. The DON stated an investigation had been started regarding the incident after she was notified. She stated the RN Evening Shift Supervisor notified her. Continued interview with the DON revealed residents should not be left wet and soiled by any shift. Interview, on 07/03/14 at 7:25 PM, with the Administrator revealed it was her expectation staff would ensure residents were clean and dry. She stated staff should be completing rounds every two (2) hours as per the facility's policy. The Administrator stated for residents who need it, rounds should be completed more frequently. Continued interview with the Administrator revealed if a resident was fully saturated with urine, then the employee should be removed from duty and a full investigation initiated to determine if there was a neglect related to the resident's care. The Administrator stated she would have wanted to have been notified that morning when the incident involving the residents had occurred. The Administrator indicated any form of abuse or neglect of residents should be reported to Administration immediately and residents being left soiled was a form of neglect. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14 that alleged removal of the IJ effective 07/29/14. Review of the AOC revealed the facility implemented the following: 1. The facility opened and investigated the five (5) reported allegations of neglect identified on the 06/30/14 through 07/03/14 Survey for Residents #5, #26, #27, #28, and #29. Initial Reports were completed with the five (5) day follow up reports pending completion of the investigations. The allegations were investigated by the Clinical Nurse Executive, Corporate Nurse Consultant, Special Projects Administrator, Administrator, HR Director, SSD, Corporate Director of Compliance and Signature Care Consultant. 2. One hundred percent (100%) of the resident population received head to toe assessments by the DON, the ADON, MDS Coordinator, Wound Care Nurse, SDC, Evening Nurse Supervisor, Corporate Nurse Consultant and Charge Nurses on 07/23/14. 3. Residents with a BIMS of eight (8) or above were interviewed by the ADON, Admissions Director, Dietary Director, MDS Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, SDC, Supply Coordinator, Quality of Life Director or Chaplain which was completed on 07/25/14 for any abuse, neglect, or misappropriation concerns. 4. Families and responsible parties were interviewed for residents with a BIMS below eight (8) which was initiated on 07/25/14 and as of 07/28/14, thirty-seven (37) of fifty-six (56) had been completed, for any abuse, neglect, or misappropriation concerns. The facility would continue to attempt contacting families and responsible parties daily to identify any concerns until remaining Power of Attorney's (POA's) had been reached. Concerns were addressed per policy and procedure as to reporting requirements and resident protection. 5. Staff was interviewed for any abuse, neglect, or misappropriation concerns by the ADON, Admissions Director, Dietary Director, MDS Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, SDC, Quality of Life Director or Chaplain on 07/25/14. Initial reports were made on the allegations relative to those interviews. 6. Initial Reports were made on 07/25/14 related to the alleged allegations relative to the interviews with residents, families, responsible parties, and staff. Thorough investigations were initiated on 07/25/14 by the Clinical Nurse Executive, Corporate Nurse Consultant, Special Projects Administrator, Administrator, HR Director, SSD, Corporate Director of Compliance and Signature Care Consultant on those residents identified with appropriate follow up reporting on the allegations received. 7. Abuse, neglect and misappropriation audits, assessments, interviews and questionnaires were reviewed by the Special Projects Administrator, DON, Corporate Nurse Consultant or Chief Nurse Executive on 07/27-07/28/14 for any indications of abuse, neglect or misappropriation concerns. 8. The Medical Director was notified of the Immediate Jeopardy on 07/25/14 by the DON and Special Projects Administrator. An Emergency Quality Assurance (QA) Meeting was held on 07/26/14 with the Corporate Director of Risk Management, Clinical Nurse Executive, Corporate Nurse Consultant, Medical Director, Special Projects Administrator, DON, HR Director, SSD and SDC related to the Immediate Jeopardy. 9. The DON, two (2) ADONs, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions, Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse were re-educated on 07/23/14 and the Administrator was re-educated on 07/28/14, upon his return, by the Corporate Nurse Consultant on the Abuse, Neglect and Misappropriation Policy and Procedure which included training, prevention, identification, investigation, protection and reporting, as well as, providing care per residents' individualized care plans. They could not return to work until the abuse, neglect, misappropriation education was provided and post test administered and a one hundred percent (100%) score was obtained on the post test. If a manager did not score a one hundred percent (100%) on post test, the manager was immediately re-educated and a post test was re-administered. 10. The facility's Administrator, DON, ADON's, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse educated stakeholders related to the Abuse, Neglect, and Misappropriation Policy which included training, prevention, identification, investigation, protection and reporting, as well as, providing care per residents' individualized care plans starting on 07/23/14 and continued until 07/28/14. No staff would be allowed to work until this education was provided and the post test administered and a one hundred percent (100%) score obtained. Eighty-seven (87) of ninety-six (96) were completed by 07/28/14. 11. Administrator, DON, ADON's, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse provided education to stakeholders which was initiated on 07/26/14 to nursing staff related to incontinence care and Activities of Daily Living (ADL's) care per the Care Plan and answering call lights. Calls and certified letters had been sent notifying staff they must complete training before returning to work relative to incontinence care and Activities of Daily Living (ADL's) Care per resident individualized Care Plan and answering call lights in a timely manner. 12. Education regarding the Abuse, Neglect and Misappropriation Policy would be included in the orientation process for newly hired staff. No newly hired person w

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on interview, record review, review of the facility's investigation reports and policy, during the 08/01/14 survey, it was determined the facility failed to have an effective system in place to ensure the facility's policies and procedures related to abuse/neglect were implemented for five (5) of thirty-seven (37) sampled residents (Residents #5, #26, #27, #28, #29). On 07/03/14, at approximately 5:30 AM, Resident #26 rang his/her call light to request assistance, from the night shift staff, to be cleaned after being incontinent. However, Resident #26 did not receive the requested assistance until approximately 7:45 AM, when the day shift State Registered Nursing Assistants (SRNAs) assisted the resident. Interviews with the day shift SRNAs revealed Resident #26 was covered in bowel movement (BM) and urine soaked when they assisted the resident. Interviews with the day shift staff revealed other residents were also left urine soaked or soiled with BM that same morning, 07/03/14. The other residents included Resident #5, Resident #27, Resident #28 and Resident #29. (Refer to F-224, F-225) Additionally, during the facility's investigation a conflict was identified between the two (2) night shift SRNAs usually assigned to care for the residents involved, who did not work together when providing care for residents. However, the facility failed to address the conflict between the SRNAs which impacted resident care on night shift on the South Unit, where the residents all resided, leaving residents at risk for further neglect. In addition, review of the facility's policy and procedure related to abuse and neglect revealed the policy did not clearly state all allegations of abuse would be investigated per the regulation, F-225. The facility's failure to have an effective system in place to ensure the implementation of abuse policies and procedures to prevent neglect was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 07/25/14, and determined to exist on 07/03/14. The facility was notified of the Immediate Jeopardy on 07/25/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14, with the facility alleging removal of the Immediate Jeopardy on 07/29/14. The Immediate Jeopardy was verified to be removed on 07/29/14, prior to exiting the facility on 08/01/14, with remaining non-compliance at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure an effective system is in place to ensure abuse policies and procedures are implemented to prevent neglect of residents. The findings include: Review of the facility's policy titled, "Abuse, Neglect and Misappropriation", dated April 2013 revealed the facility prohibited abuse or neglect of residents. Review of the Policy revealed staff was to be trained on abuse to include what constituted abuse, neglect or misappropriation of resident property. The Policy revealed all allegations of abuse were to be investigated, and the Administrator/designee was to make all reasonable efforts to investigate and address alleged reports, grievances and concerns. Further review revealed Social Services or the Chaplain were to follow up with the resident to monitor his/her emotional well-being after an incident, and families were to be notified of the outcome of the investigation. Post-survey interview with the current Administrator, on 08/12/14 at 4:40 PM, revealed where the facility's abuse policy stated the Administrator/designee was to make reasonable effort to investigate and address allegations of abuse or neglect meant "doing whatever" it took to "find out the circumstances" of an incident. He stated all investigations were to be investigated and reported, and all efforts made to address all investigations, allegations, concerns or grievances. However, he indicated the policy wording was confusing, and indicated the wording in the policy needed to be changed to clearly state all allegations of abuse would be investigated as per the regulation. Review of the facility's investigation report forms dated 07/03/14, and documented as concluded on 07/07/14, revealed Resident #26 had voiced concerns related to "possible" failure by a night shift SRNA to provide care. Review of the staff's written statements and interviews revealed staff interviewed during the investigation reported Resident #5, Resident #27, Resident #28 and Resident #29 had also been left wet and/or soiled the morning of 07/03/14. However, continued review of the statements and staff interviews revealed no documented evidence Resident #5, Resident #27, Resident #28 and Resident #29 were assessed or staff concerns were investigated or followed-up on related to these residents as per facility policy. Additional review of the staff interviews and written statements in the investigation report revealed two (2) staff had reported SRNA #9 had voiced concerns regarding resident care issues on 07/03/14, and staff also, indicated there was a conflict between SRNA #19 and SRNA #21 who worked on night shift. However, there was no documented evidence SRNA #9 was interviewed regarding her concerns and no documented evidence the facility had addressed the conflict reported between SRNA #19 and SRNA #21 to ensure an investigation was conducted to prevent neglect as per facility policy. Interview on 07/23/14 at 5:49 PM, with the Human Resources (HR) Director, Social Services Director (SSD) and Director of Nursing (DON) revealed the investigation conducted on 07/03/14 had been "focused" on Resident #26's concerns. The HR Director stated she interviewed the staff she thought had been assigned to the residents the morning of 07/03/14; however, she was not sure why SRNA #9 was not interviewed. Further interview revealed even though she had assisted with the investigation performed 07/03/14 through 07/07/14 where staff interviewed indicated a conflict between SRNA #19 and SRNA #21, she was not aware of a conflict between the two (2) SRNAs. The HR Director stated she had missed the information in staff's statements she obtained on 07/03/14, such as, SRNA #9's concerns reported to two (2) staff regarding resident care, and the conflict between SRNA #19 and SRNA #21. In interview, the DON stated after completion of the investigation on 07/07/14, she had not reviewed the investigation report. According to the DON, she was not aware of SRNA #9's concerns reported during the investigation; however, she stated the investigation should have noted why the staff had not taken action, when the SRNA expressed concerns regarding resident care to staff. However, interview, on 07/31/14 at 10:14 AM, with the former Administrator, who was in charge of the facility until 07/11/14, revealed the DON did make her aware of the conflict between SRNA #19 and SRNA #21. However, she failed to follow-up on it during the investigation conducted on 07/03/14. She stated the conflict could have impacted resident care if the SRNAs did not work together. She further revealed the HR Director or Staff Development Nurse (SDN) should have addressed the conflict, as per facility policy. The former Administrator stated the DON, the HR Director and SSD had performed the investigation, and her part of the investigation had been to review it and come up with findings; however, the investigation information was verbally reported to her and she had not read the investigation report. The former Administrator indicated as Administrator she should have ensured a thorough investigation was performed to include: interviewing SRNA #9's regarding her concerns of residents left wet and/or soiled on 07/03/14; ensuring those residents were assessed; ensuring the interviewable residents concerns were investigated; and ensuring the conflict between SRNA #19 and SRNA #21 was investigated and addressed as per the policy. Interview, on 07/31/14 at 11:47 AM, with the current Administrator revealed he had taken over as Administrator on 07/11/14, and indicated he was aware of the facility's abuse policy, he had been involved in investigations, and was aware of the status of investigations. He stated as Administrator he read the final investigation reports, and findings were also verbally reported to him by staff involved in the investigations. The current Administrator stated this process was in place prior to his taking over as Administrator of the facility. However, interview and record review revealed the process/procedure had not been implemented. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14 that alleged removal of the IJ effective 07/29/14. Review of the AOC revealed the facility implemented the following: 1. The facility opened and investigated the five (5) reported allegations of neglect identified on the 06/30/14 through 07/03/14 Survey for Residents #5, #26, #27, #28, and #29. Initial Reports were completed with the five (5) day follow up reports pending completion of the investigations. The allegations were investigated by the Clinical Nurse Executive, Corporate Nurse Consultant, Special Projects Administrator, Administrator, HR Director, SSD, Corporate Director of Compliance and Signature Care Consultant. 2. One hundred percent (100%) of the resident population received head to toe assessments by the DON, the ADON, MDS Coordinator, Wound Care Nurse, SDC, Evening Nurse Supervisor, Corporate Nurse Consultant and Charge Nurses on 07/23/14. 3. Residents with a BIMS of eight (8) or above were interviewed by the ADON, Admissions Director, Dietary Director, MDS Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, SDC, Supply Coordinator, Quality of Life Director or Chaplain which was completed on 07/25/14 for any abuse, neglect, or misappropriation concerns. 4. Families and responsible parties were interviewed for residents with a BIMS below eight (8) which was initiated on 07/25/14 and as of 07/28/14, thirty-seven (37) of fifty-six (56) had been completed, for any abuse, neglect, or misappropriation concerns. The facility would continue to attempt contacting families and responsible parties daily to identify any concerns until remaining Power of Attorney's (POA's) had been reached. Concerns were addressed per policy and procedure as to reporting requirements and resident protection. 5. Staff was interviewed for any abuse, neglect, or misappropriation concerns by the ADON, Admissions Director, Dietary Director, MDS Coordinators, Medical Records Director, Business Office Manager, Housekeeping Director, SDC, Quality of Life Director or Chaplain on 07/25/14. Initial reports were made on the allegations relative to those interviews. 6. Initial Reports were made on 07/25/14 related to the alleged allegations relative to the interviews with residents, families, responsible parties, and staff. Thorough investigations were initiated on 07/25/14 by the Clinical Nurse Executive, Corporate Nurse Consultant, Special Projects Administrator, Administrator, HR Director, SSD, Corporate Director of Compliance and Signature Care Consultant on those residents identified with appropriate follow up reporting on the allegations received. 7. Abuse, neglect and misappropriation audits, assessments, interviews and questionnaires were reviewed by the Special Projects Administrator, DON, Corporate Nurse Consultant or Chief Nurse Executive on 07/27-07/28/14 for any indications of abuse, neglect or misappropriation concerns. 8. The Medical Director was notified of the Immediate Jeopardy on 07/25/14 by the DON and Special Projects Administrator. An Emergency Quality Assurance (QA) Meeting was held on 07/26/14 with the Corporate Director of Risk Management, Clinical Nurse Executive, Corporate Nurse Consultant, Medical Director, Special Projects Administrator, DON, HR Director, SSD and SDC related to the Immediate Jeopardy. 9. The DON, two (2) ADONs, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions, Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse were re-educated on 07/23/14 and the Administrator was re-educated on 07/28/14, upon his return, by the Corporate Nurse Consultant on the Abuse, Neglect and Misappropriation Policy and Procedure which included training, prevention, identification, investigation, protection and reporting, as well as, providing care per residents' individualized care plans. They could not return to work until the abuse, neglect, misappropriation education was provided and post test administered and a one hundred percent (100%) score was obtained on the post test. If a manager did not score a one hundred percent (100%) on post test, the manager was immediately re-educated and a post test was re-administered. 10. The facility's Administrator, DON, ADON's, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse educated stakeholders related to the Abuse, Neglect, and Misappropriation Policy which included training, prevention, identification, investigation, protection and reporting, as well as, providing care per residents' individualized care plans starting on 07/23/14 and continued until 07/28/14. No staff would be allowed to work until this education was provided and the post test administered and a one hundred percent (100%) score obtained. Eighty-seven (87) of ninety-six (96) were completed by 07/28/14. 11. Administrator, DON, ADON's, MDS Coordinators, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Nurse provided education to stakeholders which was initiated on 07/26/14 to nursing staff related to incontinence care and Activities of Daily Living (ADL's) care per the Care Plan and answering call lights. Calls and certified letters had been sent notifying staff they must complete training before returning to work relative to incontinence care and Activities of Daily Living (ADL's) Care per resident individualized Care Plan and answering call lights in a timely manner. 12. Education regarding the Abuse, Neglect and Misappropriation Policy would be included in the orientation process for newly hired staff. No newly hired person would be able to work until this education was provided and a post test administered and one hundred percent (100%) score obtained provided by staff development. 13. Staff assessment of knowledge test regarding abuse, neglect and misappropriation was being administered by the Administrator, DON, ADON's, MDS Coordinator, SDC, Dietary Director, Medical Records Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director, Quality of Life Director and Wound Care Nurse to five (5) staff members on each shift and different staff members until the immediacy was removed. 14. Ten (10) staff questionnaires would be administered daily to ensure continued understanding of the Abuse, Neglect and Misappropriation Policy. Results of the questionnaires, tests, ten (10) resident skin assessments of residents with a BIMS less than eight (8) per day, ten (10) residents with a BIMS greater than eight (8) interviews would be reviewed daily until the immediacy was resolved by the Administrator, DON, Nurse Consultant or Chief Nurse Executive. Any concerns revealed on the above to include injuries of unknown source would be reported immediately to the Abuse Coordinator, Administrator, DON, Corporate Nurse Coordinator, Regional Vice President of Operations, Special Projects Administrator, or Chief Nurse Executive. 15. Results of the staff questionnaires, resident interviews and skin assessments would be reviewed daily by the Administrator, DON, Nurse Consultant or Chief Nurse Executive with results reported to the Quality Assurance (QA) Committee weekly to determine the further need of continued education or revision of plan. Based on the evaluation the QA Committee would decide at what frequency the staff questionnaire would need to continue. Concerns identified would be corrected immediately and reported to the Administrator or DON to ensure an investigation of suspected abuse, neglect or misappropriation was investigated/completed and reporting guidelines were met along with any reporting of violation of resident rights. 16. Administrator, DON, ADONs, MDS Coordinator, SDC, Dietary Director, Business Office Manager, SSD, Chaplain, Admissions Director, Medical Records Director, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Director, Plant Operations Director, Quality of Life Director, Wound Care Nurse, Corporate Nurse Consultant, Regional Vice President or Clinical Nurse Executive would conduct call light audits through direct observation and monitoring tool daily twenty-four (24) hours a day seven (7) days a week on each shift to monitor compliance until the immediacy was removed. Then five (5) call lights daily on each shift (fifteen (15) total) ongoing and reported to QA Committee weekly during immediacy and monthly after immediacy was removed. Charge Nurses would provide direct observation of call light responsiveness and ensure all residents were getting needs met for plan of care each shift. Incontinence care observation would be completed for ten (10) residents daily until the immediacy was removed then ongoing for five (5) residents daily with results being reported to the QA Committee weekly during immediacy and monthly after the immediacy was removed. 17. Human Resources (HR) Director performed an audit of staff files for any abuse, neglect or misappropriation concerns 7/26/14 through 7/27/14 and the items reviewed included coaching, counseling forms, suspension forms, termination forms, abuse registry checks, background checks and licensure to 07/03/14. Results of the audit was given to the Administrator, DON or Corporate Nurse Consultant on 07/27/14, to review for any abuse, neglect or misappropriation concerns that needed reported. None were identified. 18. Information on "Caring for the Caregiver" which addresses the signs of stress and burn out, showing the caregiver ways to cope and reduce stress and useful ways that friends could offer help to the caregiver were posted by the time clock on 07/27/14 by the Special Projects Administrator. 19. A nurse from the regional team or corporate office had been onsite since 07/21/14 and would remain in the facility daily until the Immediate Jeopardy was lifted. The nurses from the regional team home office were assisting with investigations, observing staff treatment of [REDACTED]. The Chief Nurse Executive would be in daily contact with the Corporate Nurse Consultant and would review allegations. 20. Grievances and Resident Questionnaires since 07/23/14 were reviewed by the Administrator, DON, Chief Nurse Executive, HR Director, Admissions Director or Regional Nurse Consultants 07/27/14 through 07/28/14 to determine if any items documented were a reportable event. All issues identified were reported and investigations initiated per the facility's policy and procedure. The Administrator, SSD, or the DON would review daily, the grievances and Incident/Accident Reports, until immediacy was lifted, starting 07/27/14 to determine if there were reportable allegations which had been identified, then daily Monday through Friday during the Morning Stand-Up Meeting. SSD or the DON would report to the Administrator any identified allegations of abuse, neglect or misappropriation immediately after their review. The Administrator would review any allegations of abuse, neglect or misappropriation for reporting to the Office of Inspector General, Adult Protective Services and Ombudsman and appropriate authorities as required by state law. 21. The Administrator, DON, SSD would review and discuss abuse, neglect and misappropriation allegations daily to ensure the resident was protected, the perpetrator was removed from resident care area, reports to the State Survey Agency, APS and Ombudsman were filed timely, and a thorough investigation was completed. The Abuse Coordinator (SSD) would maintain an abuse, neglect and misappropriation investigation log starting on 07/27/14 that would include documentation of the following: validate protection of residents; perpetrator was removed from resident care area; reports to the State Survey Agency and Adult Protective Services (APS) were filed timely; and a thorough investigation was completed. The Abuse Coordinator and one of the following: Administrator, DON, Chief Nurse Executive or Regional Nurse Consultant would review the abuse, neglect and misappropriation log daily until removal of the Immediate Jeopardy, beginning on 07/27/14, to validate protection of the resident, that the perpetrator was removed from the resident care area, that reports to the State Survey Agency and APS and appropriate authorities required by state law, were filed timely, and a thorough investigation had been completed. 22. In the event of any new reports of alleged abuse, neglect, or misappropriation of property, after the Immediate Jeopardy was removed, the Signature Care Consultant or Chief Nursing Executive would validate the resident was protected, report was filed timely, the perpetrator was removed from resident care area and a thorough investigation was completed. 23. Beginning on 07/27/14, the care plan conferences for each resident would include any abuse, neglect or misappropriation concerns which the residents or families had. Resident safety would be validated and then the allegation would be reported to the Charge Nurse. The Abuse,Neglect and Misappropriation Policy would then be followed. 24. Administrative oversight of the facility would be completed by the Special Projects Administrator, the Regional Vice President of Operations, Chief Nursing Officer, Signature Care Consultant, member of the regional staff team or Chief Operating Officer daily until removal of the immediacy beginning 07/21/14, then weekly for four (4) weeks, then monthly. 25. A Quality Assurance Meeting would be held weekly for four (4) weeks beginning 07/26/14, then monthly for recommendations and further follow up regarding the above stated plan. At that time based upon evaluation the QA Committee would determine at what frequency any ongoing audits would need to continue. The State Survey Agency validated the implementation of the facility's AOC as follows: 1. Review of the facilities investigations revealed the five (5) reported allegations involving Resident's #5, #27, #28, and #29 have been completed with a five (5) day follow up. A re-investigation was done related to allegations for Resident #26. Interview, on 07/31/14 at 7:08 PM, with the Corporate Nurse Consultant revealed the facility had investigated the allegations regarding Resident's #5, #26, #27, #28, and #29 and found them all to be substantiated. 2. Review of copies of resident head to toe assessments revealed all residents were assessed and the assessments were performed on 07/23/14 on North and South Hall, with a recorded census on 07/23/14 of fifty six (56) residents on North Hall and fifty-one (51) residents on South Hall. There was no concerns revealed during review of the skin assessments. Interview, on 07/31/14 at 5:26 PM, with the Wound Care Nurse revealed she was in charge of the skin assessments, and she and other nurses completed skin assessments on one hundred percent (100%) of the residents in the building. 3. Review of Resident Interviews revealed residents with a BIMS of eight (8) and above were interviewed, which included forty-six (46) residents, related to abuse, neglect, and misappropriation concerns. Concerns were addressed per policy and procedure as to reporting requirements and resident protection. 4. Review of family interviews for residents with a BIMS of less than eight (8) revealed thirty-seven (37) of fifty-six (56) of these interviews were completed as of 7/28/14 related to abuse, neglect, and misappropriation concerns. Concerns were addressed per policy and procedure as to reporting requirements and resident protection. Interview with the DON on 08/01/14 at 10:00 AM, revealed the interviewable residents were interviewed, as well as, the families of residents with a BIMS score of less than eight (8) and she reviewed the interviews for any concerns. 5. Review of the Stakeholder (Staff) Investigative Interviews revealed they were conducted in reference to abuse, neglect and misappropriation concerns 7/23/14 through 7/25/14 for all regular and part-time staff. Interview on 07/31/14 with SRNA #24 at 2:00 PM; Activity Assistant at 2:15 PM; SRNA #37 at 2:20 PM; Dietary Aide #5 at 2:30 PM; SRNA #36 at 2:30 PM; SRNA #11 at 2:40 PM; Housekeeper #4 at 2:45 PM; SRNA #5 at 2:55 PM; SRNA #34 at 3:30 PM; LPN #11 at 3:40 PM; SRNA #16 at 3:50 PM; RN #1 at 3:55 PM; LPN #12 at 4:10 PM; ADON/Unit Manager (UM) of the South Unit at 4:30 PM; ADON/UM of the North Unit at 4:45 PM; RN #5/Evening Shift Supervisor at 5:00 PM; LPN #3 at 5:17 PM; SRNA #35 at 5:49 PM; LPN #13 at 6:05 PM; Dietary Manager at 6:15 PM; and SRNA #4 at 7:40 PM revealed they were all interviewed and asked if they were aware of any abuse, neglect, or misappropriation. 6. Review of the allegations relative to the interviews with residents, families, responsible parties, and staff concerns revealed they were investigated with initial reports completed. Interview with the Corporate Nurse Consultant on 07/31/14 at 7:08 PM revealed there was several reportable allegations from the interviews which she assisted with conducting, and the facility investigated with follow up actions and reporting. 7. Review of the Abuse, Neglect, and Misappropriation audits, assessments, interviews and questionnaires revealed they were reviewed by the DON, Corporate Nurse Consultant, Chief Nurse Executive or Special Projects Administrator on 07/27/14 and 07/28/14. Interview with the DON on 08/01/14 at 10:00 AM revealed they expanded on the abuse questions giving scenarios to the staff to have them choose which type of abuse was occurring in the scenarios. She stated she reviewed the abuse audits, assessments, interviews, and questionnaires. 8. Review of the Quality Assurance Signature Sheet and Minutes revealed an Emergency QA meeting was held on Saturday, 07/26/14, with the Medical Director, Special Projects Administrator, Director of Nursing Services, Director of Clinical Risk Management, Staff Development, Certified Nurse Executive, Corporate Nurse Consultant, Human Resources Director, and Social Services Director to discuss current Immediate Jeopardy deficiencies and a Plan of Correction. Interview with the DON on 08/01/14 and the Corporate Nurse Consultant on 07/31/14 at 7:08 PM confirmed the QA Meeting was held on 07/26/14 with the Medical Director. Interview with the HR Director on 07/31/14 at 5:45 PM revealed during the emergency QA Meeting they discussed the Immediate Jeopardy deficiencies and the reason for the deficiencies as well as discussed the audits, interviews, questionnaires and interviewing that was being done related to the deficiencies. 9. Review of the sign in sheets dated 07/23/14 regarding training for the Administrative staff of the facility regarding the Abuse, Neglect and Misappropriation Policy revealed the Certified Nurse Executive educated the DON, ADON's, MDS Coordinator, SDC, Dietary Director, Business Office Manager, Social Services Director, Chaplain, Admissions Director, Medical Records, HR Director, Therapy Services Manager, Supply Manager, Environmental Services Manager, Plant Operations Director , Quality of Life Director and Wound Care Nurse received the training. Review of the sign in sheet on 07/28/14 for training on the Abuse, Neglect and Misappropriation Policy, revealed the Administrator of the facility was educated on skin assessments, interviews, the Abuse, Neglect, and Misappropriation Policy, and the Education session regarding the Plan of Correction. Interview with the ADON/UM of the South Unit on 07/31/14 at 3:30 PM, ADON/UM of the North Unit on 07/31/14 at 4:45 PM, HR Director on 07/31/14 at 5:45 PM, the Dietary Director on 07/31/14 at 6:15 PM, and the DON on 08/01/14 at 10:00 AM, revealed they received training on abuse, neglect and misappropriation and had to take a post test in which they had to score a one hundred percent (100%). Review of the POS [REDACTED]. Interview on 07/31/14 at 7:08 PM with the Corporate Nurse Consultant, revealed the Department Administrative Managers scored a one hundred percent (100%) on the post test related to abuse, neglect and misappropriation education. 10. Review of the inservices revealed education was conducted with stakeholders related to abuse, neglect, and misappropriation 07/23/14 through 07/28/14 in which they had to score a one hundred percent (100%) on the post test or retake the test. Interview with the Staff Development Coordinator (SDC) on 07/31/14 at 5:15 PM, and the SSD on 07/31/14 at 6:30 PM revealed she and other administrative staff educated the stakeholders related to abuse, neglect and misappropriation and completed these inservices. Interview on 07/31/14 with SRNA #24 at 2:00 PM; Activity Assistant at 2:15 PM; SRNA #37 at 2:20 PM; Dietary Aide #5 at 2:30 PM; SRNA #36 at 2:30 PM; SRNA #11 at 2:40 PM; Housekeeper #4 at 2:45 PM; SRNA #5 at 2:55 PM; SRNA #34 at 3:30 PM; LPN #11 at 3:40 PM; SRNA #16 at 3:50 PM; RN #1 at 3:55 PM; LPN #12 at 4:10 PM; ADON/Unit Manager (UM) of the South Unit at 4:30 PM; ADON/UM of the North Unit at 4:45 PM; RN #5/Evening Shift Supervisor at 5:00 PM; LPN #3 at 5:17 PM; SRNA #35 at 5:49 PM; LPN #13 at 6:05 PM; Dietary Manager at 6:15 PM; and SRNA #4 at 7:40 PM revealed they were all educated on the facility's Abuse, Neglect and Misappropriation Policy, which included training, prevention, identification, investigation, protection and reporting. Review of the sign in sheets from 07/23/14 through 07/28/14 revealed inservices were conducted with the facility staff regarding the Abuse and Neglect Policy. Review of the POS [REDACTED]. Documentation provided from the facility revealed telephone calls and certified letters were sent to staff who did not complete education and informed they could not return to work until the education was completed. Interview on 07/31/14 with SRNA #24 at 2:00 PM; Activity Assistant at 2:15 PM; SRNA #37 at 2:20 PM; Dietary Aide #5 at 2:30 PM; SRNA #36 at 2:30 PM; SRNA #11 at 2:40 PM; Housekeeper #4 at 2:45 PM; SRNA #5 at 2:55 PM; SRNA #34 at 3:30 PM; LPN #11 at 3:40 PM; SRNA #16 at 3:50 PM; RN #1 at 3:55 PM; LPN #12 at 4:10 PM; ADON/Unit Manager (UM) of the South Unit at 4:30 PM; ADON/UM of the North Unit at 4:45 PM; RN #5/Evening Shift Supervisor at 5:00 PM; LPN #3 at 5:

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on observation, interview, record review, and review of the facility's Fire Emergency Plan and Evacuation Plan, during the 07/03/14 survey, it was determined the facility failed to have an effective system to ensure the facility's emergency evacuation plan was updated related to ongoing construction, and to ensure all employees were trained in emergency procedures related to safety and evacuation. On 06/24/14, construction began outside the Northwest hallway exit and and the Dining room exit and on 06/27/14 the Southwest hallway exit door had pavement removed, affecting the safe path to a public way for these three (3) exits. The facility failed to update the emergency evacuation plan related to the Northwest hallway, Dining room, and Southwest hallway exits and failed to provide training to staff regarding using the exits as a means of evacuation during the construction. Staff interviews revealed they would have used the affected exits to the outside if an emergency arose which required residents to be evacuated. (Refer to F-323) The facility's failure to ensure the emergency evacuation plan was updated and failure to have an effective system in place to ensure staff were adequately trained in emergency procedures related to safety and evacuation was likely to cause risk for serious injury, harm, impairment or death. The Immediate Jeopardy was identified on 06/30/14, and was determined to exist on 06/24/14. The facility was notified of the Immediate Jeopardy on 06/30/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/03/14 with the facility alleging removal of the Immediate Jeopardy on 07/02/14. The Immediate Jeopardy was verified to be removed on 07/02/14, with remaining non-compliance at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure the emergency evacuation plan is updated and all staff are trained in emergency procedures related to safety and evacuation. The findings include: Review of the facility's, "Disaster Preparedness" Manual, dated January 2005, revealed a fire safety procedure plan which stated when preparing for an evacuation after a fire alarm sounded, staff should first check the primary exit route and if it was clear and safe use that exit. Further review of the fire safety procedure plan revealed no documented evidence it had been changed to address the construction taking place outside the Northwest hallway exit door, the Dining room exit door, or the Southwest hallway exit door. Additionally, the facility was unable to provide documented evidence they had developed and implemented a revised emergency evacuation plan specific to address the three (3) exits involved in construction. Review of the facility's, "Fire Safety Procedures Orientation Training", undated, revealed in an evacuation staff should first check the primary exit route, as indicated in the fire safety procedure plan, and use that exit if it was clear and safe. Review of the facility's, "South Nursing Department Fire Emergency Guidelines" and "North Nursing Department Fire Emergency Guidelines" both undated, revealed staff should check the primary exit route and if it was blocked use the secondary route. Review of the facility's maps for the Southwest hallway and Northwest hallway revealed the exit doors at the end of the hallways were noted to be used as an exit route. Review of the facility's map in the dining room revealed the exit door located there was noted to be used as an exit route. Review of the "Town Hall Meeting and Inservice Agenda" dated 06/20/14, revealed a bullet list which included "construction on drive". There was no written information regarding what the inservice included for reference. Continued review revealed there were twenty-eight (28) staff signatures listed on the inservice out of one hundred and fifty (150) employees in the facility. Further review of the facility's documentation revealed no documented evidence the facility had provided inservice training for all staff regarding the fire exits affected by the construction and on any changes to the facility's evacuation plan. Observations on 06/30/14 from 5:15 PM to 5:24 PM, of the three (3) areas affected by construction revealed: the dining room fire exit door had a concrete pad leading to a three and a half (3.5) inch drop off to gravel and rebar (common steel bar used widely in construction to reinforce concrete); the Northwest hallway fire exit had a ramp which led to a three (3) inch drop off from the ramp to gravel and rebar; and the Southwest hallway fire exit door had a ramp which led to a four and a half (4.5) inch drop off with gravel. Observation outside all three (3) of these fire exit doors revealed there was a dirt and rocky uneven surface. Additional observation on 06/30/14 revealed no signs were posted at the affected exits to alert staff these exits were not accessible due to the construction, and there were no new evacuation routes observed posted. Interview with the Director of Plant Operations, on 06/30/14 at 2:20 PM, revealed construction began on 06/24/14. Per interview, he was unaware of any updated evacuation plan related to the new construction. He stated staff including himself received no formal training related to any new evacuation plan due to construction although these three (3) exits were not safely accessible in case of an emergency evacuation. Interview, on 06/30/14 at 5:01 PM, with the Social Service Director (SSD) revealed she knew about the construction project. However, she was unaware of any new evacuation plan and thought the staff were to use the Northwest, and Southwest exits in the case of an emergency situation. The SSD stated staff should have been educated on a new evacuation plan due to construction because under the current evacuation plan the Northwest and Southwest exits as well as the dining room exit were to be used in the case of an emergency evacuation. Interview, on 06/30/14 at 3:16 PM, with State Registered Nursing Assistant (SRNA) #1 revealed if an emergency situation arose she would have used the Northwest hallway, Southwest hallway, and Dining room exits to evacuate residents. She stated even though she was aware of the construction, as far as she knew those exits were not affected by it. Interview, on 06/30/14 at 3:20 PM, with Housekeeper #1 revealed she had not been told not to use the Northwest hallway, Southwest hallway or Dining room exits, and indicated she would have used the exits to evacuate residents in the case of an emergency. Interview, on 06/30/14, at 5:15 PM, with Licensed Practical Nurse (LPN) #4 revealed prior to 06/30/14 she had not been notified of any new evacuation routes or that there was construction outside the building. However, she received education today, 06/30/14, related to a new emergency plan after the State Survey Agency entered the building. Interview, on 06/30/14 at 5:17 PM, with the second shift Supervisor/Registered Nurse (RN) #5 revealed she did not formally inservice all of her staff not to use the exits affected by the construction; however, did verbally tell some of the staff. She stated formal inservicing related to a new evacuation plan in the case of an emergency had started that day, 06/30/14, after the State Survey Agency entered the building. Interview, on 06/30/14 at 5:30 PM, with Housekeeper #2 revealed his supervisor informed him of the construction in the back of the building; however, he had not received an inservice related to a new evacuation plan in case of emergency due to the construction. Interview, on 06/30/14 at 5:52 PM, with LPN #1 revealed she was not educated prior to 06/30/14 regarding not using the Northwest hallway and Southwest hallway exit doors because of the construction. She stated the State Survey Agency was already in the building before she received any inservicing. She indicated staff should have been formally inserviced regarding not using the affected exits "last" week when construction began. Interview, on 06/30/14 at 5:55 PM, with SRNA #3 revealed she had not been aware there was construction at the back of the facility until 06/30/14. She stated she had received education that day, 06/30/14, by the Assistant Director of Nursing (ADON)/Unit Manager of the North Hall. SRNA #3 indicated she had also been told that day staff was not use the affected exit doors at the back of the building. Interview, on 06/30/14 at 7:30 PM, with LPN #3 revealed even though she knew construction was taking place, she had not received any new information regarding a new evacuation plan. She indicated she was unaware of the affected exits which were not accessible because of the construction. Interview, on 06/30/14 at 5:17 PM, with the Assistant Director of Nursing (ADON)/Unit Manager for the South hall revealed before the construction started there had been no formal inservices related to a new evacuation plan in the case of an emergency; however, the facility had initiated formal inservicing that day, 06/30/14. She stated educating the staff prior to the construction would have been important, as the Northwest hallway and Southwest hallway exit doors were not accessible due to the construction. Interview, on 06/30/14 at 5:05 PM, with the Director of Nursing (DON) revealed she was told on 06/17/14 in a "Stand Up Meeting", that construction would start on 06/18/14; however, the construction was delayed and started at a later date. According to the DON, staff in the "Stand Up Meeting" were told not to use the exit doors in the Northwest hallway and Southwest hallway as the sidewalks were being replaced outside those doors. However, she had not been educated regarding alternate routes to use for emergency evacuation. The DON stated it would be important to have an alternate evacuation plan and to ensure all staff were inserviced on the plan. She stated the Staff Development Nurse (SDN) inserviced staff regarding the construction; however, she did not know if all staff had received the inservice and if alternate routes for emergencies was included in the inservice. Interview with the Staff Development Nurse (SDN) on 06/30/14 at 5:30 PM, revealed she was told by the Director of Plant Operations during a morning "Stand Up Meeting", about the construction project and was told staff could not use the exits to the back of the building including the Dining room exit. Continued interview revealed the DON had asked her to let staff know which doors would be inaccessible due to construction; however she was not told who to inservice and was not formally notified of new evacuation routes. She stated she did an informal verbal inservice at the last "Town Hall Meeting", on 06/20/14, and told the staff present which doors would be inaccessible due to construction, which were the Southwest door, the Dining room door, and the kitchen door. She stated she also told staff to they could use the front doors, therapy doors, north side door and south side door, and the door to the employee parking lot for evacuation of residents. The SDN stated she also told staff during the inservice if the residents were in the dining room during an evacuation they were to use the employee parking lot doors or the front doors to exit. According to the SDN, she told staff in the inservice if residents needed to be evacuated from the Southwest wing they were to use the Southeast exit door to the parking lot. The SDN further stated she had also verbally inserviced the South Unit SRNAs and nurses, the Activity Director, the Minimum Data Set (MDS) Coordinators and the wound nurse related to the construction and which doors to use for an emergency evacuation. However, she stated she was unaware of the date of the inservice, and was unable to submit the inservice or signatures of staff present from the inservice. Further interview revealed she was unaware there was construction near the Northwest exit door and did not inservice staff related to that door. She stated she was unaware of any new formal evacuation plan in case of fire or other emergency. Review of the "Town Hall Meeting and Inservice Agenda" dated 06/20/14, revealed a bullet list which included "construction on drive". There was no written information in the inservice for reference. There were twenty-eight (28) signatures listed for the inservice out of one hundred and fifty (150) employees in the facility. Interview with the Administrator on 06/30/14 at 7:00 PM, revealed she started at the facility on 05/15/14, and was told by the previous Administrator there would be construction which included replacing damaged pavement on the west or back side of the building. She stated during the "morning meetings" she discussed the construction project with the managers; however, they did not discuss the safety aspects related to the construction. She stated in hindsight she should have ensured there was a new emergency evacuation plan specifically addressing the three (3) exits affected during the construction, as well as, formal inservicing and education of staff related to which doors were affected related to construction and which doors were to be used for alternate routes. Further interview with the Administrator and previous Administrator on 07/01/14 at 12:00 PM, revealed it would be very important for staff to be aware of which doors led to the construction zone in order to ensure those doors were not used in the case of an emergency evacuation. The facility was unable to provide documented evidence they had developed and implemented a revised emergency evacuation plan specific to address the three (3) exits involved in construction. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 07/03/14, which alleged removal of the Immediate Jeopardy (IJ), effective 07/02/14. Review of the AOC revealed the facility implemented the following: 1. The Regional Nurse Consultant (RNC) inserviced the Administrator and the entire Safety Committee (Human Resources Director/Safety Director, ADON North, Business Office Manager (BOM), Chaplain, Clinical Social Worker (CSW), Rehabilitation (Rehab) Manager, Medical Records Director, Dietary Director, Housekeeping Director, Activity Director, Staff Development Coordinator (SDC), Plant Operations Director, DON, ADON South, MDS LPN, MDS RN and Marketing Director, who were also the Quality Assurance (QA) Committee, on 06/30/14 during a Safety Committee meeting held to discuss the facility's Fire Safety Procedure for alternate evacuation routes due to construction. The education covered construction planning and continued safety of residents. Additionally, the construction plan and assignments, that delineated which staff member was responsible for what piece of the AOC, were dispersed to all departments by the Administrator and the Safety Committee Director. The construction plan included the creation of new routes and temporary exit diagrams, placement of signage outlining the construction plan in appropriate areas that included the front entrance, parking lot entrance and the doors which were closed related to the construction. New signs stating "DO NOT USE" were also placed on the affected doors. 2. Inservices were initiated on 06/30/14 and 07/01/14, by the DON, Assistant Director of Nursing (ADON), Dietary Manager (DM), Staff Development, Business Office Manager (BOM), Housekeeping Director and Rehabilitation (Rehab) Director for all staff, including dietary, housekeeping, therapy, laundry and maintenance. The education consisted of the new evacutation plan and continued safety of residents. Additionally, no employee would be allowed to work until the education was provided and the post test completed to ensure compliance with exit routes. The Administrator maintained an employee roster to crosscheck with the training log to assure no employee was allowed to work until the education was received. One hundred and fifty-five (155) employees of one hundred and sixty-three (163) employees had been educated by 07/01/14. The facility did not utilize agency staff. 3. All residents with a BIMS score of eight (8) or greater on their last MDS were informed of the construction and alternate evacuation routes, as well as, the the new evacuation signs. Forty-eight (48) residents met the criteria and were informed as indicated by the Activity Director and Social Service Director on 06/30/14 and 07/01/14. Responsible Parties of residents, who were frequent visitors to the facility, were notified of the construction and temporary evacuation routes, by telephone by the Chaplain and Marketing Director. Thirty (30) Responsible Parties were notified on 06/30/14 and 07/01/14, with plans to continue notifications daily until all resident families/responsible parties were notified. 4. Signs were placed on the Main Entrance and the employee entrance doors on 06/30/14 by the Maintenance Director to inform all visitors that "Construction is in progress". Also, new temporary exit diagrams (maps) were created for the South West/North West/ Dining Room/Dietary Services/Laundry Area by the Safety Committee on 06/30/14 and posted on all temporary alternate evacuation routes. Signs were created and posted on all "temporarily closed" evacuation exits that stated, "STOP-DO NOT USE" by the Maintenance Director on 06/30/14. 5. The Medical Director was notified of the IJ 07/01/14 by the DON. 6. A QA meeting was held on 07/01/14 to review the new temporary exit diagrams for the South West/North West/Dining Room, Dietary Services and Laundry areas. Signs were created and posted on all areas of temporary alternate evacuation routes. Signs were created and posted on all temporarily closed evacuation exits to "STOP-DO NOT USE". The the entire plan was reviewed with the Medical Director on 07/01/14 during the QA meeting. The Medical Director approved the plan developed by the facility to address the IJ. Another QA meeting was scheduled for 07/09/14. 7. Maintenance was to audit daily beginning 07/01/14, to ensure signage was in place on the Main Entrance and employee entrance door informing all visitors "Construction is in process". The maintenance audit was to include a daily check to ensure the new temporary exit diagrams created for the South West/North West/Dining Room, Dietary Services and Laundry area's remain posted on all temporary alternate evacuation routes and to ensure that signs created and posted on all "temporarily closed" evacuation exits saying "STOP-DO NOT USE" remain in place. The results of the audits will be turned in daily to the Administrator until the construction project is completed. The Administrator was do daily rounds of the signage to assure accuracy of maintenance audits until the project is completed. 8. A staff questionnaire regarding exit routes and evacuation plan was being administered by the Administrator, DON, ADONs, SDC, Dietary Director, BOM, Social Services Director (SSD), Chaplain, Admissions Director, Medical Records Director, and HR Director to five (5) staff members on each shift and different staff members until the immediacy was removed beginning 07/01/14. After the immediacy was removed ten (10) staff questionnaires were to be done daily to ensure continued understanding of exit routes and evacuation plan. All results of the questionnaires were to be reviewed by the Administrator, DON or Regional Nurse Consultant. The Administrator was to review all audits for completeness and accuracy, as well as, conduct "spot checks" of questionnaires to staff to ensure knowledge and accuracy of audits. Results of the staff questionnaires were to be reviewed by the QA Committee weekly to determine the further need of continued education or revision of the facility's plan. The QA Committee was to determine at what frequency the questionnaires for staff would need to continue. Any concerns identified were to be corrected immediately and reported to the Administrator. 9. A RNC has been onsite since 06/30/14, to assist with compliance with staff education, ensure daily audits were completed by the Maintenance Director and turned into the Administrator with no issues identified, and ensure daily staff questionnaires were completed as scheduled to ensure staff were aware of the new exits/evacuation plan. The Vice President (V/P) of Operations or Chief Nurse Executive were in daily contact with the RNC to review the above. Before the construction areas are re-opened, the areas are to be inspected by the Administrator and Maintenance Director to ensure the areas were safe for use. The State Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she and the entire Safety Committee had been inserviced by the RNC on the construction plan, resident safety and the new, temporary evacuation routes and diagrams on 06/30/14 at approximately 8:15 PM. Review of the education information revealed the construction plan which included the creation of new routes and temporary exit diagrams, placement of signage at the front doors, parking lot entrance and doors which were to be closed related to the construction. 2. Review of the education information, including the post tests, provided to all staff, revealed the education included education on the construction plan and new signs posted and included the following statement, "due to the recent construction on the back driveway of the facility, new evacuation routes have been implemented until further notice". Continued review of the education material revealed the alternate evacuation plan was included, as well as, the questions for the post test to ensure competency and understanding. Interviews on 07/02/14 with Certified Occupational Therapy Aide (COTA) #1 at 12:00 PM; the Rehab Manager at 12:02 PM; SRNA #5 at 12:03 PM; SRNA #6 at 1:55 PM; SRNA #7 at 1:58 PM; SRNA #8 at 2:01 PM; SRNA #9 at 2:04 PM; SRNA #10 at 2:07 PM; SRNA #11 at 2:10 PM; Housekeeper #3 at 2:20 PM; Housekeeper #1 at 2:23 PM; Maintenance Assistant #1 at 2:24 PM; Dietary Aide #3 at 2:28 PM; Dietary Aide #1 at 2:32 PM; SRNA #3 at 3:11 PM; SRNA #1 at 3:13 PM; SRNA #12 at 3:15 PM; SRNA #13 at 3:17 PM; SRNA #14 at 3:24 PM; SRNA #15 at 3:26 PM; LPN #8 at 5:30 PM; RN #1 at 5:35 PM; LPN #9 at 5:40 PM; and LPN #10 at 5:45 PM revealed they had been in-serviced on the construction plan and the new, temporary evacuation routes and the new temporary exit diagrams, along with taking a post test to ensure they understood the education material. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she used an employee roster in conjunction with training logs to assure no employee worked without the education, she continued by stating that to ensure accuracy/staff understanding of the education, she would select two (2) completed post tests and re-interview that staff person. Review of documentation revealed the employee roster had been crosschecked against an employee training log to ensure employees had not worked without receiving the education and post test to ensure competency. 3. Review of the education documents revealed all interviewable residents had been educated and a questionnaire was used to ensure resident understanding of the education related to the new evacuation plan and evacuation routes. Interviews with Resident #24 on 07/02/14 at 11:30 AM and Resident #23 at 11:35 AM, revealed they had been educated and completed a questionnaire related to the new construction and new evacuation plans. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had been her assigned task to educate residents with a BIMS of eight (8) or greater on the construction plan and the new temporary evacuation routes while construction was in place. The SSD indicated she had performed her education with interviewable residents on 06/30/14 and 07/01/14. Review of the education documents revealed the same education tool used for interviewable residents had been used to educate residents' responsible parties regarding the construction and new evacuation plans. Record review of phone logs revealed Resident #25's family had been contacted regarding the construction and educated on the temporary evacuation routes. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had also been her assigned task to educate residents' responsible parties on the construction plan and the temporary evacuation routes while construction was in place. The SSD stated she initiated the education for responsible parties on 06/03/14 and 07/01/14. Continued interview revealed she had answered any questions the responsible parties might have had. She indicated she would continue notification and education until all responsible parties/families had been contacted. Further interview revealed she used the facility census sheet to ensure responsible parties of non-interviewable residents received the construction education. 4. Observations, on 07/02/14 at 11:15 AM, revealed the new signage was in place at the Main Entrance and employee entrance doors as alleged on the AOC. Continued observation revealed the new temporary exit diagrams were also posted as alleged. Observation, on 078/02/14 at 11:32 AM, revealed signs stating "STOP-DO NOT USE" were posted on the "temporarily closed" evacuation exits. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed he had placed the new signage and temporary exit diagrams on 06/30/14 at approximately 8:30 PM. 5. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM, revealed he had been notified by the DON of the IJ on 07/01/14. 6. Review of the minutes revealed a QA meeting was held on 07/01/14, and revealed the Medical Director was in attendance via telephone. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM revealed he had been notified by the DON of the IJ on 07/01/14, during the QA meeting. He stated the plan implemented by the facility was a good plan, and he didn't think there was anything he would have added to the plan. Continued interview revealed he provided insight on Quality Measures and acted as a resource for facility staff education as part of his responsibilities as the Medical Director. 7. Review of the daily Maintenance Audit logs beginning 07/01/14 revealed Maintenance was performing daily rounds to verify, by initialing the log, that the Main Entrance and employee entrance door signage remained in place to inform visitors that construction was in progress, the temporary exit diagrams remained posted on all temporary evacuation routes and the "STOP-DO NOT USE" signs remained in place on the temporarily closed evacuation routes. Continued review of the Audit log revealed the Administrator was also initialing the log indicating she had performed walking rounds as verification of the accuracy of the Maintenance audits until the construction process is completed. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed maintenance was performing the daily audits and initialing the log for verification. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she was performing her walking rounds daily of the signage posted and initialing the maintenance audit log. 8. Review of the staff education revealed a questionnaire related to the exit routes and evacuation plan. Review of the completed questionnaires revealed the Administrator, DON, ADON, SDC, Dietary Director, Medical Records Director or HR Director had administered the questionnaire. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she, the DON or RNC had reviewed the questionnaires. She indicated she was performing "spot checks" of questionnaires as per the AOC. The Administrator stated the questionnaire results would be taken to the facility's QA Committee weekly and QA would determine the frequency at which the questionnaires would be used. According to the Administrator, if there were any concerns identified they were to be reported to her. 9. Interview with the RNC on 07/02/14 at 4:45 PM revealed she had been on site daily since 06/30/14. Continued interview revealed she assisted the Administrator in any capacity she needed to ensure compliance with staff education and ensure the daily Maintenance audits were completed accurately and turned into the Administrator. Interview with the Chief Nursing Executive on 07/02/14 at 4:50 PM, via telephone, revealed she was in daily contact with the RNC and facility and acted as a resource when needed. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed prior to the construction areas being re-opened, she and the Maintenance Director will inspect the construction area to ensure it is safe to use and institute re-education for all staff, residents and/or their responsible party.

A Recertification Survey/Extended Survey concluded on 07/03/14 identified Immediate Jeopardy in the areas of 42 CFR 483.25 Quality of Care (F-323) and 42 CFR 483.75 Administration (F-490, F-518 and F-520) all at a Scope and Severity (S/S) of a "K". After Supervisory review the Recertification Survey was re-opened and an Abbreviated Survey investigating KY 980 was initiated on 07/22/14 and concluded with a new exit date of 08/01/14. A second Immediate Jeopardy was identified on 07/25/14 in the areas of 42 CFR 483.13 Resident Behavior and Facility Practice (F-224, F-225 and F-226), 42 CFR 483.30 Nursing Services (F-353), and 42 CFR 483.75 Administration (F-490) all at a Scope and Severity (S/S) of a "K". Based on observation, interview, and review of the facility's "Disaster Preparedness" Manual, Fire Emergency Guidelines and Evacuation Plan, during the 07/03/14 survey, it was determined the facility's Administrator failed to have an effective system in place to ensure the residents' environment remained as free from accident hazards as possible, and failed to ensure the facility's evacuation route was updated and facility staff was trained and knowledgeable regarding which fire exits were appropriate for evacuation during the construction, which affected three (3) exits identified by the facility as emergency exits. On 06/24/14 the facility began construction by removing the concrete pavement outside the Northwest hallway exit and and the Dining room exit and on 06/27/14 the the Southwest exit door had pavement removed, affecting the safe path to a public way for these three (3) exits. Although these three (3) exits were designated as fire evacuation exits, observation revealed the three (3) exit doors led to drop offs, large gravel, rebar and an uneven rocky and dirt surface. The facility's emergency exit routes included these exits at the end of the Northwest and Southwest hallways. There was a total of sixty (60) of the facility's one hundred and twenty-four (124) residents residing on these hallways with the potential to be affected in case of an emergency evacuation. Also, the map posted in the Dining room revealed arrows leading to the outside, indicating the door located in the dining room was an exit route, although there was construction outside that exit. (Refer to F-323, F-518 and F-520) The facility's Administrator's failure to have an effective system in place to ensure the residents' environment remained as free from accident hazards as possible, and each resident received adequate supervision to prevent accidents was likely to cause risk for serious injury, harm, impairment or death. Immediate Jeopardy was identified on 06/30/14 and determined to exist on 06/24/14. The facility was notified of the Immediate Jeopardy on 06/30/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/03/14 with the facility alleging removal of the Immediate Jeopardy on 07/02/14. The Immediate Jeopardy was verified to be removed on 07/02/14, with remaining non-compliance at a Scope and Severity of a "E", while the facility develops and implements a Plan of Correction, and the facility's Quality Assurance continues to monitor to ensure compliance with systemic changes. Based on interview, record review, and review of the facility's investigation reports and policies, during the 08/01/14 survey, it was determined the facility's Administrator failed to ensure their abuse and neglect policies were implemented by staff as evidenced by failing to ensure all allegations of abuse, including neglect were investigated thoroughly, and failing to ensure residents were protected from further neglect. On 07/03/14, Resident #26 rang the call bell for incontinence care assistance at approximately 5:30 AM; however was not assisted until approximately 7:45 AM, ( two hours and fifteen minutes later). Interview with the day shift State Registered Nursing Assistant (SRNA), who assisted Resident #26 at 7:45 AM, revealed the resident was soaked with urine and covered in bowel movement. Staff interviews further revealed other residents were also left soaked in urine or soiled with bowel movement the morning of 07/03/14, after day shift reported to work at 7:00 AM. These residents included #5, #27, #28, and #29. Although Administration became aware of the allegations related to Resident #5, #26, #27, #28, and #29, on 07/03/14, and completed an investigation, the investigation was not thorough and was not reviewed by the Director of Nursing (DON) or the Administrator. In addition, the investigation revealed a conflict between the two (2) SRNA's who worked the South Unit on the night shift noting they did not work together as a team for residents requiring two (2) person assist with ADL's. However, Administration failed to address this conflict between the two (2) SRNA's to prevent further resident neglect. (Refer to F-224, F-225, F-226) The facility's Administrator's failure to have an effective system in place to ensure residents were protected from neglect was likely to cause serious injury, harm, impairment, or death. Immediate Jeopardy was identified on 07/25/14 and was determined to exist on 07/03/14. The facility provided an acceptable Credible Allegation of Compliance (AOC) on 07/30/14 with the facility alleging removal of the Immediate Jeopardy on 07/29/14. The Immediate Jeopardy was verified to be removed on 07/29/14, prior to exiting the facility on 08/01/14, with remaining non-compliance at 42 CFR 483.75 Administration (F-490) at a Scope and Severity of a "E" while the facility develops and implements a Plan of Correction (POC), and the facility's Quality Assurance monitors to ensure compliance with systemic changes. The findings include: Reference F-323, F-518 and F-520 1. Review of the facility's, "Disaster Preparedness" Manual, dated January 2005, revealed the fire safety procedure plan which noted what staff were to do when preparing for an evacuation. Review revealed when the fire alarm sounded staff were to first check the primary exit route, and if it was clear and safe, use that exit if evacuation of the facility was ordered. Review of the facility's Fire Emergency Guidelines, undated, for the North and South Units revealed staff were to check the primary exit route, and if it was blocked they were to use the secondary route. Review of the maps on 06/30/14, posted across from the nurse's station on both units and in the Dining room revealed the Northwest hallway exit door, Southwest hallway exit door, and Dining room exit door were marked with arrows indicating they were exit routes to be taken. Observations on 06/30/14 from 5:15 PM to 5:24 PM revealed outside the dining room exit door a concrete pad leading to a three and a half (3.5) inch drop off to gravel and rebar (steel bar used in construction to reinforce concrete); outside the Northwest hallway exit door a ramp which led to a three (3) inch drop off from the ramp to gravel and rebar; and, outside the exit door at the end of the Southwest hallway a ramp which led to a four and a half (4.5) inch drop off with gravel. Further observation on 06/30/14 from 5:15 PM to 5:24 PM revealed there were no signs posted at the Southwest hallway exit door, Northwest hallway exit door, and dining room exit door to alert staff, residents, and visitors these exits were not accessible due to construction. Also, there was no posting of new evacuation routes in case of fire or other emergencies due to the exits not being accessible, despite the facility's knowledge there was not a safe pathway to a public way due to construction for those three (3) exits. The facility's Administration provided no documented evidence it had evaluated and/or revised the evacuation plan related to the Northwest hallway fire exit, the Southwest hallway fire exit or the dining room fire exit having no safe path to a public way. In addition, there was no documented evidence staff was trained and knowledgeable regarding which fire exits were appropriate for evacuation during construction. Interviews with staff revealed they would have used the Northwest hallway, Southwest hallway, and dining room exits to the outside if an emergency arose which required residents to be evacuated from the facility. Interviews revealed they did not think those exits had been affected and they had not been told by the facility to not use those exits. Interview, on 06/30/14 at 5:05 PM, with the Director of Nursing (DON), revealed she was told on the morning of 06/17/14, during the "Stand Up Meeting" construction was to start on 06/18/14 and this included repairing concrete and those present were told to stay clear of the exit doors to the Northwest and Southwest hallway exits as the sidewalks were being replaced outside those doors. She revealed the Staff Development Nurse (SDN) inserviced staff related to the construction; but, she was not sure if all facility staff had been inserviced by the SDN. The DON reported she had not been inserviced as to an alternate evacuation route for an emergency evacuation. Per interview the DON stated knowledge of an alternate evacuation plan and inservicing staff on it would be important to have as staff would not be able to get residents' wheelchairs out the exits where the construction was taking place. Interview with the SDN on 06/30/14 at 5:30 PM, revealed she was told by the DON to inform staff of which doors would be inaccessible due to construction; however, she was not told who to inservice and was not told exactly what the new evacuation routes would be. According to the SDN, therefore she did an informal verbal inservice at the last "Town Hall Meeting" which was held on payday Friday on 06/20/14 with staff who were picking up their paychecks. Review of the facility's, "Town Hall Meeting and Inservice Agenda" dated 06/20/14, revealed there was a list with bullets which included a bullet stating, "construction on drive". However, continued review revealed no written information referencing the information provided. Further review revealed there were twenty-eight (28) staff signatures listed for the inservice out of the one hundred and fifty (150) employees in the facility. Interview, on 06/30/14 at 7:00 PM, with the Administrator revealed she came to work at the facility on 05/15/14, and was told by the previous Administrator that day there would be construction taking place and this included replacing damaged pavement on the west or back side of the building. She stated she learned on 06/17/14 construction would be starting on 06/18/14; however, the construction was delayed and did not start until 06/24/14. The Administrator stated during the "morning meetings" she discussed the construction every few days. According to the Administrator, she talked about how the construction would consist of tearing up the concrete and re-pouring it at the back of the building. Per interview she stated however, they had not discussed the safety aspects related to the construction. Continued interview revealed she knew the SDN had inserviced staff at the last "Town Hall Meeting" which occurred on 06/20/14; but the SDN had not been told to specifically inservice all staff, and was not appraised of any new evacuation plan. The Administrator stated the facility's evacuation plan stated if an exit could not be used for some reason, staff should use another exit. She stated however, if staff was unaware they could not use certain fire exit doors, that could delay residents getting out of the building in an emergency situation. Further interview with the Administrator revealed she had never been through construction in a building as an Administrator, and had not thought about needing a new emergency evacuation plan. However, she stated, in hindsight she should have ensured there was a new emergency evacuation plan specifically addressing the three (3) emergency fire exits affected during the construction. She indicated she should have ensured formal inservicing and education for all staff related to construction and which doors were to be used for alternate evacuation routes. She stated she had not discussed any safety aspects of the construction with the Quality Assurance (QA) Committee meeting held prior to the construction starting; however, indicated she had informed the QA members construction was getting ready to start. The facility provided an acceptable, credible Allegation of Compliance (AOC) on 07/03/14, which alleged removal of the Immediate Jeopardy (IJ), effective 07/02/14. Review of the AOC revealed the facility implemented the following: 1. The Regional Nurse Consultant (RNC) inserviced the Administrator and the entire Safety Committee (Human Resources Director/Safety Director, ADON North, Business Office Manager (BOM), Chaplain, Clinical Social Worker (CSW), Rehabilitation (Rehab) Manager, Medical Records Director, Dietary Director, Housekeeping Director, Activity Director, Staff Development Coordinator (SDC), Plant Operations Director, DON, ADON South, MDS LPN, MDS RN and Marketing Director, who were also the Quality Assurance (QA) Committee, on 06/30/14 during a Safety Committee meeting held to discuss the facility's Fire Safety Procedure for alternate evacuation routes due to construction. The education covered construction planning and continued safety of residents. Additionally, the construction plan and assignments, that delineated which staff member was responsible for what piece of the AOC, were dispersed to all departments by the Administrator and the Safety Committee Director. The construction plan included the creation of new routes and temporary exit diagrams, placement of signage outlining the construction plan in appropriate areas that included the front entrance, parking lot entrance and the doors which were closed related to the construction. New signs stating "DO NOT USE" were also placed on the affected doors. 2. Inservices were initiated on 06/30/14 and 07/01/14, by the DON, Assistant Director of Nursing (ADON), Dietary Manager (DM), Staff Development, Business Office Manager (BOM), Housekeeping Director and Rehabilitation (Rehab) Director for all staff, including dietary, housekeeping, therapy, laundry and maintenance. The education consisted of the new evacuation plan and continued safety of residents. Additionally, no employee would be allowed to work until the education was provided and the post test completed to ensure compliance with exit routes. The Administrator maintained an employee roster to crosscheck with the training log to assure no employee was allowed to work until the education was received. One hundred and fifty-five (155) employees of one hundred and sixty-three (163) employees had been educated by 07/01/14. The facility did not utilize agency staff. 3. All residents with a BIMS score of eight (8) or greater on their last MDS were informed of the construction and alternate evacuation routes, as well as, the the new evacuation signs. Forty-eight (48) residents met the criteria and were informed as indicated by the Activity Director and Social Service Director on 06/30/14 and 07/01/14. Responsible Parties of residents, who were frequent visitors to the facility, were notified of the construction and temporary evacuation routes, by telephone by the Chaplain and Marketing Director. Thirty (30) Responsible Parties were notified on 06/30/14 and 07/01/14, with plans to continue notifications daily until all resident families/responsible parties were notified. 4. Signs were placed on the Main Entrance and the employee entrance doors on 06/30/14 by the Maintenance Director to inform all visitors that "Construction is in progress". Also, new temporary exit diagrams (maps) were created for the South West/North West/ Dining Room/Dietary Services/Laundry Area by the Safety Committee on 06/30/14 and posted on all temporary alternate evacuation routes. Signs were created and posted on all "temporarily closed" evacuation exits that stated, "STOP-DO NOT USE" by the Maintenance Director on 06/30/14. 5. The Medical Director was notified of the IJ 07/01/14 by the DON. 6. A QA meeting was held on 07/01/14 to review the new temporary exit diagrams for the South West/North West/Dining Room, Dietary Services and Laundry areas. Signs were created and posted on all areas of temporary alternate evacuation routes. Signs were created and posted on all temporarily closed evacuation exits to "STOP-DO NOT USE". The the entire plan was reviewed with the Medical Director on 07/01/14 during the QA meeting. The Medical Director approved the plan developed by the facility to address the IJ. Another QA meeting was scheduled for 07/09/14. 7. Maintenance was to audit daily beginning 07/01/14, to ensure signage was in place on the Main Entrance and employee entrance door informing all visitors "Construction is in process". The maintenance audit was to include a daily check to ensure the new temporary exit diagrams created for the South West/North West/Dining Room, Dietary Services and Laundry area's remain posted on all temporary alternate evacuation routes and to ensure that signs created and posted on all "temporarily closed" evacuation exits saying "STOP-DO NOT USE" remain in place. The results of the audits will be turned in daily to the Administrator until the construction project is completed. The Administrator was do daily rounds of the signage to assure accuracy of maintenance audits until the project is completed. 8. A staff questionnaire regarding exit routes and evacuation plan was being administered by the Administrator, DON, ADONs, SDC, Dietary Director, BOM, Social Services Director (SSD), Chaplain, Admissions Director, Medical Records Director, and HR Director to five (5) staff members on each shift and different staff members until the immediacy was removed beginning 07/01/14. After the immediacy was removed ten (10) staff questionnaires were to be done daily to ensure continued understanding of exit routes and evacuation plan. All results of the questionnaires were to be reviewed by the Administrator, DON or Regional Nurse Consultant. The Administrator was to review all audits for completeness and accuracy, as well as, conduct "spot checks" of questionnaires to staff to ensure knowledge and accuracy of audits. Results of the staff questionnaires were to be reviewed by the QA Committee weekly to determine the further need of continued education or revision of the facility's plan. The QA Committee was to determine at what frequency the questionnaires for staff would need to continue. Any concerns identified were to be corrected immediately and reported to the Administrator. 9. A RNC has been onsite since 06/30/14, to assist with compliance with staff education, ensure daily audits were completed by the Maintenance Director and turned into the Administrator with no issues identified, and ensure daily staff questionnaires were completed as scheduled to ensure staff were aware of the new exits/evacuation plan. The Vice President (V/P) of Operations or Chief Nurse Executive were in daily contact with the RNC to review the above. Before the construction areas are re-opened, the areas are to be inspected by the Administrator and Maintenance Director to ensure the areas were safe for use. The State Agency validated the implementation of the facility's AOC as follows: 1. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she and the entire Safety Committee had been inserviced by the RNC on the construction plan, resident safety and the new, temporary evacuation routes and diagrams on 06/30/14 at approximately 8:15 PM. Review of the education information revealed the construction plan which included the creation of new routes and temporary exit diagrams, placement of signage at the front doors, parking lot entrance and doors which were to be closed related to the construction. 2. Review of the education information, including the post tests, provided to all staff, revealed the education included education on the construction plan and new signs posted and included the following statement, "due to the recent construction on the back driveway of the facility, new evacuation routes have been implemented until further notice". Continued review of the education material revealed the alternate evacuation plan was included, as well as, the questions for the post test to ensure competency and understanding. Interviews on 07/02/14 with Certified Occupational Therapy Aide (COTA) #1 at 12:00 PM; the Rehab Manager at 12:02 PM; SRNA #5 at 12:03 PM; SRNA #6 at 1:55 PM; SRNA #7 at 1:58 PM; SRNA #8 at 2:01 PM; SRNA #9 at 2:04 PM; SRNA #10 at 2:07 PM; SRNA #11 at 2:10 PM; Housekeeper #3 at 2:20 PM; Housekeeper #1 at 2:23 PM; Maintenance Assistant #1 at 2:24 PM; Dietary Aide #3 at 2:28 PM; Dietary Aide #1 at 2:32 PM; SRNA #3 at 3:11 PM; SRNA #1 at 3:13 PM; SRNA #12 at 3:15 PM; SRNA #13 at 3:17 PM; SRNA #14 at 3:24 PM; SRNA #15 at 3:26 PM; LPN #8 at 5:30 PM; RN #1 at 5:35 PM; LPN #9 at 5:40 PM; and LPN #10 at 5:45 PM revealed they had been in-serviced on the construction plan and the new, temporary evacuation routes and the new temporary exit diagrams, along with taking a post test to ensure they understood the education material. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she used an employee roster in conjunction with training logs to assure no employee worked without the education, she continued by stating that to ensure accuracy/staff understanding of the education, she would select two (2) completed post tests and re-interview that staff person. Review of documentation revealed the employee roster had been crosschecked against an employee training log to ensure employees had not worked without receiving the education and post test to ensure competency. 3. Review of the education documents revealed all interviewable residents had been educated and a questionnaire was used to ensure resident understanding of the education related to the new evacuation plan and evacuation routes. Interviews with Resident #24 on 07/02/14 at 11:30 AM and Resident #23 at 11:35 AM, revealed they had been educated and completed a questionnaire related to the new construction and new evacuation plans. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had been her assigned task to educate residents with a BIMS of eight (8) or greater on the construction plan and the new temporary evacuation routes while construction was in place. The SSD indicated she had performed her education with interviewable residents on 06/30/14 and 07/01/14. Review of the education documents revealed the same education tool used for interviewable residents had been used to educate residents' responsible parties regarding the construction and new evacuation plans. Record review of phone logs revealed Resident #25's family had been contacted regarding the construction and educated on the temporary evacuation routes. Interview with the SSD on 07/02/14 at 2:37 PM, revealed it had also been her assigned task to educate residents' responsible parties on the construction plan and the temporary evacuation routes while construction was in place. The SSD stated she initiated the education for responsible parties on 06/03/14 and 07/01/14. Continued interview revealed she had answered any questions the responsible parties might have had. She indicated she would continue notification and education until all responsible parties/families had been contacted. Further interview revealed she used the facility census sheet to ensure responsible parties of non-interviewable residents received the construction education. 4. Observations, on 07/02/14 at 11:15 AM, revealed the new signage was in place at the Main Entrance and employee entrance doors as alleged on the AOC. Continued observation revealed the new temporary exit diagrams were also posted as alleged. Observation, on 078/02/14 at 11:32 AM, revealed signs stating "STOP-DO NOT USE" were posted on the "temporarily closed" evacuation exits. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed he had placed the new signage and temporary exit diagrams on 06/30/14 at approximately 8:30 PM. 5. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM, revealed he had been notified by the DON of the IJ on 07/01/14. 6. Review of the minutes revealed a QA meeting was held on 07/01/14, and revealed the Medical Director was in attendance via telephone. Interview with the facility's Medical Director on 07/02/14 at 5:20 PM revealed he had been notified by the DON of the IJ on 07/01/14, during the QA meeting. He stated the plan implemented by the facility was a good plan, and he didn't think there was anything he would have added to the plan. Continued interview revealed he provided insight on Quality Measures and acted as a resource for facility staff education as part of his responsibilities as the Medical Director. 7. Review of the daily Maintenance Audit logs beginning 07/01/14 revealed Maintenance was performing daily rounds to verify, by initialing the log, that the Main Entrance and employee entrance door signage remained in place to inform visitors that construction was in progress, the temporary exit diagrams remained posted on all temporary evacuation routes and the "STOP-DO NOT USE" signs remained in place on the temporarily closed evacuation routes. Continued review of the Audit log revealed the Administrator was also initialing the log indicating she had performed walking rounds as verification of the accuracy of the Maintenance audits until the construction process is completed. Interview with the Maintenance Director on 07/02/14 at 11:40 AM, revealed maintenance was performing the daily audits and initialing the log for verification. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed she was performing her walking rounds daily of the signage posted and initialing the maintenance audit log. 8. Review of the staff education revealed a questionnaire related to the exit routes and evacuation plan. Review of the completed questionnaires revealed the Administrator, DON, ADON, SDC, Dietary Director, Medical Records Director or HR Director had administered the questionnaire. Interview with the Administrator on 07/02/14 at 4:03 PM revealed she, the DON or RNC had reviewed the questionnaires. She indicated she was performing "spot checks" of questionnaires as per the AOC. The Administrator stated the questionnaire results would be taken to the facility's QA Committee weekly and QA would determine the frequency at which the questionnaires would be used. According to the Administrator, if there were any concerns identified they were to be reported to her. 9. Interview with the RNC on 07/02/14 at 4:45 PM revealed she had been on site daily since 06/30/14. Continued interview revealed she assisted the Administrator in any capacity she needed to ensure compliance with staff education and ensure the daily Maintenance audits were completed accurately and turned into the Administrator. Interview with the Chief Nursing Executive on 07/02/14 at 4:50 PM, via telephone, revealed she was in daily contact with the RNC and facility and acted as a resource when needed. Interview with the Administrator on 07/02/14 at 4:03 PM, revealed prior to the construction areas being re-opened, she and the Maintenance Director will inspect the construction area to ensure it is safe to use and institute re-education for all staff, residents and/or their responsible party. Reference to F-224, F-225, F-226 2. Review of the facility's policy titled, "Abuse, Neglect and Misappropriation", dated April 2013 revealed abuse and neglect of residents was prohibited. Review of the Policy revealed staff were to be trained on abuse to include what constituted abuse, neglect or misappropriation of resident property. The Policy revealed all allegations of abuse were to be investigated, and the Administrator/designee was to make all reasonable efforts to investigate and address alleged reports, grievances and concerns. Further review revealed Social Services or the Chaplain were to follow up with the resident to monitor his/her emotional well-being after an incident, and families were to be notified of the outcome of the investigation. Interview, on 07/03/14 at 2:26 PM, with Resident #26 revealed that morning, he/she had waited for over an hour for someone to respond to his/her call light before, and had "pooped" on himself/herself during the night before as a result of having to wait for staff's assistance. The resident further stated SRNA #19 had been assigned to his/her care the night before when he/she had "pooped" on himself/herself, and did not change him/her after he/she asked the SRNA to be changed. Resident #26 revealed staff did not changed him/her until day shift reported to work that morning. Interviews with day shift State Registered Nurse Aides (SRNA's), and nurses were conducted revealed other residents were left wet and/or soiled the morning of 07/03/14 who were assigned to SRNA #19 including Residents #5, #27, #28, and #29. Further, staff interviews revealed there was a conflict between SRNA #19 and SRNA #21 who both worked the night shift on the South Unit, stating they did not work together as a team and did not answer call lights for each other. Continued staff interviews revealed this impacted the care the residents received when the two (2) SRNA's were assigned as the only SRNA's on the unit. The facility conducted an investigation which was initiated on 07/03/14 and conducted through 07/07/14 related to Resident #26's concerns regarding the lack of care on the night shift. Review of the investigation revealed there was no documented evidence non-interviewable residents who could not speak for themselves who were cared for by SRNA #19 on 07/03/14, had been assessed, or their families/responsible parties interviewed. Administration failed to ensure these residents were assessed for signs of neglect related to care not provided by night shift staff. Also, as part of the investigation the facility interviewed staff who cared for Resident #26 on 07/03/14. According to the staff interviews, per the investigation, Resident #26 was noted to be very soiled with urine and bowel movement going up to her/his chest and backside, on the morning of 07/03/14, and Resident #29 did not appear as though incontinence care had been performed on the previous shift and the bed was very wet. In addition, staff interviews further revealed there was a conflict between SRNA #19 and SRNA #21 who worked the night shift on the South Unit and they did not work together to assist residents who required two (2) staff to assist with care. The staff interviews from the investigation, also revealed SRNA #9 had complained that her whole group of residents was left wet on the morning of 07/03/14, and LPN #12 and the ADON/Unit Manager of the South Units was aware of SRNA #9's concerns. However, the facility failed to interview SRNA #9 as part of the investigation. Although the staff interviews revealed the conflict between SRNA #19 and SRNA #21, Administration failed to address and investigate this conflict which was impacting the care of the residents. Interview, on 07/23/14 at 5:49 PM and 07/25/14 at 7:20 PM, with the Human Resources (HR) Director, DON, and Social Services Director (SSD) revealed, it would be neglect of residents if incontinence care was not performed timely or when requested. Per the SSD, the investigation initiated on 07/03/14, was focused on Resident #26, due to her/his voiced concerns. The SSD further acknowledged she should have involved nursing in the investigation to assess those residents who could not speak for themselves and were left wet on 07/03/14 including Residents #5, #28, #29, and #27. Continued interview revealed she was unaware of a conflict with the night shift staff, and had not realized this was a concern through reviewing the interviews with staff. Even though staff had written statements regarding the conflict. The SSD stated the investigation was a team approach and the former Administrator, who was the Administrator during the investigation, reviewed the initial investigation report and the final five (5) day report. The SSD stated the former Administrator had decided the allegations from the morning of 07/03/14 were unsubstantiated, because the

Based on interview and record review, it was determined the facility failed to ensure services provided were in accordance with each resident's Comprehensive Care Plan, or the Interim Care Plan, for six (5) of thirty-seven (37) sampled residents. (#16, #17, #26, #32 and #35). Resident #17, who had a history of [REDACTED]. Interventions included monitoring the resident's bowel elimination status, reporting changes in bowel status to Physician, and administering and monitoring the effectiveness of bowel medications. However, Resident #17 had a period of greater than three (3) day period, from 07/15/14 through 07/19/14, with no documented evidence of a BM, and no documented evidence of assessment and monitoring of the resident's bowel elimination status as directed by the care plan. On 07/19/14 at 10:02 PM, Resident #17 received a PRN bowel medication with no documented evidence of results and/or monitoring or assessing by nurses according to the care plan. On 07/20/14, at 10:20 AM, Resident #17 complained of abdominal pain, and began to vomit bright red blood. The Physician was notified and the resident was transported to the hospital emergency room (ER), where after assessment and diagnostic testing, the resident was diagnosed with [REDACTED]. Resident #32 also had a care plan related to ensuring the resident had a bowel movement (BM) every three (3) days; however, the resident experienced three (3) periods of time, between 06/25/14 and 07/18/14, of going greater than three (3) days without a documented BM, as per the care plan goal. In addition, there was no documented evidence Resident #32 was assessed and monitored, and PRN (as needed) bowel medications were administered as directed by the care plan. On 05/15/14, Resident #26 became acutely ill with abdominal pain, nausea and vomiting, and a firm abdomen. The resident was sent to the emergency room and was diagnosed with [REDACTED]. Review of the hospital Discharge Summary, dated 05/17/14, revealed Resident #26 suffered an abdominal crisis of pain and nausea, and was found to be massively constipated, with a large volume of BM induced by the administration of enemas. Although Resident #26 returned to the facility on [DATE], after being diagnosed and treated for [REDACTED]. Review of the Bowel Elimination Record, dated 05/14, revealed there was no documentation on the Record until 05/22/14, five (5) days after the resident returned to the facility from the hospital. Resident #16 was care planned for the potential for constipation and had a goal to produce an adequate bowel movement at least every three (3) days. However, review of the "Elimination Report" revealed Resident #16 had a period of no documented bowel movements between the dates of 06/15/14 through 06/22/14 and 07/14/14 through 07/19/14 with no documented evidence the nurses recognized Resident #16 had not had a bowel movement for greater than three (3) days and no documented evidence of intervention as per the care plan. In addition, newly admitted Resident #35 was care planned for "alteration in comfort/pain", related to a [DIAGNOSES REDACTED]. However, the resident requested his/her pain medication on 07/02/14 at 8:00 PM but did not receive the medication until 07/03/14 at 3:05 PM. The findings include: Interview with the Director of Nursing (DON), on 07/27/14 at 12:42 PM, revealed the facility had no written policy related to staff following the Comprehensive Care Plan or the Interim Care Plan. However, she stated it was the expectation of the facility for staff to follow each resident's written plan of care. 1. Medical record review revealed the facility admitted Resident #17 on 03/29/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/23/14, revealed the facility assessed Resident #17 to have a Brief Interview for Mental Status score of fifteen (15), which indicated the resident was cognitively intact. Continued review of the MDS revealed Resident #17 was assessed as always incontinent of urine and frequently incontinent of BM, and the resident required two (2) staff for extensive assistance with toileting. Review of Resident #17's Comprehensive Care Plan, dated 04/08/13, revealed the resident was care planned to be at risk for bowel elimination problems due to the [DIAGNOSES REDACTED]. Continued review revealed the goal was for Resident #17 to have a BM at least once every three (3) days. Further review of the care plan revealed the interventions included monitoring Resident #17's bowel elimination status, reporting any bowel status changes to the Physician, and administering and monitoring the effectiveness of bowel medications. Review of Resident #17's July 2014 computerized "Elimination Report" revealed no documented evidence, from 07/15/14 through 07/19/14, of the resident having had a BM. Review of the July 2014 Physicians Orders revealed Resident #17 had the stool softener, [MEDICATION NAME] Sodium 100 milligram (mg) by mouth every other day, ordered for a [DIAGNOSES REDACTED].#17 had four (4) PRN bowel medications ordered which included two (2) different mini-enemas, Senna 8.6 mg two (2) tablets by mouth daily PRN (laxative), and Polyethylene [MEDICATION NAME] 17 grams (gm) in 240 ml (milliliters) of fluid by mouth daily PRN (laxative). Review of the July 2014 Medication Administration Record [REDACTED]. Review revealed the PRN medication, Senna 8.6 mg two (2) tablets by mouth was administered on 07/19/14 at 10:02 PM and was noted to have had a "minimal effect". Further review of the MAR indicated [REDACTED]. Record review revealed the Nurse's Notes dated 07/15/14 through 07/18/14 contained no documented evidence of Resident #17 experienced a BM. In addition, there was no documented evidence the resident's bowel elimination status was monitored, or any of the four (4) PRN bowel medications were administered as directed by the care plan. Continued review of the Nurses Notes, dated 07/19/14 at 9:50 PM, revealed the Physician ordered Milk of Magnesia (MOM) thirty (30) ml PRN (laxative) for constipation and the medication was administered. However, continued review revealed no documented evidence the effectiveness of the MOM was monitored as per the care plan. Review of the Nurses Notes, dated 07/20/14 at 10:20 AM, revealed Resident #17 complained of abdominal pain and PRN bowel medications were administered as ordered. Continued review of the 07/20/14 10:20 AM Nurses Note revealed the resident vomited bright red blood two (2) times, the Physician was notified and an order was received to send the resident to the ER. The nurse also documented she had assessed Resident #17's abdomen to have positive bowel sounds in all four (4) quadrants, and noted the resident was complaining of right upper quadrant abdominal tenderness. Furthermore, the nurse noted emergency medical services (EMS) were notified to transport Resident #17 to the ER. Review of the hospital ER record revealed Resident #17's arrival time at theER on [DATE] was 11:24 AM. Review of the ER Physician's documentation revealed the resident had "quiet" bowel sounds and was experiencing right upper quadrant abdominal pain. Continued review revealed the ER Physician ordered diagnostic testing which included a computerized tomography (CT) scan of the pelvis and abdomen. Review of the results of the CT scan revealed Resident #17 was severely impacted. Further review of the ER record revealed Resident #17 received an enema, was manually disimpacted with "good results", and was discharged back to the facility. Interview with Resident #17, on 07/25/14 at 10:50 AM, revealed the resident had problems related to constipation due to his/her immobility and history [MEDICAL CONDITION]. Resident #17 reported having about four (4) different medications ordered for constipation. Per interview, Resident #17 stated he/she had been constipated and had not experienced a BM the week before being sent to the ER. Resident #17 stated he/she was not "positive", but thought nurses had given him/her bowel medications before going to the ER. Further interview with Resident #17 revealed he/she had been "so sick" when sent to the ER. Interview with State Registered Nursing Assistant (SRNA) #6, on 07/25/14 at 2:48 PM, SRNA #8 on 07/25/14 at 3:05 PM, SRNA #31 on 07/29/14 at 3:20 PM, and SRNAs #18 and #20 on 07/30/14 at 2:55 PM, revealed all had cared for Resident #17 prior to him/her being sent to the ER and were aware the resident had a history of [REDACTED].#6, SRNA #31 and SRNA #20, Resident #17 had complained of constipation prior to going out to the hospital on [DATE]. SRNA #6 stated Resident #17 reported to her the nurses were giving him/her "stuff" for the constipation. SRNA #31 stated Resident #17 had complained of constipation prior to being sent to theER on [DATE], and he had reported Resident #17's complaints to the nurses who informed him they had "given what they could". SRNA #20 stated Resident #17 had complained of constipation prior to going to the ER, and this was reported to the nurses. Interview with Licensed Practical Nurse (LPN) #10 on 07/29/14 at 3:55 PM, revealed she indicated she had cared for Resident #17 in July 2014 during the timeframe before the resident was sent to the ER. LPN #10 indicated she could not recall if the resident complaints of constipation prior to going to theER on [DATE], or if she had performed an abdominal assessment on the resident during the week prior to him/her going to the ER. She stated Resident #17 should never go more than three (3) days without a BM due to his/her history of constipation. Continued interview with LPN #10 revealed she thought Resident #17's Comprehensive Care Plan was located in his/her "chart"; however, after looking through the resident's medical record, she stated she did not know where the care plan was located and would have to ask another nurse. She reported she had never seen Resident #17's Comprehensive Care Plan, and indicated she was not aware of the problems or interventions located in it. Interview with LPN #8, on 07/30/14 at 2:40 PM, revealed she thought she had cared for Resident #17 during the 07/15/14 through 07/20/14 timeframe. She stated she could not remember if she had performed an assessment of Resident #17's abdomen prior to him/her being sent to theER on [DATE], and indicated she also could not recall if Resident #17 had complained of constipation during the week prior to being sent to the ER. She stated Resident #17 could tell staff if he/she was constipated as the resident was alert and oriented. She further stated Resident #17 had a history of [REDACTED]. Continued interview revealed LPN #8 was not aware if Resident #17 was care planned for constipation, or if interventions were in place to prevent it. 2. Review of the medical record revealed the facility admitted Resident #32 on 05/24/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 04/13/14, revealed the facility assessed Resident #32 to have a BIMS score of fourteen (14), which indicated the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #32 to require extensive assistance of two (2) staff for toileting, and to be frequently incontinent of urine and always continent of bowels. Review of Resident #32's Comprehensive Care Plan, revised June 2014, revealed the resident was care planned for a risk for bowel elimination problems due to decreased mobility and [MEDICAL CONDITION]. Review of the care plan for bowel elimination revealed a goal for the resident to have a BM as least once every three (3) days. Continued review of the care plan revealed interventions included reporting changes in bowel status to the Physician, monitoring the resident's bowel elimination status, and administering and monitoring the effectiveness of bowel medications. Review of the June 2014 "Elimination Report" for Resident #32, revealed three (3) periods of time with no documented evidence the resident had a BM: 06/25/14 through 07/01/14; 07/03/14 through 07/08/14; and 07/14/14 through 07/18/14. Review of the June 2014 physician's orders [REDACTED]. Review of the MAR for June 2014 and July 2014 revealed the PRN MOM was administered on 06/30/14, the sixth day of no documented BM. Additional review of the MAR indicated [REDACTED]. Review of the Nurse's Notes from 06/25/14 through 07/18/14 revealed no documented evidence an abdominal assessment was performed of Resident #32, and no documented evidence PRN bowel medications were administered as per the care plan during the three (3) episodes of no documented BM for a period greater than three (3) days. Interview with Resident #32, on 07/31/14 at 6:25 PM, revealed sometimes he/she would go for three (3) or four (4) days or longer with no BMs. Resident #32 stated he/she thought the nurses gave him/her "something" for his/her bowels; however, the resident was not sure what was given. Interview with the Advanced Practice Registered Nurse (APRN), on 07/31/14 at 9:55 PM, revealed she was one of Resident #17's primary healthcare providers. Continued interview revealed the resident had a history of [REDACTED]. Interview with Licensed Practical Nurse (LPN) #10, on 07/29/14 at 3:55 PM, revealed she had cared for Resident #32 in June and July 2014. LPN #10 indicated she could not recall if the resident complained of constipation from 06/25/14 through 07/18/14, or if she had performed an abdominal assessment on the resident during that timeframe. She stated she had never seen Resident #32's Comprehensive Care Plans, and indicated she was not aware of the problems or interventions located on it. Interview with LPN #8, on 07/30/14 at 2:40 PM, revealed she thought she had cared for Resident #32 during June and July 2014. She indicated she could not remember if she had performed an assessment of Resident #32's abdomen, or if Resident #17 had complained of constipation from 06/25/14 through 07/18/14. She indicated she was not aware if Resident #32 was care planned for constipation or if there were interventions in place to prevent it. 3. Review of the clinical record revealed the facility admitted Resident #26 on 07/23/12 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 06/23/14, revealed the facility assessed the resident as having a BIMS score of thirteen (13) which indicated the resident was not cognitively impaired. Further review revealed the facility assessed the resident to require the extensive assist of two (2) staff for bed mobility, transfers, and toileting. In addition, the resident was assessed as frequently incontinent of bowel and bladder. Review of Resident #26's Comprehensive Plan of Care, revised November 2013, revealed the resident had the potential for constipation related to decreased physical function and a [DIAGNOSES REDACTED]. The goal stated the resident would produce adequate bowel movements at least every three (3) days. The interventions included: encourage direct care staff to record BMs accurately, administer medications as ordered, and routinely review BM records to determine any necessary interventions. Review of the Nurses Notes for 05/15/14 revealed Resident #26 became acutely ill with abdominal pain, nausea and vomiting, and a firm abdomen. The resident was sent to the ER per the physician's orders [REDACTED]. Review of the hospital Discharge Summary, dated 05/17/14, revealed Resident #26 suffered an abdominal crisis of pain and nausea, and was found to be massively constipated, with a large volume of BM induced by the administration of enemas. Although Resident #26 returned to the facility on [DATE], after being diagnosed and treated for [REDACTED]. Review of the Bowel Elimination Record, dated 05/14, revealed there was no documentation on the Record until 05/22/14, five (5) days after the resident returned to the facility from the hospital. However, review of the Nurses Notes, dated 05/21/14 at 1:00 AM, revealed Resident #26 had several loose stools. Interview with RN #4/Unit Manager (UM) for the South Unit, on 07/29/14 at 5:17 PM, revealed upon return to the facility from the hospital, the facility failed to re-enter Resident #26 into the computer system, and no documentation was completed related to the resident's bowel elimination. Further interview revealed the UM was not aware anyone was monitoring daily to ensure staff was documenting each shift if a resident had a BM. Interview with the Director of Nursing (DON), on 07/31/14 at 8:05 PM, revealed the resident would not have shown up on the Report which was run from the computer daily to identify those residents who had no BM in seventy-two hours (72) hours if the resident had not been entered into the computer system on return from the hospital. The DON stated it would be important to closely monitor Resident #26 for bowel elimination after being treated in the hospital for Obstipation. She further stated the Comprehensive Care Plan should have been followed related to ensuring the resident had a BM every three (3) days. Continued interview revealed the nurse assigned to Resident #26's care at any given time was responsible for following the care plan. 4. Record review revealed Resident #16 was admitted by the facility on 02/01/12 with [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan, dated 06/2014, revealed Resident #16 was care planned for the potential for constipation and had a goal to produce an adequate bowel movement at least every three (3) days. Interventions included: encourage direct care staff to record bowel movements accurately, administer medications if ordered, observe for signs and symptoms of discomfort, and review bowel movement records to determine any necessary interventions. Review of the "Elimination Report" revealed Resident #16 had a period of no documented bowel movements between the dates of 06/15/14 through 06/22/14. Review of the Nurses Notes for the same period revealed no documented evidence the nurses recognized Resident #16 had not had a bowel movement for greater than three (3) days, contrary to the care planned goal for the resident. Although nursing documentation revealed the resident had abdominal assessments conducted, there was no reference to any PRN medications being administered when there was no BM after three (3) days, and no evidence the bowel record was monitored, according to the care plan. Further review of Resident #16's "Elimination Report" revealed another period of no documented BM between the dates of 07/14/14 through 07/19/14. Review of the Nurses Notes for the same time period revealed no documented evidence the nursing staff recognized Resident #16 had no BM every three (3) days, as per the stated goal on the Comprehensive Care Plan. In addition, continued review of the Nurses Notes revealed no documented evidence any PRN bowel medications were administered as directed by the care plan. Review of the MAR for June 2014 and July 2014 revealed Resident #16 had no PRN bowel medications ordered or administered between 06/15/14 and 07/19/14. Review of the Physician order [REDACTED]. Interview with LPN #8, on 07/30/14 at 12:50 PM, revealed if a resident did not have a bowel movement for several days she would give the resident a PRN medication on the third day if it were prescribed, or notify the Physician if an order was required. Interview with the DON, on 07/31/14 at 8:05 PM, revealed if Resident #16's Comprehensive Care Plan had a goal for an adequate bowel movement every three (3) days, it was her expectation for the licensed nursing staff to follow the care plan. 5. Medical record review revealed Resident #35 was admitted by the facility on 07/02/14 with [DIAGNOSES REDACTED]. Continued review revealed the resident was admitted at 2:15 PM. Review of the Interim Care Plan, dated 07/02/14, revealed Resident #35 had the identified problem of "alteration in comfort/pain". Interventions to manage the resident's pain included the administration of medications as ordered. Further review of the clinical record revealed Resident #35's admission orders [REDACTED]. Review of the Nurses Notes, dated 07/02/14 at 8:00 PM, revealed RN #6 documented Resident #35 was upset because her pain medicine was not available. The nurse documented she notified the Pharmacy and was told the medication would be delivered on the at approximately midnight or 1:00 AM. Continued review revealed the nurse informed the resident the pain medication would be given when it was received from the Pharmacy. Interview with RN #6, on 07/31/14 at 10:05 AM, revealed Resident #35 began asking for pain medication at approximately 8:00 PM on 07/02/14, the day of admission. She stated she contacted the Pharmacy at 8:00 PM on 07/02/14 about the resident's pain medication and was told it would be delivered on the midnight run; however, the medications did not arrive at the facility until 4:00 AM on 07/03/14. At that time, Resident #35 was asleep and the nurse did not awaken the resident to administer the medication. RN #6 further stated the resident was upset and disappointed because he/she had been assured by the hospital staff his/her pain medication would be available at the facility. Further interview revealed RN #6 did not remember if she asked the Pharmacy for a STAT delivery. Continued interview revealed RN #6 did check the emergency box when Resident #35 requested pain medication, but the [MEDICATION NAME] was not stocked at the ordered dose. The nurse acknowledged she did not follow the written plan of care related to managing Resident #16's pain, and should have taken additional steps to secure the medication, including informing the Physician to seek additional orders or a change in dose for the [MEDICATION NAME]. Review of the MAR indicated [REDACTED]. Interview with the Pharmacist, on 07/31/14 at 10:45 AM, revealed Resident #35's admission medication orders were processed by the Pharmacy on 07/02/14 at 6:00 PM, and delivered to the facility on [DATE] at 4:08 AM. He stated the nurses were instructed to use the emergency box at the facility when medications were needed prior to delivery from the Pharmacy. He further stated if the medications were not available in the emergency box, the nurse should contact the Pharmacy and request a STAT delivery. Continued interview revealed the Pharmacist could find no documentation to indicate the Pharmacy had been contacted for a STAT delivery for Resident #35 on 07/02/14, although all calls from facilities were logged by the Pharmacy staff when the call came in. Interview with the DON, on 07/31/14 at 3:30 PM, revealed Resident #35's nurse should have notified the Pharmacy for a STAT delivery of the resident's medications. She stated the nurse could take other steps to ensure the resident's care was provided according to the care plan. For example, if the resident's medication was not delivered from the Pharmacy in a timely manner, and was not available in the facility's emergency box, the nurse should call the DON for assistance, and notify the Physician for possible additional orders. Continued interview revealed the DON had the expectation for the nursing staff to follow the care plan Resident #35 was discharged from the facility on 07/09/14, prior to the State Agency survey. An attempt to interview Resident #35 by telephone, on 07/29/14 at 3:30 PM, was unsuccessful.

Based on interview and record review, it was determined the facility failed to ensure necessary care and services were provided for residents in accordance with the comprehensive assessment and plan of care related to following the facility's unwritten bowel protocol, and ensuring the availability of prescribed medications, for six (6) of thirty-seven (37) sampled residents (#16, #17, #26, #32, #35, and #36). Interviews with staff revealed the facility's bowel protocol directed if a resident did not have a bowel movement (BM) within three (3) days they were placed on the computerized bowel list which was printed out each day, and were to receive follow-up assessments and PRN (as needed) bowel medications. Resident #17, who had a history of [REDACTED]. A PRN bowel medication was given to the resident late in the evening of 07/19/14, at 10:02 PM, with no documented evidence of results. On 07/20/14, staff administered another PRN bowel medication, and obtained an order for [REDACTED]. At 10:20 AM on 07/20/14, Resident #17 complained of abdominal pain, and began to vomit bright red blood. The Physician was notified and the resident was transported to the hospital emergency room (ER), where he/she was diagnosed with [REDACTED]. In addition, the facility failed to provide documented evidence Residents #32, #16, and #36 had a BM every three (3) days, for periods ranging from five (5) to six (6) days. Additionally, there was no documented evidence the facility followed their protocol related to completing bowel assessments and administering bowel medications as ordered for these residents. Also, although Resident #26 returned to the facility on [DATE] after being diagnosed and treated for [REDACTED]. Review of the Bowel Elimination Record revealed there was no documented BM after the resident returned from the hospital until 05/22/14, five (5) days later. In addition, Resident #35 was admitted on [DATE] at 2:15 PM, and requested pain medication later that evening, at 8:00 PM. However, the medication was not delivered to the facility from the Pharmacy until 4:00 AM in the morning on 07/03/14, and was not administered to Resident #35 until 3:05 PM on 07/03/14. There was no documented evidence the facility assessed and monitored the resident's pain, and no evidence any additional attempts to obtain the resident's medication were made. The findings include: Interview with the Director of Nursing (DON), on 07/27/14 at 12:42 PM, revealed the facility had no written policy related to bowel elimination or a bowel protocol; however, she reported the facility had an unwritten protocol which staff followed. The DON stated a computerized report was generated and printed daily from the Bowel Elimination Reports, and indicated which residents had not had a BM in the past three (3) days, or seventy-two (72) hours. Continued interview revealed the Reports were given to the two (2) Assistant Directors of Nursing (ADONs) in the clinical meeting each morning Monday through Friday, and the Weekend Supervisor obtained the Report on weekends and distributed them to the nurses on each of the facility's two (2) units. The DON stated the nurses assigned to the medication carts were to complete an abdominal assessment on each resident listed on the Report. The assessment included checking for the presence of bowel sounds, and assessing for abdominal distension or firmness. She further stated the nurse was also to assess the residents' hydration status by observing the oral cavity and mucous membranes, skin turgor (elasticity) and fluid intake. Continued interview revealed the nurse could initiate non-medical interventions such as prune juice if that normally worked for the resident, or could administer a PRN laxative or obtain an order for [REDACTED]. She stated the resident would keep appearing on the Report until a BM was documented on the Kiosk (computerized charting program), and the nurses were to continue with the abdominal and hydration assessments and continue to administer other laxatives or call the Physician as needed for additional orders. The DON stated the residents who had not had a BM in seventy-two (72) hours were discussed in the clinical meetings Monday through Friday and the ADONs were to follow up with the nurses and ensure the PRN medications were administered and the assessments were documented. Interview with the Registered Nurse (RN) #4/Assistant DON for the South Unit, on 07/29/14 at 5:17 PM, revealed she was given a list of residents who had not had a BM in three (3) days daily Monday through Friday during the morning clinical meeting. She stated she hung the list at the nurses' station on her unit for reference by the nurses assigned to the medication carts. She explained if a resident had no BM in three (3) days, bowel assessments were to be completed by the nurse, and the nurse was to administer a PRN laxative medication or a non-medicinal intervention such as prune juice or whatever was appropriate for the specific resident. She further stated, if there was no response (no BM) later that day, the next shift was to follow up with another laxative or enema, or call the Physician for orders. Continued interview revealed there was no follow-up monitoring related to whether the laxative was given or if it was effective. However, she stated, about a week ago she started having staff turn the list back to her so she could check to see if a laxative was given and if it was effective for residents with no BM in three (3) days. She stated the Report of residents with no BM in seventy-two (72) hours was taken each morning Monday through Friday to the clinical meeting; however, each resident was not discussed individually, only the list was distributed. 1. Review of Resident #17's medical record revealed the facility admitted the resident on 03/29/13 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 06/23/14, revealed the facility assessed Resident #17 to have a Brief Interview for Mental Status (BIMS) score of fifteen (15) which indicated no cognitive impairment. Continued review of the MDS revealed the facility assessed Resident #17 to always be incontinent of urine and frequently incontinent of BM, and to require extensive assistance of two (2) staff with toileting. Review of Resident #17's Comprehensive Care Plan, dated 04/08/13, revealed the resident was care planned for "at risk for bowel elimination problem related to decreased mobility and [MEDICAL CONDITION]". Review of the risk for bowel elimination care plan revealed a goal for Resident #17 to have a regular bowel elimination pattern as evidenced by "soft/formed" BMs at least "once every three (3) days". Continued review of the risk for bowel elimination care plan revealed interventions included: monitoring bowel elimination status; reporting changes in bowel status to the Physician; and administering medications used for bowel elimination problems and monitoring for effectiveness and side effects of the medications. Review of the Physician order [REDACTED].#17 was to receive [MEDICATION NAME] Sodium 100 milligram (mg) by mouth every other day for a [DIAGNOSES REDACTED]." 8.6 mg, two (2) tablets by mouth daily PRN. Review of Resident #17's "Elimination Report" for July 2014, revealed no documented evidence the resident had a BM from 07/15/14 through 07/20/14, a total of six (6) days. Review of the Nurses Notes from 07/15/14 through 07/18/14, revealed four (4) days of no documented BMs. Further review revealed no documented evidence the unwritten bowel protocol had been implemented for Resident #17 in regards to performance of an abdominal assessment to include whether Resident #17 had positive bowel sounds in all four (4) quadrants, and whether he/she had abdominal distention, or whether the resident's rectal vault was checked digitally for impaction. Continued review revealed no evidence of the administration of PRN bowel medications during that timeframe, although the unwritten protocol was for an abdominal assessment to be completed if the resident had not had a BM in the last three (3) days, and PRN medications were to be administered. Continued review of the Nurses Note dated 07/19/14 at 9:50 PM, revealed an order for [REDACTED]. Further review of the Nurses Notes, dated 07/20/14 at 10:20 AM, revealed the following: Resident #17 complained of abdominal pain and PRN bowel medications were administered as ordered; the resident was drinking warm coffee and vomited bright red blood two (2) times; and the Physician was notified and an order was received to send the resident to the ER. Further review of the Nurses Note revealed the nurse assessed Resident #17 to have positive bowel sounds in all four (4) quadrants, and complaints of tenderness in the right upper abdominal quadrant. Continued review of this Note revealed a late entry for 07/19/14 documented within it, which indicated Resident #17 had PRN bowel medications given on 07/19/14 at 9:00 AM and at 6:45 PM. Review of the late entry note revealed the resident was given a PRN enema for complaints of constipation with no results, "no stool visible". However, the nurse documented the abdominal assessment as non-tender, non-distended, with bowel sounds present times four (4) quadrants. Review of the July 2014 Medication Administration Record (MAR) revealed the [MEDICATION NAME] Sodium was administered every other day as ordered; however, there was no documented evidence PRN bowel medications were administered from 07/15/14 until 07/19/14 at 10:02 PM when Senna 8.6 mg two (2) tablets by mouth was given. Continued review of the MAR revealed the Senna laxative medication was again administered on 07/20/14 at 11:27 AM, and MOM 30 ml was administered at the same time. Review of the MAR, "As Needed Administrations Report" revealed: the Senna laxative was administered on 07/19/14 at 10:02 PM, and the effectiveness noted to be "with minimal effect"; the Senna and the MOM were noted to have been administered on 07/20/14 at 11:27 AM "with no effect". Further review of the MAR and the "As Needed Administrations Report" revealed no documented evidence PRN bowel medications were administered on 07/19/14 at 9:00 AM, or on 07/19/14 at 6:45 PM, as indicated by the nurse's late entry note for that date. Review of the hospital ER record revealed Resident #17 arrived at the ER at 11:24 AM on 07/20/14, and was triaged at 11:26 AM by an ER Registered Nurse, who noted the resident's complained of nausea, vomiting and abdominal pain, and reported having vomited bright red blood. Review of the ER Physician's History and Physical revealed the resident had right upper quadrant abdominal pain and bowel sounds were noted as "quiet". Review of the ER physician's orders [REDACTED]. Review of the Radiology Results of the CT scan revealed "fecal impaction noted severely involving the rectal vault", with the "conclusion" noted as "severe fecal impaction rectal vault". Continued review of the ER record revealed the Physician noted an enema was administered and manual "disimpaction" (removal of BM) with "good results". Further review of the ER record revealed Resident #17 was discharged back to the facility at 4:10 PM in stable condition. Interview with Resident #17, on 07/25/14 at 10:50 AM, revealed the resident had trouble with constipation because of his/[MEDICAL CONDITION] and immobility. Resident #17 reported he/she had approximately "four (4) poop medicines" ordered. Continued interview revealed prior to being sent to theER on [DATE], Resident #17 was constipated and had not had a BM all the week before. Resident #17 believed staff had given him/her bowel medications before going to the ER; however, the resident was not "positive" of this. Resident #17 reported having been "so sick" at the time of transfer to the ER. Interview with State Registered Nursing Assistant (SRNA) #6, on 07/25/14 at 2:48 PM, and SRNA #8 at 3:05 PM, revealed both had cared for Resident #17. They stated they documented residents' BMs in the "Kiosk", computer system, and if any residents had not had a documented BM in three (3) days the nurses let them know, from the list, if they had given the residents bowel medications, and to watch those residents for a BM. SRNA #6 stated Resident #17 had complained of constipation prior to going out to the hospital on [DATE]. SRNA #6 reported Resident #17 had told her the nurses were giving him/her "stuff" for the constipation. She stated she could not recall if Resident #17 had a BM the week before; however, she indicated if the resident had a BM it should be documented in the "Kiosk". Interview with SRNA #31, on 07/29/14 at 3:20 PM, revealed he had cared for Resident #17 before. SRNA #31 stated the facility's process was if a resident did not have a BM in three (3) days the nurses would give the resident whatever constipation medication they had ordered. Continued interview revealed the nurses had a "bowel list", and alerted the SRNAs to which residents were on it. He stated the SRNAs "generally" cared for the same residents from day to day, so they knew how long a resident went without a BM, and the nurses monitored the resident. SRNA #31 reported residents' BMs were documented in the "Kiosk". Per interview, SRNA #31 stated Resident #17 "usually" just went a "few days" without a BM, and it was not "usually" a week. Further interview with SRNA #31 revealed Resident #17 had complained of constipation "a couple of times" before going to theER on [DATE], and he reported this information to the nurses who told him they had "given what they could". Interview, on 07/30/14 at 2:55 PM, with SRNA #18 and SRNA #20, revealed they had cared for Resident #17 before, and were aware he/she had problems with constipation. SRNA #20 stated Resident #17 had complained to the SRNAs of being constipated before being sent out to the ER, and the SRNAs had told the nurses. The SRNAs stated they thought the nurse had given Resident #17 enemas, but they could not be sure. Interview with LPN #1, on 07/25/14 at 3:11 PM, revealed the facility did not have a written bowel protocol; however, there was a process in place whereby every Monday through Friday a list was printed from the "Kiosk" (computer) for residents who had not had a BM in seventy-two (72) hours, and the list was given to the nurses on the medication carts. LPN #1 stated when she received a list of residents without BMs, she talked to the SRNAs and verified the resident had not had a BM. She stated sometimes the SRNAs didn't get everything documented in the "Kiosk" as they should, therefore the "Kiosk" was not always accurate. Continued interview with LPN #1 revealed after verifying there had been no BMs, she performed an abdominal assessment of the resident, listening for bowel sounds and looking for distention and signs and symptoms of constipation. LPN #1 stated the nurses were responsible for monitoring to ensure residents had BMs. Therefore, LPN #1 stated, if a resident had not had a BM in seventy-two (72) hours, after assessment the nurse should give a PRN bowel medication; if the resident did not have PRN medications ordered they were to notify the Physician for orders. Interview with LPN #10, on 07/29/14 at 3:55 PM, revealed she had cared for Resident #17 before, and she indicated she thought she had cared for the resident during the 07/15/14 through 07/20/14 timeframe. She stated the facility had a bowel protocol where a "bowel care list" of residents was printed out each morning for residents who had not had a BM in seventy-two (72) hours. LPN #10 stated the list was brought to the nurses by RN #4/ADON or by the Director of Nursing (DON); and, on weekends the Weekend Supervisor obtained the list to give to the nurses. Continued interview revealed after receiving the list, the nurses asked the SRNAs about the resident's BMs, and if the resident was alert and oriented, she would ask the resident if they had a BM. She further stated the nurse assessed the resident to check for bowel sounds and distention, which would be documented in the resident's medical record. LPN #10 stated if the resident and SRNAs reported no BM, the nurse would administer PRN bowel medications. According to LPN #10, if the resident did not experience a BM before the end of the nurse's shift, who administered the PRN bowel medication, the resident's name and information was passed along to the oncoming shift and placed on the facility's twenty-four (24) hour report for follow-up. Further interview with LPN #10 revealed Resident #17 had a history of [REDACTED]. She stated Resident #17 should never go more than three (3) days without a BM due to his/her history. She indicated she could not recall if Resident #17 had complained of constipation, or if she had performed an abdominal assessment of the resident during the week prior to the resident going to theER on [DATE]. Interview with LPN #8, on 07/30/14 at 2:40 PM, revealed she had cared for Resident #17, and indicated she thought she had cared for the resident during the 07/15/14 through 07/20/14 timeframe. Continued interview with LPN #8 revealed the facility had a "bowel list" which was printed each day for residents who had no documented BM for seventy-two (72) hours. She stated RN #4/ADON gave the list to the nurses assigned to the medication carts so they could determine which of the residents they were responsible for, and check further to see if the resident really had not had a BM. LPN #8 stated if the resident had not had a BM, the nurse would perform a "bowel assessment" and administer a PRN bowel medication. She reported residents stayed on the "bowel list" until they had a BM, and if a PRN was administered with no results the Physician was notified for additional orders. LPN #8 stated she was aware of Resident #17's history of constipation, and knew she had several different PRN medications for the constipation. Further interview revealed LPN #8 could not recall if she had assessed Resident #17's abdomen during the week before he/she went to the ER, and could not recall if Resident #17 had complained of constipation before being sent out to theER on [DATE]. She stated Resident #17 was alert and oriented and could tell staff if he/she was constipated. LPN #8 stated when Resident #17 went out to the ER, he/she was found to be severely impacted. The LPN indicated Resident #17 should never go greater than three (3) days without a BM related to his/her history of constipation. Interview on 07/31/14 at 9:55 PM, with the Advanced Practice Registered Nurse (APRN), who was Resident #17's primary healthcare provider, revealed she saw the resident at least one (1) time per month, unless the resident had an acute problem in which case the APRN saw the resident more often. The APRN stated Resident #17 had a history of [REDACTED]. She explained the resident's main problem was slow peristalsis (a series of muscle contractions which occur in the digestive tract to move food through the digestive system). The APRN stated as Resident #17's peristalsis was "so slow", the resident needed "a lot" of laxatives. She further stated she had ordered several PRN bowel medications for Resident #17, and if the resident did not have a BM for three (3) days, he/she should be given a PRN bowel medication. Continued interview with the APRN revealed the facility had a "bowel list" of residents who had not had a BM in three (3) days, and the healthcare provider was supposed to be notified of this information. She stated if she had been notified of Resident #17 not having a BM for greater than three (3) days, she would have told the nurses to check the resident "digitally" and ask if the resident wanted a suppository. The APRN stated if the suppository didn't work, she would have had the nurses give Resident #17 an enema. Further interview revealed she did not like for any of her residents to go more than three (3) days without a BM, and if the resident went that long they would need "to take something" for their bowels. She stated she had never been made aware of Resident #17 having been severely impacted when he/she went to theER on [DATE]. She reported the primary care Physician may have known about the [DIAGNOSES REDACTED]. 2. Review of the medical record revealed the facility admitted Resident #32 on 05/24/13 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS Assessment, dated 04/13/14, revealed the facility assessed Resident #32 to have a BIMS score of fourteen (14), indicating the resident was cognitively intact. Continued review of the MDS Assessment revealed the facility assessed Resident #32 to be frequently incontinent of urine and always continent of bowels, and to require extensive physical assistance of two (2) staff with toileting. Review of Resident #32's Comprehensive Care Plan, dated 06/06/13, revealed the resident was care planned for "at risk for bowel elimination problem related to decreased mobility and [MEDICAL CONDITION]". Continued review revealed a goal for Resident #32 to have a regular bowel elimination pattern as evidenced by "soft/formed" BMs at least "once every three (3) days". Continued review of the risk for bowel elimination care plan revealed interventions included: monitor bowel elimination status; report changes in bowel status to the Physician; check and remove hard stool PRN; and administer and monitor effectiveness and side effects of medications used for bowel elimination problems. Further review of Resident #32's Comprehensive Care Plan, revised June 2014, revealed the resident was care planned for an ADL (activities of daily living) self care deficit related to the resident's diagnoses, including a History of Stroke with Right [MEDICAL CONDITION]. Review of the June 2014 Physicians Orders revealed Resident #32 had [MEDICATION NAME] Sodium 100 milligram (mg) by mouth twice daily for a [DIAGNOSES REDACTED]. Review of Resident #32's "Elimination Report" for June 2014, revealed no documented evidence the resident had a BM from from 06/25/14 through 07/01/14, a total of seven (7) days, from 07/03/14 through 07/08/14, a total of six (6) days, or from 07/14/14 through 07/18/14, a total of five (5) days. Review of the June and July 2014 MAR revealed the scheduled [MEDICATION NAME] Sodium was administered as ordered. However, continued review of the MAR revealed the following: for the 06/25/14 through 07/01/14 timeframe, the PRN MOM thirty (30) ml was administered on 06/30/14, the sixth day of no documented BM; and for the periods from 07/03/14 through 07/08/14, and 07/14/14 through 07/18/14, there was no documented evidence a PRN bowel medication was administered. Review of the June and July MAR, "As Needed Administrations Report" revealed the MOM was administered on 06/30/14 at 9:47 AM, with the "effectiveness" documented as "with good effect" at 10:59 AM, even though the Elimination Report had no documented evidence of a BM on that date. Further review of the Report revealed no documented evidence a PRN bowel medication was administered from 07/03/14 through 07/21/14. Review of the Nurses Notes from 06/25/14 through 07/18/14 revealed no documented evidence the unwritten bowel protocol was implemented for Resident #32 related to the performance of an abdominal assessment after the resident went three (3) days without a BM, even though staff interviews revealed the unwritten protocol directed staff to complete an abdominal assessment when there was no BM in three (3) days. Interview with Resident #32, on 07/31/14 at 6:25 PM, revealed the resident sometimes went three (3) or four (4) days, or longer, with no BM. Continued interview revealed Resident #32 thought he/she got "something" for his/her bowels, but was not sure what it was. Further interview revealed Resident #32 had hemorrhoids which were painful at times. Interview with LPN #10, on 07/29/14 at 4:17 PM, revealed she had cared for Resident #32 before, and she thought she had cared for the resident between 06/25/14 and 07/18/14. She stated the facility's unwritten bowel protocol should have been followed for Resident #32. Continued interview revealed LPN #10 could not recall if Resident #32 had been on the "bowel care list", printed each morning for residents who had not had a BM in seventy-two (72) hours. Further interview revealed she could not recall if she had assessed the resident's abdomen during that timeframe. She stated the resident should not go longer than three (3) days without a BM. Interview with LPN #8, on 07/30/14 at 2:40 PM, revealed she had cared for Resident #32, and thought she had cared for the resident from 06/25/14 through 07/18/14. Continued interview with LPN #8 revealed she could not recall if Resident #32 was on the "bowel list" during that timeframe, and she did not remember assessing the resident's abdomen during that time. Interview, on 07/31/14 at 9:55 PM, with the APRN who provided healthcare services for Resident #32, revealed if the resident was on the "bowel list" of residents who had not had a BM in three (3) days, he/she would require a PRN bowel medication. The APRN stated she did not like her residents to go longer than that without a BM. 3. Review of the medical record revealed the facility admitted Resident #26 on 07/23/12 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) Assessment, dated 06/23/14, revealed the facility assessed the resident as having a BIMS score of thirteen (13), which indicated the resident was cognitively intact. Further review of the MDS revealed the facility assessed the resident as requiring the extensive assist of two (2) staff for bed mobility, transfers, and toileting. In addition, the facility assessed the resident as being frequently incontinent of bowel and bladder. Review of Resident #26's Comprehensive Plan of Care, revised 11/13, revealed the resident had the potential for constipation with a goal stating the resident would produce adequate bowel movements at least every three (3) days. There were several interventions including: encourage direct care staff to record BMs accurately, administer medications as ordered, and routinely review BM records to determine any necessary interventions. Review of the Bowel Elimination Record, dated 05/14, revealed Resident #26 had a BM documented on 05/12/14 as large and soft; and, on 05/15/14 as medium and soft at 2:42 PM. Review of the Nurses Notes dated 05/15/14, revealed Resident #26 became acutely ill at 6:45 PM, when the resident exhibited nausea and vomiting. At 8:30 PM, the resident again vomited. At 11:50 PM, the resident had increased vomiting with a new onset of a firm abdomen and a decrease in bowel sounds. Continued review of the Nurses Notes revealed throughout the evening of 05/15/14, the nurse monitored the resident's condition, assessed the abdomen, was in contact with the Physician and the APRN, and administered medications based on new orders as they were received. At 11:50 PM, Resident #26 was sent to the ER per the physician's orders [REDACTED]. Despite the resident's history of adequate BMs in the previous three (3) days, a review of the Hospital Discharge Summary dated 05/17/14 revealed Resident #26 was admitted with a [DIAGNOSES REDACTED]. Continued review revealed the resident had vomiting, an abdominal crisis of pain and nausea, and was found to be massively constipated. Further review revealed a large volume of stool was induced via enemas and a large amount of material was pulled via the nasogastric tube (a tube which is passed through the nose and into the stomach). Review of the report for the CT (Computerized Tomography) Scan of the Abdomen and Pelvis performed on 05/16/14 revealed the rectum was distended with stool measuring eight (8) centimeters diameter, and the stomach was distended. Further review of the Summary revealed mild Pneumonia was identified and the resident was started on [MEDICATION NAME] (antibiotic medication). Although Resident #26 returned to the facility on [DATE], after being diagnosed and treated for [REDACTED]. Review of the Bowel Elimination Record revealed there was no documentation until 05/22/14, five (5) days later after the resident returned to the facility. However, review of the Nurses Notes, dated 05/21/14 at 1:00 AM, revealed the resident had several loose stools. Interview with RN #4/Unit Manager (UM) for the South Unit where Resident #26 resided, on 07/29/14 at 5:17 PM, and review of the Elimination Report with the UM, revealed there was no documentation to indicate the resident did, or did not, have a BM on any shift from 05/17/14 through 05/20/14. The UM explained, since there was no documentation at all, it looked as though the resident was not put back in the system prior to 5/21/14; therefore, the SRNAs were not able to document anything related to the resident's BMs or lack thereof. The UM stated when a resident was transferred out of the building, they were taken out of the main computer system of the facility, and when the resident returned they were to be entered back into the system. She further stated the floor nurses, the DON, the MDS Coordinators and a few others, including herself, had the ability to take residents out of the system and enter them back into the system. Continued interview revealed she had no knowledge anyone was monitoring daily to ensure staff were documenting on each shift if a resident had a BM. She further stated the computer gave a percentage at the end of each shift to show how much required documentation had been completed, and indicated which questions had not been answered. The UM stated she looked at this daily Monday through Friday and reminded the SRNAs to document in the Kiosk about 2:30 PM; however, she was unsure sure if the nurses on the second and third shifts, and on the weekends, knew how to do this. Interview with the DON, on 07/31/14 at 8:05 PM, revealed the nurses on the unit took the residents out of the computer system when they were transferred out of the facility, and the nurse assigned to the resident upon the resident's return was to enter the resident back into the system. She stated there was no check system she was aware of to ensure residents were put back in the system when they returned to the facility. Continued interview revealed the resident would not show up o

Based on interview, record review, and review of the facility's policy and procedures and incident report it was determined the facility failed to ensure residents' environment remained free from accidental hazards and failed to provide the appropriate assistive devices to prevent an avoidable accident as evidenced by injuries sustained by one (1) of ten (10) sampled residents (Resident #5). On 05/05/11, the facility conducted an outdoor stick horse derby race for residents in wheelchairs; however, the facility failed to assess each resident to ensure the activity was safe for the residents and failed to check wheelchairs prior to the race activity. Resident #5 fell out of a wheelchair that staff was pushing during the race and sustained a fractured left femur, hematoma to the forehead, and facial bruising. The findings include: Review of the facility's policy titled "Fall Policy" dated 12/10, revealed it was the intent of this facility to provide residents with assistance and supervision in an effort to avoid falls and minimize injury and complications that may result from a resident falling. Review of the clinical record revealed the facility admitted Resident #5 on 10/15/08 with [DIAGNOSES REDACTED]. Review of the 04/07/11 Quarterly Minimum Data Set (MDS) Assessment revealed the facility assessed the resident's cognitive status as seven (7) out of fifteen (15) which, according to the MDS scale, 0-7 indicated severely impaired cognitive status. Review of the Comprehensive Care Plan, revised on 04/19/11, revealed Resident #5 had impaired cognitive skills, short-term memory loss, impaired decision making skills, impaired communication and had problems understanding others and making his/herself understood. Further review of the MDS revealed the facility assessed Resident #5 as requiring a wheelchair for mobility, impaired range of motion in the lower extremities, and requiring extensive assistance of two (2) staff for transfers. Review of the clinical record for Resident #5 revealed on 05/05/11 Resident #5 was participating in an outdoor stick horse derby race. Review of the facility's incident report revealed the race consisted of the resident sitting in the wheelchair while being escorted/pushed by a staff member in the facility parking lot. The wheelchair came to sudden stop and Resident #5 fell out onto the concrete. Interview on 05/12/11 at 1:10 PM with the Activity Director (AD) revealed the stick horse derby was held in the South Parking lot at approximately 2:30 PM on 05/05/11. Per interview, the residents made the stick horses from a wooden dowel (3/4" in diameter and 3 feet long). The head was made from a poster board and the mane was made from yarn. She revealed approximately 5-10 feet into the race, Resident #5's wheelchair abruptly stopped, the resident tumbled forward, and the left side of his/her forehead hit the pavement. The resident complained of head pain. Interview on 05/12/11 at 2:10 PM, with the Activity Assistant (AA), who was pushing Resident #5, on 05/05/11, revealed while pushing the resident, the chair suddenly stopped abruptly and the resident fell forward, out of the wheelchair onto the pavement. The nurses assessed the resident, called 911, and the resident was transferred to the hospital. Interview, on 05/15/11 at 11:15 AM, with Licensed Practical Nurse (LPN) #1 revealed Resident #5 was lying on the ground, blood was on the resident's pants and arm. Three nurses log rolled the resident and there was a hematoma on the resident's forehead. She further stated the resident complained of leg pain. Review of the hospital discharge summary revealed Resident #5 sustained a left femur fracture, hematoma to the forehead, bruising to the face, and a skin tear to the left elbow. Further interview on 05/12/11 at 1:10 PM with the Activity Director (AD) revealed during the stick horse derby, residents were pushed, in their wheelchairs, by the facility's staff members. She stated she checked the parking lot for uneven pavement, chips, cracks, and debris prior to the derby. Per interview, there was no formal assessment process to determine if each resident who participated in the race was able to participate safely. Further interview revealed she instructed the staff to go only as fast as they considered safe. Interview on 05/12/11 at 2:40 PM with the Administrator revealed residents were assessed for proper seating and the residents were pushed at a safe speed. However, interview revealed the Administrator was not at the "derby" and record review revealed no evidence residents had been assessed for safety. Further interview with the Administrator on 05/13/11 at 1:10 PM revealed she was unsure if a trial run was performed prior to the activity. Interview on 05/13/11 at 1:30 PM with the AD revealed she assessed Resident #5 as being able to participate in the activity based on her knowledge of working with the resident. Further interview with the AD, when asked how the facility assessed the residents' safety to participate in the race, revealed she used common sense getting to know the resident's likes/dislikes and developed activities to suit their broad interests. She stated she knew that accidents happened and she didn't plan activities that she thought would be harmful to the residents. She stated she did not perform a trial run, but assessed the area prior to the race. Interview on 05/16/11 at 2:35 PM with the AA revealed they didn't perform a trial run but did complete one race before the incident happened. Interview on 05/16/11 at 10:45 PM with the Social Services Director revealed she assessed the residents for cognition on the MDS. She further stated someone could be injured during any activity, but the residents have the right to participate in any of the activities. We (the facility) have to take precautions and the more we can do to help them connect with their community increases their happiness and makes them have a better life. If a resident was willing to participate, we let them participate. It's not standard practice to assess residents before activities. Further interview on 05/17/11 at 12:25 PM with the Administrator revealed the stick horse derby wasn't an event where safety was a concern and no trial run was performed because every wheelchair and resident were different and "safety was not considered an issue".